Ebola and an American Nurse- Must Read

Here’s what’s scary about the Dallas health-care worker infected with Ebola: she knew she was treating an Ebola patient.

That’s not supposed to happen. Its said that Ebola can be stopped using modern medical protocols. An American health-care worker who is part of a team that knew it was treating an Ebola patient and she was supposed to be able to protect herself. So what happened?

The simple answer is that the Ebola treatment protocols are complicated. It helps to look at this Centers for Disease Control and Prevention checklist. These are the instructions the federal agency gives caregivers for how to take off the protective gear that workers wear when treating patients with deadly diseases, like Ebola.

It is 21 items long. There are full sections on the gloves, and the gowns, and the face mask —each with multiple steps. Imagine trying to keep all this in mind while also trying to treat a patient:

ppe removal


There are “ifs” and “thens” and asterisks to better define terms. There’s a big caveat at the bottom about what to do if the checklist fails and hands get contaminated, but nothing about other body parts.



Then, there’s a whole other page outlining an alternative way to remove the gear, with no clear preference expressed for when which method ought to be used.



CDC director Tom Frieden has stressed how important it is for health care workers to follow government protocols like these. During a press conference on Sunday, he also acknowledged that it can be difficult.

“The care of Ebola can be done safely but it’s hard to do it safely,” Frieden said in his Sunday press conference. “Even an innocent slip-up can result in contamination.”

Forty-nine slides, but still not enough detail

This summer, the CDC produced a PowerPoint detailing how to put on and take off Personal Protective Equipment, or PPE. It has 49 slides.



“Change gloves as needed,” captions to this slide, meant to be read by a CDC official using the PowerPoint in a training, instruct. “If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task.”

What counts as “as needed” or “heavily soiled”? Health care workers have to decide. A separate slide makes this point more blatantly, while discussing the use of personal respirators.



“YOU are responsible for fit checking your respirator before use to make sure it has a proper seal,” the caption to that slide reads. The CDC does not officially recommend respirators for Ebola, since it is not airborne, but Frieden said that the hospitals treating Ebola patients have been using them anyway.

These presentations are summaries of a longer, more official set of guidance, the 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

This 225-page document (145 pages without footnotes) is arguably the United States’ most comprehensive guide to wearing protective health care equipment. One section, on page 52, talks about the challenges of finding the right mask:

Since procedure/isolation masks are not regulated by the FDA, there may be more variability in quality and performance than with  surgical masks. Masks come in various shapes (e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment (e.g., ties, elastic, ear loops). Healthcare facilities may find that different types of masks are needed to meet individual healthcare personnel needs.

How does a hospital choose the right mask after reading that paragraph?

Protocols can be followed. But it takes work.

Three hospitals have treated Ebola patients without a health care worker becoming infected. Those three facilities — Emory University, University of Nebraska and the National Institute of Health — all have specialized biocontamination units. These are the places where workers who contracted Ebola in Africa were sent specifically because these hospitals have spent years running drills and preparing for patients with contagious and deadly diseases. They are facilities we built for these exact situations.

Most hospital workers don’t have that kind of background. Digesting lengthy guidelines and implementing them during high-adrenaline and high-stakes situations is incredibly difficult. Here’s how the New Republic’s Jonathan Cohn describes the challenge:

Hospital officials say that she was observing safety protocols, like wearing recommended protective gear. CDC Director Tom Frieden said that some kind of breach in those protocols must have occurred. The two statements might sound contradictory, but they may not be. The safety procedures are complicated and, particularly if you’re tired, it’s easy to make a mistake. “Look, even in a regular, garden variety operating room, there’s a charge nurse watching to make sure no one has broken sterile technique, like scratching their nose or wiping their brow or touching something, and that is damned hard to do,” says Howard Markel, a professor at the University of Michigan Medical School and author of When Germs Travel. “Now multiply this scrutiny a million fold because it’s Ebola and you get an idea how tough it is to maintain the protocol.”

The CDC has recognized the importance of not just having protocols, but making them easy to use. “One of the things that’s important is that we have practical solutions,” Frieden said in a Monday press conference. “We’re looking at the ways to do this most safely and easily.”

