When a Liberian man brought Ebola to Dallas late last month, CDC Director Dr. Thomas Frieden boldly predicted that the U.S. would "stop it in its tracks." But the spread of the virus to two nurses who cared for the man raises new questions about how prepared caregivers are to treat and corral the virus.
As officials investigate how the nurses contracted Ebola, despite safety guidelines, caregivers in Maryland are examining whether they have the training and equipment to protect themselves should the virus travel here.
Doctors and nurses who are used to taking precautions around patients with infectious diseases but unfamiliar with Ebola are seeking extra instruction on protective gear. Paramedics are considering steps to prevent contamination of ambulances should they carry any Ebola patients. State health officials and providers, meanwhile, are discussing employing buddy systems or staff whose sole responsibility would be to monitor safe donning and doffing of gloves, masks and gowns.
Alarm over whether the United States is ready for Ebola was raised further Wednesday when the Centers for Disease Control and Prevention said a second nurse who had cared for the Liberian who became sick in Dallas tested positive for the virus. Health officials were contacting more than 130 people who were passengers on a plane from Cleveland to Dallas with the nurse, a woman who said she had a low-grade fever before the flight.
The threat of Ebola's spread is not expected to wane. World Health Organization officials said that by December there could be as many as 10,000 new cases of the disease each week in West Africa. The WHO also recently revised estimates of the outbreak's mortality rate from 50 percent to 70 percent. About 4,500 people have died in the outbreak, all but two of them in West Africa.
Now, the transmission of the disease to the nurses suggests that more must be done to prepare caregivers for the rare and deadly virus — and to protect them from it, Maryland officials acknowledged.
"We absolutely have to provide the best support for people on the front line," state Health Secretary Joshua Sharfstein said. "We have to approach this with a good deal of humility given what happened in Texas, and we continually have to be asking ourselves what should we be doing."
The second nurse, Amber Vinson, 29, was isolated Tuesday after reporting a fever, Texas Department of State Health Services officials said. She had treated Liberian patient Thomas Eric Duncan, the first patient diagnosed with the virus in the U.S. He died Oct. 8 at Texas Health Presbyterian Hospital.
Vinson took a Frontier Airlines flight from Cleveland to Dallas/Fort Worth International Airport on Monday, officials said. She had been instructed to monitor herself for Ebola symptoms and had a 99.5 degree fever before taking the flight, Frieden said. Still, he said, the risk to other passengers was thought to be low because Vinson was not vomiting or bleeding on the flight. Ebola is transmitted through direct contact with bodily fluids and is not thought to be airborne.
Over the weekend, 26-year-old nurse Nina Pham became the first person to be infected with Ebola in the United States. The hospital said on Tuesday that Pham was "in good condition."
Maryland health care providers said the nurses' cases were prompting them to pursue additional training, specific to Ebola. While hospitals have been operating since August under CDC guidelines to screen for Ebola and prepare for its arrival, some were heightening the alarm further after the missteps in Texas.
The infection of the nurses "makes it personal as well as professional," said Dr. Tyler Cymet, president of MedChi, the state physicians' society.
Anne Arundel Medical Center held an Ebola training seminar Wednesday night for its doctors and nurses, and hospital staff were preparing training materials such as posters showing proper steps for donning and removing gowns, gloves and masks. At Mercy Medical Center, a task force is undertaking education and training on Ebola preparation.
Some advocates for health care providers have said the training the Dallas nurses had received wasn't enough. National Nurses United, a union and professional association for U.S. nurses, said Tuesday that the Texas hospital lacked protocols to deal with an Ebola patient, offered no advance training and provided nurses with insufficient gear, including suits that left their necks exposed.
In Maryland, nurses take annual online courses on how to protect themselves from diseases spread by blood and other bodily fluids, said Kathleen Ogle, an associate professor of nursing at Towson University and a nurse practitioner in Arnold. But the instruction is not specific to Ebola.
Ogle said she expects training opportunities to increase given the Ebola risks. But there is little nurses and other providers can change until more is known about how the virus spread in the Dallas hospital, she said.
"We still don't know, was there a minuscule tear in their suit?" she asked. "We just don't know."
While training for nurses has significantly cut down on hospital-acquired infections by emphasizing hand washing and proper handling of equipment, extra training on CDC and WHO guidelines is needed for a pathogen as unfamiliar as Ebola, said Yolanda Ogbolu, assistant professor in Maryland's nursing school and deputy director of the Office of Global Health.
