Patient Three

A second health worker who had cared for Ebola patient Thomas Eric Duncan has contracted the virus:

The second worker was immediately isolated and tests conducted after they reported coming down with a fever on Tuesday. Test results came back overnight confirming the diagnosis, and interviews immediately began to identify anyone the person may have come in contact with, so they could also be monitored for symptoms. More than 100 people are currently being watched after having come in contact with Duncan before he entered the hospital. …

As news of the new infection broke, more information has been revealed about the care that Duncan received when first trying to gain treatment, and not all of it is good. National Nurses United, a California-based union, has made a number of claims about poor preparation and infection control on behalf of the nursing staff at Texas Health Presbyterian Hospital. Among the charges are claims that Duncan was left in an open room with other patients “for hours,” employees were given substandard protective gear, and hazardous waste piled up to the ceiling.

By the CDC’s account, the hospital was ill prepared to handle an Ebola patient and improvised safety protocols on the fly:

“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. … He said the hospital originally had no full-body biohazard suits equipped with respirators but now has about a dozen. Protocols evolved at the hospital while Duncan was being treated, he said: “Collecting samples, with needles, then you have to have two people, one to watch. I think when the patient arrived they didn’t have someone to watch.”

The CDC itself was also slower to act than it should have been:

CDC Director Thomas Frieden expressed regret Tuesday that his agency had not done more to help the hospital control the infection. He said that, from now on, “Ebola response teams” will travel within hours to any hospital in the United States with a confirmed Ebola case. Already, one of those teams is in Texas and has put in place a site-manager system, requiring that someone monitor the use of personal protective equipment. “I wish we had put a team like this on the ground the day the first patient was diagnosed,” he said. “That might have prevented this infection.”

Boer Deng details how complex these hospital safety protocols can be:

It is hard to track just what goes wrong if a misstep occurs, says Maureen O’Leary, secretary of the American Biological Safety Association. A case of Ebola reported in Spain last week involved a nurse trainee who admitted that she broke protocol by touching her face with a gloved hand after handling patient waste. Removing protective items that were used during care is complicated by the specificity of the process by which it must be done: “Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove; Hold removed glove in gloved hand; Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove,” the CDC’s glove-removal instructions read.

The meticulousness is necessary to distinguish between the contaminated parts of a gown or facemask and the parts that are safe to touch. Contamination often can’t be seen, so even the smallest deviation might create a problem, says Ken Anderson of the American Hospital Association. For this reason, “the sequence of removal is key” to prevent clean surfaces from touching dirty ones. The CDC recommends two possible protocols. Both end with washing hands thoroughly (for the duration of two rounds of “Happy Birthday to You,” according to Anderson).

Amesh Adalja proposes a way to ensure that any future Ebola patients are treated at facilities that are prepared to handle them:

[W]e should seriously consider designating certain medical centers as our primary response centers for any further cases that are treated in the US. Such is the model employed for many diseases including trauma, burns and strokes. In fact, such a regionalization model organically arose during the H1N1 influenza pandemic, when smaller hospitals worked in a hub-and-spoke model to transfer their sickest patients to major medical centers—a phenomenon I studied. Such tiering of levels of care is being implemented now in the UK, which has treated one airlifted Ebola case successfully.