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Sultana Peffley

Nicole Brooks

Marilyn Galindo, MD

Vincent Valentine, MD
University of Texas Medical Branch
Galveston, TX, USA

Flush. Gurgle. Chomp. Pounding. Gulp. Type. Clack. Inhale. Exhale. These are the sounds we make every day, the interactions each of us has with our environment and with each other. Each action is a potential opportunity for transmission of our distant relatives. No, not your great aunt twice removed - the organisms with which we share our environment. We have special names for them: E. coli, tuberculosis, A. lubricoides, C. difficile, and Ebola. Some of these relationships are symbiotic, others are commensal, and still others are parasitic. With such diverse invaders, how do Homo sapiens protect themselves from the parasitic organisms that threaten their existence?

Splish Splash! We've all heard the importance of hand washing and covering our coughs/sneezes in disease prevention, but let's review the steps in a little more detail. It is necessary to wash hands: before entering and upon exiting a patient's room, before and after touching the patient, between patient contacts, before putting on and after taking off gloves, after any contact with body fluids, and when visibly soiled. In short, "wash in and wash out" or "gel in and gel out" is a good criterion to consistently uphold. Steps of hand hygiene:

  1. Use warm water to wet the hands.
  2. Apply antiseptic soap (containing chlorhexidine).
  3. Rub hands together and apply to all surfaces of the hands.
  4. Wash hands for at least 15 seconds.
  5. Rinse, avoid splashing.
  6. Keep hands pointed towards the sink so that runoff will go into the sink and not down the forearms to the elbows.
  7. Dry well with paper towels and use the paper towels to turn off the faucet. Discard paper towels.

Handwashing is the most cost effective and efficient manner to decrease the spread of ailments. Another such method is the "dracula cough/sneeze" in which the sneezer covers their face with their inner elbow and expels the forceful droplets into their shoulder, behaving as though they are enrobed in Dracula's cape. Bet you hadn't realized that Count Dracula was both charming and hygienic! However, the cape has in fact been long held as a garment of protection, be it from the cold weather, rain, soil and now germs. The scientist's modern day cape is commonly known as the 'white coat', which is universally worn to protect its wearer's clothes from the onslaught found in particles, droplets, and air of the clinical environment. But a charming white cape and clean hands aren't the only things we need to fight against parasitic organisms - we've learned how best to adapt to each organism's infectious pattern [1].

Bordetella pertussis, Neisseria meningitidis, and influenza are spread through droplets larger than 5 microns in diameter. Achoo! An organism just caught a wave onto your face. Droplets are propelled shorter distances (<3 feet) and therefore droplet precautions are less stringent than those for organisms indiscernible in ambient air. We don surgical masks upon entering patient rooms while patients wear the same during transportation [1]. We have also developed vaccines that can defend us from these organisms pre-emptively. Vaccinations prime our immune system to defend and attack the recognized intruder. Despite these efforts, 17,325 cases of pertussis have been reported to the CDC in 2014 thus far. The CDC reports this as a 30% increase from the previous year [3]. At this rate, Whooping cough will cease being a tale of our grandparents and become a current event instead.

Clostridium difficile (C. diff), norovirus, and Methicillin resistant Staphylococcus aureus (MRSA) are disseminated through bodily fluids- uncontrolled secretions, uncovered wounds, and diarrhea. Splat! Slap! Organisms ride these exit floods or excreta and generate the same storm at their next stop. When a patient is suffering from uncontrollable release of bodily fluids rife with infectious agents, then we must exercise strict contact precautions. This includes wearing gloves, a gown, and washing hands prior to entering and upon exiting a patient's room. It is especially important to use antimicrobial soap to remove toxins/spores produced by C. diff and others of the like [1]. C difficile is the culprit in 337,000 infections and 14,000 deaths every year in the United States, imagine the worldwide impact [4]. Norovirus is notorious among cruise ships, causing illness frequently; MRSA is dreaded by most healthcare workers because it actively develops resistance to even our newest biocides.

