
Dallas health worker who tested positive for Ebola wore ‘full’ protective gear - cmrivers
http://www.washingtonpost.com/news/post-nation/wp/2014/10/12/dallas-health-care-worker-who-treated-thomas-eric-duncan-has-tested-positive-for-ebola/?hpid=z1
======
kyro
More people should understand that hospitals are messy. Really messy. From
wiping vomit to feces to rolling over patients to changing chucks to wiping
down monitor cables to handling bottles of saline that you may inadvertently
leave out in the open for others to touch to not disposing spare gauze that
may be contaminated to forgetting to wipe down your stethoscope to tearing
your gown off as you rush to see another patient, etc etc etc. There are any
number of people going in and out of a patient's room, performing a wide array
of tasks, handling an even wider array of objects. Add to that the often
hurried nature of hospitals and you get an environment prone to breaches of
protocol.

I say this not to incite panic, but to provide insight that many might not
have. It is more likely that during the thousands of interactions that this
patient saw, the messiness led to a breach, instead of the virus infecting via
a vector we've not yet realized.

~~~
wozniacki

      More people should understand that hospitals are messy.
    

_American hospitals_ are messy. It gives me no pleasure to uniquely qualify
that. The fact is that, the more you read on the topic, the more you will
learn that this is an uniquely American thing, at least among the
industrialized advanced nations.

If you exclude the Cleveland Clinics, Cedar Sinais, Beth Israels & Stanford
Meds of the hospital world, most American hospitals are woefully bad for
patients, in terms of HAI rates(Hospital Acquired Infections).

Buried in a pile of books, surveys and studies during the passing of the
Affordable Care Act (ACA) a few years ago, was an eminently readable book
called

    
    
      Catastrophic Care: How American Health Care Killed
      My Father--and How We Can Fix It by David Goldhill. 
    

In 2007, David Goldhill's father, in good overall health, checked into the
hospital with a minor case of pneumonia. Within a few days, he developed
sepsis, then a wave of secondary infections. A few weeks after entering the
hospital and the day after his 83rd birthday, he died.

Here's an Atlantic piece by Mr. Goldhill

[http://www.theatlantic.com/magazine/archive/2009/09/how-
amer...](http://www.theatlantic.com/magazine/archive/2009/09/how-american-
health-care-killed-my-father/307617/)

A Reason TV discussion with him

[https://www.youtube.com/watch?v=GvSa9nC4JcQ](https://www.youtube.com/watch?v=GvSa9nC4JcQ)

I think his points are still relevant, even after the passage of the ACA.

In a few years, I am certain that we will have to revisit the issue of how
little we get as consumers of healthcare in America, for how much we spend as
a nation, all over again.

~~~
tezza
Um, it's not just the USA:

[http://www.dailymail.co.uk/news/article-1327766/Mid-
Stafford...](http://www.dailymail.co.uk/news/article-1327766/Mid-
Staffordshire-NHS-hospital-scandal-left-1-200-dead-happen-again.html)

1200 dead because of avoidable cleanliness problems

------
JshWright
PPE is hard... Every time you take it off is an opportunity for infection.
It's very easy to get complacent and not be as careful as you should be (yes,
even when dealing with something like Ebola). When you're donning and doffing
dozens of times a day, mistakes happen. It's very likely she wasn't the only
one to be exposed, but hopefully she's the only one that was infected.

~~~
toomuchtodo
Do they do a decontamination shower before you remove your PPE?

~~~
frankydp
Showers can actually do more harm than good if the equipment is permeable, or
the individual did not follow protocol when donning. Meaning even little
things like not cuffing your gloves.

The can cause overconfidence in regards to contamination.

------
zippie
Entering panic mode too fast, according to the chief of the CDC "there was a
breach in protocol"[1]

Frankly, this hospital mismanaged the index patient from the beginning and
though the woman infected now wasn't on the initial list...the list itself
wasn't complete because they didn't properly diagnose the index patient ebola
to begin with.

[1] [http://www.cbsnews.com/news/cdc-chief-on-second-ebola-
case-t...](http://www.cbsnews.com/news/cdc-chief-on-second-ebola-case-there-
was-a-breach-in-protocol/)

~~~
001sky
Isn't the breach in protocol using anything under BSL 4? The problem is there
is no way to ensure BSL 4 outside of a couple specialist labs. So the
protocols are basically dumbed down to the lowest common denominator.

"Only 15 BSL-4 facilities were identified in the U.S. in 2007, including nine
at federal labs."

