The Texas Department of State Health Services (DSHS) and Texas Health Presbyterian Hospital in Dallas announced Sunday that an ICU nurse at the hospital has become the first victim Ebola of transmission in the United States. This is only the second known case of someone contracting the disease outside its epicenter outside in West Africa. The first, in Spain, also involving a health care worker, was announced last week.
The Dallas case is particularly worrisome because the individual, whose identity has not been released but who is reportedly a 22-year-old female nurse, was believed to have followed protocols for using protective gear and had not been on the Centers for Disease Control and Prevention (CDC)’s watch list for people who’d had contact with the vector patient, Liberian Thomas Duncan, who was infected prior to flying to the U.S. in September and died last week at the Dallas hospital.
According to a DSHS release, the healthcare worker had self-tested with a low grade fever Friday night and was isolated and referred for testing, with a preliminary test result from the state public health laboratory in Austin received late Saturday. Confirmation testing will be conducted by CDC labs in Atlanta
“We knew a second case could be a reality, and we’ve been preparing for this possibility,” commented DSHS commissioner Dr. David Lakey, on Sunday. “We are broadening our team in Dallas and working with extreme diligence to prevent further spread.”
The DSHS reports that health officials have interviewed the patient and are identifying any contacts or potential exposures. People who had contact with the health care worker after symptoms emerged will be monitored based on the nature of their interactions and the potential they were exposed to the virus. Ebola is spread through direct contact with bodily fluids of a sick person or exposure to contaminated objects such as needles. People are believed to not be contagious before symptoms such as fever develop.
Texas Health Presbyterian Hospital in Dallas affirms that it had prepped and drilled front line personnel involved with treating Mr. Duncan in protective protocols during his inpatient care, beginning September 28, and that the worker had worn Centers for Disease Control and Prevention (CDC)-recommended protective gear during treatment, including gowns, gloves, masks and shields. However CDC director Dr. Thomas Frieden told a news conference Sunday that the spread of infection points to a “professional lapse” that may have put other health workers at the hospital in danger of being infected as well.
According to news reports based on information provided by Mr. Duncan’s family, he had been projectile vomiting and experiencing “explosive diarrhea” during the first two days following his Sept. 28 admission before clinical staff began donning hazmat suits and exercising the meticulous infection control measures necessary to contain the virus.
On August 1, the CDC released guidance titled, ”Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals,” recommending that in the care of patients who are persons under investigation, or with probable or confirmed Ebola virus infections, hospitals are advised to apply and exercise stringent personal protective equipment (PPE) and disinfection/decontamination protocols.
The directive notes that enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces in contrast with non-enveloped viruses that are more resistant to disinfectants. And that as a precaution, use of disinfectant products with a higher potency than what is normally required for an enveloped virus is being recommended at this time, and that EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.
CDC recommendations include daily cleaning and disinfection of hard, non-porous surfaces (e.g., high-touch surfaces such as bed rails and over bed tables, housekeeping surfaces such as floors and counters) using chemical disinfectants.
“We are evaluating other potential healthcare worker exposures because if this individual was exposed, which they were, it is possible that other individuals were exposed,” Dr. Frieden noted, adding that the CDC has dispatched additional staff members to Dallas to assist with responding to this new development.
Texas Health Presbyterian Hospital in Dallas Chief Clinical Officer and Senior Executive Vice President Dr. Dan Varga issued a statement Sunday saying that contact individuals being monitored are required to take their temperature twice daily, and as a result of that procedure, the infected care-giver notified the hospital of her imminent arrival and was immediately admitted to the hospital in isolation. Dr. Varga says the entire process, from the patient’s self-monitoring to the admission into isolation, took less than 90 minutes.
According to a DallasNews report, the infected person drove herself to the Presbyterian emergency room, where she was admitted and immediately placed in isolation. Her car and apartment and the common area of her apartment complex have been professionally disinfected by CG Environmental-Cleaning Guys, a Dallas hazardous material company.
The CDC cites a study data that indicating that under favorable conditions Ebola viruses can remain viable for up to six days on solid surfaces, with concentrations falling slowly, over several days. In a follow up study, Ebola virus was found, relative to other enveloped viruses, to be quite sensitive to inactivation by ultraviolet light and drying; yet sub-populations did persist in organic debris. And while there is no epidemiologic evidence of Ebola virus transmission via either the environment or fomites (objects that could become contaminated during patient care that may become contaminated with infectious organisms and serve as vectors in their transmission, such as bed rails, doorknobs, bathroom surfaces, or laundry) the CDC advises that given the apparent low dose required to transmit infection, potential of high virus titers in the blood of ill patients, and the disease’s severity, high levels of precaution are warranted to reduce potential risk posed by contaminated surfaces in the patient care environment.
