Eur Radiol (2015) 25:33683371

DOI 10.1007/s00330-015-3748-6

RADIOLOGICAL EDUCATION

Radiographic imaging in Ebola Virus Disease: protocol

to acquire chest radiographs
Elisa Busi Rizzi 2,6 & Vincenzo Puro 3 & Vincenzo Schinina 2 & Emanuele Nicastri 4 &
Nicola Petrosillo 5 & Giuseppe Ippolito 1

Received: 22 December 2014 / Revised: 26 February 2015 / Accepted: 27 March 2015 / Published online: 23 April 2015
# European Union 2015

Abstract Proper procedures to minimize the risk of contamination in contagious and potentially lethal viral infections are
needed; therefore radiology departments should develop appropriate imaging protocols. We describe the imaging protocol used by National Institute for Infectious Diseases Lazzaro
Spallanzani to acquire chest radiographs in patients with Ebola
virus disease.
Key points
Nosocomial transmission to healthcare workers can be
prevented using protective equipment.
Chest radiographs can be required in Ebola Virus Disease.
The protocol for performing chest radiographs on patients
with Ebola is described.

Keywords Chest radiographs . Ebola virus . Infectious

Diseases . Educational Personnel . Safety

* Elisa Busi Rizzi

elisa.busirizzi@inmi.it
1

National Institute for Infectious Diseases BLazzaro Spallanzani^

Rome-Italy, Rome, Italy

Diagnostic Imaging Department, National Institute for Infectious

Diseases BLazzaro Spallanzani^ Rome-Italy, Rome, Italy

Department of Epidemiology, Emerging Infections Unit, National

Institute for Infectious Diseases BLazzaro Spallanzani^ Rome-Italy,
Rome, Italy

Clinical Department, 4nd Division, National Institute for Infectious

Diseases BLazzaro Spallanzani^ Rome-Italy, Rome, Italy

Clinical Department, 2nd Division, National Institute for Infectious

Diseases BLazzaro Spallanzani^ Rome-Italy, Rome, Italy

Diagnostic Imaging Department INMI L.Spallanzani, Rome, Italy

Introduction
According to the World Health Organization update, since
December 2013 and as of February 1, 2015, there have been
almost 22,500 reported confirmed, probable, and suspected
cases of Ebola, with almost 9000 reported deaths. Country
reports fall into three categories: those with widespread, intense, and ongoing transmission (Guinea, Liberia, and Sierra
Leone), those that have had an initial localized transmission
(Nigeria, Senegal, and Mali), and those outside Africa with
few cases of occupational transmission among health care
workers (one in Spain, and two in the United States of
America).
In this unprecedented outbreak, a total of 822 health-care
workers (HCWs) are known to have been infected with EVD,
and 488 have died. The total case count includes two HCWs in
Mali, 11 HCWs infected in Nigeria, one HCW infected in
Spain, and two HCWs in the US [13].
At least 31 EVD cases or Ebola exposed healthcare or
humanitarian workers have been evacuated or repatriated
from affected countries. Among them, a physician who
contracted the infection in Sierra Leone, was transferred to
the high level isolation unit (HLIU) of the National Institute
for Infectious Diseases Lazzaro Spallanzani (INMI) in Rome
[1]. The unit is staffed by infectious diseases and critical care
specialists and the personnel is trained in strict infection control practices optimized to prevent spread of potentially transmissible agents such as Ebola.
As the epidemic is still evolving and people are deployed in
the affected countries within the international response and
support plan, the risk of import of EVD cases into unaffected
countries is increasing.
The risk associated with repatriation of EVD patients can
be presumed as controlled, since the infection has already
been diagnosed and patients are directly transferred to HLIU