~~~
hga
Those are labs, and there's some surge capability, that count of 15 either
includes some that can move to BSL4, or there are a few that can do that.

There are 4 hospitals in the nation that have a total of less than 20 beds
that are set up for diseases like this. Emory (CDC), the NIH in Bethesda, the
biggest with 10 beds is in Omaha, Nebraska, and there's one in Missoula,
Montana, not far from one of those BSL4 labs.

~~~
hga
Ah, it turns out we have a grand total of 23 hospital beds nation wide in
theory qualified for Ebola:

3 at Emory:
[http://www.emory.edu/EMORY_REPORT/erarchive/2005/July/July%2...](http://www.emory.edu/EMORY_REPORT/erarchive/2005/July/July%205/isolationunit.htm)

3 in Montana, and they've never used them or put their protocols to the test:
[http://missoulian.com/news/local/st-patrick-hospital-of-
site...](http://missoulian.com/news/local/st-patrick-hospital-of-sites-in-u-s-
ready-for/article_da521772-4839-11e4-b266-4342d105e33f.html)

7 at the NIH, and it sounds like they've gotten some use:
[http://clinicalcenter.nih.gov/translational-research-
resourc...](http://clinicalcenter.nih.gov/translational-research-
resources/resources/special_clinical_studies.html)

As mentioned before, 10 in Nebraska, and they _don 't_ have a BSL-4 lab handy;
hopefully they have, or are setting up, a mini-lab there, for as Emory
realized, it's not practical to send samples from Ebola patients to the
hospital's main lab: [http://www.nebraskamed.com/biocontainment-
unit](http://www.nebraskamed.com/biocontainment-unit)

------
tokenadult
As reported in this news story, "'Clearly there was a breach in protocol. We
have the ability to prevent the spread of Ebola by caring safely for
patients,' [Thomas Frieden, head of the Centers for Disease Control and
Prevention] said in an interview Sunday on CBS’s _Face the Nation._

"Frieden also promised that protocols at the hospital would be reexamined to
find out how the disease was apparently transmitted." Other patients with
quite advanced cases of ebola, who were on the brink of death, have been
successfully treated in United States hospitals without any health care
workers in those hospitals being infected so far. The Dallas hospital where
this latest incident happened will definitely have to review its infection
control protocols, but we know already that other United States hospitals are
doing things right.

Terrifying news like this came out when SARS was first spreading around the
world in 2003. SARS is especially easy to transmit from one person to another
because it is an airborne virus. No doubt there will be other cases of ebola
infection spreading in the developed world, even in hospital settings, now
that the first few cases have been discovered. But SARS transmission decreased
a lot once people in China started taking precautions like self-isolation and
masks to cover coughs. West Africa has a lower availability of equipment,
supplies, trained personnel, and even information today than rural China had
in 2003, but with sufficient outside help the transmission of ebola can also
decrease a lot, until numbers of new cases start falling instead of rising.

~~~
fourstar
You can't compare this thing to SARS at all. Not only does it have a longer
incubation period, but SARS lives outside the host for up to 6 hours (4 days
in poop). Filoviruses can live up to weeks outside of the host.

Not to mention SARS is spread from respiratory droplets. This thing is spread
by: A) vomit B) saliva C) sweat and if you are running a high grade fever you
are going to be sweating and transmitting this thing from every pore in your
body.

So no, this is not going to be as easy to contain as SARS especially once it
hits somewhere like India.

------
chimeracoder
The WaPo headline is rather sensationalist.

Of course he was wearing protective gear (it would have been news if he _hadn
't_).

He may have worn it, but what procedures did he follow for removing it? That's
where infections are likely to occur - the article even notes at the very end
that the nurse in Spain who was infected was probably infected this way.

~~~
carbocation
This is the critical question. She probably dons and doffs protective gear a
few dozen times per day, as do most of us who work in a hospital, but we
rarely practice doing so correctly. The topological distinction between in and
out becomes totally blurred when most people remove their gowns. Therefore, it
is probable that many people would think they are correctly removing full
protective gear, but have never or rarely correctly removed such gear and
therefore got themselves contaminated in the process. Less likely, we don't
understand the transmission vector and some fomite is at play. Ideally, in an
unusual situation such as this, there should be observers closely eying all
contact including de-gowning.

