The health care worker reported a low grade fever Friday night and was isolated. Ebola readiness questions emerge

Two cases of Ebola disease on U.S. shores are raising concerns about just how ready Americans hospitals and health care workers are to fight the lethal virus, despite all the assurances from public health officials that it can be identified, isolated and safely treated.

The first case was initially missed, potentially exposing more people in Dallas to Ebola and delaying treatment for the patient, a Liberian national who later died.


The second case, announced Sunday, involves an ICU nurse who had treated Thomas Duncan. She wore full protective gear, including a gown, gloves, mask and shield — and still was exposed.

Ebola is not spread through the air like the flu or a cold but through contact with bodily fluids of a sick person. How the nurse became infected isn’t yet known. Yet it happened even after a spate of guidelines, briefings and recommendations meant to get the nation’s facilities and health care workers ready.

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The hospital at the center of both cases, Texas Health Presbyterian Hospital in Dallas, has said it had prepped and drilled. On Sunday, its leaders and the CDC were facing a new reality given the new patient.

“At some point there was a breach in protocol, and that breach in protocol resulted in this infection,” said CDC Director Tom Frieden, who called himself “deeply concerned.”

Once again, the circle of other possible exposures rippled outward. More than a dozen workers in that ICU will now be monitored closely for the 21 days that represent Ebola’s full incubation period.

“If this individual was exposed … it is possible that other individuals were exposed,” Frieden said. His agency must help identify those in that circle, and contain the virus.

After a briefing on the latest development, President Barack Obama immediately directed the CDC to move as quickly as possible with an investigation and to “take immediate additional steps to ensure hospitals and healthcare providers nationwide are prepared to follow protocols should they encounter an Ebola patient.”

Groups that represent health care workers have expressed sharp concerns about safety. Having protective gear isn’t enough; nurses and others need to know how to correctly put it on and take it off, without contaminating themselves or others.

The case of Duncan, who was infected in his home country and only became sick after flying to Texas to visit relatives, was the first diagnosed in the United States. He went to Texas Health Presbyterian twice but was only admitted the second time. He died last Wednesday.

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The ICU nurse is the first case of transmission of Ebola in the United States — and only the second time the disease has been spread outside of West Africa. The other incident, in Spain, also involves a health care worker.

Sunday’s announcement raised more issues about the Dallas hospital.

Only several days ago, CDC had starting to ramp up education and training there because of the facility’s multiple errors in caring for Duncan. Whatever potential mistake the nurse made after he was admitted on Sept. 28 — and officials have yet to identify the lapse — may have been repeated by others.

“Even a single, inadvertent, innocent slip can result in contamination,” Frieden said.

Despite the CDC’s efforts to ensure providers were ready for Ebola, some organizations and infectious disease specialists have questioned how much more may need to be done.

Last week, a survey by National Nurses United of more than 1,700 registered nurses found that many felt their hospitals’ preparation was lagging. More than three-quarters said they had not received any communication on their hospital’s policy regarding potential admission of infected patients.

The nurse’s infection is sure to heighten those concerns — and fears.

“This could happen anywhere,” union spokesman Charles Idelson said Sunday. Hospitals need to have the right gear to safeguard staffs, and they need to make sure everyone involved knows how to don and discard those materials, he said. Drilling and practicing is essential.

“It’s not just having the proper protective gear. It’s hands on training,” Idelson said. “They need to practice in teams and practice over and over again — we don’t need more people infected.”

Mark Catlin of SEIU, the nation’s largest health care union, stressed the same point about drilling, drilling and more drilling. Such repetition is especially important with the nearly head-to-toe protective gear that physicians and nurses wear when dealing with acute infectious diseases.

“It’s difficult for workers wearing all that gear to come out and take if off properly,” said Catlin, SEIU’s occupational health and safety director. A hospital may have the right protocols on paper, but unless they continually go step by step during what-if testing, “it’s not clear how well facilities implement them,” he said.

