米国ダラスのエボラ感染 Update 2014/10/17

リベリアからのエボラ感染者Duncan氏(死亡)を受け入れて、看護師2名が感染したTexas Health Presbyterian Hospitalのエボラ対応について、当初、CDCは看護師の手順ミスの可能性を指摘していたが、その後、それは看護師たちの責任を問うものではにと謝罪していた。
Frieden also apologized to Texas Health Presbyterian Hospital about his previous “breach of protocol” comments, saying that he did not intend to put the blame on the hospital or on Pham. “I apologize if people thought I was criticizing the hospital,” Frieden said. “And I feel awful that a health care worker became infected while helping an Ebola patient.”

[CDC training hospitals to ‘think Ebola’ after first case contracted in U.S. (2014/10/13) on PBS]
There was no advance preparedness on what to do with the patient, there was no protocol, there was no system. The nurses were asked to call the Infectious Disease Department. The Infectious Disease Department did not have clear policies to provide either.

Initial nurses who interacted with Mr. Duncan nurses wore a non-impermeable gown front and back, three pairs of gloves, with no taping around wrists, surgical masks, with the option of N-95s, and face shields. Some supervisors said that even the N-95 masks were not necessary.

The suits they were given still exposed their necks, the part closest to their face and mouth. They had suits with booties and hoods, three pairs of gloves, no tape.

For their necks, nurses had to use medical tape, that is not impermeable and has permeable seams, to wrap around their necks in order to protect themselves, and had to put on the tape and take it off on their own.

Nurses had to interact with Mr. Duncan with whatever protective equipment was available, at a time when he had copious amounts of diarrhea and vomiting which produces a lot of contagious fluids.

Hospital officials allowed nurses who had interacted with Mr. Duncan to then continue normal patient care duties, taking care of other patients, even though they had not had the proper personal protective equipment while caring for Mr. Duncan.







["Statement by RN’s at Texas Health Presbyterian Hospital as provided to National Nurses United" (2014/10/15) on National Nurses United]
エボラ感染した看護師Nina PhamとAmber Joy Vinsonが何らかの手順ミスをしたのではなく、そもそも病院側が医師や看護師を防護できる準備をしていなかったことが、感染の原因のようである。

Federal health officials effectively acknowledged the problems with their procedures for protecting health care workers by abruptly changing them. At 8 p.m. Tuesday, the Centers for Disease Control and Prevention issued stricter guidelines for American hospitals with Ebola patients.

They are now closer to the procedures of Doctors Without Borders, which has decades of experience in fighting Ebola in Africa. In issuing the new guidelines, the C.D.C. acknowledged that its experts had learned by working alongside that medical charity.

[DONALD G. McNEIL Jr.: "Lax U.S. Guidelines on Ebola Led to Poor Hospital Training, Experts Say" (2014/10/15) on NYTimes]
先週エボラで死亡したリベリア人Thomas Eric Duncanの治療チームにいた看護師2名がダラスでエボラ陽性診断されて以降、連邦保健当局は米国の病院のエボラ感染者対応ガイドラインを厳格化した。North Shore Long Island Jewish Health Systemや、米国の4つのバイオコンテイメント設備(危険な感染症患者の隔離))の1つであるオマハのNebraska Medical Centerなどの多くの病院が、CDC(2014/10/15)よりも厳格なガイドラインを以前から定めている。
  • Original C.D.C. Guidelines: 感染者の血液や体液に触れない医療従事者向けの、CDCの最初のガイドラインに沿ったもの。
  • North Shore-L.I.J. Level 2 Suit: 感染者の血液や体液に触れる可能性のある医療従事者向け。Nebraska centerを含む、多くの病院はこれは最低基準としている。North Shore-L.I.J.では先週までは、これでエボラ感染者に対応していたが、Level 3にアップグレードした。
  • North Shore-L.I.J. Level 3 Suit: ダラスで2人目の看護師がエボラと診断されて以降、North Shore-L.I.J.は不浸透性の頭部を加えた。これが西アフリカの医療従事者の標準装備となり始めている。CDCは米国で全身防護服を義務付ける

[Changes to Ebola Protection Worn by U.S. Hospital Workers (2014/10/15) on NYTimes]
この改定以前のガイドラインは、バイオコンテイメント設備のあるEmory University hospitalの感染コントロールを監督するSean G Kaufmanによれば、ゆるすぎて役に立つものではなかった。
Sean G. Kaufman, who oversaw infection control at Emory University Hospital while it treated Dr. Kent Brantly and Nancy Writebol, the first two American Ebola patients, called the earlier C.D.C. guidelines “absolutely irresponsible and dead wrong.”

