You will probably never contract Ebola. The average patient with Ebola only infects just two other people, even in the least developed parts of Africa, making it far less virulent than HIV, mumps, or measles, which spread to 4, 10, and 18 people respectively. But that fact is of little consolation when you consider that multiple health care providers are still getting sick, having contracted the disease despite wearing protective gear.
It’s easy to blame incompetence at moments like this, but the fact of the matter is, our best protective suits aren’t stopping Ebola. And even if some hypothetical Ebola-proof suit did exist, you’d have a heck of a lot of trouble producing it, distributing it, and wearing it.
Ebola measures less than a micron across and spreads through fluids. There can be millions of particles in a single drop of blood, and just a single viral particle entering your bloodstream can cause a fatal infection. Because it’s not an airborne virus, it can’t flow from infected lungs, through the air for miles, into your nose, and infect you via breathing. But as The Centers for Disease Control (CDC) and World Health Organization (WHO) say, it can spread through membranes. If infected blood or mucus lands in someone’s eye, mouth, an open wound, or even just very dry, cracked skin, he or she can contract the disease. Ebola can also live for days or weeks in blood outside of the body (but the risk of catching the virus diminishes as blood dries).
Officials recommendations on protective suits are vague. WHO: “When in close contact (within 1 metre) of patients with [Ebola], health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures).” The CDC revised its standards on October 20th, and has a much longer, but similarly vague, set of guidelines. The organization recommends double gloves (quality unspecified), “waterproof” boots or booties, an n95 mask–which is a pretty standard surgical mask that can block 95% of airborne particles–and that you not expose your skin. The CDC has also published a longer, 20-step procedure medical professionals should follow when they remove protective gear–which, most importantly, is to be sterilized before the doctor or nurse disrobes. Operators sanitize their hands afterward, too. Neither the CDC nor WHO takes a stance on the grade of suit material that should be used to protect against Ebola.
In Africa now, Doctors Without Borders volunteers have been wearing suits produced by Dupont made of either Tyvek or Tychem material. Each is a woven textile, coated in patented industrial goo. (Similar suits are sold by a small handful of competitors.) These suits aren’t seamless footy-pajama-style garments. For the full-skin protection recommended by the CDC, they necessitate boots, gloves, surgical masks, and facial splash guards be added as well. And to seal the seams between a pant and boot or a glove and shirt, doctors will often use duct tape.
Tyvek is relatively cheap at $10 per suit. Tyvek can breathe a bit in the sweltering heat of West Africa, where temperatures regularly range from 80 to over 100 degrees Fahrenheit.
Both the U.S. and the European Union have their own somewhat convoluted grading systems for assessing the permeability of personal protective materials like Tyvek, in which independent labs put the materials through a series of tests and rate their performance. The E.U.’s tests, in particular, sound like strange, gruesome delights: soaking material in fake, red blood that’s been filled with bacteria and spraying an aerosol of viruses at a cloth then checking how many virus particles made it through.
Dupont makes no promise that Tyvek shields wearers from viruses. It’s unranked, falling below the lowest grade, which E.U. standards would call Class 1. (A Class 1 material, sprayed with aerosol mist, allows 10% or more of the contagion through in lab testing.) Its liquid resistance doesn’t fare much better. In just 15 minutes, blood can soak through the material, bringing dangerous pathogens along with it.
Tychem, and its peers, are Class 3 against viral aerosols–stopping all but .001% of viruses trying to make it through. They’re about as cheap as Tyvek. And they can be soaked in blood for more than 75 minutes before contaminants begin to pass.
During the initial Ebola outbreak at Texas Presbyterian, the medical staff members were consulting with Emory University Hospital in Atlanta, which had treated Ebola, and the CDC. They faced suit standards that were “constantly changing,” and as the gravitas of Ebola set in, nurses upgrade from aprons to Tyvek suits with hoods and respirators. The CDC has since said that it’s possible too much gear increased their risk of contraction, as, paradoxically, the CDC’s recommendations for protective garments are designed for the less invasive treatment of Ebola patients in Africa, rather than the riskier, potentially fluid-filled operations that might be attempted in a U.S. hospital. The New York Times has published a superb side-by-side on CDC standards compared with those of the Nebraska Medical Center in Omaha–one of the few U.S. hospitals with a formalized isolation unit that would receive a patient suspected to have Ebola. Nebraska Medical Center in Omaha now deploys Tychem-level suits for doctors treating such patients. They also mandate more serious splash proof gear, like an overhanging neck protector, that doesn’t just cover your skin. It adds another overlapping barrier of protection over the suit’s seams.
But for doctors in the field who are treating patients with Ebola, the highest grades of personal protection aren’t as attractive as they may seem. Because in practice, the safest gear is virtually unwearable.
Dr. John Hardham, PhD, former Medical Director at the Office of the Assistant Secretary of Defense for Nuclear and Chemical and Biological Defense Programs, led the President’s Medical Countermeasure Initiative with the Department of Defense until 2011. He’s also a Navy officer who has been deployed to detect chemical and biological agents–scenarios in which he’d wear suits made of a Tyvek or Tychem-grade material.
