The use of Personal Protective Equipment (PPE) is evolving in ways that could not have been foreseen, as a collective brain trust of medical experts and front line workers push for modifications of PPE guidelines to wall off any potential exposure to the Ebola virus. PPE has always been at the forefront of any safety protocol in protecting healthcare workers from infectious diseases, including blood borne pathogens. On a daily basis, healthcare workers in the United States are at risk of contracting a variety of life-threatening diseases, including the human immunodeficiency virus (HIV), hepatitis C, tuberculosis, typhoid fever, malaria (which, like Ebola, is also prevalent in Africa), and meningitis, not to mention numerous strains of the potentially deadly influenza virus that keep medical laboratories guessing on the most effective vaccination to release. Healthcare workers, particularly nurses and physicians in direct contact with infected patients, are trained to adhere to PPE guidelines designed to reduce their risk of exposure to all forms of infectious diseases. The goal is to avoid exposure to infected blood and body fluids, contaminated objects, or other contaminated environmental surfaces while treating an infected patient.

Appropriate PPE guidelines, of course, depend on how the disease is transmitted and what the current recommendations are from the Centers for Disease Control and Prevention (CDC), the federal advisory body charged with developing guidelines and tracking health-related matters in the United States. The CDC, comprised of experts in the field, at times coordinates with global information sources such as the World Health Organization (WHO) and Doctors Without Borders to develop universal precautions applicable to healthcare workers. Those guidelines stood largely intact, and untouched, for years, until a virus called Ebola showed up unexpectedly in North Texas.

The Recent Spread of Ebola

The reappearance of Ebola in West Africa in recent months (cases of Ebola were first reported in 1976) has been alarming because the fatality rate has hovered around 50 percent or higher and because the disease in remote areas has spread rapidly—meaning that the spread of the disease qualifies as an outbreak.

The track record of this disease is the problem. While the risk of transmission and pandemic potential varies on a case-by-case basis per infectious disease and while an argument might be made by the healthcare community that Ebola presents less risk when you apply those algorithms, its known impact has already had dire consequences. The collective thinking shifts when there is no known vaccination for a disease and when the death of the first Ebola patient in the United States resulted in two nurses contracting the disease, despite having taken all the usual precautions.

The Impetus to PPE Changes

And so PPE evolves. To prevent additional healthcare workers from being exposed and to assure the public that our healthcare system is safe, the CDC has worked with various agencies—both global and national—as well as the very workers who are required to wear PPE and interact with ill patients, to make changes to existing PPE guidelines as they apply to Ebola patients. The CDC heard from the workers who cared for the first Ebola patient, physicians nationwide, and staff at designated treatment facilities in Nebraska, Maryland, and Georgia. The learning curve resulted in more stringent guidelines.

The Changes to PPE

The official, published guidelines are expected to post in the next day or so, but in the meantime, the CDC has released a Fact Sheet summarizing the key changes. The enhanced guidance focuses on three main areas:

  1. “Rigorous and repeated training.” The guidance promotes rigorous and repeated training of healthcare workers, including putting on and taking off (otherwise known as “donning and doffing”) protective equipment in a systematic manner. The emphasis of the guidance is that the training be repeated. The CDC wants healthcare workers regularly practicing the procedure—removing contaminated clothing in the same order and manner—so the method stays fresh and so no errors are made at a critical moment.
  2. “No skin exposure when PPE is worn.” This is a key change to previous PPE conditions, which typically permit the exposure of the wrist and neck. The CDC suggests modifications when wearing fluid-resistant gowns to keep them in place (e.g., using thumb holds anchoring sleeves inside gloves instead of the common practice of taping edges together). Also, the guidelines ramp up quantity of protective gear to be worn by healthcare workers, which now include coveralls and single-use, disposable hoods that cover the neck. Goggles are no longer recommended, in favor of a single-use full-face shield that is disposable. Also, when obvious fluids are present during treatment, the healthcare worker has the option of wearing an apron that is waterproof and covers the torso to mid-calf. The use of powered air purifying respirators (PAPR) is optional given the current evaluation that Ebola is not airborne. As a final push to ensure skin is protected, the process of taking the contaminated outer layers of PPE off has changed, with a current recommendation that gloved hands first be disinfected with an EPA-registered disinfectant wipe or alcohol-based hand rub between steps.
  3. “Trained monitor.” The CDC recommends that a trained monitor actively observe and supervise each worker while donning and doffing PPE. This is a novel and significant shift in CDC protocol. It is not always easy for healthcare workers to see what they are doing while wearing cumbersome gear and a face shield. A trained monitor can ensure that the worker follows the precise protocol, including disinfecting all visibly contaminated PPE while taking off the gear. If the monitor catches any deviation from protocol, the monitor can address it immediately.

Technically speaking, the guidelines are suggestions only, but we expect most healthcare facilities to adopt these guidelines, if they haven’t already. The new recommendations will become the primary standard for infection control in the nation’s acute care facilities when treating an Ebola-infected patient. Employers should also be aware that the Occupational Safety and Health Administration (OSHA) may look to the recommended protocol in assessing the appropriate workplace standard for Ebola countermeasures, bridging its existing regulations (for example, the Bloodborne Pathogens standard, the Respiratory Protection standard, the Personal Protective Equipment standard, and the General Duty Clause of the Occupational Safety and Health Act of 1970) with CDC guidance.

Join us on October 22, 2014, and October 29, 2014, for “Ebola and Employers: The Law To Know, The Plans To Make,” a webinar covering the law that applies to workplaces affected by the disease, or by fear of the disease. Register for the October 22 webinar here and for the October 29 webinar, which will include the latest information and updates on Ebola guidance here.



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The attorneys in Ogletree Deakins’ Healthcare Industry Group understand the unique legal challenges facing healthcare industry clients that must balance vital and demanding work with numerous compliance regimes and heavy regulation.

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