At the moment of this writing, the patient’s condition is reportedly listed as stable. A close contact has also been proactively placed in isolation. The care-giver and the family have requested total privacy, so the hospital will not divulge greater personal detail.
“We have known that further cases of Ebola are a possibility among those who were in contact with Mr. Duncan before he passed away last week,” Dr. Varga adds. “The system of monitoring, quarantine and isolation was established to protect those who cared for Mr. Duncan as well as the community at large by identifying any potential Ebola cases as early as possible and getting those individuals into treatment immediately.
“Finally, we have put the ED on diversion until further notice because of limitations in staffed capacity meaning ambulances are not currently bringing patients to our emergency department. While we are on diversion we are also using this time to further expand the margin of safety by triple-checking our full compliance with updated CDC guidelines. We are also continuing to monitor all staff who had some relation to Mr. Duncan’s care even if they are not assumed to be at significant risk of infection. All of these steps are being taken so the public and our own employees can have complete confidence in the safety and integrity of our facilities and the care we provide.”
Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) is an extremely aggressive affliction disease with a mortality rate ranging from 25 to 90 percent of cases. It may be caused by any of four of the five known ebola viruses: Bundibugyo virus (BDBV), Ebola virus (EBOV), Sudan virus (SUDV), and Ta Forest virus (TAFV, formerly and more commonly Cte d’Ivoire Ebola virus (Ivory Coast Ebolavirus, CIEBOV)). EVD is a viral hemorrhagic fever (VHF), and is a close relative, and clinically nearly indistinguishable from Marburg virus disease (MVD). Ebola, and Marburg, are both filoviruses.
According to Wikipedia, manifestation of Ebola fever begins with a sudden onset of an influenza-like stage characterized by general malaise, fever with chills, arthralgia, myalgia, and chest pain. Nausea is accompanied by abdominal pain, diarrhea, and vomiting. Respiratory tract symptoms include pharyngitis with sore throat, cough, dyspnea, and hiccups. The central nervous system involvement is manifested by development of severe headaches, agitation, confusion, fatigue, depression, seizures, and sometimes coma. Development of hemorrhagic symptoms is indicative of a negative prognosis, but contrary to popular belief, hemorrhage does not lead to hypovolemia and is not the cause of death (total blood loss is low except during labor). Instead, death occurs due to multiple organ dysfunction syndrome (MODS) due to fluid redistribution, hypotension, disseminated intravascular coagulation, and focal tissue necroses.
Bleeding from mucous membranes and puncture sites is reported in 40-50 percent of cases, while maculopapular rashes are evident in approximately 50 percent of cases. Sources of bleeds include hematemesis, hemoptysis, melena, and aforementioned bleeding from mucous membranes (gastroinestinal tract, nose, vagina and gingiva). Diffuse bleeding, however, is rare, and is usually exclusive to the gastrointestinal tract.
The CDC say they recognize that even a single case of Ebola diagnosed in the United States raises concerns, and now that the possibility has been realized, medical and public health professionals across the country, as well as in Canada, Europe, and elsewhere, have been preparing to respond. Infectious disease expert Dr. Neil Rau told CTV News Channel last week that Ebola has run rampant in West Africa because countries there lack proper medical facilities and protocols to deal with the virus, and noted that North America has the training, technology and hospital space to handle Ebola. “It’s not actually that easy to spread,” Dr. Rau observed. “It’s very difficult to actually get it without being a household member or a health-care worker in contact.”
While the Dallas cases are the first to have been diagnosed in the U.S., America’s public health and medical systems have had prior experience with sporadic cases of hemorrhagic viral diseases such as Ebola. The CDC notes that in the past decade, the United States had five imported cases of viral hemorrhagic fever (VHF) diseases similar to Ebola (1 Marburg, 4 Lassa), and none resulted in any transmission in the United States. But now Ebola has.
Texas Department of State Health Services (DSHS)
Centers for Disease Control and Prevention (CDC)
Texas Health Presbyterian Hospital in Dallas
CTV News Channel