~~~
hga
Somewhere I read that if you're really serious about this, you get yourself
sprayed with something that glows in ultraviolet light, remove the protective
gear, and then look for spots where the agent made its way onto you.

~~~
JshWright
That's a common training technique (a lower tech method is simply to spread
some sticky liquid (like maple syrup) on your PPE).

------
kenjackson
There was an Ebola documentary on PBS a few nights ago and one of the people
noted that he touched a need and that's how he contracted Ebola.

People have likened Ebola to HIV, but HIV does not transmit this easily. Even
during seroconversion (which is when you might get vomiting and such with
heightened viral load) I've never heard of anyone contracting HIV in a
hospital.

I feel like the information on transmission has been poor. For example, is
skin a barrier for the virus?

~~~
hga
" _is skin a barrier for the virus_ "

We don't know. It's strongly suspected broken skin is not a barrier.

~~~
kenjackson
I'd expect broken skin isn't, but what about intact skin? With HIV we can
answer a bunch of questions about transmission. With Ebola I can answer very
few. I think this increases the anxiety.

~~~
dpcan
It absolutely does. I think the problem is that the virus can live on a
surface in bodily fluids for a long time, or a dead body for days.

So you touch the surface with the virus then you wipe your nose, rub your
eyes, eat with your hands.... and you could get infected.

------
nathannecro
A lot of this thread is speculation. Let me interject by actually citing some
research which may answer some questions.

@kenjackson: "Is skin a barrier for Ebola?"

Yes. According to Bausch et al.

"Taken together, our results support the conventional assumptions and field
observations that most EBOV transmission comes from direct contact with blood
or bodily fluids of an infected patient during the acute phase of illness. The
risk of casual contacts with the skin, such as shaking hands, is likely to be
low."

In the same paper, they note that:

"We found [Ebola] to be shed in a wide variety of bodily fluids during the
acute phase of illness, including saliva, breast milk, stool, and tears. In
most cases, the infected bodily fluid was not visibly contaminated by blood."

This lends credence to Kyro and JshWright's assertions that hospital and PPE
protocol are hard to exactly follow, every time (I'm certainly guilty
sometimes). Even if the equipment or chucks aren't stained with blood, there
is a possibility that the patient's tears have leaked onto the material and
remain unseen.

[http://jid.oxfordjournals.org/content/196/Supplement_2/S142....](http://jid.oxfordjournals.org/content/196/Supplement_2/S142.full.pdf+html)

~~~
samstave
Would UV lights kill the virus, if, for example, it were to be sneezed out
from a patient. Assuming the patient room was awash in UV light, would that
kill the virus if it found airborne/aerosol method of transport from an
infected patient?

~~~
nathannecro
Yes. In a sense.

According to several sources, it may take up to an hour for the virus to be
invalidated by UV light. That makes it not really practical for the patient or
the HCP involved.

Not only that, but I suspect at the energies required, the amount of UV
radiation would be quite harmful to the patient as well.

"Inactivation of virus stocks.Virus stocks were inactivated by exposure to UV
light for 1 h. Proper inactivation was controlled by the incubation of Vero E6
cells with the inactivated virus particles and subsequent screening for the
presence of viral proteins (immunofluorescence) and viral RNA (reverse
transcription [RT]-PCR targeting virus-specific transcripts). The UV-
inactivated stocks were used at the same dilutions as the noninactivated
stocks."

[http://jvi.asm.org/content/75/22/11025.full](http://jvi.asm.org/content/75/22/11025.full)
[http://link.springer.com/article/10.1007%2Fs00705-010-0847-1](http://link.springer.com/article/10.1007%2Fs00705-010-0847-1)

