New Ebola Case Means New Safety Approach, CDC Says

October 13, 2014

The case of the nurse at Texas Health Presbyterian Hospital Dallas who contracted the Ebola virus from Thomas Eric Duncan despite wearing personal protective equipment (PPE) has forced the Centers for Disease Control and Prevention (CDC) to "rethink the way we address Ebola infection control," the agency's chief said today at a press conference.

Less than two weeks ago, CDC Director Tom Frieden, MD, MPH, said that "essentially any hospital in the country can safely take care of Ebola" provided they faithfully follow CDC guidelines for infection control. Today he seemed to say that the job is easier said than done.

"I think what we recognize is that [Ebola care] is complex," said Dr. Frieden.

"We're now working very closely with the hospital to make that care simpler and easier with hands-on training, hands-on oversight and monitoring. And that is something we'll do anytime there is a case of Ebola."

Dr. Frieden said handling Ebola cases involves two different sets of hospitals — those that diagnose the virus in people coming through the emergency room door and those that care for the diagnosed patient on a sustained basis. The first set includes all US hospitals. The second set, he suggested, may be smaller.

"Every hospital needs to think about the possibility of Ebola in anyone with fever or other symptoms who has travelled in Sierra Leone, Liberia, and Guinea in the previous 21 days," he said. "Whatever else we do, that is critical for our entire healthcare system."

When a reporter asked if small US hospitals were up to the task of managing Ebola patients in isolation, Dr. Frieden said the agency is going to "look carefully at...the optimal way to care for people with Ebola, but whatever we do on that issue, it's important that every hospital be prepared to diagnose someone with Ebola."

Another reporter asked Dr. Frieden if the CDC was considering designating certain qualified regional hospitals for Ebola care. "We're looking at all of the possibilities," he replied.

No Intent to Find Fault, Frieden Said

Over the weekend, the Texas health department and the CDC reported that a female nurse at Texas Health Presbyterian who had cared for Thomas Eric Duncan tested positive for the Ebola virus after she was admitted to the hospital with a low-grade fever on October 10. She was in stable condition as of this morning, according to Dr. Frieden.

Duncan, who traveled to Dallas last month after being exposed to the Ebola virus in his native Liberia, was admitted on September 28, three days after an emergency department visit when his infection was not diagnosed. He died on October 8. He was the first person to be diagnosed with Ebola on US soil.

The nurse — the first person to contract the virus here in the United States — had worn a gown, gloves, mask, and face shield as she cared for Duncan after his hospitalization on September 28. Yesterday, Dr. Frieden attributed her infection to a yet undetermined "breach in protocol" that the agency is investigating. The CDC will focus on how the nurse took off her PPE — an exposure risk — after being with Duncan, and how his kidney dialysis and intubation might have possibly exposed her to the virus. Dr. Frieden said it is possible that the infection may show up in other healthcare workers who crossed paths with Duncan.

His reference to a "breach of protocol" drew criticism from leaders of the giant nurses' union National Nurses United (NNU), who said the CDC chief was scapegoating a nurse who had not received proper training on Ebola care. In an NNU survey, 85% of nurses said their hospital had not provided any Ebola instruction that afforded them the opportunity to "interact and ask questions."

Dr. Frieden today said he was not finding fault with the nurse or the hospital.

"I'm sorry if that was the impression given," he said. "That was certainly not my intention. I feel awful that a healthcare worker became infected in the care of an Ebola patient. She was there trying to help the first patient survive."

Dr. Frieden said the CDC had dispatched additional personnel to Texas Health Presbyterian to step up infection-control training on Ebola. Among other things, they are watching how healthcare workers put on and take off PPE, and advising them on how to do it safely. They are also assessing which types of PPE are easiest to get in and out of.

Besides asking for more Ebola training for its members, the NNU also wants hospitals to provide nurses with hazmat suits to safeguard them against infection. In today's press conference, Dr. Frieden did not address the issue of hazmat suits, but he did note that some healthcare workers mistakenly believe that more PPE — additional gloves or coverings, for example — is always better.

"That may actually end up paradoxically making things less rather than more safe, because it may be so difficult to remove those layers that it inadvertently increases the risk," he said. "We don't know that that happened here, but that's one of the things we've been addressing."

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