Physicians, nurses and other medical staff who are the first line of defense against the spread of Ebola are not always adequately protected from the virus, a situation that has contributed to more than 200 health worker deaths in west Africa since the outbreak began in December 2013. As the virus spreads outside of Africa, so do reports that problems with procedures, protective equipment and training for using that equipment are putting health workers at risk.



The nurse at Madrid’s Carlos III Hospital who earlier this week became the first person outside west Africa to contract Ebola, told media outlets in Spain that she may have accidentally touched her face with one of her gloved hands as she removed her protective gear. This revelation comes amidst reports that several health workers who attended to the nurse are now being tested for the disease and that hospital workers have been complaining about inadequate training and equipment related to Ebola treatment.



One doctor attending to the nurse wrote a letter to his superiors pointing out that the sleeves of his protective suite were too short, the Guardian reported Thursday. Spain’s El País stated earlier this week that Carlos III workers were wearing latex gloves secured with adhesive tape to their overalls.



Scientific American In-Depth Report, Ebola: What You Need to Know”



The infected nurse and her colleagues had been attending to missionaries Manuel García Viejo, 69, who had been to Liberia and died four days after being brought to Carlos III Hospital on September 20, and Miguel Pajares, 75, who likewise returned from Liberia with the disease in August and died five days later.



Although once a distant threat to a specific region in Africa, Ebola has obviously become a concern for countries on other continents as well. A Norwegian woman infected with Ebola in Sierra Leone is now receiving treatment with the experimental ZMapp drug in her native country. And in the U.S. Ebola patient Thomas Eric Duncan died in Dallas Wednesday morning after contracting the disease in Liberia. Duncan’s apartment and surrounding area have cleaned and the other residents of the apartment taken to medical facilities for observation.



Proper training and equipment as well as an abundance of caution are necessary, given the lack of experience health care and cleanup workers have in dealing with Ebola. “We followed the recommendations of the [U.S. Centers for Disease Control and Prevention] but went one level above that as far as personal protective equipment,” says Brad Smith, vice president of the Cleaning Guys, who were contacted by Dallas County officials to clean and disinfect the apartment where Duncan had been staying.



The Cleaning Guys workers who operated in the apartment wore full-face respirators and Level B Saranac suits, which are completely enclosed to protect against particulates and liquids, as per Occupational Safety and Health Administration (OSHA) regulations. These workers typically wear this type of gear when cleaning biohazardous materials and crime scenes, both of which may require protection from blood-borne pathogens, according to Smith. He would not go into detail about the process used to clean the apartment and surrounding area but did say that all of the items in the apartment were removed and placed in containment, with transportation and disposal to be handled by a different company.



Smith also points out that his cleanup workers wore three layers of gloves to protect themselves while working but also to safely undress after the work was done. “That way, you can undress in layers, keeping your hands protected as you remove layers of possibly contaminated clothing,” he says.



Concerns over the spread of Ebola prompted the U.S. Agency for International Development (USAID) to launch the “Fighting Ebola: A Grand Challenge for Development” initiative on October 7. The idea is to solicit ideas that can be used to improve the equipment available to African health workers treating Ebola patients on the front lines, particularly as they operate in hot, humid environments that make impermeable suits very difficult to wear. Pres. Obama had announced the initiative late last month at the Global Health Security Summit in Washington, D.C., and his administration has said they want to field any new innovations within months.



Doctors Without Borders is running six Ebola centers in the three most-affected countries—Liberia, Guinea and Sierra Leone. A spokesman for the aid organization says that staffs at those locations are issued personal protective equipment that includes, among other things:



Rubber surgical apron

Surgical trousers and tunic

Wraparound protective goggles

Antifog spray (for goggles)

Gloves

Rubber boots

Hood

Cape

Respirator mask/face protector



Together, the items cost about $90. The apron, trousers, tunic, goggles and protective gloves are sanitized and reused, whereas the other wearable items are used once and then destroyed.



In west Africa health facilities make do with much less: A survey conducted by Doctors Without Borders in July and August in the Monrovia area of Liberia, a country struggling to recover from more than a decade of civil war. The study, which covered 104 health facilities, found that many were not using basic protective items such as gloves, masks and disinfectant. At least some of this has been attributed to that country’s slow response to the outbreak at its inception, making it difficult to adequately equip workers as the problem escalated.



Such measures are crucial for protection from the Ebola virus, which is transmitted from person to person via close and direct physical contact with infected bodily fluids. The most infectious fluids are blood, feces and vomit, although the virus has also been detected in breast milk, urine and semen, according to the World Health Organization. Saliva and tears may also carry some risk. Researchers have detected fragments of the virus in sweat, but the whole live virus has never been isolated in it, WHO reports, so the possibility of transmission by perspiration is unclear.



The Ebola virus can also be transmitted indirectly, through contact with previously contaminated surfaces and objects. The risk of transmission from these surfaces is low, according to WHO, and can be reduced even further by appropriate cleaning and disinfection. The health organization also emphasizes that Ebola virus disease is not an airborne infection. The organization, however, acknowledges the possibility that the virus could be transmitted a short distance if virus-laden droplets of vomit or mucus are directly “propelled onto the mucus membranes or skin with cuts or abrasions of another person.” WHO says it is not aware of any studies that actually document this mode of transmission.