From Clinician to Suspect Case: My Experience After a Needle Stick in an Ebola Treatment Unit in Sierra Leone
Am. J. Trop. Med. Hyg.
Perspective Piece From Clinician to Suspect Case: My Experience After a Needle Stick in an Ebola Treatment Unit in Sierra Leone
Lewis Rubinson 0 1
0 Trauma Center, University of Maryland School of Medicine , 22 South Greene Street, Baltimore, MD 21210
1 R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, Maryland
While providing clinical care in the confirmed ward of the
Ebola Treatment Unit (ETU) at the Kenema Government
Hospital (KGH) in Kenema, Sierra Leone, I accidentally stuck
an 18-gauge hollow-bore needle deep into my left thumb.
I could immediately feel some blood oozing under my gloves,
and I squeezed the area of penetration to try to promote
additional bleeding. I rinsed the outside of my gloves with the only
available option0.5% bleach. In an ETU, one cannot simply
remove ones gloves and clean ones hands with soap and water
as one would with a needle stick in other clinical environments.
After the momentary shock and embarrassment subsided,
I notified my clinical partner about what transpired and then
called by radio to have an urgent egress from the ETU.
When I arrived in the personal protective equipment (PPE)
doffing area, Dario Gramuglia, chief of logistics for the World
Health Organization (WHO) at Kenema, maintained full
discipline, and we adhered to the stringent protocol of proper PPE
removal without deviation; in all honesty, I was quite anxious to
examine the needle stick and clean it properly as soon as
possible. When my inner glove was removed, I had blood on my
thumb and thenar eminence. I now was able to confirm that it
was a fairly deep penetration. I first cleaned the wound with
water and had trouble finding soap, because 0.05% bleach was
frequently used for handwashing. Ultimately, I had to make do
with 2% chlorhexidine gluconate swabs to clean the wound.
As I walked up the hill from the doffing station toward the
WHO office, I now had time to begin contemplating what my
risks were of exposure to Ebola virus disease (EVD) and other
blood-borne pathogens. The needle had been stuck in the side
of a plastic intravenous (IV) bottle, a practice some local
nursing staff used to extract crystalloid fluid into syringes to create
flushes. Usually, clean needles were used for such practices, but
the IV for this particular patient had been started at a different
isolation unit before her arrival in Kenema; therefore, the
needles history was unknown, meaning it was uncertain
whether the needle had been used to draw blood from any
patient. Still, as I considered the risk from the needle itself then
and over the following days, I always considered it to be fairly
low. The real risk in my mind, which was confirmed by other
consultants, was whether the needle carried infectious
materials from the outside of my glove into my thumb. Before the
needle stick, I had been assisting a confused person with EVD
to return to the confirmed ward, and then shortly afterward,
I was examining and providing parenteral crystalloid therapy
to several severely ill persons with EVD. My gloves did not
have visible blood on the outside before the needle stick,
because if so, I would have disinfected with 0.5% bleach
whenever such a circumstance was noted. Had there been blood on
my glove, I would have been fairly concerned, but I also would
have been partially reassured; in a past investigation, blood on
a healthcare workers glove only yielded Ebola RNA, and
infectious virus could not be cultured.1 Still, those data were
limited. This event would be considered a high-risk exposure.2
The public health definition of high-risk exposure does not
necessarily equate with high probability of sequelae. As I
digested the event, I believed that my risk of becoming ill with
EVD was low but not zero. Nevertheless, it was much more
likely I would never get ill. Because I met the definition for a
high-risk exposure, I was to be medically evacuated from Sierra
Leone back to the United States.
Hundreds of healthcare workers have become ill with EVD
during the 2014 West African outbreak.3 Most of these people
did not realize that they were exposed until they became ill.
I found myself in a different situation. Statistically speaking, it
was unlikely that I would become ill with EVD, but I had a
specific exposure, which increased my risk above the everyday
risk of working in the ETU. I now just had to wait for the
future to find out what would be the consequence of the needle
stick. It was also very hard for me to reconcile that I was not ill
and likely never to be ill, but I was to be assisted with
tremendous resources to get me back home. I am extremely grateful
for all of those who made that happen. At the same time, many
West Africans were actually ill or dying with EVD, and most
were unable to get anything beyond very basic healthcare. This
truth would continue to plague me throughout my experience.
We frequently witnessed as many as half a dozen or more
persons with EVD at a time transported for hours in makeshift
ambulances in sweltering heat without water and brought to
KGH, a referral treatment unit. When they arrived dehydrated
and prostrate, even the most basic acute care functions, such as
provision of adequate levels of hydration and use of clinical
laboratories to guide rehydration, remained elusive. Many died
on the floor or soiled mattresses without access to basic
comforts, such as pillows or blankets. Many died alone. Together
with our Sierra Leonean colleagues, we tried system fixes, but
they consistently seemed to be a bridge too far.
I had to hastily leave KGH to get to past the EVD control
checkpoints and be assured that I would be in Freetown when
the aeromedical evacuation plane arrived. In retrospect, this
was one of the hardest emotional burdens from the experience.
