#PPE for preventing highly #infectious #diseases due to #exposure to contaminated #body #fluids in #healthcare #staff (Cochrane Database Syst Rev., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Cochrane Database Syst Rev. 2019 Jul 1;7:CD011621. doi: 10.1002/14651858.CD011621.pub3. [Epub ahead of print]

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff.

Verbeek JH1, Rajamaki B, Ijaz S, Tikka C, Ruotsalainen JH, Edmond MB, Sauni R, Kilinc Balci FS.

Author information: 1 Cochrane Work Review Group, University of Eastern Finland, Kuopio, Finland, 70201.




In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients’ contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.


To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols.


We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.


We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes.


Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results.


We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.

Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.

Evidence for all outcomes is based on single studies and is very low quality.

Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).

Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).

The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).

Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.

Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.

Different methods of donning and doffing procedures.

Double gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).

Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).

Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).

Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).

Different types of training.

The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).

A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.

Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.

There were no studies on effects of training in the long term or on resource use.

The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.


We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.

PMID: 31259389 DOI: 10.1002/14651858.CD011621.pub3

Keywords: PPE; HCWs; Infectious Diseases.



#Outbreak #response as an essential #component of #vaccine #development (Lancet Infect Dis., abstract)

[Source: The Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

Outbreak response as an essential component of vaccine development

Richard Hatchett, MD, Prof Nicole Lurie, MD

Published: June 27, 2019 / DOI: https://doi.org/10.1016/S1473-3099(19)30305-6



The Coalition for Epidemic Preparedness Innovations (CEPI) was created as a result of an emerging global consensus that a coordinated, international, and intergovernmental effort was needed to develop and deploy new vaccines to prevent future epidemics. Although some disease outbreaks can be relatively brief, early outbreak response activities can provide important opportunities to make progress on vaccine development. CEPI has identified six such areas and is prepared to work with other organisations in the global community to combat WHO priority pathogens, including the hypothetical Disease X, by supporting early activities in these areas, even when vaccine candidates are not yet available.

Keywords: Pandemic Preparedness; Vaccines.


#Clinical #management of respiratory syndrome in #patients hospitalized for suspected #MERS #coronavirus #infection in the #Paris area from 2013 to 2016 (BMC Infect Dis., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

BMC Infect Dis. 2018 Jul 16;18(1):331. doi: 10.1186/s12879-018-3223-5.

Clinical management of respiratory syndrome in patients hospitalized for suspected Middle East respiratory syndrome coronavirus infection in the Paris area from 2013 to 2016.

Bleibtreu A1,2,3,4, Jaureguiberry S5, Houhou N6, Boutolleau D7, Guillot H5, Vallois D8, Lucet JC9,10,11, Robert J12,13, Mourvillier B10,11,14, Delemazure J15, Jaspard M5, Lescure FX8,10,11, Rioux C8, Caumes E5, Yazdanapanah Y8,10,11.

Author information: 1 APHP, Hôpital Bichat Claude Bernard, Service des Maladies Infectieuses et Tropicales, Paris Diderot University, Paris, France. alexandre.bleibtreu@aphp.fr. 2 APHP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Service des Maladies Infectieuses et Tropicales, Paris, France. alexandre.bleibtreu@aphp.fr. 3 INSERM, IAME, UMR 1137, Paris, France. alexandre.bleibtreu@aphp.fr. 4 Univ Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, Paris, France. alexandre.bleibtreu@aphp.fr. 5 APHP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Service des Maladies Infectieuses et Tropicales, Paris, France. 6 Virology Department, APHP-Bichat-Claude Bernard Hospital, Paris, France. 7 AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Service de Virologie, et Sorbonne Universités, UPMC Univ Paris 06, CR7, CIMI, INSERM U1135, Paris, France. 8 APHP, Hôpital Bichat Claude Bernard, Service des Maladies Infectieuses et Tropicales, Paris Diderot University, Paris, France. 9 APHP, Infection control unit, Bichat Claude Bernard hospital, Paris Diderot University, Paris, France. 10 INSERM, IAME, UMR 1137, Paris, France. 11 Univ Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, Paris, France. 12 AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Bactériologie-Hygiène Hospitalière, Paris, France. 13 Faculté de Médecine P. & M. Curie Paris-6 – Site Pitié, Centre d’Immunologie et des Maladies Infectieuses (CIMI) – E13, Paris, France. 14 APHP- Hôpital Bichat Claude Bernard, Service de Réanimation médicale et Infectieuse, Paris, France. 15 Service de pneumologie et réanimation Département R3S, AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, unité de Soin de Réadaptation Post Réanimation (SRPR), Paris, France.




