Tuberculosis, HAZMAT Suits, and Tons of Confusion

Most hospital infection prevention and control programs have a handful of stories regarding an incident involving an infectious disease that resulted in a lot of hysteria and not a lot of critical thinking. As an infection preventionist in both adult and pediatric acute care, I’ve seen health care workers brazenly walk into the room of a patient who is under isolation precautions for horribly resistant infections like CRE (Carbapenem-resistant Enterobacteriaceae) without wearing 1 piece of personal protective equipment (PPE); however, they will then wear every scrap of protection they can find (including a coverall suit, shoe covers, etc) when caring for a patient with bed bugs. Threat perception and understanding is a serious issue when it comes to infectious diseases.

The latest example of this occurred at the prestigious Johns Hopkins Hospital in Baltimore, Maryland. Last Thursday afternoon, 2 buildings were evacuated and employees within a certain area were isolated and medically-evaluated because of a potential infectious-disease related incident. HAZMAT suits were involved and of course, a lot of press coverage.

So what happened? Perhaps a rule-out Ebola patient or a patient with measles?

In fact, what caused the alarm was potential exposure to Mycobacterium tuberculosis. An employee inadvertently dropped a test tube containing a frozen sample of the bacteria on an internal bridge between 2 oncology research buildings and although the lid came off, the frozen sample stayed put. This left many of my infectious disease colleagues a bit confounded. Why the evacuation? This incident has drawn attention to what many of us infection prevention already know: Despite health care worker education on tuberculosis and blood-borne pathogens, which is required in new employee orientations, when faced with the airborne transmission associated with infectious patients, people tend to throw logic out the window and induce worry.

The dropping of a sample tube can be worrisome and perhaps we are hypersensitive to such incidents, particularly because of the biosafety breaches that have occurred with more dangerous Select Agents. What is most concerning, though, is that this event induced such a large an overzealous response.

HAZMAT suits are not necessary for tuberculosis and the only PPE needed is a N95 or higher respirator. In fact, the application of HAZMAT suits or Powered Air Purifying Respirators (PAPRs) has the potential to create more confusion and hysteria. Moreover, the dropping of a frozen vile, especially of M tuberculosis, does not translate to an immediate threat. Tuberculosis is an airborne spread organism; however, even health care worker exposures require spending time near someone with the disease who is coughing, sneezing, etc. Aerosolization occurs from those aerosol-generating actions or procedures and dropping a frozen vial is definitely not one of them. In fact, Dr. Landon King, executive vice dean at the Johns Hopkins School of Medicine stated, "[W]e have determined that there is actually no risk, meaning zero risk, to anybody involved. So there is no preventive measure or testing that's required for anyone in the buildings or on the campus as a result of this event."

This incident reveals 2 issues: 1) gaps in infectious disease understanding, and 2) communication failures during potential outbreak response. Johns Hopkins Hospital infection control, emergency preparedness, and laboratory officials are likely reviewing the incident to understand why such a massive response was triggered. My guess would be that the initial messages that went out had limited information and, based on my own experiences, infection prevention and control was probably not consulted until later in the event. Communication is a huge weakness in health care and it goes beyond the bedside, encompassing all partners in the hospital. We know that communication during an emergency is flawed, but the truth is that communication leading up to response is just as critical and just as imperfect. Helping health care workers and hospital employees understand the infectious disease risks of their jobs and who to contact if they have concerns is one of the hardest aspects of infection control and this event shines a glaring spotlight on these issues.

Tuberculosis is a real hazard for health care workers in many cases, such as when a patient walks into the emergency department with a prolonged cough, night sweats, and weight loss. A frozen vial that fell off the transport cart is not one of these hazards. Realistically, with nearly one-third of the world’s population infected with tuberculosis, going to a mall or airport poses a significantly larger risk of infection than a frozen sample being dropped. As more information is released, it will be interesting to see what triggered this response and what failures occurred. Ultimately, although the response was larger than necessary, it represents a good learning lesson for us all in terms of how health care partners respond to and work with each other during infectious disease events, whether they are perceived or real.