A second Ebola case in Texas — identified Sunday as a hospital worker who cared for the Liberian man who died last week from the disease — is raising fresh doubts about the preparedness of the U.S. health system to handle the deadly outbreak.
It is also prompting new questions about whether U.S. health officials need better measures to identify hospitals that may not be able to handle complex diseases such as Ebola.
"Ebola is a serious disease," said Dr. Mark Rupp, who heads the infectious diseases division at Nebraska Medical Center. "All the hospitals across the U.S. need to be better prepared." The Omaha hospital, which is one of four in the country with special facilities to treat diseases such as Ebola, has cared for two patients who contracted the virus in West Africa.
Federal officials said Sunday that a breach in medical protocols had caused the infection at Texas Health Presbyterian Hospital in Dallas, which already is under fire for not immediately identifying the first Ebola case.
"It is certainly very concerning and tells us that there's a need to enhance the training and protocol to make sure the protocols are followed," Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention, said at a news conference Sunday.
The hospital worker, whom officials have not identified, was in isolation Sunday in the intensive care unit at the Dallas hospital, according to health officials.
The federal public health agency said the worker had been monitoring herself and developed a low-grade fever overnight Friday. She was promptly isolated.
The CDC confirmed an Ebola diagnosis on Sunday.
"The level of her symptoms and indications from the test itself suggest that the level of virus she had was low," Frieden said.
But health officials said they had identified one close contact who was at risk and had been proactively isolated.
By Sunday afternoon, the two-story east Dallas apartment where the healthcare worker lives, on a tree-shaded street with well-landscaped yards, was being guarded by Dallas police officers who had roped it off behind red police tape. Outside was a yellow biohazard barrel.
Theresa Pittard, 56, lives next door to the off-limits apartment building. She stood outside Sunday evening, watching a hazmat crew arrive in biohazard suits and gas masks.
Officials had pounded on her door at 5:30 a.m. and dropped off public health information about Ebola, she told The Times. The apartment management company advised tenants not to walk their dogs outside until the lawn and surroundings had been decontaminated.
"All of this is very intimidating," Pittard said.
Jeffrey Ross, 42, a stagehand who lives down the street from the apartment where the infected worker lives, watched as neighbors posed for photos near the yellow biohazard barrel.
"I can't wrap my head around it. I haven't done enough research about how this stuff spreads," Ross said. "The first thing I thought was, I wonder if she shops at the same grocery store I do?"
Richard Cameron, general manager of Fort Worth-based Protect Environmental Services, said his company had been called in by the governor's office as a state contractor to ensure the apartment area was cleaned correctly.
He said the company has more than 20 years of experience cleaning places exposed to HIV, hepatitis and anthrax, but this would be their first case of Ebola.
Texas Christian University emailed faculty and students Sunday night that the healthcare worker was a 2010 graduate of its nursing program who did not appear to have visited campus recently. "We ask everyone to please keep this 2010 alum in your thoughts and prayers during this time," it said.
The new case has sent national and local public health officials scrambling to review how the Dallas hospital handled the case of Thomas E. Duncan, the 42-year-old man who contracted Ebola in Liberia and died Wednesday.
The White House said President Obama also ordered federal health authorities to take additional steps to ensure that healthcare facilities nationwide are prepared to follow infection control protocols in the event they confront a possible Ebola case.
Health officials said they are specifically looking into whether the Dallas hospital worker improperly removed gloves or other protective clothing, or became infected while the hospital took extreme measures to save Duncan's life.
Dr. Daniel Varga, chief clinical officer at Texas Health Resources, which owns the Dallas hospital, said the worker, who officials said was in close contact with Duncan, was in full protective gear when providing care.
The hospital performed kidney dialysis on Duncan and intubated him as he struggled to live, two intensive and complicated medical procedures that may have heightened the risk of spreading contaminated materials.
Ebola is transmitted through contact with an infected person's bodily fluids, such as blood, saliva, feces and sweat.
"At some point, there was a breach in protocol, and that breach in protocol resulted in this infection," Frieden said Sunday. "We know that even a single lapse or breach can result in infection."
Health officials have been monitoring 48 people after Duncan's diagnosis, but the healthcare worker was not among them.
Infectious disease experts stress that Ebola can be effectively controlled.
Those procedures — including the correct use of protective clothing and rigorous standards for isolating infected patients and limiting their contact with health workers — are widely credited with controlling previous Ebola outbreaks.
More recently, Doctors Without Borders, the international aid group that has provided front line assistance in West Africa since the outset of the current Ebola outbreak, has largely succeeded in protecting its health workers with strict controls.
And a strong public health and medical response helped prevent a wider Ebola outbreak in Nigeria, Africa's most populous nation.
"Infection prevention works," said Dr. Lisa Maragakis, who oversees infection control efforts at Johns Hopkins Hospital in Baltimore. "We know what needs to be done."
But the second Dallas case has highlighted the holes in even basic infection control procedures.
The simple use of protective clothing can be difficult if not practiced, said Dr. Trish Perl, Johns Hopkins' senior infection control official.
Particularly important is a good system for removing infected clothing, which is best done with a "buddy" who watches to ensure that contaminated material is not touched.
"It's like driving a car," said Perl, who has studied the evolution and use of protective gear. "No one can get into a car and drive it really well the first time. It's a really complicated process."
Strict training can overcome the complexities. But U.S. hospitals historically have been resistant to standardizing procedures, and there is still disagreement among healthcare workers about which infection control steps are always necessary, Perl said.
"This is one of those processes that requires a very systematic, military-style approach. That doesn't really adopt very well in medicine, unfortunately," she said.
At Nebraska Medical Center, someone with a checklist always stands by and tells a healthcare worker the order in which to remove each piece of protective gear, regardless of how experienced the worker is. The observer also makes sure the worker washes their hands properly.
Every hospital should follow such a procedure, division head Rupp said.
Nurses, too, are sounding the alarm about the need to improve hospital practices.
"We're hearing about 'protocols,' but it seems there's a real disconnect in regard to what those protocols are and what preparations hospitals should be taking," said RoseAnn DeMoro, executive director of National Nurses United, a union of registered nurses.
In Dallas, hospital leaders said they are now working "to further expand the margin of safety by triple-checking our full compliance with updated CDC guidelines."
And in Los Angeles, Dr. Mark Morocco, professor of emergency medicine at Ronald Reagan UCLA Medical Center, said the hospital is doing a "top to bottom review" of how it deals with infectious disease patients.
"Clearly there were some difficulties in Dallas and we don't want that to be the case here should a patient arrive with possible symptoms of Ebola," Morocco said.
Such reviews are critical, according to public health experts, as any hospital and clinic in America could see an Ebola patient or a case of some other serious infectious disease.
But Dr. Thomas Inglesby, who heads the UPMC Center for Health Security in Pittsburgh, said healthcare leaders may also need to ask whether some medical facilities will not be able to meet the rigorous standards necessary to treat an Ebola patient.
"These are important questions to ask now," he said. "Luckily, we have the flexibility to take care of these patients where they can be most effectively cared for."
Hennessy-Fiske reported from Dallas, Levey from Washington and Lee from Los Angeles. Staff writers Michael Memoli in Washington and Lauren Raab in Los Angeles contributed to this report.