Patients with suspected Middle East respiratory syndrome coronavirus (MERS-CoV) infection should be hospitalized in isolation wards to avoid transmission. This suspicion can also lead to medical confusion and inappropriate management of acute respiratory syndrome due to causes other than MERS-CoV.


We studied the characteristics and outcome of patients hospitalized for suspected MERS-CoV infection in the isolation wards of two referral infectious disease departments in the Paris area between January 2013 and December 2016.


Of 93 adult patients (49 male (52.6%), median age 63.4 years) hospitalized, 82 out of 93 adult patients had returned from Saudi Arabia, and 74 of them were pilgrims (Hajj). Chest X-ray findings were abnormal in 72 (77%) patients. The 93 patients were negative for MERS-CoV RT-PCR, and 70 (75.2%) patients had documented infection, 47 (50.5%) viral, 22 (23.6%) bacterial and one Plasmodium falciparum malaria. Microbiological analysis identified Rhinovirus (27.9%), Influenza virus (26.8%), Legionella pneumophila (7.5%), Streptococcus pneumoniae (7.5%), and non-MERS-coronavirus (6.4%). Antibiotics were initiated in 81 (87%) cases, with two antibiotics in 63 patients (67.7%). The median duration of hospitalization and isolation was 3 days (1-33) and 24 h (8-92), respectively. Time of isolation decreased over time (P < 0.01). Two patients (2%) died.


The management of patients with possible MERS-CoV infection requires medical facilities with trained personnel, and rapid access to virological results. Empirical treatment with neuraminidase inhibitors and an association of antibiotics effective against S. pneumoniae and L. pneumophila are the cornerstones of the management of patients hospitalized for suspected MERS-CoV infection.

KEYWORDS: Isolation ward; Legionella; Middle East respiratory syndrome coronavirus (MERS-CoV); Pilgrims; Respiratory tract infection; Saudi Arabia

PMID: 30012113 PMCID: PMC6048819 DOI: 10.1186/s12879-018-3223-5 [Indexed for MEDLINE]  Free PMC Article

Keywords: MERS-CoV; France.


The #effect of #global #change on #mosquito-borne #disease (Lancet Infect Dis., abstract)

[Source: The Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

The effect of global change on mosquito-borne disease

Lydia H V Franklinos, MSc, Prof Kate E Jones, PhD, David W Redding, PhD, Prof Ibrahim Abubakar, PhD

Published: June 18, 2019 / DOI: https://doi.org/10.1016/S1473-3099(19)30161-6



More than 80% of the global population is at risk of a vector-borne disease, with mosquito-borne diseases being the largest contributor to human vector-borne disease burden. Although many global processes, such as land-use and socioeconomic change, are thought to affect mosquito-borne disease dynamics, research to date has strongly focused on the role of climate change. Here, we show, through a review of contemporary modelling studies, that no consensus on how future changes in climatic conditions will impact mosquito-borne diseases exists, possibly due to interacting effects of other global change processes, which are often excluded from analyses. We conclude that research should not focus solely on the role of climate change but instead consider growing evidence for additional factors that modulate disease risk. Furthermore, future research should adopt new technologies, including developments in remote sensing and system dynamics modelling techniques, to enable a better understanding and mitigation of mosquito-borne diseases in a changing world.

Keywords: Arbovirus; Mosquitoes; Emerging Diseases; Climate Change.


Estimating #undetected #Ebola #spillovers (PLoS Negl Trop Dis., abstract)

[Source: PLoS Neglected Tropical Diseases, full page: (LINK). Abstract, edited.]


