Friday, September 19, 2014


Last month the Department of Defense (DOD) issued a new version of "Directive 2310.01E."  Hmm...sounds ominous.  It is.  This directive is one of the central documents outlining the policies and rules applicable to the DoD Detainee Program (think Guantánamo and, at least for a few more months, Bagram).  What is this all about anyway, this new updated version?  Gabor Rona writing at Just Security notes at some length,

We all know that after 9/11, the Bush administration tried to wiggle out of its Geneva Conventions obligations in order to shield its arbitrary and abusive detention operations from the rule of both domestic and international law. The device it used was the invention of a new name and status for detainees, eschewing the established categories of “civilian” or “combatant” that are recognized in the law of armed conflict. The new name was “unlawful enemy combatant.” The term was alleged to have precedent in the WW II era US Supreme Court Quirin case, which spoke of “unlawful combatants.” However, what the purveyors of the term didn’t note is the simple fact that the Quirin Court was not creating or recognizing any such new status under the law.  In fact, the defendants in that case were garden variety “lawful” combatants – members of the German military. But they arrived on US shores masquerading as civilians to commit acts of sabatoge. It was their conduct under civilian cover that was unlawful, indeed, the war crime known as perfidy. Their status was not the issue.
The Obama lawyers were more sophisticated. They recognized the flaw in the “unlawful combatant” concept and replaced it with the less inaccurate “unprivileged enemy belligerent.”  We can’t, however, simply say the term is “accurate” because it is construed so broadly as to sweep up individuals who are neither members of enemy armed forces nor civilians directly participating in hostilities in armed conflict against the United States. The fact is, the term, as spplied, includes individuals who the law of armed conflict considers civilians.
The combatant/civilian distinction is important in both targeting and detention, but in different ways that I can’t exhaustively detail here. For now, the crucial point is that the Directive includes giving “substantial support” to the enemy as an example of what makes one an unprivileged belligerent. But like the crime of “material support” to terrorism, “substantial support” doesn’t necessarily make you targetable, and if you’re a civilian, it doesn’t make you a combatant, but it may make you subject to detention and prosecution.
So when the new Directive defines an “unprivileged belligerent” to include anyone who provides “substantial support” to the enemy, it asserts arguably valid grounds for detention but uses those grounds to justify a label that screams “we can also kill you if we decline to detain you.” Now it’s one thing to say “if you can kill ‘em, you can detain ‘em” but the new Directive comes dangerously close to saying “if you can detain ‘em, you can kill ‘em.”
Back to why this change and why now. One benign theory is that it’s simply a case of bad drafting, with no intent to change the landscape of targetability. The flip side of the coin is, of course, that it’s a stealth effort to bootstrap an expanded concept of targetability in anticipation of an ever-widening war against ever-increasingly amorphous threats. That would be bad law and bad policy. As so many military and civilian strategists have noted, we can’t kill (or for that matter, detain) our way out of the terrorism problem and attempting to do so simply plays into the hands of those who try to draw us in to “forever war” by so publicly and viciously murdering our citizens.

Why now for the new directive, you may ask?

Personally, I have no idea.  Some see sinister motives, some don't.  What do I know?

Well, since I don't, in fact, know much, for Jails and Cops Friday, I am posting the following from Invictus.  If you are interested in such things, and I know some of you are, here goes.... 

By the way, isn't it amazing how torture becomes something boring?

New DoD Directive on Detainees Allows Sleep and Sensory Deprivation, Biometric IDs

On August 19, 2014, the Department of Defense released an updated version of its Directive 2310.01E on the "DoD Detainee Program." It supercedes the previous version, dated September 5, 2006.

Earlier this month, Steve Vladek at the Just Security blog, pondered why the government chose this particular time to release the new, updated directive. While his observations are important and worth considering, much of importance is omitted from his brief analysis.

In my analysis -- besides the potential legalities explored by Vladek, which impact the definition of what the government considers the definition of an “unprivileged belligerent" (like the detainees at Guantanamo), and access of legal counsel to these prisoners -- the new directive propounds a number of new rules that summarize the Obama administration's detainee regime, particularly as it relates to Guantanamo.

The new directive expands upon what "humane treatment" means for those caught in its "detainee program." It also adds an item about the collection of biometric identification information (BII). Such information "will be collected from all detainees in accordance with DoDD 8521.01E." It also includes a statement of how long a detainee can be held, which appears to operationalize Obama's policy of indefinite detention of detainees. Finally, the directive greatly expands on the issue of who can be held, how charges can be brought against detainees, and what procedures are necessary for a detainee's release. (This article will not cover the very last item.)

A long analysis of all the changes would take many pages, and I am going to concentrate on those of immediate relevance to me. I would hope that Vladek, or other attorneys or human rights organizations will pursue the relevant legalities in the sections on how detainees are held and released.