------
thewarrior
Maybe we need to create Robot nurses to treat Ebola patients.

~~~
arbuge
Can be hacked. Still vulnerable to viruses.

------
oskarth
I posted the following in the now killed thread
([https://news.ycombinator.com/item?id=8444976](https://news.ycombinator.com/item?id=8444976)):

 _As many commentators undoubtedly will say, additional cases are to be
expected. However, it 's a problem that both in Texas and Spain, the people
infected have been health workers. Health workers that are supposedly well-
protected and well-informed about Ebola specifically (at least the spanish
nurse was, it's not clear in this case yet).

Now it's true that there are more bodily fluids in a hospital than outside,
but given all the protection and procedures, is the difference so big that a
health worker is at a much bigger risk than a person who happen to sit next to
someone infected on a bus?

There are two cases as I see it. Either it's likely that other people, non-
health workers, have been infected. We just don't know about it yet, or it has
been decided that it's not in the public's interest to know. Or the protective
measures are so bad, the disease so misunderstood or hard to protect against,
that health workers effectively can't protect themselves against the risk.

Either case, it's a big problem. In the west too._

In that thread people were saying the health worker was infected before they
knew Duncan had Ebola. In this thread, when it turns out that the health
worker did know Duncan had Ebola, people are saying that it's obvious. Funny
how these things work.

No one except mainstream US media is advocating panic. That doesn't mean it's
not a serious issue that requires our attention. Saying "Ebola is overrated,
more people die of X every year, don't panic ffs" doesn't add anything to the
debate - it's neither controversial nor insightful.

To guide the discussion, here's a suggestion for people who disagree with me.
Either argue why there are more than the two cases that I outlined, or argue
for why either of the two cases aren't a problem in the coming weeks and
months.

~~~
maxerickson
At the time you posted this, there were 1 or 3 other comments. Yet you still
summarize, _In this thread, when it turns out that the health worker did know
Duncan had Ebola, people are saying that it 's obvious._

Going one step further, none of the comments that were posted at the time you
made that summary really said much about whether the worker knew that Duncan
had Ebola.

------
spikels
So far this hospital has completely screwed up both in providing medical
services and explaining what happened. Does it really make sense that an
apparent emergency room worker would be wearing full protective gear including
a face shield before they had even diagnosed Ebola? And if so how did the
virus get through? Magic? No somebody, most likely the infected person,
screwed up. All it takes is a touch of your comtaminated gloved hand to your
unprotected face.

Like when they blamed the computer system then later denied it was a problem
or when they said the initial patient's fever was 101 and it later turned out
to be 104 we may have to wait for the truth to come out, if it ever does.

~~~
rst
From the Post article linked here, "The person treated Duncan, the Ebola
patient, after his second visit to the ER, on Sept. 28." This was not an ER
worker, and their contact with the patient was after the diagnosis.

~~~
spikels
I may be wrong that it may be an ER worker but according to the NY Times "it
occurred at some point DURING or after his second visit to the hospital on
Sept. 28."[1] He tested positive on Sept. 30.[2] We will have to wait to see
what the facts turn out to be.

[1] [http://www.nytimes.com/2014/10/13/us/texas-health-worker-
tes...](http://www.nytimes.com/2014/10/13/us/texas-health-worker-tests-
positive-for-ebola.html?_r=0)

[2] [http://www.modbee.com/2014/10/11/3587238_timeline-for-
first-...](http://www.modbee.com/2014/10/11/3587238_timeline-for-first-case-
of-ebola.html?rh=1)

------
sidcool
I wonder what makes this virus so much more contagious that other strains.

~~~
giarc
It's actually not that contagious. There is a unit of measurement for this
called the Ro number (high #=more contagious). Ebola is about 1.8 currently,
pandemic flu was 1.9, measles is 15-20.

~~~
fourstar
What? You do realize that a RO can actually grow in size which is exactly what
this is doing right?

When the outbreak began in Guinea it was RO = 1.5 Early July, the RO in Sierra
Leone was 2.5. Today in Liberia, the virus has been spreading so fast that the
RO hasn't been computed (and we won't officially know since Liberia has been
acting shady and is not reporting all of their statistics).

I think you probably saw some infographic floating around and are citing that,
but that RO is a variable number.

~~~
giarc
I assumed the inclusion of the word "currently" would have implied that the
number is dynamic, my apologies if that wasn't a safe assumption. I haven't
seen any data putting the Ro in any country over 3.0. Obviously waiting to see
new data that includes September.

Data until Aug 26, 2014.
[http://www.eurosurveillance.org/images/dynamic/EE/V19N36/art...](http://www.eurosurveillance.org/images/dynamic/EE/V19N36/art20894.pdf)

Data until mid Aug, 2014.
[http://arxiv.org/abs/1408.3505](http://arxiv.org/abs/1408.3505)

------
Bud
At some point, we're going to have to talk about how this black, uninsured man
walked into a Dallas hospital, which discharged him and then later lied about
his condition when he first went to a hospital. And we're going to need to
talk about Republicans slashing CDC funding and every other type of public
health funding they could get their hands on. And we're going to need to talk
about how the two white Christian missionaries got flown directly to a
specialized hospital in Nebraska immediately upon diagnosis, and survived.

(edit: very predictable downvoting on this. But it's simply a fact that
politics and race have played a part here. I don't like posting it any more
than you like admitting it to yourselves.)