In the news, we are bombarded with images of people in HAZMAT suits treating people infected with Ebola. Whiz! It's scary. Voomp! Ebola is highly contagious, and its mortality rate can be as high as 90%. Neither a cure nor a vaccine has been well established. However, the spread of Ebola can be prevented with contact precautions and decontamination with bleach or alcohol. Ebola is transmitted through direct contact of bodily fluids (blood, saliva, urine, semen, etc.) and contact with contaminated surfaces like bedding and linens used by the infected person. Crinkle. Ebola is not airborne. Patients are not contagious until they start to have symptoms, which include fever, chills, bleeding, vomiting, and diarrhea. Necessary viral load to contract the pathogen has yet to be determined. Furthermore, some individuals who have had exposure to the virus never experience clinical symptoms and are never aware of their body's infection.

The World Health Organization (WHO) recommends the strict use of personal protection equipment (PPE) that includes face protection, a non-sterile long-sleeved gown, and gloves. PPE equipment acts as a barrier that keeps Ebola virus out. Hazmat suits were designed for toxic environments in which the wearer requires a combination of airborne, droplet, and contact precautions. From what you now know about Ebola virus, you can easily understand why HAZMAT suits are not required to be worn by healthcare providers when caring for patients suspected of Ebola infection. Regardless, careful precautions should be taken when removing any PPE:

  1. First remove gloves.
  2. Remove eyewear.
  3. Remove gown by pulling it away from you.
  4. Remove mask.

Contact tracing is also a vital part of preventing the spread of Ebola in the community. Contact tracing involves informing individuals who have been potentially exposed of the worrisome symptoms to be aware of. If the contact displays the symptoms, they are encouraged to immediately seek care and are placed in isolation; then the process repeats using their potential contact exposures. If they do not display symptoms within the 21-day incubation period, nothing occurs. Therefore, all contacts with potential for exposure are not unnecessarily isolated and monitored for 21 days [5].

13,703- the number of recorded Ebola cases in the world; 4,922 - the number of deaths caused by Ebola during this outbreak as of October 27th [6]. Influenza/pneumonia killed approximately 50,000 people in the U.S. in 2011. Why then do people neglect to receive their annual influenza vaccine? Heart disease is the number 1 killer in the US - around 500,000 people die in the US from heart disease every year. Heart disease kills 10 times more people than any infectious disease [7]. There are more mortalities associated with operating motor vehicles, something we all do multiple times a day: 3,328 people were killed in events linked to distracted driving in 2012 [8] and 76, 309 individuals were involved in fatal motor vehicle accidents in 2009 [9].

Ebola is serious, it is the unknown, and adequate attention along with the appropriate precautions must be observed. The aforementioned diseases were once cut from the same loin as Ebola - each condition was once unfamiliar and novel, and each was given ample attention. The purpose of this article is not to belittle Ebola, but to remind us of epidemics that are being overlooked. It is imperative we observe the standard precautions, not only for the sensational diseases but also for the known intruders. Lest the increased time spent disregarding them results in such a built up capacitance that our internal capacitors can no longer contain their bio destructivity, τ= RC, after all. And with that, here is a quote by Samuel Johnson, the renowned English author, "Health is merely the slowest possible rate at which one can die." So, let's all die as slowly as possible and observe the following definition of universal precautions: If it's wet and it's not yours, don't touch it! ■

Disclosure Statement:The authors have no conflicts of interest to disclose.


  1. Sanderson, Ellen. Isolation Precautions. N.p.: U of Texas Medical Branch, n.d. Print. Healthcare Epidemiology
  2. Lawn SD, Zumla AI. Tuberculosis. Lancet. 2011;378(9785):57-72.
  3. "Pertussis Outbreak Trends." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 27 Aug. 2014. Web. 26 Oct. 2014.
  4. CDC. Investigating Clostridium Difficile Infections Across the U.S. (n.d.): n. pag. Web.
  5. "Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola." World Health Organization, n.d. Web.
  6. "2014 Ebola Outbreak in West Africa." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 25 Oct. 2014. Web. 26 Oct. 2014.
  7. Statistics, National Center For. National Vital Statistics Reports, Volume 61, Number 6, 10/10/2012 (n.d.): n. pag. Web.
  8. "Distracted Driving." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 10 Oct. 2014. Web. 26 Oct. 2014.
  9. Table 1105. Fatal Motor Vehicle Accidents-National Summary: 1990 to 2009 (n.d.): n. pag. Web.

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