Estimating undetected Ebola spillovers

Emma E. Glennon , Freya L. Jephcott, Olivier Restif, James L. N. Wood

Published: June 13, 2019 / DOI: https://doi.org/10.1371/journal.pntd.0007428



The preparedness of health systems to detect, treat, and prevent onward transmission of Ebola virus disease (EVD) is central to mitigating future outbreaks. Early detection of outbreaks is critical to timely response, but estimating detection rates is difficult because unreported spillover events and outbreaks do not generate data. Using three independent datasets available on the distributions of secondary infections during EVD outbreaks across West Africa, in a single district (Western Area) of Sierra Leone, and in the city of Conakry, Guinea, we simulated realistic outbreak size distributions and compared them to reported outbreak sizes. These three empirical distributions lead to estimates for the proportion of detected spillover events and small outbreaks of 26% (range 8–40%, based on the full outbreak data), 48% (range 39–62%, based on the Sierra Leone data), and 17% (range 11–24%, based on the Guinea data). We conclude that at least half of all spillover events have failed to be reported since EVD was first recognized. We also estimate the probability of detecting outbreaks of different sizes, which is likely less than 10% for single-case spillover events. Comparing models of the observation process also suggests the probability of detecting an outbreak is not simply the cumulative probability of independently detecting any one individual. Rather, we find that any individual’s probability of detection is highly dependent upon the size of the cluster of cases. These findings highlight the importance of primary health care and local case management to detect and contain undetected early stage outbreaks at source.


Author summary

Emerging infectious diseases are often not investigated in rural Africa unless outbreaks involve a sizeable number of cases. A number of different Ebola virus disease (EVD) outbreaks have been reported in the literature and in surveillance reports since its discovery in 1976. The majority of the reports are of large outbreaks. Given the low reported rate of transmission of Ebola, and the high frequency with which cases infect no one else, one might expect most outbreaks to be very small (<5 people). This is the first study to the authors’ knowledge that quantitatively estimates the number of undetected EVD outbreaks or probabilities of EVD outbreak detection by outbreak size. Although the total amount of evidence in this area is still limited, this study’s main result—that at least half of EVD outbreaks go undetected—is consistent under many different sets of assumptions. This is the most thorough estimation of EVD outbreak detection to date and corroborates the majority of more qualitative work on EVD surveillance, suggesting greater investment in primary health care and local surveillance will be important to detect EVD outbreaks early and consistently.


Citation: Glennon EE, Jephcott FL, Restif O, Wood JLN (2019) Estimating undetected Ebola spillovers. PLoS Negl Trop Dis 13(6): e0007428. https://doi.org/10.1371/journal.pntd.0007428

Editor: Benjamin Althouse, Institute for Disease Modeling, UNITED STATES

Received: October 30, 2018; Accepted: May 1, 2019; Published: June 13, 2019

Copyright: © 2019 Glennon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data and R code used in this analysis are publicly available at https://github.com/eeg31/evd-detection (doi: 10.5281/zenodo.2602105).

Funding: EEG is funded by the Gates-Cambridge Trust (Bill & Melinda Gates Foundation [OPP1144]). OR and JLNW are funded by the ALBORADA Trust. JLNW is funded by the Medical Research Council (MR/P025226/1). The funding bodies had no involvement in the design, writing, or decision to publish of this manuscript.

Competing interests: The authors have declared that no competing interests exist.

Keywords: Infectious Diseases; Emerging Diseases; Ebola.


A rapid #research needs appraisal #methodology to identify evidence #gaps to inform #clinical research #priorities in response to #outbreaks-results from the #Lassa fever pilot (BMC Med., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

BMC Med. 2019 Jun 11;17(1):107. doi: 10.1186/s12916-019-1338-1.

A rapid research needs appraisal methodology to identify evidence gaps to inform clinical research priorities in response to outbreaks-results from the Lassa fever pilot.

Sigfrid L1, Moore C2, Salam AP2,3, Maayan N4, Hamel C5, Garritty C5, Lutje V6, Buckley B7, Soares-Weiser K8, Marshall R9, Clarke M10, Horby P2.

Author information: 1 Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. louise.sigfrid@gmail.com. 2 Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. 3 United Kingdom Public Health Rapid Support Team, London, UK. 4 Cochrane Response, Cochrane, London, UK. 5 Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada. 6 Cochrane Infectious Diseases Group, Liverpool School of Tropical Medicine, Liverpool, UK. 7 Department of Surgery, Philippine General Hospital, National University of the Philippines, Manila, Philippines. 8 Editorial & Methods Department, Cochrane Central Executive, Cochrane, London, UK. 9 , London, UK. 10 Evidence Aid, Centre for Public Health, Queen’s University Belfast, Belfast, UK.