No protection from sleep deprivation

In the 2006 version of the directive, the issue of humane treatment of detainees is summarized in a sentence: "All detainees shall be treated humanely and in accordance with U.S. law, the law of war, and applicable U.S. policy."

In the new 2014 version, the section on "humane treatment" expands to nearly 250 words. To understand the significance of what is written here, one must realize that the procedures "established for the treatment of persons consistent with this directive" includes U.S. Army Field Manual 2-22.3, “Human Intelligence Collector Operations" (AFM).

As I have written at various times, numerous human rightsmedical, and legal groups have identified the AFM, and in particular its Appendix M on a "restricted Separation technique," to include methods of interrogation and conditions of confinement that amount to torture and/or cruel, inhumane and degrading treatment of prisoners. In particular, it allows use of isolation, sleep deprivation, use of drugs, sensory deprivation, environmental manipulation, and techniques that induce fear and degrading verbal treatment of prisoners, intending thereby to induce, according to the manual iself, "hopelessness and helplessness" in its victims.

Hence, while the new DoD directive makes some pretty noises about providing detainees with "Adequate food, drinking water, shelter, and clothing"; and while DoD claims detainees will be protected "against threats or acts of violence, including rape, forced prostitution, assault, theft, public curiosity, bodily injury, reprisals, torture, and cruel, inhuman, or degrading treatment or punishment," DoD never mentions any provision of adequate sleep. This is not, in my opinion, a mere oversight.

Sleep deprivation is a key foundational element, along with isolation (solitary confinement), of the torture program to break down individuals used by the CIA and the Department of Defense. The AFM's Appendix M provides specifically that prisoners (of the "unprivileged" sort) can be limited to 4 hours sleep per day for up to 30 days, and even longer. In principle, that can even be done indefinitely.

This sort of sleep deprivation is not as dramatic as the kind advertised in the CIA's "enhanced interrogation" version of torture, but it is debilitating nevertheless. Former DoD interrogator Matthew Alexander wrote in the New York Times, "The [Army Field] manual also allows limiting detainees to just four hours of sleep in 24 hours. Let’s face it: extended captivity with only four hours of sleep a night (consider detainees at Guantánamo Bay who have been held for seven years) does not meet the minimum standard of humane treatment, either in terms of American law or simple human decency."

Alexander added, "And if this weren’t enough, some interrogators feel the manual’s language gives them a loophole that allows them to give a detainee four hours of sleep and then conduct a 20-hour interrogation, after which they can “reset” the clock and begin another 20-hour interrogation followed by four hours of sleep. This is inconsistent with the spirit of the reforms, which was to prevent “monstering” — extended interrogation sessions lasting more than 20 hours."

Alexander was not alone in his analysis. The right to sleep is considered part of "humane treatment" under international law. A 2003 US Southern Command instruction (pdf) to then-Secretary of Defense Donald Rumsfeld, stated sleep deprivation was defined "as keeping a detainee awake for more than 16 hours" (see pgs. 5-6).

It is worth noting that the version of the AFM that preceded the current September 2006 version forbid use of sleep deprivation and stress positions.

The current version of the AFM, used to help define the parameters of treatment in the just released directive, eliminated the prohibitive language concerning sleep deprivation and stress positions. This is not an accident. And additionally, DoD's new directive also contains no prohibition on stress positions.

No protection from non-punitive sensory deprivation

Directive 2310.01E, like Appendix M of the Army Field Manual, does contain a prohibition on the use of sensory deprivation. The problem is in how the government defines "sensory deprivation."

The directive states, detainees "will not be subjected to medical or scientific experiments or to sensory deprivation intended to inflict suffering or serve as punishment."

One must ask, why is there a condition put on the prohibition of sensory deprivation? Sensory deprivation intended to inflict suffering, or as punishment is prohibited, but what about in other matters?

The directive is being opaquely coy here, as sensory deprivation is allowedin a particular procedure in the current Army Field Manual. In the description of the latter's "Field Expedient Separation," goggles or blindfold and earmuffs are put on a detainee for up to 12 hours. Again this is expandable upon official approval.

The AFM warns that care must be taken to protect the blindfolded, earmuffed prisoner from self-injury, and the prisoner must be medically monitored. The AFM doesn't explain why this is necessary, but the reason is that such sensory deprivation is intolerable for some people and can lead to hallucinations and self-injurious behavior. The inclusion of a procedure that so obviously needs medical monitoring should be a red flag that it violates basic humane treatment.

The purpose of the blindfold, goggles and earmuffs (and here, one may recall those pictures of be-goggled and earmuffed and bound detainees taken out of doors at Camp X-ray in the very earliest days at Guantanamo) is not to "inflict suffering." No, according to the AFM itself, it is to "prolong the shock of capture," prevent communication with other detainees, "and foster a feeling of futility." While the prevention of communication with other detainees may have a security factor, the other instances do not.