Eur Radiol (2015) 25:33683371

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with a limited need for contact tracing. A higher risk could be

associated with newly diagnosed subjects in Western countries, who were exposed in Africa; in this case, a late diagnosis
can occur and the first contact could be in an unprepared
hospital with the effect of late exposures and complex contact
tracing.
Adequate levels of preparedness are needed to reduce the
risk of missed introductions and containment as soon as possible. Early symptoms of EVD are common and nonspecific.
They include high fever (temperature of up to 40 C), malaise,
fatigue, and body aches; by day 3 to 5, gastrointestinal symptoms typically begin, with epigastric pain, nausea, recurrent
vomiting, and large volumes of watery diarrhoea. Associated
signs and symptoms included asthenia, headache, conjunctival injection, chest pain, abdominal pain, arthralgias, and myalgias. Clinically significant haemorrhage from the upper or
lower gastrointestinal tract or both occurred in less than 5 % of
patients before death. Respiratory symptoms, such as cough,
were rare.
Nosocomial transmission to healthcare workers (HCWs)
can be prevented by strict adherence to infection control measures and correct use of personal protective equipment. The
lack of well established procedures validated at hospital level
and inadequate training are the major determinants of infection among HCWs [1, 2].
Diagnostic medical imaging, mostly chest radiographs, can
be required in the initial assessment in the emergency ward or
during the treatment in HLIUs. Moreover, the risk must be
evaluated and a predefined procedure established; in general,
portable radiographic and bedside ultrasound systems could
be used, while computed tomography should be avoided to
limit the exposure of personnel and equipment.
We describe the protocol developed at INMI to perform
chest radiographs in patients with confirmed cases of Ebola
virus disease (EVD), in order to minimize the risk of exposure
of the staff and contamination of the equipment. For probable
and suspected cases, the imaging must be postponed until the
diagnosis is verified, unless required for urgent differential
diagnosis.

When necessary, portable digital radiographic equipment is

moved in the BU.
The staffs involved are a radiologic technologist, a physician or nurse caring for the patient, and an additional nurse is
located outside the anteroom for decontamination procedures.
Technologists cover the arm of the digital X-ray unit with a
plastic wrap; the x-ray detector is triple bagged to protect
sensitive surfaces, and each bag is separately taped prior to
entering the patient room. The digital X-ray unit and the cassette will be moved in the clean area around the hot room. In
this area the radiologic technologist will put on personal protective equipment (PPE), an impervious gown, gloves, and
goggles. To reduce exposure to EVD, the radiologic technologist remains in the clean area and provides medical and nursing staff verbal instructions for use of the equipment inside the
patient room.
The staff member in charge of patient care will bring the
bagged X-ray detector into the patients hot room.
The next steps could vary, depending on the clinical status
of the patient.
The cooperative patient sits in a chair in the hot room, near
the door close to the clean area around the hot room, where the
digital X-ray unit is placed (distance from patient-unit is 1.5-2
mt), and is instructed to keep the X-ray detector in the right
position . Then the staff member will open the door and go
into the anteroom. The technologist remains in the clean area
and uses the remote control to take the radiography, being
careful to always keep the arm outside the hot room. The door
remains closed when the X-ray is being taken.
When the patient is noncooperative, the staff member, physician or nurse caring for the patient, move the X-ray unit and
the bagged X-ray detector into the hot room. Once the X-ray
cassette and machine are positioned following the instruction
of the technologist, who remains in the clean area, the staff
prepares to take the X-ray. The technologist will take the radiography with the remote control.
The door is closed while the X-ray is being performed.
When the X-ray is taken, the radiologic technologist moves
to the clean area around the anteroom.
Therefore:

Chest radiograph protocol

1. Patients staff will remove the X-ray cassette from behind

the patient, and changes gloves.
2. Patients staff will walk to the line of the clean area in
front of the anteroom, and hold the outside bag to allow
the anteroom nurse to decontaminate the cassette and the
gloved hands of the patients staff with sodium hypochlorite 0.5 %; then changes gloves.
3. Patients staff removes the outer bag and puts the cassette
in a percolating container.
4. The anteroom nurse in full PPE decontaminates the cassette and the gloved hands of the patients staff with sodium hypochlorite 0.5 %.

