Second Ebola Worker’s Trip Raises Concerns on U.S. Spread

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A second Texas nurse infected with Ebola alerted U.S. health officials to her elevated temperature before flying from Cleveland to Dallas on a commercial airline.
The nurse’s movements after helping care for the first Ebola patient to die in the U.S. at Texas Health Presbyterian Hospital in Dallas increased the number of people potentially exposed to the virus in the country.

Source: Akron Public Schools via Bloomberg Amber Vinson graduated in 2003 from Firestone High School in Akron.
Source: Akron Public Schools via Bloomberg
Amber Vinson graduated in 2003 from Firestone High School in Akron.

While the risk of infection is low, U.S. officials are contacting at least 132 people who were on the Frontier Airlines flight used by the woman, along with people she visited over her three days in Cleveland. The Ohio Health Department said it will implement quarantines if needed.
Thomas Frieden, the director of the Centers for Disease Control and Prevention, said yesterday that the nurse shouldn’t have traveled on a commercial airline. But she alerted CDC officials to her condition before returning to Dallas and wasn’t told not to take the flight, Barbara Reynolds, an agency spokeswoman, said later in the day.
The woman was in Ohio when public health officials began requiring hospital workers who had contact with Ebola patients to offer daily reports on their condition, Reynolds said. Before she boarded the flight to Dallas, she informed the CDC that she had a temperature of 99.5 degrees. The temperature is below the CDC’s fever threshold for those exposed to Ebola, Reynolds said in a phone interview. The agency lowered the fever threshold two weeks ago from 101.5 degrees to 100.4 degrees, she said.
Elevated Temperature
“She did report as a part of her screening an elevated temperature at that time but not a fever,” Reynolds said. The woman then flew to Dallas.
“She spent the night wherever she was and the next morning she reported to the hospital with fever,” she said.
The back-to-back infections, complaints about lax hospital safety and the worker’s flight have added to concern that federal officials may not be able to contain the virus, despite earlier assurances the U.S. won’t face an Ebola epidemic. The CDC now says it will create medical SWAT teams to quickly respond to infections and expand national protocols for hospitals dealing with Ebola.
Frieden said the risk from the nurse to those around her during her travels “would be extremely low.”
“She did not vomit and she was not bleeding,” he said during the call.
Frieden didn’t say whether the worker was told not to leave the city, or discuss what other instructions she might have received. State and local officials in Dallas also declined to discuss details of the case.
Headed to Atlanta
The nurse was transferred from Texas Health Presbyterian Hospital Dallas to Emory University Hospital in Atlanta, which has already cared for three patients with the virus, two of which have been released. She will be placed in the same unit as the previous patients, Holly Korschun, a spokeswoman for Emory, said in an e-mail.
The infected patient has been identified as Amber Vinson, said Dan Ball, a spokesman for the Cleveland mayor’s office. She flew to Cleveland to prepare for her wedding, and visited with her mother and fiance, according to Toinette Parrilla, director of Cleveland’s health department.
The community has now set up an emergency command center, that will “educate the public, inform them about what they need to know to protect themselves, and to trace, track and contain” the disease should it appear, Parrilla said in a call with reporters. If a case is found, she said Cleveland is ready to enact quarantine measures.
Infection Details
More details have been emerging about how the two health-care workers may have become infected. Frieden said both were in close contact with Thomas Eric Duncan, who flew from Liberia to visit family in Texas before showing symptoms and then dying at the Dallas hospital on Oct. 8.
National Nurses United, which has 185,000 members, said in a statement that workers who cared for Duncan were initially given safety suits with exposed necks, forcing them to use medical tape to cover their skin. Hospital managers also played down the need for more protective masks, and sent around lab specimens that weren’t specially sealed through the hospital’s tube system, the group said.
They also said Duncan initially was kept in a room with other patients before being isolated.
‘Retaliation Fear’
The information on safety lapses came from “registered nurses” who have “familiarity with what occurred at the hospital,” according to the group. The nurses are anonymous “out of fear of retaliation,” the union said in its report.
“This month has been a nightmare for nurses across the nation,” RoseAnn DeMoro, executive director of the nursing group, said yesterday in a conference call.
The organization called on President Barack Obama to mandate strict standards for Ebola infection control at U.S. hospitals, including creating detailed systems for training and the use of full-body protective suits.
“If we do these protocols properly, if we follow the steps and get the information out, the likelihood of widespread Ebola in this country is unlikely,” Obama said yesterday after meeting with members of his Cabinet on the response to Ebola.
