During the historic Ebola outbreak in West Africa that is now making its last stand, 509 healthcare workers have given their lives trying to save others. The deaths translate to a mortality rate of 58% of the 875 healthcare workers infected as of July 5, 2015, the WHO reports.

Factors that have been cited by the WHO for the occupational Ebola infections include shortages of personal protective equipment, improper use of PPE, and for much of the outbreak, far too few medical staff for the overwhelming number of cases. In such circumstances, healthcare workers demonstrate a compassion that contributes to working in isolation wards far beyond the number of hours recommended as safe, the WHO notes.

With a few exceptions — like some of the U.S. healthcare workers — many of the infected caregivers were treated under the very conditions of the epidemic they were fighting, making it difficult to deliver the full measure of care needed. Consider that the two deaths among the 10 cases treated in the U.S. cases translates to a mortality rate of 20%, suggesting that part of the reason Ebola is so deadly in Africa is that the level of patient care demanded cannot be adequately delivered. In particular, clinicians who treated some of the first cases in the U.S. said Ebola patients have massive fluid loss — rivaling conditions seen in cholera — that can be difficult to restore.

From Alabama to Africa

The knowledge that they could be flown back to the U.S. for better treatment may have provided some reassurance for the American healthcare workers, but facing Ebola, even in a simulated training situation, has a way of getting one’s attention. Last September in a hot Alabama field, trainees in full PPE regalia and respirators entered a mockup Ebola Treatment Unit (ETU) as part of a three-day training program by the CDC.

“When they entered that mock ETU from the classroom, you could sense the increased level of concentration and also some anxiety,” says Rupa Narra, MD, a CDC Epidemic Intelligence Service officer and one of the Ebola trainers. “I think that was an appropriate response — we really wanted to get them in that mindset and try to prepare them as well as we could.”

The sense of urgency was intensified by the knowledge that those who completed the three-day course could soon be bound for West Africa, where they would do some additional onsite training and then step into ranks of a healthcare response that was being practically overwhelmed at that point. Having faced Ebola in Guinea and worked with Médecins Sans Frontières (MSF)/Doctors Without Borders for years, Narra was well aware what they were in for.

“We basically put them through what they would normally go through in an Ebola treatment unit,” she tells Hospital Infection Control & Prevention. “Starting with getting on scrubs and gum boots and then donning all the high-level PPE. And of course in Alabama in September in head-to-toe PPE they were sweating. I felt they could really see what the situation or atmosphere [in Africa] was going to be like.”

Developed in collaboration with the WHO and the MSF, the CDC course also included lectures and table-top exercises. Ninety-eight different instructors taught at eight course sessions; each required approximately 20 instructors. The situation called for a different mindset for both the first responders taking the course and the trainers, she says.

“We had a classroom aspect and a hands-on aspect, which required these responders putting on PPE, taking it off or doffing it and also doing some patient care exercises in the PPE,” Narra says.

In particular, donning and carefully doffing the protective gear was emphasized in a routine and ritual observed by a partner.

“We taught them the kind of breaches to look for; for example, if you have some skin showing between your mask and your goggles,” she says. “We did this through a buddy system and they would be checking themselves as well. Then after they got dressed we would have them enter what we called the ‘hot zone’ — the patient care area — and do simulated patient care activities in the PPE.”

The workers were taught that if they detected a breach in PPE in themselves or others, stop the procedure and have that person immediately leave and doff their gear.

“We showed them the different [disinfection] methods — a sprayer with chlorine or someone wiped you down,” she says. “We tried to show them all the different things they may see in the field. [Always] adopt a safety culture [mindset] when doing the procedures — that was really the theme.”

Doffing a challenge

Removing protective equipment without contaminating yourself after treating an Ebola patient is probably the biggest employee health challenge in both the classroom and the real world.

“Doffing seemed to be a common theme in breaches or problems,” Narra says. “The responders felt like they needed the most practice in doffing, and we agreed. That is the most critical part of the process. It is just small things like making sure not to touch the inside of the suit with a dirty glove and making sure they are washing their hands with chlorine during every step of what is about a 15-step process. And being very rigorous and methodical about it — even though they were hot, tired, sweaty and dehydrated. That was the most challenging and the most repeated process. It was important to them.”

Using dummy patients for drilling care procedures, in one exercise the trainees had to draw lab specimens from a suspect Ebola patient. Thus, they reviewed how to safely draw the specimen, how to prepare it after drawing, and how do you carefully dispose of waste materials.

“We also had them practice putting a [dead] patient into a body bag and take them to the morgue,” she says. “We really tried to recreate what it would be like in the field.”

A total of 570 responders graduated from 16 separate three-day courses. Some 70% of them were clinical care providers, including 175 nurses and 167 physicians.

“The others were infection control, logistics engineers, mental care providers,” Narra says. “We are very happy to report at this time — though we still have people in the field — that no [CDC trainee] has contracted Ebola.”