Speaking by phone from Liberia, where he was training workers for Samaritan’s Purse, the medical charity that Dr. Brantly and Ms. Writebol worked for, Mr. Kaufman said he had warned the agency as recently as a week ago that its guidelines were lax.

[DONALD G. McNEIL Jr.: "Lax U.S. Guidelines on Ebola Led to Poor Hospital Training, Experts Say" (2014/10/15) on NYTimes]

また、CDCはモニタリング対象者の航空機などの公共交通機関の利用に関して、ゆるい対応をしていた。エボラに感染した2人目の看護師Amber Vinsonがエボラ陽性判定を受ける24時間前に、ClevelandからDallasへの航空機に搭乗する前にCDCに問い合わせたが、CDCは搭乗に問題はないと回答していた。
Before she boarded that flight, the woman, identified by Ohio officials as Amber Joy Vinson, 29, informed the Centers for Disease Control and Prevention that she was running a temperature of 99.5 degrees, a federal official told The Washington Post.

That was below the 100.4-degree- threshold in CDC guidelines for screening travelers who have been in Ebola-affected countries, and which triggers a secondary screening. The CDC did not prohibit Vinson from traveling on the plane back to Dallas, said the official ...

オハイオ州当局者がAmber Joy Vinson(29)であることを確認している女性が航空機に搭乗する前に、体温が99.5F(37.5℃)であることをCDCに連絡していたと、連邦政府当局者がWashington Postに述べた。それは、第2次スクリーニングを実施する基準でもある、エボラ感染地域からの旅行者のスクリーニングのCDCガイドラインの閾値100.4F(38℃)以下だった。CDCはVinson看護師がDallasへ航空機で帰ることを認めたと、連邦政府当局者が述べた。

But on Wednesday, CDC Director Thomas Frieden said that Vinson should not have been flying anywhere given her possible exposure to Ebola at her workplace, Texas Health Presbyterian Hospital Dallas ...

しかし、2014/10/15に、CDCのThomas Friedenセンター長は、Vinsonは職場Texas Health Presbyterian Hospital Dallasでエボラに触れた可能性があるので、航空機に搭乗すべきではなかったと述べていた。

[Mark Berman, Lena H. Sun and Joel Achenbach: "Health-care worker with Ebola was allowed to fly despite slight fever" (2014/10/15) on WashingtonPost]
さらに、Texas Health Presbyterian Hospital Dallasの別の医療従事者が旅行に出かけていることがわかった。
Meanwhile, a different Dallas hospital worker who may have handled Duncan's fluid samples has been quarantined on a cruise ship in Belize ...

Though the employee did not have direct contact with Duncan, he or she "may have had contact with his specimen," the U.S. State Department said Friday.

A doctor at the cruise ship has declared the worker symptom-free and in good health, but the worker will remain under isolation as a precaution, it said.
It's been 19 days since the worker handled Duncan's fluid samples -- two days shy of the 21-day incubation period for Ebola.

The Texas Health Presbyterian Hospital worker boarded the commercial cruise ship Sunday from Galveston, Texas.

At the time, the Centers for Disease Control and Prevention had not updated its monitoring requirements, and required only self-monitoring, said Jen Psaki, a spokeswoman for the State Department.



Texas Health Presbyterian Hospitalの従業員は2014/10/12にテキサス州Galvestonから民間クルーズ船で出航していた。その時点ではCDCはモニタリング要件を改定しておらず、セルフモニタリングのみが義務付けられていたと、国務省広報担当Jen Psakiが述べた。

[Jason Hanna, Faith Karimi and Greg Botelho:"Amid Ebola fears, cruise ship quarantines worker, airline contacts travelers" (2014/10/17) on CNN]

. No individual who entered the first Ebola patient’s room can travel by commercial transportation until 21 days after that individual’s last exposure. These individuals should not travel by commercial conveyances (e.g. airplane, ship, long-distance bus, or train). Local use of public transportation (e.g. taxi, bus) by asymptomatic individuals should be discussed with the public health authority.

2. All HCW involved in the direct care of the first Ebola patient must be monitored twice a day with one of the monitoring sessions being a face to face encounter. As part of that monitoring, each HCW’s temperature will be checked twice a day;

3. No individual HCW who entered the first Ebola patient’s room can go to any location where members of the public congregate which includes but is not limited to, restaurants, grocery stores, theaters, or other places where the public may be in attendance or gather, throughout the entire 21 day time period that follows the individual’s last exposure.

4. All HCWs who provided direct care in the first Ebola patient’s room will be given the opportunity to stay at Presbyterian Hospital on a non-admission status in order to
facilitate monitoring; and

5. Any HCW that does not adhere to monitoring or any of these other measures may be subject to a communicable disease control order.

[Movement of Persons with Possible Exposure to Ebola (2014/10/16) by Texas Department of State Health Services (text by LA Times/a>)]