There was no planned transition from the intense work and
bearing witness of tragedy in Kenema to all of a sudden being
en route back to the United States. My colleagues and I had
been working to support the changeover of the KGH to a small
isolation unit, and this switch had been nearly completed, but
not fully, at the time of my needle stick. I left believing I had
not successfully completed the mission.
At the time of my needle stick, there were two post-exposure
prophylaxis (PEP) options: a live attenuated virus vaccine or a
small interfering RNA therapeutic.4 Experience in humans for
both product was extremely limited. I figured that my risk of
EVD was low, but I wanted to make it as close to zero as
possible. It is also worth noting the context of my decision. At
the time, only three persons with EVD had been treated in
the United States, and one had been critically ill. Several
healthcare workers who had been evacuated to Europe had
died. Although many of us at the time believed that the
mortality rate with early full-resource care, such as is available in
specialized centers in the United States, would be considerably
lower, in September of 2014, that still was yet to be shown.
Hence, if I did get ill, there was no telling how I would fare. I,
therefore, chose to enroll in one of the PEP studies. I received
an investigational PEP intervention flown from a study site in
the United States within minutes of stepping on the plane that
would fly me back to the United States; amazingly, this was
only 43 hours after my exposure.
En route to the United States was the first time that I had
insight into the fear and politics of EVD that would engulf the
United States during the next weeks. While refueling in the
Azores, the US Air Force leadership on site made it very clear
that we were not to open the door to the Gulfstream. I was
approximately 50 hours from exposure and asymptomatic: not
a risk to anyone, but someone who was feared. We then
landed at a small airport in Maryland, and a news crew was
trying to get footage. There, of course, was no story to tell.
The real story was the tragedy unfolding in West Africa.
I was transported to the Biocontainment Unit of the
National Institutes of Health (NIH). When I arrived, I was
febrile, with escalating rigors and chills. A terrible headache
with photophobia soon ensued, and I had significant myalgia.
I was fairly sure that my symptoms were consistent with the
PEP intervention; however, my anxiety started to increase as
I lay in bed freezing under a multitude of blankets. After
caring for hundreds of persons with EVD, I knew that my
symptoms were consistent with early EVD. I reassured myself
that my condition was more likely to be explained by the PEP.
This belief was reinforced by my conversations with
international experts who happen to be friends as well.
The staff at the NIH was well-trained, very caring, and
professional. Still, I was going through this alone. My 6-year-old
daughter was still under the impression that I was in Africa. I
held the purpose of my trip to Africa from her, because how do
you explain EVD to a child without generating enormous
anxiety in her? Now, I was back in the United States and at
risk. I missed her tremendously, but no one could visit me, and
of course, I did not want to put her at risk either physically or
emotionally. Also, if my name got released and with the fear
and lack of scientific-derived actions in the United States, I was
worried she would be shunned by some people who have
children at her school. I, therefore, kept my isolation and illness a
secret from many friends and colleagues. This was an
important decision, but at the same time, it left me isolated from
many who I care about.
Severe nausea and copious diarrhea fortunately never
occurred, and several days after arriving at the NIH, my early
symptoms improved. It became increasingly clear that my
initial symptoms were a response to the PEP and did not
represent early EVD. I felt relieved. All I wanted to do now
was go home. Instead, I remained in quarantine at the NIH
for multiple days. When I transitioned to home quarantine,
science clearly was not informing the restrictions to which
I had to adhere. I was fully asymptomatic, but I was not
allowed to leave my house at all, including not being able to
walk my dog off my property. I, of course, never would want
to harm anyone, but the restrictions seemed out of proportion
to any risk. I realize the public health agency did not want to
have to investigate possible contacts if I did become ill with
EVD. It is worth noting that the contact-tracing investigations
from the three cases in Dallas as well as the one case in New
York City have never identified a subsequent case. Public
health agencies are supposed to be the scientific defenders to
ensure that politics do not cause knee-jerk reactions to
outbreaks. In honesty, these organizations are led by political
appointees, and ultimately, science has, on occasion, been
overrun by fear and political posturing.
When my symptoms abated, I retransitioned back to
clinician from suspect case. I have engaged in escalating
preparations for sporadic cases in the United States, activities that
have been fraught with many challenges. Outside of the
specialized biocontainment units, US hospitals are largely
inexperienced with EVD, and many preparedness decisions have
been based on fear or dogma rather than scientific truth or
common sense. I hope that we start getting it right so that
there will be no additional clinicians in the United States
who have to face being suspect or confirmed cases.
Was the aeromedical evacuation, PEP, and overall resource
expenditure overkill for the risk? I remain ambivalent. The risk
was real, but it was far from a foregone conclusion that I would
develop EVD. If the healthcare infrastructure was more
functional in Sierra Leone, I could have undergone evaluation
and possible PEP in that country. I am glad that tremendous
resources are available for persons who may contract EVD. I
just wish that they were available to all and not just the handful
of expatriate responders.
Acknowledgments: The American Society of Tropical Medicine and
Hygiene (ASTMH) assisted with publication expenses.
This is an open-access article distributed under the terms of the
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