U.S. tightens rules on gear for Ebola care

In revised policy, workers urged to don full-body suits

Christine Wade, a registered nurse at the University of Texas Medical Branch, greets Carnival Magic passengers disembarking in Galveston, Texas on Sunday, Oct. 19, 2014. Nurses met passengers with Ebola virus fact sheets and to answer any questions.  A Dallas health care worker was in voluntary isolation in her cabin aboard the cruise ship because of her potential contact with the Ebola virus. (AP Photo/The Galveston County Daily News, Jennifer Reynolds)
Christine Wade, a registered nurse at the University of Texas Medical Branch, greets Carnival Magic passengers disembarking in Galveston, Texas on Sunday, Oct. 19, 2014. Nurses met passengers with Ebola virus fact sheets and to answer any questions. A Dallas health care worker was in voluntary isolation in her cabin aboard the cruise ship because of her potential contact with the Ebola virus. (AP Photo/The Galveston County Daily News, Jennifer Reynolds)

ATLANTA -- Revised guidance for health care workers treating Ebola patients will include using protective gear "with no skin showing," a top federal health official said Sunday, and the Pentagon announced it was forming a team to assist medical staff in the U.S., if needed.

Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, said those caring for an Ebola patient in Dallas were vulnerable because some of their skin was exposed.

The Centers for Disease Control and Prevention is working on revisions to safety protocols. Earlier ones, Fauci said, were based on a World Health Organization model in which care was given in more remote places, often outdoors, and without intensive training for health workers.

"So there were parts about that protocol that left vulnerability, parts of the skin that were open," Fauci said.

The CDC guidance was expected as early as Saturday, but its release has been pushed back while it continues to go through review by experts and government officials.

Health officials had previously allowed hospitals some flexibility to use available covering when dealing with suspected Ebola patients. The new guidelines are expected to set a firmer standard by calling for full-body suits and hoods that protect workers' necks, setting rigorous rules for removal of equipment and disinfection of hands, and calling for a "site manager" to supervise workers putting on and taking off equipment.

The guidelines also are expected to require a "buddy system," in which workers check each other as they go in and out, said an official who was familiar with the guidelines but was not authorized to discuss them before their release.

Hospital workers also will be expected to exhaustively practice getting in and out of the equipment, the official said.

"Very clearly, when you go into a hospital, have to intubate somebody, have all of the body fluids, you've got to be completely covered," Fauci said. "So that's going to be one of the things ... to be complete covering with no skin showing whatsoever."

Fauci also mentioned that the CDC's old treatment protocols were based on World Health Organization guidelines designed for field experience in Africa and not for "very invasive procedures" in hospitals. WHO spokesmen didn't immediately respond to emails seeking comment.

The American Nurses Association and other groups had called for better guidance that sets clearer standards on what kind of equipment to use and how to put it on and take it off.

"We're disappointed that the recommendations are still not available," association President Pamela Cipriano said. "Having a lag in official direction from the CDC doesn't instill the greatest confidence in their ability to rapidly respond."

Cipriano said she understands the guidance will also include a call for anterooms, apart from the patient room, where protective equipment must be put on and taken off.

Nurses' protective gear

The push stems from the infection of two nurses at a Dallas hospital after treating an Ebola-infected patient named Thomas Eric Duncan -- the first person diagnosed with the virus in the U.S.

Officials say that how the nurses, Nina Pham and Amber Joy Vinson, were infected remains a mystery.

Duncan's medical records, provided by his family, show Pham first encountered the patient after he was moved to intensive care at 4:40 p.m. Sept. 29, more than 30 hours after he went to the emergency room. Nearly 27 hours later, Vinson first appears in Duncan's charts.

In Pham's first entry, she makes no mention of protective gear -- though doctors and nurses might not always note their own safeguards in medical records because they are focused on logging the patient's care. When she logged again the next morning, she mentioned wearing a double gown, face shield and protective footwear -- equipment she mentioned again in later entries.

In the first mention of Vinson, she is said to have worn personal protection, including a hazardous-materials suit and face shield. Hospital officials have said masks that cover the nose and mouth were optional, consistent with CDC guidelines at the time. The CDC later advised leg covers and isolation suits, and the hospital complied, Texas Health Presbyterian Hospital officials said.

Nurses have voiced concern that they have never taken care of Ebola patients before and feel unprepared and underequipped.

"If hospital administrators had to take care of Ebola patients, they would have the gold standard and hazmat suits," said RoseAnn DeMoro, executive director of National Nurses United, a union with 185,000 members.

In some places that do have the suits, nurses have not practiced taking them on and off.

"The hospital is sending them essentially a link to the CDC website. That's not preparation. That's like a do-it-yourself manual," DeMoro said.

As the new guidelines are being prepared, Ohio has issued its own, including travel restrictions for residents who had contact with Vinson, who flew to Cleveland from Dallas on Oct. 10 and flew back Oct. 13.

Residents who are actively monitored with daily temperature checks are being told they can't leave their home county unless the health department where they are going assumes that responsibility, according to guidelines released by the Ohio Department of Health for local agencies to implement. Ohioans who are monitoring themselves and reporting to officials can't leave the U.S., according to the guidelines.

The state issued the recommendations after learning that some residents being monitored had travel plans, said Scott Milburn, a spokesman for Ohio Gov. John Kasich.

"Ohio is in the situation it is in because of travel," Milburn said. "It would have been beneficial if Texas had taken similar steps to these two weeks ago."

