Ebola-infected health care worker in Dallas may have breached PPE removal protocol after performing 'high risk' procedures on index case

March 18th, 2015

The first case of Ebola transmission to a health care worker in the United States may have resulted from a breach in protocol in removing protective equipment after performing “high-risk” procedures on the Dallas index patient in a heroic attempt to save his life.

That’s but a speculative working theory, the best we piece together based on comments at an Oct. 11 press conference by Tom Frieden, MD, director of the Center for Disease Control and Prevention.

A female health care worker at Texas Health Presbyterian Hospital in Dallas tested positive for Ebola on Friday Oct 10 after caring for Ebola patient Thomas Duncan, who died at the hospital on Oct. 8. Kidney dialysis and respiratory intubation were performed on Duncan in a last-ditch attempt to save his life.

“Both of those procedures may spread contaminated materials and are considered high risk procedures,” Frieden said at an Oct. 12 press conference. “They were undertaken on the index patient as a desperate measure to try to save his life. In taking off equipment -- we identify this as a major area for risk. When you have …contaminated gloves, masks or other things -- to remove those without risk of contaminated material touching you and being then on your clothes or face or skin and leading to an infection -- is critically important and not easy to do right. So these are areas that the investigation will look at, but we don't know what it will find.”

While reaffirming that hospitals can contain Ebola with meticulous attention to infection control, Frieden called for additional measures, including the designation of a person to observe care and look for breaks in precautions or possible exposures. “We are recommending there be a full time individual who is responsible only for the oversight, supervision and monitoring of effective infection control while an Ebola patient is cared for,” he said.

In addition, he emphasized that the number of health care workers who care for an Ebola patient be kept to an absolute minimum to decrease the pool of at-risk employees. Likewise, only essential procedures should be performed in the care of the patient.

“We're [also] looking at personal protective equipment, understanding that there is a balance and putting more on isn't always safer -- it may make it harder to provide effective care --so all aspects of personal protective equipment,” he said.

In terms of barrier precautions, the CDC has recommended essentially everything short of airborne precautions – unless aerosol-generating procedures are performed. If so, a respirator at least the equivalent of an N95 should be worn. It was not clarified at the press conference what PPE the worker was wearing, though the “high risk” procedures described would certainly appear to warrant respirator use. Other health care workers involved in the procedures and other aspects of Duncan’s care are being monitored for symptoms. The infected health care worker is hospitalized in Dallas and the CDC is dispatching a team to the site to investigate the transmission incident and assist in her care.