To that point, the new directive includes a section on the separation or "segregation" of detainees from each other for security and other reasons. It should be noted that such administrative segregation is not what is involved in the Appendix M version of "isolation." The AFM itself makes it clear that solitary confinement or isolation is used as an interrogation technique.

The use of "separation" itself as an interrogation technique should, according to the AFM, "be distinguished from segregation, which refers to removing a detainee from other detainees and their environment for legitimate purposes unrelated to interrogation...." (pg. M-1).

Isolation of prisoners is itself a form of sensory deprivation, in that it provides restricted environmental and social stimulation. (See this classic paper (long PDF) by Stuart Grassian on "The Psychiatric Effects of Solitary Confinement.")

Of course, isolation is something that is also sanctioned by the Army Field Manual, for up to 30 days, with the possibility of indefinite extension. The "humane treatment" section of the new DoD directive provides no protection against such treatment.


Also new to the DoD directive on its detainee program is a section on the collection of biometrics.

Biometric data "will be collected from all detainees... as soon as practicable after their capture by, or transfer to, the custody or control of DoD personnel, and will be included in detainee records. BII collected on detainees who are U.S. citizens or U.S. resident aliens will be conducted in accordance with U.S. law and policy and all applicable DoD regulations."

The use of biometrics deserves its own lengthy analysis. The fact that U.S. citizens or resident aliens may have different legal rights when it comes to such collection than, for instance, the Guantanamo detainees, is a matter worth pursuing.

According to DoD, biometrics is "A measurable biological (anatomical and physiological) and behavioral characteristic that can be used for automated recognition." (italics added)

As a process, biometrics concerns "Automated methods of recognizing an individual based on measurable biological (anatomical and physiological) and behavioral characteristics....

"Biometrics-enabled Intelligence. Intelligence information associated with and or derived from biometrics data that matches a specific person or unknown identity to a place, activity, device, component, or weapon that supports terrorist / insurgent network and related pattern analysis, facilitates high value individual targeting, reveals movement patterns, and confirms claimed identity."

The use of "behavioral characteristics" stretches the definition to something beyond the biological. One source I consulted said such characteristics include "Speaker Recognition, Signature Recognition, Keystroke/Keyboard Dynamics," or any "measurable behavioral trait that is acquired over time and is used to recognize or verify the identity of a person."

According to an oft-cited paper, "An Introduction to Biometric Recognition," types of biometric identification include via DNA, face and ear recognition, gait, retinal scan, odor, voice, and even the way a person signs their name or types upon a keyboard."

The new provisions for biometric collection on detainees comes just weeks before the FBI announced the full operational capability of its own biometric database system.

The possible dangers inherent in use of biometrics is beyond the scope of this article, and tend to involved concerns about privacy and the expanding use of or security of biometric databases. I've included the information here because it is something new in the detainee program, as delineated by DoD. For more discussion of the issues, see this Electronic Frontier Foundation discussion.

Indefinite Detention

In this already long essay on the new DoD Directive, I should note that it includes a brand-new item that seems to speak to the powers of indefinite detention propounded by the Obama administration. The new item states, "Subject to the requirements of the law of war and this directive, POWs and unprivileged belligerents may lawfully be detained until a competent authority determines that the conflict has ended or that active hostilities have ceased, and civilian internees may lawfully be detained until the reasons that necessitated the civilian’s internment no longer exist."

Who will this "competent authority" be? Whatever the answer to that question may be, it is frightening to see in official language the assertion that "civilian internees" can be "lawfully" detained until whatever "reasons necessitated" their internment "no long exist." In the "war on terrorism" we know that will be never. In its bold proclamation of the powers of indefinite detention, the document is profoundly unconstitutional and undemocratic.

In summary, we can see there is a lot more in the new DoD Directive on its Detainee Program than indicated in the Just Security discussion of its release. In particular, the directive makes explicit policies concerning so-called "humane treatment" of detainees that allows for the use of torture or cruel, inhumane, or degrading treatment of prisoners as set down in the current Army Field Manual. It does this despite formal statements of providing prisoners' rights, or following Geneva protocols, by omitting key items from its description of such "humane treatment," by burying actual abuse in references to other documents not specifically quoted in the directive, and by use of dodgy legalistic language that make things appear other than what they are.

If Bush or a Republican were President of the United States, this new DoD directive would have been subject to intense scrutiny and examination by a plethora of commentators and analysts. But because the Obama and the Democrats are in charge of the White House and Senate, a close examination of how Obama has perpetuated Bush and Cheney's torture program is not on the such analysts' political agenda.

The U.S. has become a Torture Nation. Torture is legalistically bound up in main government documents and how the government operates. Figures directly implicated in the planning and execution of torture have high positions in government or other major civil institutions (cf. John Yoo), while those who protest torture or expose it are punished.

