The NYC Health + Hospitals Special Pathogen Program defines special pathogens as those that:
- Are associated with high morbidity and/or mortality.
- Have a high likelihood of secondary cases (person-to-person spread).
- Lack an effective vaccine, prophylaxis, or treatment.
- Might prompt the use of a biocontainment unit due to clinical or public health concerns.
Special pathogens, or high-consequence infectious diseases, pose a significant risk to healthcare personnel and require specific healthcare facility processes to ensure early identification and isolation of infected patients and employ effective infection control practices to prevent disease transmission while the patient is further evaluated.
In 2018, the U.S. Centers for Disease Control and Prevention (CDC) developed a strategy for hospitals and healthcare facilities to determine what is needed to provide different levels of care for patients being assessed and treated for Ebola virus disease (EVD). However, this strategy has been a guideline for other special pathogens preparedness. While this tier system defines what resources and capabilities an institution must have to identify, assess, or treat special pathogens, three main capabilities are consistent between all tiers:
- Ensure staff are appropriately trained and have documented competency in safe PPE practices.
- Have systems in place to manage waste disposal, cleaning, and disinfection.
- Adhere to infection control protocols to prevent further infections.
The proper storage, use, and disposal of personal protective equipment (PPE) is paramount to effective special pathogen preparedness in all settings, and clearly written protocols adapted to the facility and community should be in place regardless of where the care is taking place.
PPE should be selected based on how a specific pathogen can be transmitted.
| Type of Precautions | PPE |
|---|
| Standard | Gloves, gown, simple mask, goggles or face shield (exact ensemble determined by the type of clinical interaction with the patient and patient signs and symptoms). |
| Contact | Fluid-resistant gown, gloves. |
| Droplet | Simple mask, eye protection (not required but recommended by most sources). |
| Airborne | Fit-tested N95 or equivalent/higher respirator or powered air-purifying respirator (PAPR). |
Other factors that influence PPE selection:
- Anticipated exposure (e.g., aerosol-generating procedures, splashes, large volumes of body fluids).
- Durability and appropriateness for the task.
- Fit on individual body types and ability to move.
It is essential to keep in mind that special pathogens often require a combination of precautions; for example, SARS-CoV-2 requires a combination of airborne and contact precautions plus eye protection. It is generally assumed that simplicity in PPE is best for frontline providers during the initial identification and screening phase, which may require less hands-on time with the patient and limited or distanced contact. NYC Health + Hospitals proposes that following the initial triage assessment, the clinical and infectious disease/infection prevention and control staff should discuss any necessary changes to the basic PPE ensemble. Overall, the facility should adopt PPE practices and protocols used during the initial screening and identification phase that align with their needs while keeping in mind the increased risks accompanying higher levels of PPE, such as heat stress, impaired mobility, and unnecessary cost/waste.
Storage and Accessibility
PPE should ideally be packaged in kits or a cart, well-labeled, and ready for use at all times. Designated staff should conduct a regular inventory of all stored PPE and ensure areas are well stocked.
Kits should contain the example ensembles below or an ensemble agreed upon by institutional infection control and be stored in areas that are easily accessible (i.e., in unlocked areas or areas that are badge-accessible to all healthcare personnel).
Ideally, the PPE ensembles should be stored in containers/carts directly outside of all patient rooms or patient care areas. However, if space is limited, larger PPE items (e.g., PAPR with head-shroud) can be stored in equipment or storage rooms on the floor. A list with clear instructions on where to find these PPE and how to properly don and doff PPE should be attached to all containers and carts outside of patient rooms or patient care areas.
Sample PPE Use Protocol When a Patient with Suspected Special Pathogen is Identified
TRIAGE
Patient
- Ask to wear a simple mask (i.e., flexible surgical mask/facemask) and perform hand hygiene.
Once a patient has been isolated, clinical staff in collaboration with infection control professional should confer and decide on a PPE ensemble. The ensemble will be determined based on the suspected disease and the clinical status of the patient. Travel, exposure history, and any additional epidemiological factors should be used to determine the suspected infection until confirmatory testing can take place.
EXAMPLE SCREENING PPE
The PPE ensembles below were written for viral hemorrhagic fever (VHF), however, if a respiratory pathogen is suspected (e.g., avian influenza, SARS, MERS), then an N95 would be required in place of a surgical mask.
If the patient is a person under investigation (PUI) and clinically stable and does not have bleeding, vomiting, or diarrhea:
- Single-use, fluid-resistant gown OR coverall extending to at least mid-calf, preferably a coverall without an integrated hood
- 2 pairs of single-use gloves with extended cuffs
- Single-use ASTM Level 2 surgical facemask
- Fit-tested N95 if a suspected respiratory pathogen
- Single-use full-face shield
- Hair cover and booties optional
If the patient is confirmed to have a viral hemorrhagic fever (VHF) infection or is clinically unstable or has bleeding, vomiting, or diarrhea:
- Single-use, fluid-resistant gown OR coverall extending to at least mid-calf, preferably a coverall without an integrated hood
- 2 pairs of single-use gloves with extended cuffs
- PAPR with full-face covering and head-shroud OR NIOSH-approved particulate respirator equipped with N95 filters or higher in combination with a single-use surgical hood extending to the shoulders and a full-face shield
- Single-use boot covers extending to at least mid-calf
- Single-use apron covering the torso to mid-calf should be worn over the gown or coveralls
Proper PPE donning and doffing techniques are also important in effective infection control and, in the case of special pathogens, should be monitored in real time by properly trained staff. The CDC offers guidance on these techniques, and exercises and drills can be found on institutional websites such as the University of Texas Medical Branch, National Emerging Special Pathogens Training and Education Center (NETEC), Minnesota Department of Health, and Northwell Health.
Alexandra McKenna Lewis is a 4th-year medical student at the University of Texas Medical Branch John Sealy School of Medicine.
Resources:
https://www.utmb.edu/spectre/education-resources/resources
https://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html
https://netec.org/education-training/
https://hhinternet.blob.core.windows.net/uploads/2019/07/NYCHH-Frontline-Hospital-Planning-Guide.pdf
https://www.cdc.gov/vhf/ebola/pdf/preparing-hospitals-ebola-P.pdf
https://www.northwell.edu/sites/northwell.edu/files/d7/ebola_preparedness_manual_20141208_1200.pdf
https://www.health.state.mn.us/diseases/hcid/exercises.html