~~~
iliveindallas
Thomas Eric Duncan took a pregnant woman who later died of Ebola by taxi to
look for treatment. He lied on a questionnaire at the airport in Monrovia that
asked if he had been in contact with anybody infected by Ebola. Because he
lied his own country said that it would prosecute him if he survived!

If Thomas Eric Duncan had not lied at the airport he never would have been
allowed onto an airplane. If Thomas Eric Duncan had told the hospital in
Dallas that he had cared for a person with Ebola he would have been isolated
immediately.

Thomas Eric Duncan isn't dead because he was black. Thomas Eric Duncan isn't
dead because he didn't have insurance. Thomas Eric Duncan isn't dead because
Republicans. THOMAS ERIC DUNCAN IS DEAD BECAUSE HE LIED!

~~~
cjschroed
Actually, what Mr Duncan did was help his neighbors drive a woman who was 7
months pregnant to the hospital. The woman was presenting symptoms that are
not unique to Ebola (fever & convulsions). The woman was not hemorrhagic. The
group was turned away at the hospital and so they drove her back home. Mr
Duncan then assisted in helping the woman back into the house. This is almost
certainly the point at which he was exposed. The woman was not tested for
Ebola until after her death, so Mr Duncan could not have known but he could
have suspected.

Thus the possibility that Mr. Duncan thought he was only helping a pregnant
woman get to the hospital to help with a troubled birth. At that point, the
most information he could provide is that he cared for a sick pregnant woman.

Relying on the fact that Liberia would prosecute him is a bad idea, due to the
precarious nature of justice in that country. I would imagine that Liberia
would say just about anything to prevent public opinion in the US from going
sour. Liberia is facing an existential crisis and are in desperate need of all
the help the US can give.

Mr Duncan's trip to the US was planned weeks in advance, so he was not fleeing
the country in response to his exposure.

~~~
zaroth
> Mr Duncan's trip to the US was planned weeks in advance, so he was not
> fleeing the country in response to his exposure.

Citation for that?

~~~
maxerickson
He needed a visa to enter the U.S. (probably to even board the plane).

It's easy to find articles talking about him receiving the visa in August (I
guess he would have applied for it some weeks or months before that).

------
taivare
Please, share this Ebola awareness poster !
[http://bit.ly/1vF1COO](http://bit.ly/1vF1COO)

------
powertower
[http://www.washingtonsblog.com/2014/10/screening-ebola-
takin...](http://www.washingtonsblog.com/2014/10/screening-ebola-taking-
temperature-cant-work.html)

"Some Ebola experts worry that the virus may spread more easily than thought
-- through the air in small spaces, for example."

Aerosol transmission is a very real possibility and has been demonstrated in
the field and in some experiments, including working its way through the air
ducts of a building, from one part to the another, infecting monkeys, and not
just through one room.

Though some strains are not as effective in that mode of transmission as
others.

edit: To the down-voters, at least make your case. The people that worked with
the virus, and in the hot-zones, made theirs.

~~~
Bud
Here's my case: you made your alarmist "case", such as it is, by posting a
junk article from a junk, far-right blog whose other charming entries include:

-9/11 truther articles -racist crap about Ebola spreading over the Mexican border because of insufficient efforts to secure said border -several other non-scientific articles about Ebola -an article about "Obama's Ukrainian stooges"

If you want to make your case, find one cite--just one will do--from a
legitimate publication of any kind.

~~~
powertower
[http://www.cidrap.umn.edu/news-
perspective/2014/09/commentar...](http://www.cidrap.umn.edu/news-
perspective/2014/09/commentary-health-workers-need-optimal-respiratory-
protection-ebola)

"We believe there is scientific and epidemiologic evidence that Ebola virus
has the potential to be transmitted via infectious aerosol particles both near
and at a distance from infected patients, which means that healthcare workers
should be wearing respirators, not facemasks."

~~~
Bud
Thank you. I very much appreciate that additional cite.

