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Gary Evans writes Hospital Infection Control & Prevention (HIC), Hospital Employee Health (HEH) and contributes to IRB Advisor (IRB). As senior writer at AHC, Evans has written numerous articles on infectious disease threats to both patients and health care workers, including pandemic influenza, MERS and Ebola. He has been honored for excellence in analytical reporting five times by the National Press Club in Washington, DC.
Faced with fear and brewing rebellion in the health care community, the Centers for Disease Control and Prevention has dropped its dogged insistence that “any U.S. hospital can take care of an Ebola patient” in favor of rapid response teams.
The CDC Ebola Response Teams will be rapidly dispersed to any hospital in the country that reports a diagnosed case, Tom Frieden, MD, CDC director, said at an Oct. 14 press conference. “We will put a team on the ground within hours with some of the world’s leading experts in how to take care of and protect health care workers from Ebola infection,” he said.
Later that same day, Texas state health officials reported that a second health care worker acquired Ebola at Texas Health Presbyterian Hospital during treatment of the index case, who died Oct. 8. The health care worker reported a fever Tuesday, was immediately isolated at the hospital and subsequently tested positive for Ebola. CDC officials had warned there could be more cases among health care workers at the Dallas hospital, in part because they have not yet been able to confirm a specific incident that led to the first nurse's infection.
Another likely factor in creating CDC rapid response teams and dropping the "all hospitals can treat" mantra is that nursing unions are charging that their members have not been sufficiently trained on Ebola at many hospitals.
“I’ve been hearing loud and clear from health care workers around the country that they are worried --- they don’t feel prepared to take care of a patient with Ebola,” Frieden said. “We know how to stop Ebola, but we know it’s hard. We know that a single breach, a single slip can cause an infection.”
Thus the new emphasis on rapid response teams, though Frieden stressed that every hospital in the country still needs to be ready to diagnose a case of Ebola.
“That means that every doctor, nurse and staff person in an emergency department who cares for someone with fever or other signs of infection should ask where have they been in the last month?” he said. “The fact is that usually infection in health care settings spreads through someone who is not yet diagnosed. We have to shore up the diagnosis of those who have symptoms and have traveled.”
Once the diagnosis is made, the hospital can call in a CDC response team, which will include experts in infection control, laboratory science, personal protective equipment, and management of Ebola units. CDC experts will also assist with experimental therapies, public education and environmental controls and waste removal, Frieden said.
This is essentially what the CDC has done in incremental fashion at Texas Health Presbyterian Hospital, where a 26-year-old nurse tested positive for Ebola on Oct. 10 after treating the index case. At Tuesday’s press conference – before the second health care worker infection had been confirmed -- Frieden expressed remorse about the first nurse’s infection, frankly admitting he wished the agency had done things differently.
“I’ve thought often about it,” he said. “I wish we had put a [response] team like this on the ground the day the first patient was diagnosed. That might have prevented [the nurse’s] infection, but we will do that from this day onward.”
Outbreaks can be humbling, as Frieden’s expression of regret comes after many CDC assurances that U.S. hospitals could handle Ebola and the virus would be “stopped in its tracks” in this country. In fairness, the CDC must establish some initial presumptions in fighting an outbreak, and that one unfortunately turned out to be wrong. A similar situation occurred during the 2001 anthrax mail attacks, when the CDC initially assumed that anthrax powder would not spread from sealed envelopes in postal processing facilities. The dogma was that postal processing workers were at risk for cutaneous disease, but not inhalational anthrax. That and several other CDC presumptions about anthrax were proven false by unfolding events, recalled Julie Gerberding, MD, MPH, former CDC director.
“Of course, in retrospect, we realized that … these ‘facts’ were wrong,” she said. “That was brought home to bear when the postal workers at Brentwood [post office] died of inhalational anthrax.” (See Hospital Infection Control & Prevention, May 2002, pp. 53-56.)
First Dallas nurse in stable condition
The first Dallas nurse infected with Ebola is in stable condition and there are hopes for a full recovery, in part because the infection was discovered so quickly through her own self-monitoring. In addition she received transfused blood from an American physician who survived Ebola. She reported one personal contact for the CDC to follow for the 21-day Ebola incubation period. (Make that one human contact -- public health officials have also quarantined her beloved dog Bentley, a King Charles spaniel who thus far shows nary a sign nor symptom.)
Regarding other hospital contacts with the index patient, the numbers are something of a surprise. Frieden reported that in addition to the original infected nurse, 76 other health care workers at Texas Health Presbyterian Hospital had some potential contact with the deceased patient or his blood. We now know that one of those became the second case of occupational transmission. The remaining 75 workers will all be followed for the Ebola incubation period, but the CDC is emphasizing that hospitals limit the number of health care workers performing Ebola care.
The CDC is investigating what breach in protocol could have led to the occupational transmission in the first case, repeatedly stressing the importance of removing contaminated personal protective equipment with the utmost caution. In that regard, the CDC is now recommending that a “site manager” be designated to observe infection control precautions during care for Ebola patients.
“That individual makes sure that the personal protective equipment is put on correctly and taken off correctly,” Frieden said. “In our work stopping Ebola in Africa this is the single most important position to protect health care workers.”
That certainly raises the fair question about why such a site manager wasn’t strongly recommended in the CDC’s recently issued Ebola infection control guidelines. The CDC may have more than one regret before this outbreak is over.