Ebola in Texas nurse triggers changes in battle plan

So far federal and Texas investigators haven't determined how a nurse was infected with Ebola while caring for a patient from Liberia, but the event has caused the Centers for Disease Control and Prevention (CDC) to rethink approaches for battling the disease.

The sick nurse, 26-year-old Nina Pham of Fort Worth, whose Ebola diagnosis was announced yesterday, is in stable condition. Health officials, though, are deeply worried that other members of the Liberian man's care team may have had similar exposure. The CDC announced late yesterday that its tests have confirmed the positive Ebola findings of the Texas lab.

At a media telebriefing today, CDC Director Tom Frieden, MD, MPH, said another team of its epidemiologists has arrived in Texas and is interviewing the hospital and its employees to pinpoint which ones helped care for Thomas Eric Duncan. Duncan died at Texas Health Presbyterian Hospital in Dallas on Oct 8 after he was sickened with the virus in Liberia.

Investigators are also probing what type of contact Pham had with Duncan, as well as personal protective equipment (PPE) protocols and gear in use at the time.

Frieden said so far it's not clear how many healthcare workers were potentially exposed, and the CDC's team may be able to fine-tune the number by tomorrow. Yesterday, a hospital official said the facility is monitoring 18 of its health workers.

The health workers bring to three the number of contact categories that are being monitored for 21 days. The others include the 48 people originally identified as Duncan’s contacts, none of whom have shown any symptoms, and one person who is a contact of Pham's and has been isolated for monitoring.

Probe focuses on PPE issues

Investigators are especially focusing on the PPE removal step (doffing), which poses a high risk because of potential contamination with virus from a sick patient. Frieden clarified his use of "breach of protocol" terminology yesterday when he spoke about Pham's infection. He said some have interpreted it as finding fault with health workers, which he said is not the case.

Health officials have ruled out transmission during an aerosol-generating procedure, because workers at US hospitals that have cared for known Ebola patients have been using powered air-purifying respirators (PAPRs), Frieden said. PAPRs would be more protective than other types of respiratory protection. Duncan was placed on a ventilator in the days before he died.

"The people on the front lines are protecting all of us from a virus that's tough to fight," he said. "We all need to take responsibility for protecting those on the front lines."

During the investigation and even before the transmission route is identified, changes are being made to better protect workers, Frieden said. For example, employees are being retrained and monitored, with an eye toward PPE changes that would make the work both safer and simpler.

Frieden said the CDC is also doubling down on PPE training and outreach for all US hospitals. He also said other ideas are being considered, such as treating all known Ebola patients at specialty facilities. He emphasized, however, that all hospitals need to know how to quickly identify and safely manage people with Ebola infections.

David Lakey, MD, commissioner with the Texas Department of State Health Services, said initial cleaning has been completed at Pham's apartment and that additional cleaning is under way. The sick employee has a dog, which is being monitored and cared for at a proper location, he added.

Entry screening status, guidance

Enhanced screening of air travelers entering the United States from Guinea, Liberia, and Sierra Leone began at New York’s JFK Airport on Oct 10, which so far identified 91 for further screening, Frieden said. Similar screening starts Oct 16 at four other US airports: Newark, Washington-Dulles, Chicago-O'Hare, and Atlanta.

So far none of the people had fevers or required other medical workup, he said, adding that the step is only one of multiple levels of steps being taken to protect Americans. He reiterated that risk will never be zero until West Africa’s outbreak is controlled.

In a related development, the European Centre for Disease Prevention and Control (ECDC) released a technical report on exit and entry screening to help European governments with their decisions on whether to take similar steps. It said if exit screening is being done effectively, the benefits of entry screening is likely to be very small, with considerable resource implications.

However, it added that entry screening could be considered if countries have doubts about the efficiency of exit screening and if they want to try to flag travelers who start having a fever between the departure and arrival interval.

"Overall, screening for EVD [Ebola virus disease] may detect a few contagious EVD cases over time," the ECDC said, adding that the poor performance of current methods represent a high investment that may provide a limited way to prevent imported cases.

Other developments

  • Liberian health workers walked off their jobs today to protest lack of PPE and to demand hazard pay, Bloomberg News reported. George Williams, who heads the 8,000-member Liberia Health Workers Association, said 8 of 10 workers don't have PPE and that some workers are reusing supplies that are meant to be destroyed after use. He said more coordination is needed to distribute supplies contributed by other countries.

  • The World Health Organization (WHO) released home care advice for families in Sierra Leone who must care for sick loved ones who must wait for an available treatment bed. Dated Oct 11 and e-mailed to journalists, the guidance said treatment centers in the country are struggling to meet demand and plans are under way to add 1,000 more beds. Though the WHO said it doesn't recommending caring for Ebola patients at home, people can reduce their infection risk, for example, by keeping the sick family member in one room, restricting the patient to a separate toilet or waste bucket that is regularly decontaminated, and designating one family member as caregiver.

  • The Johns Hopkins Bloomberg School of Public Health is hosting a webinar tomorrow to discuss the impact of West Africa's Ebola epidemic, current and future response steps, the status of vaccines and drugs, and recommendations for curbing the disease. Seventeen experts are on the agenda, including several nationally known ones from Johns Hopkins and elsewhere, such Peter Jahrling, PhD, chief scientist at the National Institute for Allergy and Infectious Diseases (NIAID) Integrated Research Facility and Michael Osterholm, PhD, MPH, from the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, publisher of CIDRAP News.

  • On Oct 15 National Nurses United (NNU) will hold a national conference call to air concerns about US hospital readiness for identifying and managing patients who have Ebola infections. According to an NNU survey of nurses, 76% said their hospital has not communicated an Ebola policy, and 37% said their facilities have an insufficient supply of PPE.

  • The CDC has posted guidance for hospitals and local health officials outlining key information on handling medical waste from Ebola patients. For example, it says medical waste contaminated with Ebola virus is a category A infectious disease substance according to Department of Transportation regulations, and it provides resources about special permits needed to obtain a variance. It added that Ebola waste can be inactivated through use of appropriate autoclaves, but chemical inactivation has not been standardized. Incinerated Ebola waste can be transported and disposed of according to standard hospital waste disposal protocols, the CDC said.

See also:

Oct 12 CDC statement

Oct 13 ECDC travel screening technical report

Oct 13 Bloomberg News story

Johns Hopkins Bloomberg School of Public Health Ebola webinar

Oct 12 NNU press release

Oct 11 CDC Ebola medical waste management document

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