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CDC rethinks methods to stop spread of Ebola

DALLAS — The transmission of the Ebola virus to a nurse here forced the Centers for Disease Control and Prevention on Monday to reconsider its approach to containing the disease, with state and federal officials re-examining whether equipment and procedures were adequate or too loosely followed, and whether more decontamination steps are necessary when health workers leave isolation units.

“We have to rethink the way we address Ebola infection control, because even a single infection is unacceptable,” Dr. Thomas R. Frieden, director of the CDC, told reporters.

Health officials still do not know how the nurse, who helped treat the Ebola victim at Texas Health Presbyterian Hospital and wore a gown, mask and other protective gear during her interactions with him, became infected.

A team of CDC officials — reinforcements sent to Dallas in the aftermath of the second Ebola case diagnosed in the United States — worked through the night at the hospital to identify what was described as a “large group” of health care workers who might be at risk of infection because they treated the original Ebola victim, Thomas Eric Duncan, 42, at the hospital from the time he was admitted on Sept. 28 until he died last Wednesday.

And they are now watching hospital personnel as they put on and take off their protective garb, retraining the staff and evaluating the type of protective equipment being used. They were considering using cleaning products that kill the virus to spray down workers who come out of the isolation unit where the nurse is being treated.

“There are a series of things that are already implemented in the past 24 hours,” Frieden said. “If this one individual was infected, and we don’t know how within the isolation unit, then it is possible that other individuals could have been infected as well.”

The agency’s acknowledgment that substantial changes were needed came in sharp contrast to its earlier tone of confidence. On Sept. 30, Frieden had declared about Ebola: “I have no doubt that we will stop it in its tracks in the U.S.” He began Monday’s press briefing by saying that “stopping Ebola is hard.”

The additional precautions announced Monday were part of what Frieden described as a “doubling down” on the amount of training, education and support the CDC provides to Texas Health Presbyterian and other hospitals around the country.

It came as the pool of people being monitored for potential exposure to the disease appeared to more than double, from 48 to perhaps more than 100, none of whom had reported any symptoms of Ebola. All of those now being evaluated for the first time were workers at Presbyterian who cared for Duncan after he was admitted.

Though the precise number of workers remains unknown, questions were also being raised about why they had not been monitored previously.

Dr. Joseph McCormick, regional dean of the University of Texas School of Public Health in Brownsville, said he was shocked that none of those monitored by officials in recent days were the hospital workers caring for Duncan after he was put in isolation. McCormick worked for the CDC in 1976, when he helped investigate the first epidemic of Ebola in Central Africa.

“You know that once this guy is really ill and he’s hospitalized, there’s going to be a lot of contact, manipulation of blood specimens, cleaning up if he’s vomiting or if he’s got diarrhea,” McCormick said. “You certainly can’t assume that because he’s hospitalized and in this unit that everything is fine and everything that goes on will be without any risk. I mean, that’s just ludicrous to think that.”

The nurse — Nina Pham, 26, a 2010 graduate of Texas Christian University in Fort Worth — had extensive contact with Duncan after he was admitted. A person who had contact with Pham was also being monitored, although health officials said the interaction came at the onset of Pham’s symptoms, meaning it was unlikely that she was infectious at the time.

Frieden acknowledged that officials “have not identified a specific problem that led to this infection,” which left them operating partly in the dark.

Officials are considering imposing a requirement that workers at Presbyterian be sprayed with a disinfectant, like chlorine, after they leave an infected patient, often in a side room that is connected to the patient’s room. The procedure, which is used in Africa, is rarely used in American hospitals.

“Every option is on the table at this moment,” said Abbigail Tumpey, a CDC spokeswoman.

Additionally, someone will be assigned to monitor health workers as they put on their protective gear and take it off, to reduce the risk that they infect themselves, for example, from fluid on gowns or gloves. And, the authorities are weighing whether procedures like intubation and dialysis are worth the grave risks they pose to the medical workers who perform them. Such modern medical procedures can extend life, but are complex, and are not part of regular care in the African countries hardest hit by Ebola.

The procedures would be tested as a pilot in Dallas, Tumpey said, and those that are deemed most useful will be used to update the CDC’s infection control guidance document, most likely next week. The agency would then send alerts via email and news flash updates to clinicians and hospitals. The agency does not have the authority to compel hospitals to change procedures.

The health agency has also sent new experts to Dallas, including Dr. Michael Bell, an epidemiologist who has worked on Ebola for the CDC, and hospital infection control experts. No decisions have been made on whether Ebola patients should be transferred to one of four specialty hospitals around the country.

State and federal health officials seemed to be, in a sense, starting over, two weeks after Duncan’s diagnosis of Ebola on Sept. 30. They were now identifying, assessing and learning more about a group of health care workers they had largely ignored, to the point that they spent more than 24 hours simply trying to identify who they were.

Frieden described the process as casting the net wider, but on Monday did not address whether he thought officials had made a mistake in not monitoring all the hospital workers initially.

Dr. Robert L. Murphy, director of the Center for Global Health at Northwestern University, said the missteps in Texas underscored the need to create a national “Ebola czar” with centralized authority to respond to the crisis, an idea proposed Sunday by Sen. John McCain, R-Ariz.

Murphy said that the American public health system is a “state-oriented” one, in which state public health departments have the primary responsibility for fighting the outbreak of an infectious disease like Ebola. The CDC, he said, acts as “a central clearinghouse and a reference center, and can provide guidelines and recommendations and assist the states in implementing these policies. But it’s strictly up to the states as to whether they follow those guidelines or not.”

Frieden and other officials briefed President Barack Obama in the Oval Office on the latest in the Ebola situation, aides said. Obama met with Sylvia Mathews Burwell, the secretary of health and human services; Susan Rice, his national security adviser; Frieden; and Lisa Monaco, the president’s homeland security adviser.

As health officials struggle to contain the disease in Texas, the political fight in Washington over funding levels for public health agencies — and whether reductions have left the country unprepared for a public-health crisis — has reached a fever pitch.

The CDC’s overall budget of $6.8 billion in fiscal 2014 was roughly similar to what it was four years earlier — a substantial cut, when one factors in inflation, said Sherri Berger, the agency’s chief operating officer. The National Institutes of Health saw its budget decrease to $30.1 billion in fiscal 2014 from $31.2 billion in fiscal 2010.

The worry over Ebola spread to Kansas City, Kansas, where a medic who had worked on a boat along the African coast showed up at the University of Kansas Hospital saying he had previously had a high fever. The man, in his 40s, was isolated in an infectious-disease unit, was undergoing tests and was considered a low to moderate risk for Ebola, said Dr. Lee Norman, the hospital’s chief medical officer.

Concern was also evident in Louisiana, where a state judge granted the state attorney general, Buddy Caldwell, a temporary restraining order Monday blocking the dumping of Duncan’s incinerated personal items in a hazardous-waste landfill in Calcasieu Parish.

According to the CDC, Ebola-associated waste that has been properly incinerated is not considered infectious. But Caldwell, a Republican, said in a statement Monday that Louisianans “just can’t afford to take any risks when it comes to this deadly virus.” In his petition before the court, Caldwell said that the agencies in his state that regulate medical waste learned about its coming to Louisiana from news media reports, and that no permits for the transportation of the waste had been applied for.

An environmental worker wears a hazard suit Monday in a staging area at the apartment of a nurse who tested positive for Ebola in Dallas.


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