Protocols can be incredibly powerful and important documents in healthcare. Atul Gawande has written extensively about the importance of checklists, and how a simple set of guidelines can go a long way. In one experiment he writes about, intensive care units who followed checklists decreased infections rates by one third in just three months.

“It’s true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds,” Gawande writes. “It’s also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care.”

It is undeniably good that the CDC has a checklist for how to put on the protective gear needed to treat Ebola patients. It’s less good, however, that the protocol is difficult to follow and leaves space for human decisionmaking — and thus space for dangerous human error.


We have no idea how bad the Ebola outbreak actually is

While official estimates suggest there are already more than 8,000 cases of Ebola this year, the real number is likely much, much higher.

“Under-reporting” has been a constant feature of the world’s worst Ebola epidemic. Cases have gone missing, deaths are uncounted, and “there is widespread under-reporting of new cases,” warns the World Health Organization.

The WHO has continually said that even its current dire numbers don’t reflect the full reality. The estimated 8,000-plus Ebola cases in West Africa could just be the tip of the iceberg.


Health workers sterilize the house and prepare a body for burial in Lango village, Kenema, Sierra Leone. (Photo courtesy of Andalou Agency)

To understand how an Ebola case could be missed, you need to understand what it takes to actually find and count a case.

Often times, potential cases are communicated through dedicated hot-lines, which citizens can call in to report on themselves or their neighbors. Health workers or doctors can call in cases, too. These reports are forwarded to local surveillance response teams.

All these cases need to be followed up on and verified to be counted. To do that, a team of two to four investigators is dispatched to hunt for the suspected Ebola victim.


Actually tracking these people down isn’t straightforward, especially in areas where the roads and communication infrastructure are poor. Investigators can spend days chasing a rumor.

These health teams also work under constant stress and uncertainty. During this outbreak, they’ve faced violence, angry crowds, and blockaded roads. They can’t wear protective gear because they’ll scare off locals.

When they finally locate an Ebola victim, he or she may not always be lucid enough to talk or even still alive. So the investigators need to interview friends, family or community members to determine whether it’s Ebola that struck — always keeping a distance.

If this chase appears to have led to an Ebola patient, the health team notifies a dispatcher to have that person transported by ambulance to a nearby clinic or Ebola treatment center for testing and isolation.

If the person is already dead, they notify a burial team, which arrives in full personal protective gear. They put the body in a body bag, decontaminate the house, swab the corpse for Ebola testing, and transport the body to the morgue.

But confirming the cause of death doesn’t always happen. There have been reports that mass graves hold uncounted Ebola cases. With limited resources, too, saving people who are alive tends to take precedent over managing and testing dead bodies.

Reported cases are then communicated to the ministry of health in the country. These reports are combined with counts from NGOs and other aid organizations working in the region. The numbers come in three forms: lab-test confirmed cases, suspected cases, and probable cases. The WHO classifies a suspected case as an illness in any person, dead or alive, who had Ebola-like symptoms. A probable case is any person who had symptoms and contact with a confirmed or probable case.

The ministry of health compiles and crunches this information and sends it to the WHO country office. They then report that to the WHO’s regional Africa office in Brazzaville, Congo and that message is passed along to Geneva, home to WHO’s headquarters.


To get to this point, Dr. David Fisman, an infectious disease modeler working on Ebola, summed up: “A person needs to have recognized symptoms, seek care, be correctly diagnosed, get lab testing — if they’re going to be a confirmed case — have the clerical and bureaucratic apparatus actually transmit that information to the people doing surveillance. At each step along the way the case can fall out of the pool of ‘counteds.'”

There’s no way to know how vastly under-reported this epidemic is, but there are estimates being floated around. Comparing surveillance figures with actual hospital beds dedicated to Ebola care in West Africa, the Centers for Disease Control and Prevention suggested that under-reporting could be happening at a rate of 2.5. This means that every one case reported equals 2.5 on the ground. If true, today’s 8,000 Ebola cases could actually look more like


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