[Update: Since writing this article, I discovered that were a few other postings at Just Security concerning the new DoD directive, besides that of Steve Vladek, including one by Gabor Rona, and one by Marty Lederman. These postings appear to be primarily concerned with the language around the definition of "unprivileged belligerents.” None of the other postings are critical of what Lederman called "expanded humane treatment provisions" in the new directive.

Meanwhile, Ryan Vogel, who says he "led the drafting and coordination process for DoDD 2310.01E", published today at Just Security a new article, "A Response on Department of Defense Directive 2310.01E (Detainee Program)."

Vogel writes, "... this new detainee directive is dramatically different from its predecessor, mandating, as a policy matter, those practices and lessons learned over the prior decade. Some of the more notable changes include: expanded humane treatment provisions and added emphasis by moving them into the main body from the attachments section; clarification regarding the general process for handling detainees from point of capture or assumption of custody until final transfer, repatriation, or release; expansion of the policies related to the transfer, repatriation, and release of detainees, including applicable humane treatment and security assurances; references to Article 75 of Additional Protocol I and Articles 4-6 of Additional Protocol II to the Geneva Conventions of 1949 as applicable detention principles (even though the United States is party to neither Protocol); and, most significantly, a new policy requirement to conduct detainee review processes, used to ascertain the status and continued necessity of detention for individuals detained by DoD under the law of armed conflict."

I think my answer to Vogel is explicitly aired above. What is disturbing is that the legal analysts at Just Security are so obtuse on the issue of what constitutes "humane treatment." Vogel is probably not obtuse. He must know where the textual bodies are buried, so to speak.]

Thursday, September 18, 2014



If you are a regular follower of Scission, you have seen my posts and articles related to the current Ebola epidemic. They have all dealt not so much with the specifics of the disease, treatments, etc.  My articles have been related to the relationship between poverty, inequality, Ebola, and other infectious diseases (herehere, and here).  Today, I return to the Ebola epidemic, but hone in on what should not be particularly a political question, but sort of is, me thinks.

All the experts and pundits always tell us Ebola is not airborne.  They tell us you have to have direct contact with bodily fluids.  They tell us it is hard to get.  They tell us they know how it is transmitted and they know how to contain it.  Up until this outbreak that rap has made some sense.  But, hey guys, something appears hinky here this time around.  You have not contained the outbreak which is now an epidemic.  It seems to anyone with any real knowledge of this sort of thing that too many healthcare workers have become infected.  You say these healthcare workers have made mistakes.  You say these healthcare workers haven't had enough protection.  The problem with that response is the sheer number of healthcare workers who are experts at this sort of thing who have become infected.  How come?  Something just isn't right here.

Ebola is a rapidly mutating virus.  Rapidly mutating virus mutate really rapidly in large outbreaks and epidemics which are out of control.  Viruses can be very resilient, very "clever" at finding modes of transmission.  I think that is what has happened here.

Is Ebola airborne?  Well, maybe that depends on how you define airborne to some degree.  Is a virus that can be transmitted through the air on moisture droplets airborne?  Well, yes, no, maybe, whatever.  

I think the response of the USA this past week to send in the troops (that is always the response of the USA to a crisis, send in the military) is indicative of the fact that the powers that be have become more than a little concerned that something just isn't right here.

I am not predicting doom.  I am simply saying that global capital and the pervasive inequality in general, and inequality in healthcare in particular, may find itself paying a higher price that it anticipated for its drive for profit and accumulation.  The chickens could come home to roost in more ways than one.  Global capital could care less if a few thousand poor Africans die.  Global capital doesn't need them.  However, a few hundred thousands of Africans, some not even poor, may be another matter.  That can kind of screw a globalized economy up a bit, can create security problems, can even lead to the people global capital actually does care about dying.  That isn't part of global capital's game plan.  

The problem for them, for the bosses of the world,  is that things are on the verge of getting totally out of hand and they aren't all that sure of what to do about it.  They have never really fought a war against a virus, not one like Ebola, or H5N1.  They have  used ye olde containment strategy against infectious diseases like Tuberculosis, malaria and AIDS.  They have largely contained those viruses to the people they don't need.  That was and is the plan here, but it may not be working.

Meanwhile out on the front lines things are not getting any better.  The numbers of those infected with Ebola, the numbers of those who have died is increasing exponentially.  Those are the numbers they know, and they are, we all know, way low. The World Health Organization (WHO) this week  issued a stern warning that there may be thousands of new and presently undiagnosed cases of Ebola, each week in Sierra Leone, Guinea and Nigeria, which will surface by early October of 2014. A total of 15 countries could be involved in the outbreak and this could put the lives of 22 million people at risk. These projections by WHO are based on the fact that the present strain of Ebola will remain transmissible through only direct physical contact with bodily fluids and exposure to an infected food supply.