“They’re hot. They don’t ventilate well,” he says. “When you’re wearing a suit of Tyvek-type material, that lets nothing in and nothing out–which also means your heat and your sweat get trapped in. You will generally end up with a puddle in your shoes because you’re sweating so much.”
The heat is so bad that it becomes a real operational problem for people wearing the protective suits. Hardham says you can feasibly last about an hour in one of these suits in hotter environments before you need to get out. Doctors in West Africa who are treating Ebola patients work in 45 minute shifts in response to the heat.
But breathability isn’t the only operational hazard that comes from a high-level protective suit, Hardham says. The plastic lenses of shields and goggles you wear over your eyes can warp your vision. Sweat can blur your vision further. And bulky headgear, like ventilators or gas masks that you would use for optimal protection, limit your field of view so much that you have to purposefully look down when you walk, and up to make sure you don’t hit your head through door frames.
Tactility, too, is a problem. You simply can’t feel if your protective, Tychem booties have ripped from the weight of your body pushing them into sharp a sharp rock. Thicker gloves mean that you can’t feel what you’re touching, and a pointed instrument could poke through a suit at any time. “Could some of the needle sticks be associated with that? It’s possible,” Hardham says. “There are [guidelines] on how you’re supposed to recap a needle, but sometimes there’s human error. Instead of one-handed, they go two-handed and stick themselves.”
In a lab setting, protective gear is just one level of defense, as Ebola can be quarantined inside a biosafety cabinet, and a researcher can follow all sorts of safety protocols at his or her own pace. But when Ebola infects a patient, be it in a hospital or medical tent, physical contact is necessary to care properly for the patient, and at that point, the suit is the last barrier of defense. “The fact of the matter is, when you need to intubate [a patient], you need to intubate them,” Hardham says. “You must have direct contact with them.”
So if we could build a better suit for handling Ebola patients, what would it look like? I posed that question to Todd Moncrief, vice president at Lakeland Industries, a manufacturer of the industrial-level personal protective suits being worn by some doctors in Africa.
For one, a better suit would keep the wearer cooler. He pointed out that, like the rest of the “personal protective equipment” industry, Lakeland produces a suit that has a front side made of the company’s highest grade, least breathable materials, intended to shield a doctor the most effectively from blood and liquids, but a backside made of better-breathing, lighter grade material that might make the doctor more comfortable. The implication here is that you’ll almost always be facing Ebola head-on, so you build up your forward shields at the expense of your rear. “The moment someone says they have a breathable back, and it breathes, it means an Ebola virus could potentially [make its way in],” Moncrief says. “Are you safe or not safe?”
Another option would be to introduce some sort of cooling mechanism. “If you think about getting in any material that covers your body completely, no matter where it breathes at that makes it cooler, you’re still talking about something you’d have to put cold air into,” he says. “And that takes more assets and costs a lot of money.” Cool vests, which Lakeland does produce, seem like the simplest solution, he says, but there are obvious logistical difficulties of keeping countless vests in refrigerated containers while distributing them across West Africa.
A better suit would also be easier to remove. Right now, medical staff in Africa hose down their suits with chlorinated water to denature the virus before disrobing to mitigate potential. The CDC is in talks with designers of moon suits, to see if their design, with an easily reached zipper and a large ring attached at the shoulder that can be grasped with gloves, could be incorporated into medical gear.
And a better suit would also be seamless, Moncrief says. Whereas suits today are a hodgepodge of tape-sealed boots, booties, gloves, and masks, made of different materials from a slew of different manufacturers, the ideal Ebola suit might resemble a big pair of footie pajamas with a built-in mask and gloves.
So why doesn’t Moncrief’s company, or any company in the industry, produce such a thing?
“It’s almost like saying, you make the cars, why don’t you make the tires?” Moncrief says. Producing gloves is different from making shirts, and producing them in one seamless piece of gear is another challenge entirely.
And then there’s the money problem. According to Moncrief, the personal protection equipment industry has little incentive to create an Ebola-proof suit because it can’t bank on an Ebola outbreak. Equipment companies generally serve factories, and other places where workers need protection from chemicals. They cater to the very specific needs of industrial hygienists, not to doctors treating the latest pandemic. “We’re all set up to service the industrialized world. We’re all set up to do that day in and day out, with tight supply chains and margins,” Moncrief says.
Tight supply chains also means that if a worldwide epidemic struck, these companies would have trouble manufacturing enough gear. Personal protective suits only have a shelf life of five to 10 years before they’re no longer reliable, so you couldn’t just stockpile a large cache. “None of us think this thing is going to spread out of control,” Moncrief says, “but the reality of it is, no matter how many manufacturers are doing it today, you can’t put enough garments on the ground for the number of people you’d need in a matter of months.”
But don’t let a lack of protective suits scare you. Even Moncrief admits, we’d probably run out of our supply of trained doctors and nurses first anyway.