CDC Investigating Protocol Breach in Second Dallas Ebola Case

Investigators from the US Centers for Disease Control and Prevention (CDC) are working to resolve how a health care worker in Texas contracted the Ebola virus while caring for an infected patient.

The CDC said yesterday that the nurse reported a low-grade fever overnight and was referred for testing on October 10, 2014. The nurse has been isolated in stable condition and interviewed to determine any additional potential exposures, and 1 individual who came into contact with the nurse at the onset of her symptoms is currently being monitored.

CDC officials noted a breach in protocol that had previously been laid out for American hospitals occurred at some point, and a detailed investigation is ongoing.

“We need to consider that there will probably be additional cases particularly among health care workers who cared for the index patient when he was so ill,” said CDC Director Thomas Frieden MD, MPH, during a conference call with the media today.

The nurse had been caring for Thomas Eric Duncan, who died from the Ebola virus on October 8, 2014, after traveling to Texas from Liberia. Of the 114 individuals who potentially came into contact with Duncan while he was infectious, authorities in Texas were able to rule out all but 48 patients who will now be tracked for 21 days to determine whether they exhibit any symptoms of the virus. None of those patients has shown any Ebola-related symptoms thus far.

CNN reported that disease detectives who interviewed the nurse believe there are "inconsistencies" regarding both the type of personal protective equipment she wore and the process used in putting it on and removing it. Other health care workers who cared for Duncan will continue to monitor their own health.

Dr. Frieden said today that he did not intend to imply blame on the part of the nurse or the hospital by stating there was a breach in protocol.

“The people on the front lines are really protecting all of us. The people on the front lines are fighting Ebola,” he said. “The enemy here is a virus, Ebola; it’s not a person, it’s not a country, it’s not a place, it’s not a hospital. It’s a virus that’s tough to fight, but I’m confident that together we will stop it. We need to all take responsibility for improving the safety of those on the front lines.”

In response to calls for the United States to ban air travel from the affected countries in West Africa, Dr. Frieden said that doing so would limit the ability to send the vital resources needed to stop the virus where it began, thus increasing the threat to the entire world.

“If we do things that unintentionally make it harder to get the response in, to get supplies in, that make it harder for governments to manage and get everything from economic activity to travel going, it will be harder to stop the outbreak at the source,” he said.

Dr. Frieden added that the second infection will force the CDC to substantially rethink how it approaches infection control in order to protect health care workers.

“Stopping Ebola is hard,” he noted. “We’re taking steps to make it safer and easier.”