Meanwhile, two Republican lawmakers — Representative Pete Sessions of Texas and Tom Marino from Pennsylvania — called for Frieden’s resignation as head of the CDC for not reacting quickly or strongly enough to the Ebola cases.
Duncan first went to Texas Health Presbyterian’s emergency room on the night of Sept. 25, was given antibiotics and then released back into the community. On Sept. 28, he returned in an ambulance, was admitted and eventually confirmed as having the disease.
‘Incorrect Assumptions’
“This is a disaster,” said Georges Benjamin, executive director for the American Public Health Association, a Washington-based nonprofit. “A lot of assumptions were made about the readiness of this hospital and its ability to manage this outbreak in their hospital. It appears that a lot of those assumptions were incorrect.”
Hospitals and public health departments have been “starved” of resources as government budgets have tightened, leading them to cut preparedness programs and disaster planning, Benjamin said in a telephone interview.
Daniel Varga, chief clinical officer for Texas Health Resources, which runs the hospital, said the Dallas facility has “proper protective gear.” He declined further comment on the specific allegations, except to say, “I don’t think we have a systemic institutional problem.”
Initial Contacts
The contact between Duncan and the two infected caregivers probably happened during the first three days they were treating him after he was isolated Sept. 28. A team sent by the CDC to work with hospital staff members didn’t actively help Texas Health Presbyterian with infection control at first, said Dave Daigle, a CDC spokesman in Dallas.
The two female nurses had contact with Duncan’s vomit and diarrhea at this time, and hospital workers were using a variety of different ways to protect themselves from infection, according to Frieden.
In some cases, Frieden said, they were using three or four layers of protective gear and taping it to make sure it was secure, yet those actions could have made it more difficult to remove the gear and more likely to get exposed to the virus while taking it off.
‘Dedicated People’
“These are good dedicated people and they were trying to protect themselves better but in fact by putting on more layers of gloves, it becomes much harder to put them on and take them off,” Frieden said. “The risk of contamination gets much higher.”
The CDC said their initial team was mainly involved with tracing possible connections to Duncan before he was admitted to the hospital and not overseeing what steps health workers were taking to protect themselves.
“We did consult with the team and the hospital,” but didn’t provide any hands-on care, Daigle said.
The Cleveland-to-Dallas flight taken home by Vinson, the second infected health-care worker, came the night of Oct. 13, and involved Frontier Airlines flight 1143, the CDC and the airline said. She reported symptoms to Texas health authorities hours after her return, was admitted to the hospital and was in stable condition before her transfer to Emory Hospital.
“Because of the proximity in time between the evening flight and first report of illness the following morning, CDC is reaching out to passengers,” the agency said.
The newest case is the third known instance of Ebola transmission outside of Africa, where an outbreak in Sierra Leone, Guinea and Liberia has killed about 4,500 people, the World Health Organization reported yesterday.
Improving Condition
Nina Pham, a nurse who was the first infected health-care worker in Dallas, is being cared for at Texas Health Presbyterian. She has improved since her infection was publicly disclosed on Oct. 12 and is in good condition, according to the hospital.
The infections outside Africa have spurred the U.S. and U.K. to begin screening some airline passengers on arrival in the past few days.
“It’s really concerning that health workers wearing full personal protective equipment have developed Ebola,” said Raina MacIntyre, a professor of infectious diseases epidemiology at the University of New South Wales in Sydney.
Protocols Questioned
“The initial response of authorities has been to blame the nurse, that they made a mistake in the donning and doffing of equipment or made some mistake in the protocol” she said. “But it’s also possible that the guidelines aren’t adequate.”
About 9,000 people have been infected with Ebola in the three countries, the WHO said. The number of new Ebola cases in three West African nations may jump to from 5,000 to 10,000 a week by Dec. 1 as the deadly viral infection spreads, the WHO said yesterday. The fatality rate in the current outbreak is about 70 percent.
There’s no cure for Ebola, which jumps to humans from animals such as fruit bats and chimpanzees. The virus spreads from contact with bodily fluids such as blood, vomit and feces. Burial practices in West Africa, where mourners come in contact with corpses, have fueled the spread.
To contact the reporters on this story: Caroline Chen in New York at cchen509@bloomberg.net; Shannon Pettypiece in New York at spettypiece@bloomberg.net; Zain Shauk in Dallas at zshauk@bloomberg.net
To contact the editors responsible for this story: Reg Gale at rgale5@bloomberg.net Andrew Pollack

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