Infectious disease epidemics are a constant threat, and while we can strengthen preparedness in advance, inevitably, we will sometimes be caught unaware by novel outbreaks. To address the challenge of rapidly identifying clinical research priorities in those circumstances, we developed and piloted a protocol for carrying out a systematic, rapid research needs appraisal (RRNA) of existing evidence within 5 days in response to outbreaks globally, with the aim to inform clinical research prioritization.


The protocol was derived from rapid review methodologies and optimized through effective use of pre-defined templates and global time zones. It was piloted using a Lassa fever (LF) outbreak scenario. Databases were searched from 1969 to July 2017. Systematic reviewers based in Canada, the UK, and the Philippines screened and extracted data using a systematic review software. The pilot was evaluated through internal analysis and by comparing the research priorities identified from the data, with those identified by an external LF expert panel.


The RRNA pilot was completed within 5 days. To accommodate the high number of articles identified, data extraction was prioritized by study design and year, and the clinical research prioritization done post-day 5. Of 118 potentially eligible articles, 52 met the data extraction criteria, of which 46 were extracted within the 5-day time frame. The RRNA team identified 19 clinical research priorities; the expert panel independently identified 21, of which 11 priorities overlapped. Each method identified a unique set of priorities, showing that combining both methods for clinical research prioritization is more robust than using either method alone.


This pilot study shows that it is feasible to carry out a systematic RRNA within 5 days in response to a (re-) emerging outbreak to identify gaps in existing evidence, as long as sufficient resources are identified, and reviewers are experienced and trained in advance. Use of an online systematic review software and global time zones effectively optimized resources. Another 3 to 5 days are recommended for review of the extracted data and to formulate clinical research priorities. The RRNA can be used for a “Disease X” scenario and should optimally be combined with an expert panel to ensure breadth and depth of coverage of clinical research priorities.

KEYWORDS: Clinical research priorities; Emerging infectious diseases; Lassa fever; Outbreak response; Rapid research needs appraisal methodology

PMID: 31185979 DOI: 10.1186/s12916-019-1338-1

Keywords: Lassa Fever; Infectious Diseases; Pandemic preparedness.


Developing a #PPE #Selection #Matrix for Preventing Occupational #Exposure to #Ebola Virus (Health Secur., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Health Secur. 2019 Jun 7. doi: 10.1089/hs.2019.0014. [Epub ahead of print]

Developing a Personal Protective Equipment Selection Matrix for Preventing Occupational Exposure to Ebola Virus.

Brown CK1, Matthews DL1, Thomas RJ1, Edens AL1.

Author information: 1 Christopher K. Brown, PhD, MPH, CPH, is Senior Health Scientist, and Denise L. Matthews, MSPH, is Director, both in the Office of Emergency Management and Preparedness; Richard J. Thomas, MD, MPH, is Deputy Director, Office of Occupational Medicine and Nursing; and Amanda L. Edens, MSPH, is Director; all in the Directorate of Technical Support and Emergency Management, Occupational Safety and Health Administration, US Department of Labor, Washington, DC.



In response to the 2014 Ebola outbreak in West Africa and resulting cases in the United States, the Occupational Safety and Health Administration developed a personal protective equipment selection matrix to help employers protect workers from exposure to Ebola virus in the event of additional US cases. Now, the world’s second largest Ebola outbreak on record continues to expand in the Democratic Republic of Congo, where more than 70 Ebola-infected healthcare workers serve as reminders of the importance of robust infection prevention measures in keeping infectious disease responders from becoming victims themselves. Toward facilitating preparedness for cases associated with the ongoing or future outbreaks, this article discusses the matrix of personal protective equipment recommendations. The matrix applies to a variety of job tasks in health care, laboratories, waste handling, janitorial services, travel and transportation, and other sectors where workers may be exposed to the Ebola virus during outbreak events. A discussion of the information sources and decision-making process for developing the matrix forms the basis of the recommendations. The article then emphasizes challenges and considerations for formulating the matrix, including identifying information sources to help characterize occupational exposures, aligning recommendations among stakeholders with varying viewpoints, and balancing worker protections with feasibility concerns. These considerations highlight issues that remain relevant for preparedness efforts ahead of future US cases of Ebola or other emerging infectious diseases.

KEYWORDS: Ebola virus disease; Occupational health; Personal protective equipment; Respiratory protection

PMID: 31173502 DOI: 10.1089/hs.2019.0014

Keywords: Ebola; Infectious Diseases; Biological Hazards; PPE.