Ohio officials have reached 153 people who might have had some contact with Vinson on one of the Frontier Airlines flights or at an Akron bridal shop that Vinson visited Oct. 11, according to a release from the state Health Department.

Of that number, 22 are being actively monitored and would be subject to the county travel restriction, while 48 couldn't leave the U.S., Milburn said. Fifty-two others are being asked to self-monitor and report any changes, and 28 individuals are being reviewed for their level of contact, he said.

There are three Ohioans in quarantine Sunday, an increase from one Saturday, as a precaution given their contact with Vinson, Milburn said. All of the individuals being monitored are healthy with no confirmed cases of Ebola, he said.

Dallas makes care plans

Ebola's incubation period is 21 days, and Fauci noted that Texas Health Presbyterian Hospital workers who first treated Duncan reached that mark Sunday.

"The ones now today that are going to be 'off the hook' are the ones that saw him initially in the emergency room," said Fauci, representing President Barack Obama's administration on five Sunday news shows.

Clay Jenkins, the chief executive of Dallas County, called the 75 health workers who cared for Duncan "hometown health care heroes" and said they had signed agreements with the state's public health commissioner to stay off public transportation.

Jenkins also said any new Ebola patients in Dallas will be transferred to three top infectious-disease centers in the U.S.

"We're intaking and sending away from Presbyterian now with an idea that Ebola-positive care will be somewhere else," Jenkins said. Spokesmen for the hospital didn't return emails and phone calls seeking comment.

Jenkins said he wanted the three isolation rooms at Texas Health Presbyterian Hospital to have "plenty of room" for patients who might be under observation for possible Ebola symptoms.

Patients who test positive for the deadly virus will be transferred to Emory University Hospital in Atlanta; the National Institutes of Health Clinical Center in Bethesda, Md.; or St. Patrick Hospital in Missoula, Mont., all of which have top-level biocontainment units, Jenkins said.

Emory is caring for Vinson, and the National Institutes of Health clinic has admitted Pham.

The National Institutes of Health said in a statement Sunday that it has no agreement to take patients from the Dallas hospital, adding that Pham's transfer came at the request of the hospital. The other two infectious-disease centers Jenkins named did not immediately respond to requests for comment.

The CDC is working with Texas and hospitals to coordinate a patient placement plan, said Dave Daigle, an agency spokesman.

Fauci appeared on ABC's This Week, NBC's Meet the Press, Fox News Sunday, CNN's State of the Union and CBS' Face the Nation. Jenkins was on ABC.

In other news, a cruise ship carrying 4,000 passengers, including a Dallas health care worker who was being monitored for Ebola, returned to port Sunday after a seven-day trip.

A lab supervisor who handled a specimen from Duncan showed no symptoms during the cruise but self-quarantined out of caution. Carnival Cruise Lines said it was informed by health authorities Sunday morning that she tested negative for Ebola. Vicky Rey, vice president of guest care for Carnival Cruise Lines, said the woman and her husband drove themselves home after arriving in Galveston, Texas.

Pentagon to form support team

On Sunday, the Pentagon announced that Defense Secretary Chuck Hagel had ordered the formation of a 30-person support team from across the services to assist civilian medical professionals in the U.S. if needed to treat Ebola.

The team was to be formed by Northern Command's leader, Gen. Chuck Jacoby, and was to consist of 20 critical care nurses, five doctors trained in infectious disease and five trainers in infectious disease protocols. Once formed, the team would undergo up to a week of specialized training in infection control and personal protective equipment at Fort Sam Houston in San Antonio, then remain in "prepare to deploy" status for 30 days.

The team would not be sent to West Africa or other overseas locations, and it would "be called upon domestically only if deemed prudent by our public health professionals," Pentagon spokesman Rear Adm. John Kirby said in a statement Sunday.

The day before the announcement, Spain's Defense Ministry agreed to allow the U.S. to use two military bases in the country's southwest to support its efforts to combat Ebola in West Africa.

A Defense Ministry statement says the deal permits U.S. armed forces to use the air base at Moron de la Frontera near Seville and the naval station at Rota on Spain's Atlantic coast to transport personnel and materials to and from Africa.

Defense Minister Pedro Morenes agreed to the deal with Hagel in Washington.

Authorities in Madrid also said Sunday that the Spanish nursing assistant who became the first person infected outside West Africa in the current outbreak appears to have recovered from the virus.

An initial test shows that Teresa Romero, 44, is now clear of all traces of the virus, the government said in a statement. She has been receiving treatment in quarantine at a Madrid hospital.

And in West Africa, the Ebola virus was reported to have spread to new regions in Guinea, with new cases of infection appearing in the Siguiri area, about 434 miles from Conarky, the nation's capital.

The death toll in Guinea has risen to 887 since the outbreak started in December, the ministry said in its statement. More than 4,500 people have died in Guinea, Liberia and Sierra Leone, the nations affected worst by the virus.

Information for this article was contributed by Mike Stobbe, Marilynn Marchione, Matt Sedensky, Jill Craig, Josh Hoffner, Harold Heckle and Alan Clendenning of The Associated Press and by Harry R. Weber, Caroline Chen, John Lauerman, Romy Varghese, Robert Langreth, Mark Niquette, Ougna Camara, Kevin Crowley and Pauline Bax of Bloomberg News.

A Section on 10/20/2014

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