The new case has already triggered a change in CDC’s care recommendations. Frieden, who sounded exceptionally somber during Sunday’s briefing, said the agency was directing Texas Health Presbyterian to keep the number of people caring for the stricken nurse to “an absolute minimum” and only perform essential procedures.

He noted, for example, that Duncan had been put on kidney dialysis and a ventilator “as a desperate measure to try to save his life” — two actions that not only were unusual for Ebola treatment and ultimately futile but may have greatly increased the risk of exposure to the hospital’s ICU staff.

The hospital also has been directed to appoint someone whose only job would be to oversee, supervise and monitor the care of the nurse-turned-patient. She was in stable condition, with mild symptoms, on Sunday, Frieden said.

Some in Congress are suggesting other action. Mississippi Rep. Bennie Thompson (D-Miss.), ranking member of the Committee on Homeland Security, said Sunday evening that the CDC should consider whether the nurse and any future Ebola patients should be transferred to the highly specialized biocontainment units available at four U.S hospitals. Two of those units — at Emory University Hospital in Atlanta and Nebraska Medical Center in Omaha — are each caring for an individual sickened with Ebola while working in West Africa.

The disease has no cure, but supportive treatment — keeping the body strong enough and critical organs working until the virus runs its course — can enhance chances of survival. Three American medical missionaries flown back for treatment after becoming sick in West Africa have survived.

Since the start of the Ebola outbreak in that region, health care workers have become stricken at a particularly high rate because of the challenging conditions in which they’re caring for patients there. The latest numbers from the World Health Organization show that more than 400 workers have contracted Ebola; 232 have died.

The first known transmission outside of West Africa was the nursing assistant in Spain. The woman cared for a priest who had contracted Ebola in Sierra Leone and then was brought home. She was quoted in a Spanish newspaper as saying she may have become infected when she touched her face while removing protective gear. She remains in serious condition in a Madrid hospital.

In Texas, the state health department did the preliminary testing of the Dallas health care worker, and results of CDC’s further testing confirmed the diagnosis.

Public health officials have been monitoring four dozen people, including seven doctors, nurses and paramedics, who had direct or indirect contact with Duncan after he fell ill but before he was hospitalized on Sept. 28.

The infected worker dealt with Duncan after he was admitted, when he was in isolation and precautions should have been at their highest. Frieden characterized her “extensive contact” with him on “multiple occasions.”

When she began running a low-grade fever Friday night, she notified Texas Health Presbyterian “of imminent arrival and was immediately admitted to the hospital in isolation,” according to a hospital statement.

“The entire process, from the patient’s self-monitoring to the admission in isolation, took less than 90 minutes,” the statement detailed. “The patient’s condition is stable. A close contact has also been proactively placed in isolation.”

Texas Health Presbyterian said it would be using the coming weeks “to further expand the margin of safety by triple-checking our full compliance with CDC guidelines.” Its performance to date has been scrutinized and criticized because of its disclosure that it initially sent Duncan home after he came to the emergency department on Sept. 25. He had a spiking fever, severe abdominal pain and his recent travel from West Africa — collectively, details that should have prompted the hospital to immediately isolate him. On Sept. 28, he returned via ambulance two days later and was put into intensive care.

“We knew a second case could be a reality, and we’ve been preparing for this possibility,” state health Commissioner David Lakey said Sunday. “We are broadening our team in Dallas and working with extreme diligence to prevent further spread.”

The American Hospital Association’s Ken Anderson said Sunday the two events in Dallas reveal the “complex interplay of people, process and technology” that is crucial in successfully treating Ebola and preventing its spread.

Hospitals across the country are re-evaluating and testing their own procedures based on the latest updates from CDC, said Anderson, a physician who is the chief operating officer of the AHA’s Health Research and Educational Trust. “What they want to make sure of before any changes is that the direction of change and the intensity of change are appropriate and measured.”

Joanne Kenen contributed to this report.