But will it?  Could it go (or have gone) airborne.  Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota said last week on CNN that, “It’s the single greatest concern I’ve ever had in my 40-year public health career.” Echoing Osterholm, Dr. David Heymann, professor for the London School of Hygiene of Tropical Medicine, said,  “It is impossible to predict how any virus will mutate."  As Before its News puts it:

 Both Osterholm and Heymann note that virologists are extremely hesitant to discuss the possibility of discussing the possibility and potential for Ebola to become an airborne virus because they are scared to death of being professionally discredited and accused of whipping up hysteria with regard to the dangers posed by the present Ebola outbreak. However, in private, they both state, that anyone close to the virus are expressing grave fears about this possibility. In fact, Osterholm specifically stated in the New York Times article that … it’s something they are “definitely considering in private.”

The statistical models themselves, some of which predict staggering numbers of deaths, aren't even really of any use at this point since they are based on the conventional wisdom which no longer seems to be so wise.

Yesterday we learned a staff member from Doctors without Borders (MSF), a group that knows a thing or two about this sort of thing, has become hospitalized with Ebola.  MSF said the sick staff member is a woman from France who had been working in Monrovia, Liberia's capital.  The Center for Infectious Disease Research and Policy (CIDRAP) writes:

It's unclear how the woman became infected, but MSF teams are investigating the contamination as part of standard procedures, the group said. 

The important word there is "unclear."    

Why would the powers that be, the global bosses, keep the possibility that Ebola may already be airborne to themselves?  You tell me.  Markets, financial stress, global economics, you tell me.

I could be totally off base, of course.  I hope so, but then comes a piece yesterday at CIDRAP which I am posting below whose implications are, to say the least, frightening.  I point out this is not the ravings of some mad men, some conspiracy theorists, some doomsayers.   The fellows who wrote the following are   national experts on respiratory protection and infectious disease transmission.  Dr Brosseau is a Professor and Dr Jones an Assistant Professor in the School of Public Health, Division of Environmental and Occupational Health Sciences, at the University of Illinois at Chicago.

COMMENTARY: Health workers need optimal respiratory protection for Ebola

Editor's Note: Today's commentary was submitted to CIDRAP by the authors, who are national experts on respiratory protection and infectious disease transmission. In May they published a similar commentary on MERS-CoV. Dr Brosseau is a Professor and Dr Jones an Assistant Professor in the School of Public Health, Division of Environmental and Occupational Health Sciences, at the University of Illinois at Chicago.

Healthcare workers play a very important role in the successful containment of outbreaks of infectious diseases like Ebola. The correct type and level of personal protective equipment (PPE) ensures that healthcare workers remain healthy throughout an outbreak—and with the current rapidly expanding Ebola outbreak in West Africa, it's imperative to favor more conservative measures.
The precautionary principle—that any action designed to reduce risk should not await scientific certainty—compels the use of respiratory protection for a pathogen like Ebola virus that has:
  • No proven pre- or post-exposure treatment modalities
  • A high case-fatality rate
  • Unclear modes of transmission
We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.1
The minimum level of protection in high-risk settings should be a respirator with an assigned protection factor greater than 10. A powered air-purifying respirator (PAPR) with a hood or helmet offers many advantages over an N95 filtering facepiece or similar respirator, being more protective, comfortable, and cost-effective in the long run.
We strongly urge the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to seek funds for the purchase and transport of PAPRs to all healthcare workers currently fighting the battle against Ebola throughout Africa—and beyond.
There has been a lot of on-line and published controversy about whether Ebola virus can be transmitted via aerosols. Most scientific and medical personnel, along with public health organizations, have been unequivocal in their statements that Ebola can be transmitted only by direct contact with virus-laden fluids2,3 and that the only modes of transmission we should be concerned with are those termed "droplet" and "contact."
These statements are based on two lines of reasoning. The first is that no one located at a distance from an infected individual has contracted the disease, or the converse, every person infected has had (or must have had) "direct" contact with the body fluids of an infected person.
This reflects an incorrect and outmoded understanding of infectious aerosols, which has been institutionalized in policies, language, culture, and approaches to infection control. We will address this below. Briefly, however, the important points are that virus-laden bodily fluids may be aerosolized and inhaled while a person is in proximity to an infectious person and that a wide range of particle sizes can be inhaled and deposited throughout the respiratory tract.
The second line of reasoning is that respirators or other control measures for infectious aerosols cannot be recommended in developing countries because the resources, time, and/or understanding for such measures are lacking.4
Although there are some important barriers to the use of respirators, especially PAPRs, in developing countries, healthcare workers everywhere deserve and should be afforded the same best-practice types of protection, regardless of costs and resources. Every healthcare worker is a precious commodity whose well-being ensures everyone is protected.
If we are willing to offer infected US healthcare workers expensive treatments and experimental drugs free of charge when most of the world has no access to them, we wonder why we are unwilling to find the resources to provide appropriate levels of comparatively less expensive respiratory protection to every healthcare worker around the world.

