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A Nurse Should Not Have Contracted Ebola. We Need New Policies.

Mike Stone/Getty Images

A second Ebola case has appeared in Dallas, Texas. This time, it’s a nurse who was taking care of Thomas Duncan, the Liberian man who died last week. The nurse is the first person to contract the disease on American soil. She probably won't be the last.

Is it time to panic? No, say the experts. But it may be time to start handling these cases differently.

Here’s what we know about the new patient, according to the U.S. Centers for Disease Control and media reports. She works at Texas Health Presbyterian Hospital and had multiple contacts with Duncan after his admission. When she developed symptoms on Friday, she came to the hospital for assessment and was promptly put into isolation. By Saturday, tests had confirmed that she had the virus. As of Sunday afternoon, she was in stable condition.

Hospital officials say that she was observing safety protocols, like wearing recommended protective gear. CDC Director Tom Frieden said that some kind of breach in those protocols must have occurred. The two statements might sound contradictory, but they may not be. The safety procedures are complicated and, particularly if you’re tired, it’s easy to make a mistake. “Look, even in a regular, garden variety operating room, there’s a charge nurse watching to make sure no one has broken sterile technique, like scratching their nose or wiping their brow or touching something, and that is damned hard to do,” says Howard Markel, a professor at the University of Michigan Medical School and author of When Germs Travel. “Now multiply this scrutiny a million fold because it’s Ebola and you get an idea how tough it is to maintain the protocol.”

Officials say they aren’t sure how the nurse acquired the disease, although one possibility is that she contaminated herself while “doffing” (taking off) her protective gear. Frieden noted that Texas Presbyterian staff’s efforts to save Duncan included dialysis and respiratory intubation, during which contamination would have been more likely. That’s the tragedy of cases like these: The nurse got sick because she was trying to save a dying man’s life. Worse still, Frieden warned, more such cases may soon appear.

The assumption, to date, is that most hospitals could handle these cases as long as C.D.C. provided guidance. But that approach doesn’t appear to have worked at Texas Presbyterian—and maybe that’s not so surprising. Inconsistent safety practices have been a problem in U.S. hospitals for a long time. In some cases, simply getting all caregivers to practice basic hand hygiene has been a struggle. Expecting workers who have never seen Ebola before to get the protocols right, every single time, is asking an awful lot.  

Ideally, every facility with Ebola patients would adopt the kinds of practices that groups like Doctors Without Borders have developed and honed over the years. They have thorough checklists, for example, and follow them meticulously. They also use a buddy system or, in some cases, have trained professionals who focus on the disposal of infected material and make sure caregivers take off protective gear properly. Frequently they are “WatSan” specialists, meaning they deal with water and sanitation.

The CDC seems to be moving in that direction already: Frieden said on Sunday that “we are recommending there be a full-time individual who is responsible only for the oversight, supervision and monitoring of effective infection control while an Ebola patient is cared for.” But simply “recommending” hospitals take these steps may not be enough. CDC, or some other arm of the federal government, may need to dispatch these infection control officers and pay for their services.

A more drastic, but possibly necessary, step would be moving all Ebola patients to hospitals that specialize in these sorts of infectious diseases. Four U.S. hospitals have such facilities, along with staff that have received special training for Ebola. Those facilities are Emory University Hospital (Atlanta), the National Institutes of Health (Bethesda, Maryland), Nebraska Medical Center (Omaha), and St. Patrick Hospital (Missoula, Montana). Many of the nation’s top teaching hospitals might also be more prepared for cases like these.

Of course, moving patients can expose other people to infection. "We have to consider that transferring patients might just put more people at risk," says Dan Kelly, an infectious disease specialist at the University of California-San Francisco. Those are the trade-offs that public health officials are weighing: Every new step has potential benefits but also potential costs.

Jonathan Cohn

The latest news

CLIMATE: In Iowa's Senate race, the Environmental Protection Agency has taken center-stage. Joni Ernst, facing attacks over her connections to the Kochs, defended eliminating the EPA in its entirety at a debate this weekend. (James Hohmann, Politico)

OBAMACARE: Hundreds of thousands of people who signed up for Medicaid several months ago still haven’t been gotten their coverage. And officials expect an uptick in new applications next month, when Obamacare’s next open enrollment period begins. (Stephanie Amour, Wall Street Journal)

IMMIGRATION: Government statistics show that, as the U.S. economy grows, we’re seeing the largest uptick in immigration since before the recession. (Neil Shah, Wall Street Journal)

Articles Worth Reading

Government spending doesn’t sound so awful now. Sam Stein interviewed a bunch of public health experts who think we might already have an Ebola vaccine, if only NIH had gotten more funding. (Huffington Post)

How Obama saved his presidency—and won over Paul Krugman: Ezra Klein says the secret was rejecting Obama’s promise that he could repair American politics. (Vox)

A new way to fight poverty: Catherine Rampell reports on a non-profit that helps low-wage workers connect with needed social services. The program is unique: Employers pay the non-profit to do this work in order to reduce turnover—and it has paid big dividends to everyone involved. (Washington Post)

They’re still kids: Dara Lind analyzes a study from the Bureau of Justice Statistics on teenagers in adult prisons. The findings are grim: Teens in adult prison facilities are twice as likely to commit suicide as their fellow inmates, and more likely to engage in violence once they’re released. (Vox) 

Do not read this if you’re afraid to fly: William Langewiesche tells the story of Air France Flight 447, which crashed in 2009, and discovers a paradox: The same automation that has made planes safer means pilots have less experience dealing with crises. (Vanity Fair)

Stories we’ll be watching

(1) Ebola (2) The midterms. Yeah, that’s what we said on Friday.


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