Key Question: How Did Dallas Worker Catch Ebola?

[morningfog]

How did it happen?

That's the big question as federal health officials investigate the case of a Dallas health worker who treated an Ebola patient and ended up with the disease herself.

These are professionals and this is the United States, where the best conditions and protective gear are available, unlike in West Africa, where the Ebola epidemic is raging in much poorer conditions.

The health worker wore protective gear while having extensive contact with Thomas Eric Duncan, the Liberian man who died Wednesday of Ebola at Texas Health Presbyterian Hospital.

Officials say she has not been able to pinpoint any breach in infection control protocols, although there apparently was a breach, they say.

Experience shows that health workers can safely care for Ebola patients, "but we also know that it's hard and that even a single breach can result in contamination," Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said Sunday on CBS' "Face the Nation."

The situation also raises fresh concerns about whether any U.S. hospital can safely handle Ebola patients, as health officials have insisted is possible.

Some questions and answers about the new case.

Q: What protection do health workers have?

A: The exact gear can vary. A hazardous material type suit usually includes a gown, two sets of gloves, a face mask, and an eye shield. There are strict protocols for how to use it correctly.

"When you put on your garb and you take off your garb, it's a buddy system," with another health worker watching to make sure it's done right, said Dr. Dennis Maki, University of Wisconsin-Madison infectious disease specialist and former head of hospital infection control.

Q: How might infection have occurred?

A: Officials are focusing on two areas: How the garb was removed, and the intensive medical procedures Duncan received, which included kidney dialysis and a breathing machine. Both involve inserting tubes — into blood vessels or an airway. That raises the risk a health worker will have contact with the patient's bodily fluids, which is how Ebola spreads.

"Removing the equipment can really be the highest risk. You have to be extremely careful and have somebody watching you to make sure you remember all the steps," said Dr. Eileen Farnon, a Temple University doctor who formerly worked at the CDC and led teams investigating past Ebola outbreaks in Africa.

"After every step you usually would do hand hygiene," washing your hands with antiseptic or being sprayed with a chlorine spray, she said.

Q: How else could infection have happened?

A: Some of the garb the health worker takes off might brush against a surface and contaminate it. New data suggest that even tiny droplets of a patient's body fluids can contain the virus, Maki said.

"I can have on the suit and be very careful, but I can pick up some secretions or body fluids on a surface" and spread it that way, he said.

http://abcnews.go.com/Health/wireStory/key-question-dallas-worker-catch-ebola-26142212

[Jamastiene]

1. Was this the same hospital that totally ignored the fact that he possibly had

Ebola the first time around and sent him away? If so, that would explain it completely, imnsho. I'm still reeling from the idiocy displayed by at least one of my local hospital's emergency room doctors.

Otherwise, that is a very good question. It could be anything from a tiny pin prick in a glove or anything.

I feel bad for the nurse either way in this case. Trying to care for someone then ending up with such a devastating virus like that has to be horrible.

[Kelvin Mace]

2. Yep, same hospital

Sloppy protocols will get people killed.

[Jamastiene]

3. Exactly.

Couple that with the original ignorance that did not even think to maybe check him for Ebola and that explains it, to me.

[TBF]

6. The more troubling fact I think is that

TX Presbyterian Hospital in Dallas is a big hospital that is ranked pretty high in Texas. It does make you wonder what would happen if we had an outbreak of these cases in the US. If large city sophisticated hospitals can't handle them we have a more serious issue.

[Kelvin Mace]

22. Just an observation

It is also a big hospital in a state that hates government regulation and has worked overtime to destroy medical infrastructure.

[TBF]

28. Excellent point -

although we have some pretty amazing hospitals in Houston that I think could potentially be the type of "regional center" we may need to tackle Ebola. You make a very good point though. Even though millions (literally) voted for Barack Obama in Texas, we technically have a very reactionary governor who does get in the way.

[Voice for Peace]

15. I'm surprised more cases haven't turned up from that initial contact.

[LisaL]

17. Virus builds up in the patient.

They are at most infectious when near death and after.
So maybe he wasn't shedding a lot of virus yet until he became near death (which is when the nurse was dealing with him).

[enlightenment]

4. I think this interview is worth

listening to - or reading. It is talking about training healthcare workers:

http://www.npr.org/2014/10/08/354507416/cdc-sets-up-mock-ebola-ward-set-up-in-alabama

It was startling to me to hear how easy it is to make an error.

[Warpy]

5. No hair covering, no shoe covering

Ebola is different. The virus itself is incredibly infectious and can live in droplets for up to an hour. There is often spray when sick people vomit. The CDC needs to wake up a little bit and listen to what nurses have been telling them for years.

