Ebola: how ready would New Zealand nurses be?

5 October 2014

Would ED nurses here send away an unwell man recently arrived from Liberia? Though the chance of an Ebola victim arriving in New Zealand is very unlikely, both the Ministry of Health and the Infection Control Nurses’ College believe the devastating West African epidemic is a good wake-up call to be ready for what could walk through the door some day…

EbolaThe first Ebola victim walking into a US hospital recently brought one step closer to home the – still very faint – possibility it might happen here.

The recent arrival from Liberia was initially sent away from a Texas Hospital with just antibiotics, which infection control nurse leader Robyn Boyne says just “beggars belief”. Getting a recent travel history is one of the key points stressed in New Zealand’s Ministry of Health advice on preparing for the unlikely event of Ebola (or any other potentially deadly virus or organism) arriving in New Zealand. (See update below from the Texas hospital concerned about taking of travel history

Boyne, the chair of the Infection Prevention and Control Nurses College, NZNO, also sees the sad irony that the man initially turned away in the US had likely been infected with Ebola after trying to help a 19-year-old pregnant woman who was turned away from overcrowded hospitals in Liberia’s capital Monrovia and then died later that night. Several days later, the man flew out to visit family in Texas…

New Zealand has the advantage of not only having no direct flights from West Africa but also a first world health system, well-established infection protection and control (IPC) protocols, and an infrastructure that has not been weakened by recent civil war and extreme poverty, unlike the three West African countries – Liberia, Sierra Leone, and Guinea – stricken by the devastating epidemic.

But a health system’s IPC protocols are only as good as the people who carry them out.

The Ministry of Health’s director of public health Dr Darren Hunt says district health boards and public health managers have been receiving regular updates on the viral haemorrhagic fever outbreak and requested to ensure that their response plans are up-to-date including ill traveler protocols and border emergency response plans.

Border screening was introduced for people arriving from affected West African countries in August, and as at the end of September, 47 people had been screened, with none having had symptoms.

Hunt points that New Zealand hospitals – and nurses – are experienced at dealing with a variety of infectious diseases transmitted through direct and indirect contact with blood, secretions, organs and body fluids, and Ebola is less easily transmitted than many other viruses. Also airborne transmission of Ebola – as occurs with measles or influenza – has never been documented.

But Hunt adds as Ebola virus infections are very serious the Ministry has provided further information and guidance to health professionals – including extra personal protection equipment (PPE) requirements and using negative pressure rooms (see web-link in Ebola: the basics below – and established a technical advisory group to provide advice as needed on managing a suspected Ebola case.

The Ministry believes that if New Zealand does get ill travelers from the affected areas, it is more likely they have malaria or typhoid than Ebola but an Ebola diagnosis had to be ruled out first.

Hunt says that as nurses are the people who handle IPC at the bedside more than any other health professionals they are generally well up-to-date with procedures.

“However, it is important that health professionals are regularly trained in the use of PPE and IPC practices,” says Hunt.

Particularly important with viruses like Ebola is having a ‘buddy’ observe a health professional donning and taking off the PPE to prevent coming in contact with contaminated clothing or equipment. (See Canadian study of how health care workers got infected in 2003 SARS outbreak in Toronto.) The key to minimising any healthcare infections remains, as always, good hand hygiene and strictly carrying out the 5 moments of hand hygiene.

While Ebola remains a very unlikely risk in New Zealand, Hunt agrees that it can only be a good thing if the resulting heightened awareness prompts nurses, and other health professionals, to brush up on contact and droplet transmission precautions and to practise donning and doffing PPE.

“Absolutely, practice and being comfortable with equipment that protects yourself and others cannot be over emphasised.”

Robyn Boyne also agrees and adds that for infection control nurse specialists and coordinators like herself around the country, it is “business as usual” promoting the importance of IPC precautions and particularly hand hygiene to all staff – including refreshers for emergency departments.

“Because if it’s not Ebola it could be something else – that’s the message we are trying to get out – that all staff should be prepared at all times for anything unexpected that could come through the door.”

“The thing is, we know how Ebola is spread – there’s no mystery – they know what it is and they know how it is spread,” says Boyne. “Whereas if something else comes along – like SARS (severe acute respiratory syndrome) – we didn’t know what it was and didn’t how it was spread. So that was actually scarier because you had to use all precautions if you had a case because you didn’t know what its mode of spread was.” (See story about 2003 outbreak and study of SARS health care worker infection in Canada.)

With Ebola, the lack of a safe and effective vaccine or treatment and the virus’s high death rate has led to the Ministry of Health advising a step-up in recommended PPE from the usual regime if a case does appear in New Zealand.

“Like the use of cover-all suits,” says Boyne. “Well some DHBs don’t have those currently, and neither are all-in-one suits something used routinely.”

She says removing an all-in-one suit  is also more complicated to remove then the kind of gowns that most DHBs do have and which most staff are very familiar with. Staff will therefore need extra training to do this safely.

“So you’ve got to look at your risk: it might be better to use something that staff are familiar with, and are going to use correctly, until they can be safely trained in the use of the all-in-one suits."

The ministry has said in its Ebola guidelines that the “anxiety of healthcare workers related to the high mortality rate” had been taken into consideration when drawing up the recommended IPC measures for Ebola.

The measures are based on advice from the World Health Organisation and its own specialists in the Health Care Associated Infections Governance Group (HAIGG).

Boyne said none of the nurses she had spoken with had seemed particularly concerned about Ebola – helped by the unlikelihood of it coming here – but IPC clinical nurse specialists like herself were using it as a “wake-up call” for nurses and other health professionals to take getting accurate travel histories seriously, to brush up on their standard and droplet transmission precautions, and emphasise, once, again the importance of hand hygiene.

“I guess what we’d have to deal with first is how we would deal with a suspected case and hopefully we’d do better than what happened in Texas…”

“If a person had been to Liberia recently and they came to your hospital feeling a bit sick I’d like to think we’d have a much higher level of suspicion.”

There is also the Middle Eastern Respiratory Syndrome (MERS) virus just a plane trip away (see more below). “We’re far more likely to have someone to turn up with that sort of virus – so we have to be prepared for anything really.”

“But the major basis of all of this (infection control for ‘flu to Ebola) is absolutely meticulous hand hygiene following the five moments of hand hygiene,” says Boyne. “Because the biggest danger to you is if you get something on your hand and then touch your own face with your dirty hand. So it’s being aware of where your hands are – not touching your face and cleaning your hands with alcohol hand gel or washing with soap and water.”

Meanwhile, Boyne points out that there have been Ebola outbreaks for many, many years in Africa and most of them don’t get out of control like the West African outbreak. “So normal infection control procedures have worked in a lot of outbreaks – just this one has been in some of the poorest countries with the least amount of health care workers.” In our first world health system we should and could do better.

*A statement from the Texas Health Presbyterian Hospital, Dallas issued on October 3 said the triage nurse did take a travel history when Liberian man Thomas Duncan first presented at the hospital and the nurse recorded that he had been in Africa in the past four weeks. They corrected an initial statement and said that electronic travel history was available to the attending physician who did the final assessment and discharged the man (who later returned to the hospital with confirmed Ebola).  The full statement can be read at:Texas Health Presbyterian Hospital

 NB This article was edited at 12.45pm October 8