A second health care worker at Texas Presbyterian Hospital in Dallas has tested positive for Ebola, according to public health officials. The worker is yet another member of the team that cared for Thomas Duncan, the Liberian man who died at the hospital last week.
The worker, whom authorities have not identified, came to the hospital with a fever on Tuesday night and has been in isolation since that time. There's no word on her condition. CDC officials are monitoring people who came into contact with her—and that includes tracking down people who were on a Cleveland-to-Dallas flight with her Monday afternoon, when she had a (very) low-grade fever but hadn't yet reported symptoms.
The development is not surprising. Given the way Ebola is transmitted, through bodily fluids from very sick people, health care workers treating the infirmed are among the most vulnerable to getting it. Experts have expected more cases and the diagnosis is not a sign that the disease is out of control here in the U.S. The fact that only symptomatic people transmit the disease makes it possible to contain the spread and, when caught early, the prospects for successful treatment are much higher. In fact, the one piece of good news from Dallas is that doctors have upgraded Nina Pham, the first nurse who tested positive for Ebola, from "stable" to "good."
Still, the new case confirms what officials at the U.S. Centers for Disease Control were already acknowledging on Tuesday. Expecting staff at a community hospital to handle these cases on their own, without a lot more training and guidance, was a mistake—one CDC officials say they will not make again.
Media reports from the last 24 hours have painted a pretty distressing picture of what happened at Texas Presbyterian. Nurses, speaking anonymously through the National Nurses United union, have said they initially had to care for Duncan with inadequate protective gear—and that hospital officials resisted putting him into isolation, despite a request from the nurse supervisor on the scene. There’s been no independent verification of those statements, but CDC investigators have confirmed that Texas Presbyterian workers were basically figuring out how to handle Ebola on the spot, as they were treating Duncan with increasingly heroic measures.
Here’s an account from the Washington Post:
“They kept adding more protective equipment as the patient [Duncan] deteriorated. They had masks first, then face shields, then the positive-pressure respirator. They added a second pair of gloves,” said Pierre Rollin, a CDC epidemiologist.
CDC Director Thomas Frieden expressed regret Tuesday that his agency had not done more to help the hospital control the infection. … “I wish we had put a team ... on the ground the day the first patient was diagnosed,” he said. “That might have prevented this infection.”
In the Duncan case, the CDC sent disease detectives to help track down people who might have been exposed, but the agency largely let the hospital handle its own infection control.
That last part, about leaving infection control to the hospital, is arguably the most crucial error that authorities made. CDC had sent bulletins to hospitals, explaining how to handle Ebola patients. But avoiding contamination is not easy to do and removing the protective gear ("doffing") is a particular challenge. Professionals with experience with Ebola, like those at Doctors Without Borders, use lengthy checklists and typically take off their gear in the presence of somebody else monitoring the process, step by step. Either they use a buddy system or they bring in specialists just for that purpose.
"Using the gear isn't something you can learn to do by reading a paper," Claire Farel, an infectious disease specialist at the University of North Carolina at Chapel Hill, told me. "It's like learning a procedure—you have to see it and practice it, many times, before getting it right. There's a saying in medicine that is often applied to procedures, 'see one, do one, teach one' but in this case it really requires more than that."
Charles van der Horst, another UNC specialist and frequent writer on these subjects, said “It's not that complicated, you just have to practice it.” He went on to explain,
When we did it [at a Federal Emergency Management Agency center], we practiced every afternoon. We practiced cleaning up vomit, what you do when somebody knocks your face shield, the MSF [Doctors Without Borders] method of donning and doffing, the World Health Organization method. We did that every day. You need the muscle memory—it needs to be rote, you need to practice not touching your face.
CDC officials seem to realize their previous efforts were inadequate. On Tuesday, they announced they had dispatched infection control teams to Texas Presbyterian and would do the same for any other hospital that gets Ebola cases. These teams will apparently include specialists in the doffing of gear and disposal of waste.
Another option still under consideration is the transfer of some or all Ebola patients to facilities with staff who have undergone training for precisely these sorts of diseases. The federal government has designated four such facilities in the U.S.: Emory University Hospital (Atlanta), the National Institutes of Health (Bethesda, Maryland), Nebraska Medical Center (Omaha), and St. Patrick Hospital (Missoula, Montana). It’s possible that other, high-level hospitals could handle the cases, too. One possibility (not one I've heard discussed specifically) would be to make sure that one Level Four Trauma Center in every geographical area, or even one in every city, is ready for Ebola cases.
Of course, every policy change has its costs and downsides. Transporting patients can expose more people to infection. Resources for treating Ebola could end up being resources needed for other diseases that are, in reality, bigger threats to the health and well-being for Americans. Figuring out the appropriate balance here is not easy—and with each new Ebola case generating more anxiety, it won’t get easier.
Update: Original reports suggested that the second health care worker, since identified as Amber Vinson, had no symptoms on the flight to Dallas. During a press call, Frieden revealed that she actually had a 99.5 degree fever. Frieden said that Vinson violated CDC guidelnes by taking air transportation, although he added that fellow passengers were at "extremely low risk" of contracting the illness from her.