Ebola: Despite 'Full CDC Precautions,' Hospital Worker Infected

A nurse who helped care for Ebola patient Thomas Eric Duncan at a Texas hospital has tested positive for the virus, prompting the head of the CDC to caution that there could be more such cases "in the coming days."

Federal, state, and hospital health officials are under pressure to find out why and how a Texas healthcare worker who was part of the care team for Thomas Eric Duncan, the Ebola patient who died at Texas Health Presbyterian Hospital Dallas last week, has tested positive for the deadly virus despite wearing CDC-recommended protective gear.

Dan Varga, MD, chief clinical officer for Arlington, Texas-based Texas Health Resources, said at a news conference Sunday that the healthcare worker, an unidentified female nurse, was considered low-risk, but had been self-monitoring for Ebola symptoms by checking for a temperature twice daily.

The nurse noted a fever on Friday night, called the hospital, and was in isolation from other patients within 90-minutes. A second person who was in close contact with her is also in isolation, according to Varga.

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"We're very concerned," he said. "This individual was following full CDC precautions… which are barrier and droplet, so: gown, glove, mask, and shield."

Notification and Decontamination
As of Sunday, 48 people being watched by the county were asymptomatic and without fever. The healthcare worker was in stable condition.

As of 7:45 PM Sunday, Texas Health Presbyterian Hospital Dallas was diverting ambulances from its emergency department, though spokesman Wendell Watson said the ED remained open.

Neighbors of the infected nurse were notified at 7:15 AM Sunday via reverse 911 calls. Dallas Mayor, Mike Rawlings, said the common areas of the apartment complex where she lives, including hand railings and "everything in the parking lot" had been decontaminated.

"We had this plan in place last week," he said, "We have moved our Dallas Fire and Hazmat unit over here to Presby [hospital]  where we decontaminated the car the patient drove in and secured it."

A 'Breach' in Infection Control Protocols
Other healthcare workers who cared for Duncan at Texas Health Presbyterian Hospital may test positive for Ebola virus in coming days because they "may have had a breach (of infection control protocols) of the same nature" as the woman who tested positive for the virus Saturday night, the head of the Centers for Disease Control and Prevention said Sunday.

"Unfortunately, it is possible that in the coming days, we will see additional cases of Ebola," Tom Frieden, MD, said at a hastily called news conference Sunday. "This is because the healthcare workers who cared for this individual may have had a breach of the same nature as the individual who appears now to have a preliminary positive test."

The exact nature of that breach is yet unclear, and the healthcare worker herself was not able to identify any particular lapse, Frieden said. So the investigation of the breach will "look at every single interaction," including how personal protective equipment was put on and removed.

"The two areas [at which] we will be looking particularly closely [are] the performance of kidney dialysis and respiratory intubation." Those procedures were performed on Duncan "as a desperate measure to try to save his life," Frieden said.

But "taking off respiratory protective equipment, [was identified] as a major potential for risk," he said. Flawless handling of contaminated material during the removal process "is critically important and not easy to do right," he added.

Frieden said he was unaware of any other patient with Ebola who has undergone either intubation or dialysis, and "certainly it would be very unusual if it had happened before."

Varga said the infected healthcare worker came into contact with Duncan the second time he presented in the ED. What type of contact she had with him was not disclosed.

'Essential Procedures' Only
The CDC is advising any healthcare facility that cares for an Ebola patient to keep the number of workers taking care of that patient "at an absolute minimum," and that the number of procedures undertaken for any Ebola patient "be limited solely to essential procedures."

Frieden said more infection control officials from the CDC would be arriving at the hospital to conduct a thorough investigation of the care processes undertaken for Duncan in the hospital's intensive care unit during the 11 days from between Sept. 28 until his death Oct. 8.

The CDC and other infection control teams are already looking at all other healthcare workers involved in Duncan's care, and their contacts, and are actively monitoring them for earliest signs of infection.

The teams are also ramping up "education and training of healthcare workers at this facility." Frieden characterized the investigation as "intensive."

Furthermore, the CDC is recommending the placement of "a full-time individual responsible for the oversight and supervision and monitoring of effective infection control while any patient with suspected or confirmed Ebola is being cared for," Frieden said.

Care of patients with Ebola "requires meticulous, scrupulous attention to infection control, and even a single, inadvertent, innocent slip can result in contamination," Frieden said.

Frieden said the CDC is examining the type of and amount of personal protection equipment worn by healthcare workers treating patients with Ebola. He said "there's a balance, and putting more on isn't always safer. It may make it harder to provide effective care for all aspects of personal protective equipment."

In addition to bringing in more people from the CDC, David Lakey, MD, Commissioner of the State Department of Health in Texas, said his department has summoned more public health officials, staff, and epidemiologists "to make sure that we have the individuals we need to fully evaluate this situation."

Frieden and Lakey expressed appreciation for the healthcare worker who, Frieden said, "immediately on developing symptoms, as appropriate, contacted the healthcare system and when she came in she was promptly isolated."

Monitoring Other Workers
It was unclear Sunday whether or how many other healthcare workers involved in Duncan's care have been brought to the hospital for observation and to limit their contacts with others.

Texas Health Resources officials are monitoring 18 healthcare professionals for Ebola. THR's list is separate from the list of 48 individuals who are being monitored by Dallas County health officials.

It is unclear why there are separate lists, but Dallas County Judge, Clay Jenkins, who is in charge of the county's Ebola response, said that the 18 people who are self-monitoring will now be monitored by CDC epidemiologists instead. Jenkins also said he's requested additional resources because of the increasing workload.