How are infectious diseases transmitted via aerosols?

Medical and infection control professionals have relied for years on a paradigm for aerosol transmission of infectious diseases based on very outmoded research and an overly simplistic interpretation of the data. In the 1940s and 50s, William F. Wells and other "aerobiologists" employed now significantly out-of-date sampling methods (eg, settling plates) and very blunt analytic approaches (eg, cell culturing) to understand the movement of bacterial aerosols in healthcare and other settings. Their work, though groundbreaking at the time, provides a very incomplete picture.
Early aerobiologists were not able to measure small particles near an infectious person and thus assumed such particles existed only far from the source. They concluded that organisms capable of aerosol transmission (termed "airborne") can only do so at around 3 feet or more from the source. Because they thought that only larger particles would be present near the source, they believed people would be exposed only via large "droplets" on their face, eyes, or nose.
Modern research, using more sensitive instruments and analytic methods, has shown that aerosols emitted from the respiratory tract contain a wide distribution of particle sizes—including many that are small enough to be inhaled.5,6 Thus, both small and large particles will be present near an infectious person.
The chance of large droplets reaching the facial mucous membranes is quite small, as the nasal openings are small and shielded by their external and internal structure. Although close contact may permit large-droplet exposure, it also maximizes the possibility of aerosol inhalation.
As noted by early aerobiologists, liquid in a spray aerosol, such as that generated during coughing or sneezing, will quickly evaporate,7 which increases the concentration of small particles in the aerosol. Because evaporation occurs in milliseconds, many of these particles are likely to be found near the infectious person.
The current paradigm also assumes that only "small" particles (less than 5 micrometers [mcm]) can be inhaled and deposited in the respiratory tract. This is not true. Particles as large as 100 mcm (and perhaps even larger) can be inhaled into the mouth and nose. Larger particles are deposited in the nasal passages, pharynx, and upper regions of the lungs, while smaller particles are more likely to deposit in the lower, alveolar regions. And for many pathogens, infection is possible regardless of the particle size or deposition site.
It's time to abandon the old paradigm of three mutually exclusive transmission routes for a new one that considers the full range of particle sizes both near and far from a source. In addition, we need to factor in other important features of infectivity, such as the ability of a pathogen to remain viable in air at room temperature and humidity and the likelihood that systemic disease can result from deposition of infectious particles in the respiratory system or their transfer to the gastrointestinal tract.
We recommend using "aerosol transmissible" rather than the outmoded terms "droplet" or "airborne" to describe pathogens that can transmit disease via infectious particles suspended in air.

Is Ebola an aerosol-transmissible disease?

We recently published a commentary on the CIDRAP site discussing whether Middle East respiratory syndrome (MERS) could be an aerosol-transmissible disease, especially in healthcare settings. We drew comparisons with a similar and more well-studied disease, severe acute respiratory syndrome (SARS).
For Ebola and other filoviruses, however, there is much less information and research on disease transmission and survival, especially in healthcare settings.
Being at first skeptical that Ebola virus could be an aerosol-transmissible disease, we are now persuaded by a review of experimental and epidemiologic data that this might be an important feature of disease transmission, particularly in healthcare settings.

What do we know about Ebola transmission?