"You can get basic training and work as a nurse for 25 years and you still need to be continuously updated," she said. "Nurses are appropriate in making requests for additional training around Ebola."
MedChi has been sharing CDC updates with doctors to ensure they are up to date on what to look out for and how to react if they spot a possible Ebola case, Cymet said. But, he added, the blame should not be placed solely on care providers when unfamiliar diseases like Ebola spread in health care settings.
"It's not the health provider's fault that she caught Ebola, and [officials are] not telling her what to do differently," Cymet said. "The finger-pointing is misplaced. We need more education and more resources."
The CDC is working to provide that to the Texas hospital. It sent extra CDC staff and two nurses from Emory University, which has a specialized hospital that has treated other Ebola patients flown in from West Africa, to offer training. Around-the-clock site managers were being put in place to oversee how health care workers take on and off the protective gear used when treating Ebola patients.
The CDC recommends using gowns, gloves and masks, but in Africa the virus has nevertheless spread among health care workers who did not put the equipment on properly or unwittingly contaminated themselves while taking it off. Frieden suggested such a lapse likely allowed the nurses in Dallas to become infected.
But experts said avoiding those mistakes can be challenging when health workers are unfamiliar with the equipment or are stressed.
"There's a very dangerous moment when you undress. You're tired, you're sweaty," Dr. Trish Perl, senior epidemiologist for Johns Hopkins Medicine, said at a Hopkins symposium on Ebola on Tuesday. "It's like learning how to drive," she said of using the equipment.
At Sinai Hospital, caregivers plan to use the same equipment they employ with other infectious diseases, many of which are easier to contract but less deadly than Ebola. Dr. John Cmar, assistant director of the hospital's infectious disease division, said staff must focus on being precise when putting on and taking off equipment, instead of being tempted to use full body suits or other unfamiliar equipment, which could invite mistakes.
First responders are also adjusting to the threat of Ebola. Normally, patients with the nonspecific symptoms tied to the virus — fever, body aches, diarrhea — would be classified as low priority for first responders. But 911 dispatchers and first responders are being instructed to ask if the patient has recently traveled to Africa, said Dr. Kevin Seaman, medical director of the Howard County Department of Fire and Rescue Services.
In Baltimore County, police and fire spokeswoman Elise Armacost said officials have received two calls involving potential Ebola patients, but both ultimately turned out to be false. In one call over the weekend, Armacost said responders took "an abundance of caution" with a patient who had recently traveled to Africa. But it was later determined that the patient had not been to one of the countries where Ebola is an issue.
The Maryland Institute for Emergency Medical Services Systems is monitoring for updates from CDC as more is learned about how the Dallas transmissions occurred, and for now hasn't changed its recommendations for emergency medical technicians' use of protective equipment, said John Donohue, chief of field programs for the institute. But officials are considering whether more recommendations are needed, such as use of plastic sheeting over ambulance equipment to minimize contamination if a suspected Ebola patient is being transported.
"We're working as fast as we can with changing information and a changing threat assessment," Seaman said. "The biggest thing we've heard is, 'Can you get us more information and can you get us definitive answers as to what do we do in these circumstances?'"
Information could be the best protection. Cmar noted that four hospitals have cared for infected patients in the United States and staff members have not become sick at three, possibly because they were all familiar with protocols and equipment.
"We need to be focused on doing the right thing for patients when come in, but also doing the right things to protect our own staff," Cmar said. "We need to manage fear by making sure everyone is being appropriately cautious."
Baltimore Sun reporters Meredith Cohn and Jessica Anderson, Reuters and Tribune contributed to this article.
CDC Ebola guidelines
The Centers for Disease Control and Prevention recommends hospitals take the following precautions to prevent the spread of Ebola:
•Isolate patient in a single room with a private bathroom and the door closed
•Require all persons entering the room to wear, at least, gloves, a fluid-resistant or impermeable gown, goggles or a face shield, and a face mask
•Wear additional protective equipment, such as double gloves and shoe or leg coverings if copious amounts of infectious body fluids are present
•Use disposable medical equipment when possible, and otherwise, clean and disinfect all medical equipment used for patient care
•Limit use of needles, handle any with extreme care, and dispose of in puncture-proof containers