[kestrel91316]

7. NO HAIR COVERING??????????????????????

Please tell me they wear a cap/hood thing. PLEASE.

[LisaL]

8. Cap isn't in the guidelines.

It's face mask, face shield, goggles, gloves and gown. You can read for yourself. Then maybe you can stop arguing that these guidelines are perfectly adequate?

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

[kestrel91316]

10. Are you always this nasty or just when you are pretending to be a medical expert of some sort?

[LisaL]

12. What, you don't like the answer?

It's a fact (that you can see for yourself) that CDC guidelines don't mention hair coverings.

[LeftInTX]

9. Saw this pic of an ER worker when they admitted the sheriff deputy

Health care workers wait for the arrival of a possible Ebola patient at the Texas Health Presbyterian Hospital in Dallas, Texas, on Oct. 8, 2014. Photographer: Joe Raedle/Getty Images

[kestrel91316]

11. Excellent. I couldn't fathom that they wouldn't care about HAIR being covered.

[LisaL]

13. If CDC does care, they somehow forgot to put it into the guidelines.

[LeftInTX]

14. I don't know if the gown worn by ER worker is the same as gown worn by the nurse

who took care of Mr. Duncan. The gown in the pic looks porous to me. If the ones used on the nursing unit are the same, I can picture pathogens getting onto the nurse's clothing. Also the pants aren't 100% covered.

We wore those porous gowns when we took care of healthy newborn infants. They would sometimes vomit and it would get on the scrubs.

[kestrel91316]

16. All their attire should be TYVEK. Even the West Africans know that much, and

MSF and other aid groups use TYVEK for all their people having contact with victims. That's why it's so miserably hot for them.

[LeftInTX]

21. I doubt the average hospital in the US has TYVEK gowns

[magical thyme]

23. there is a spot on the neck exposed

The head covering needs to drape over the gown.

[Warpy]

20. Not in the CDC blood and body fluids precautions.

What they need are decontamination showers, once suited up and once before the nurse gets back into scrubs or street clothes. They also need chlorine baths to step in on the way out of the room. Or shoe coverings to take off.

The CDC hasn't come up to African standards in that regard.

The precautions in place now worked OK with HIV. They allowed MRSA to be tracked out into the community.

I think they're listening to hospital administrators complain about the costs instead of looking at the very real risks of caring for people sick with ebola-Zaire.

[rainbow4321]

18. I'm thinking the hospital had crappy protocol

If you noticed, officials said they would not be surprised to see additional cases in the next few days.

IMO, they know it was NOT just ONE worker who did the wrong thing...they know multiple workers have been exposed. So either equipment was not cleaned correctly or people were not being decontaminated correctly after being in the room or had poor protection in the room.
Something went wrong on a large scale and officials won't admit to it right now

[LisaL]

19. They have no clue what this "wrong" thing was.

They are just assuming a breach in protocol rather than considering that protocol they suggested might not be adequate.
CDC guidelines call for PPE such as gowns, face masks, face shields, gloves and goggles.
Not even full body suits like we have seen being used.

[magical thyme]

24. I'm thinking it's extremely difficult to remove PPEs in such a way as to not accidentally touch any

exposed surface.

And the hospital -- like most of the hospitals in the US, per nurse's surveys -- didn't adequately train the staff in putting on and removing PPEs.

And maybe the PPEs themselves are insufficient. They wear 3 and 4 pairs of gloves in African. Maybe 2 pairs are insufficient.

The photo posted elsewhere of a Texas ED worker preparing to take in the sheriff shows a spot of neck exposed.

[av8rdave]

25. A comment/question from a non - medical professional

We have all heard the MSM presentations about how Ebola is relatively difficult to contract. However, the specific stories I am reading about suggest otherwise.

The transmission mechanism mentioned over and over is bodily fluids. It would seem that even the smallest quantity of bodily fluid - to include airborne droplets expelled during coughing, sneezing or vomiting - is highly infectious. It also seems that any blood/open sore contact or mucous membrane contact gives the virus a point of entry.

This sounds a lot to me like the same transmission and risk factors as those for influenza or the common cold. If that's the case, it seems logical to conclude that Ebola is highly contagious and very easy to contract.

Am I out to lunch on this? If so, could someone with greater medical knowledge than I have please straighten me out?

[Fumesucker]

26. I'm getting a feeling that she removed the gear by herself

The language in the excerpt certainly implies that she was alone when she was taking off the gear.

Officials say she has not been able to pinpoint any breach in infection control protocols, although there apparently was a breach, they say.

[AngryAmish]

27. She got it from that guy who had Ebola