No one knows for certain how Ebola virus is transmitted from one person to the next. The virus has been found in the saliva, stool, breast milk, semen, and blood of infected persons.8,9 Studies of transmission in Ebola virus outbreaks have identified activities like caring for an infected person, sharing a bed, funeral activities, and contact with blood or other body fluids to be key risk factors for transmission.10-12
On the basis of epidemiologic evidence, it has been presumed that Ebola viruses are transmitted by contaminated hands in contact with the mouth or eyes or broken skin or by splashes or sprays of body fluids into these areas. Ebola viruses appear to be capable of initiating infection in a variety of human cell types,13,14 but the primary portal or portals of entry into susceptible hosts have not been identified.
Some pathogens are limited in the cell type and location they infect. Influenza, for example, is generally restricted to respiratory epithelial cells, which explains why flu is primarily a respiratory infection and is most likely aerosol transmissible. HIV infects T-helper cells in the lymphoid tissues and is primarily a bloodborne pathogen with low probability for transmission via aerosols.
Ebola virus, on the other hand, is a broader-acting and more non-specific pathogen that can impede the proper functioning of macrophages and dendritic cells—immune response cells located throughout the epithelium.15,16 Epithelial tissues are found throughout the body, including in the respiratory tract. Ebola prevents these cells from carrying out their antiviral functions but does not interfere with the initial inflammatory response, which attracts additional cells to the infection site. The latter contribute to further dissemination of the virus and similar adverse consequences far beyond the initial infection site.
The potential for transmission via inhalation of aerosols, therefore, cannot be ruled out by the observed risk factors or our knowledge of the infection process. Many body fluids, such as vomit, diarrhea, blood, and saliva, are capable of creating inhalable aerosol particles in the immediate vicinity of an infected person. Cough was identified among some cases in a 1995 outbreak in Kikwit, Democratic Republic of the Congo,11 and coughs are known to emit viruses in respirable particles.17The act of vomiting produces an aerosol and has been implicated in airborne transmission of gastrointestinal viruses.18,19 Regarding diarrhea, even when contained by toilets, toilet flushing emits a pathogen-laden aerosol that disperses in the air.20-22
Experimental work has shown that Marburg and Ebola viruses can be isolated from sera and tissue culture medium at room temperature for up to 46 days, but at room temperature no virus was recovered from glass, metal, or plastic surfaces.23 Aerosolized (1-3 mcm) Marburg, Ebola, and Reston viruses, at 50% to 55% relative humidity and 72°F, had biological decay rates of 3.04%, 3.06%. and 1.55% per minute, respectively. These rates indicate that 99% loss in aerosol infectivity would occur in 93, 104, and 162 minutes, respectively.23
In still air, 3-mcm particles can take up to an hour to settle. With air currents, these and smaller particles can be transported considerable distances before they are deposited on a surface.
There is also some experimental evidence that Ebola and other filoviruses can be transmitted by the aerosol route. Jaax et al24 reported the unexpected death of two rhesus monkeys housed approximately 3 meters from monkeys infected with Ebola virus, concluding that respiratory or eye exposure to aerosols was the only possible explanation.
Zaire Ebola viruses have also been transmitted in the absence of direct contact among pigs25 and from pigs to non-human primates,26 which experienced lung involvement in infection. Persons with no known direct contact with Ebola virus disease patients or their bodily fluids have become infected.12
Direct injection and exposure via a skin break or mucous membranes are the most efficient ways for Ebola to transmit. It may be that inhalation is a less efficient route of transmission for Ebola and other filoviruses, as lung involvement has not been reported in all non-human primate studies of Ebola aerosol infectivity.27 However, the respiratory and gastrointestinal systems are not complete barriers to Ebola virus. Experimental studies have demonstrated that it is possible to infect non-human primates and other mammals with filovirus aerosols.25-27
Altogether, these epidemiologic and experimental data offer enough evidence to suggest that Ebola and other filoviruses may be opportunistic with respect to aerosol transmission.28 That is, other routes of entry may be more important and probable, but, given the right conditions, it is possible that transmission could also occur via aerosols.
Guidance from the CDC and WHO recommends the use of facemasks for healthcare workers providing routine care to patients with Ebola virus disease and respirators when aerosol-generating procedures are performed. (Interestingly, the 1998 WHO and CDC infection-control guidance for viral hemorrhagic fevers in Africa, still available on the CDC Web site, recommends the use of respirators.)
Facemasks, however, do not offer protection against inhalation of small infectious aerosols, because they lack adequate filters and do not fit tightly against the face.1 Therefore, a higher level of protection is necessary.

Which respirator to wear?

As described in our earlier CIDRAP commentary, we can use a Canadian control-banding approach to select the most appropriate respirator for exposures to Ebola in healthcare settings.29 (See this document for a detailed description of the Canadian control banding approach and the data used to select respirators in our examples below.)
The control banding method involves the following steps:
  1. Identify the organism's risk group (1 to 4). Risk group reflects the toxicity of an organism, including the degree and type of disease and whether treatments are available. Ebola is in risk group 4, the most toxic organisms, because it can cause serious human or animal disease, is easily transmitted, directly or indirectly, and currently has no effective treatments or preventive measures.
  2. Identify the generation rate. The rate of aerosol generation reflects the number of particles created per time (eg, particles per second). Some processes, such as coughing, create more aerosols than others, like normal breathing. Some processes, like intubation and toilet flushing, can rapidly generate very large quantities of aerosols. The control banding approach assigns a qualitative rank ranging from low (1) to high (4) (eg, normal breathing without coughing has a rank of 1).
  3. Identify the level of control. Removing contaminated air and replacing it with clean air, as accomplished with a ventilation system, is effective for lowering the overall concentration of infectious aerosol particles in a space, although it may not be effective at lowering concentration in the immediate vicinity of a source. The number of air changes per hour (ACH) reflects the rate of air removal and replacement. This is a useful variable, because it is relatively easy to measure and, for hospitals, reflects building code requirements for different types of rooms. Again, a qualitative ranking is used to reflect low (1) versus high (4) ACH. Even if the true ventilation rate is not known, the examples can be used to select an appropriate air exchange rate.
  4. Identify the respirator assigned protection factor. Respirators are designated by their "class," each of which has an assigned protection factor (APF) that reflects the degree of protection. The APF represents the outside, environmental concentration divided by the inside, facepiece concentration. An APF of 10 means that the outside concentration of a particular contaminant will be 10 times greater than that inside the respirator. If the concentration outside the respirator is very high, an assigned protection factor of 10 may not prevent the wearer from inhaling an infective dose of a highly toxic organism.