At INMI, the medical, technical, and nursing personnel are

thoroughly informed about EVD and trained in donning and
doffing of correctly-sized personal protective equipment and
how to perform imaging examinations wearing full protection.
The current biocontainment units (BU) are located in a
dedicated area of the hospital not used for other patients, with
a different level of pressure to warrant maximum level of
protection: higher negative pressure in anterooms and a patients room (hot area) and a lower negative pressure in the
surrounding clean areas (Fig. 1).

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Eur Radiol (2015) 25:33683371

Fig. 1 Diagram of high-level

isolation room for EVD patient at
*BLINDED* Institute. Legend:
A: Clean area for donning
Personal Protective Equipment B:
Patient room, Bhot^ area. C: Area
for doffing Personal Protective
Equipment and assisted
disinfection

5. Patients staff removes the second bag and then changes

gloves.
6. The anteroom nurse changes gloves, sanitizes her/his
hands, removes the inner bag, checks to make sure that
the plate has no traces of sodium hypochlorite, and delivers it to the technologist who processes it in the diagnostic imaging department.
When, in the case of noncooperative patient, the X-ray
machine is moved into the BU, it will remain in the BU after
the CXR in accordance with the Institute protocol. After patient dismissal, the room is cleared of waste and of all disposable items, sealed, and closed for at least 48 h. After this
period, HCW in full PPE decontaminate the surfaces of the
room and the reusable equipment, including the x-ray machine and its wheels, through manual cleaning and disinfection with wipes and mops saturated with hypochlorite or with
other disinfectant in accordance with vendors instructions.

All items in the room are positioned in order to expose as

much surface as possible to the hydrogen peroxide vapour
decontamination that follows. The room and the equipment
are then left undisturbed for a least one week, after which it is
considered safe to be used in routine practice. If it is necessary
to reuse the x ray machine before the end of the full protocol,
only the on-rest pauses are avoided but all the disinfection
steps are performed.
The protocol outlined here is part of the Standard Operating
Procedures for Ebola management at INMI [4].

Discussion
The role of chest imaging to assess the pulmonary complications of/during EVD is limited. The protocol to safely acquire
chest radiographs in patients with or suspected EVD or other

Eur Radiol (2015) 25:33683371

potentially lethal infections spread by contact is an essential

part of the procedures for optimal clinical care.
Protocols similar to ours have been proposed by US
authors [5, 6].
The main peculiarity of our protocol is that we adopt a
different approach depending on the patients status, to minimize the risk of exposure to staff and contamination of the
equipment. In fact, the digital X-ray unit and the technologist
remains in the clean area around the hot room when the patient
is cooperative, or when the patients bed can be moved within
the room so that the digital X-ray unit can remain in the clean
area. Furthermore, the cassettes are triple not double bagged,
and each bag is taped.
The protocol is designed to fulfil logistic and organizational needs of the INMI, but could represent a useful tool for the
development of protocols by other institutions. The disinfectants used and the procedure performed must be approved by the equipment manufacturers to avoid damage
during decontamination [7].
For a safe adoption of the protocol, mock practical sessions
must be organized and repeated regularly to train nurses and
radiologic technologists to perform the procedures properly.
To further reduce the risk of exposure while handling potentially contaminated plates, hospitals should invest in a system based on computerized radiography machines with wireless plates to be placed in BUs, so that cassettes may be left in
the patients room after having acquired the image [46].
Acknowledgments We thank the entire Ebola task force, in particular
the radiology technologists for their commitment to providing lifesaving
medical care to patients with EVD. We thank Marco Cassandra for his
support in providing Figure 1.

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This study was financially supported by Ministero della Salute, ItaliaRicerca Corrente, Istituti di Ricovero e Cura a Carattere Scientifico. The
scientific guarantor of this publication is Giuseppe Ippolito. The authors
of this manuscript declare no relationships with any companies, whose
products or services may be related to the subject matter of the article. No
complex statistical methods were necessary for this paper. Institutional
Review Board approval was obtained.

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