Practical examples

Two examples follow. These assume that infectious aerosols are generated only during vomiting, diarrhea, coughing, sneezing, or similar high-energy emissions such as some medical procedures. It is possible that Ebola virus may be shed as an aerosol in other manners not considered.
Caring for a patient in the early stages of disease (no bleeding, vomiting, diarrhea, coughing, sneezing, etc). In this case, the generation rate is 1. For any level of control (less than 3 to more than 12 ACH), the control banding wheel indicates a respirator protection level of 1 (APF of 10), which corresponds to an air purifying (negative pressure) half-facepiece respirator such as an N95 filtering facepiece respirator. This type of respirator requires fit testing.
Caring for a patient in the later stages of disease (bleeding, vomiting, diarrhea, etc).If we assume the highest generation rate (4) and a standard patient room (control level = 2, 3-6 ACH), a respirator with an APF of at least 50 is needed. In the United States, this would be equivalent to either a full-facepiece air-purifying (negative-pressure) respirator or a half-facepiece PAPR (positive pressure), but standards differ in other countries. Fit testing is required for these types of respirators.
The control level (room ventilation) can have a big effect on respirator selection. For the same patient housed in a negative-pressure airborne infection isolation room (6-12 ACH), a respirator with an assigned protection factor of 25 is required. This would correspond in the United States to a PAPR with a loose-fitting facepiece or with a helmet or hood. This type of respirator does not need fit testing.

Implications for protecting health workers in Africa

Healthcare workers have experienced very high rates of morbidity and mortality in the past and current Ebola virus outbreaks. A facemask, or surgical mask, offers no or very minimal protection from infectious aerosol particles. As our examples illustrate, for a risk group 4 organism like Ebola, the minimum level of protection should be an N95 filtering facepiece respirator.
This type of respirator, however, would only be appropriate only when the likelihood of aerosol exposure is very low. For healthcare workers caring for many patients in an epidemic situation, this type of respirator may not provide an adequate level of protection.
For a risk group 4 organism, any activity that has the potential for aerosolizing liquid body fluids, such as medical or disinfection procedures, should be avoided, if possible. Our risk assessment indicates that a PAPR with a full facepiece (APF = 50) or a hood or helmet (APF = 25) would be a better choice for patient care during epidemic conditions.
We recognize that PAPRs present some logistical and infection-control problems. Batteries require frequent charging (which requires a reliable source of electricity), and the entire ensemble requires careful handling and disinfection between uses. A PAPR is also more expensive to buy and maintain than other types of respirators.
On the other hand, a PAPR with a loose-fitting facepiece (hood or helmet) does not require fit testing. Wearing this type of respirator minimizes the need for other types of PPE, such as head coverings and goggles. And, most important, it is much more comfortable to wear than a negative-pressure respirator like an N95, especially in hot environments.
A recent report from a Medecins Sans Frontieres healthcare worker in Sierra Leone30 notes that healthcare workers cannot tolerate the required PPE for more than 40 minutes. Exiting the workplace every 40 minutes requires removal and disinfection or disposal (burning) of all PPE. A PAPR would allow much longer work periods, use less PPE, require fewer doffing episodes, generate less infectious waste, and be more protective. In the long run, we suspect this type of protection could also be less expensive.

Adequate protection is essential

To summarize, for the following reasons we believe that Ebola could be an opportunistic aerosol-transmissible disease requiring adequate respiratory protection:
  • Patients and procedures generate aerosols, and Ebola virus remains viable in aerosols for up to 90 minutes.
  • All sizes of aerosol particles are easily inhaled both near to and far from the patient.
  • Crowding, limited air exchange, and close interactions with patients all contribute to the probability that healthcare workers will be exposed to high concentrations of very toxic infectious aerosols.
  • Ebola targets immune response cells found in all epithelial tissues, including in the respiratory and gastrointestinal system.
  • Experimental data support aerosols as a mode of disease transmission in non-human primates.
Risk level and working conditions suggest that a PAPR will be more protective, cost-effective, and comfortable than an N95 filtering facepiece respirator.
We thank Kathleen Harriman, PhD, MPH, RN, Chief, Vaccine Preventable Diseases Epidemiology Section, Immunization Branch, California Department of Public Health, and Nicole Vars McCullough, PhD, CIH, Manager, Global Technical Services, Personal Safety Division, 3M Company, for their input and review.
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