(CNN) — A day after the Centers for Disease Control and Prevention said a Texas health care worker tested positive for Ebola, health officials are still trying to figure out how exactly she caught it.
The woman, identified by CNN affiliate WFAA as Nina Pham, took basic precautions while treating an Ebola-stricken Liberian national at a Dallas hospital. Now she is the first person to have contracted the deadly virus in the United States.
There are few details that are known about what might have gone wrong. She wore a mask, gown, shield and gloves when treating Thomas Eric Duncan, who was in isolation at Texas Health Presbyterian Hospital, officials said.
But on Monday, Dr. Tom Frieden, director of the CDC, told reporters that it’s still unknown how the infection occurred, only that a “breach in protocol” for treating a patient happened.
Frieden said state and federal health officials are re-examining those protocols, including the removal of protective gear after contact with an Ebola patient and if it might be helpful to spray virus-killing solution on workers as they leave an isolation unit. He said Monday that the nurse is “clinically stable.”
Meanwhile, a nurse’s assistant in Spain with Ebola remains in critical condition and is having trouble breathing, authorities said. The European Centre for Disease Control and Prevention told CNN that the hospital where Teresa Romero Ramos is being treated doesn’t meet all the standards set for centers capable of Ebola care.
Before becoming sick, Ramos had treated a patient with Ebola.
How did it happen in Texas?
On Monday morning, an official with direct knowledge of the Texas nurse’s case told CNN that CDC disease detectives interviewed the nurse several times and thought there were “inconsistencies” in the type of personal protective gear she wore and with the process used to put the gear on and remove it.
Frieden has spoken of possible ways she became infected. It could have happened when the nurse removed her protective gear — a bit of infected bodily fluid somehow touching her — or it she could have come into contact with infected fluid as Duncan received kidney dialysis or respiratory intubation.
Those procedures were “a desperate measure to try to save his life,” Frieden said. “Both of those procedures may spread contaminated materials and are considered high-risk procedures.”
He said, “When you have potentially soiled or contaminated gloves or masks or other things, to remove those without any risk of any contaminated material … touching you and being then on your clothes or face or skin … is not easy to do right.”
Or the problem could have been something else entirely.
Taking extra precautions outside recommended CDC protocols can actually increase the odds of infection, Frieden has said. Caregivers are supposed to double their gloves in some situations, but triple gloving is a violation of CDC protocol because it increases the steps to remove gear and could expose a health care worker for longer than needed.
Other caregivers being monitored
The CDC concedes the Texas nurse’s case is worrisome.
“It is possible in the coming days that we will see additional cases of Ebola,” Frieden said.
That’s because others who provided care to Duncan could have had the same kind of breach as the infected nurse. The CDC is still working to compile a list of health care workers who were involved in Duncan’s care from September 28 to October 8, the day he died, an official with direct knowledge of the Texas case told CNN on Monday.
The official added that the health care workers who have been identified will be visited twice daily to be checked for fever, one of the symptoms of Ebola. Those workers had previously been self-monitoring, the official said, because they were not — before the Texas nurse tested positive — considered high-risk.
The public areas of the nurse’s apartment complex have been decontaminated and her neighbors have been notified. The city of Dallas made a reverse 911 call to residents in the area, telling them about the city’s second Ebola case.
“I think it needs to be put into context that … you can’t make an extrapolation that this is now a danger more so to the American people,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.
But fear is spreading.
When a passenger on a flight from New York to Los Angeles fell ill Sunday, the biggest concern was Ebola. The plane was taken to a remote gate at Los Angeles International Airport. After a few hours, officials determined the woman did not appear to have Ebola, and other passengers were allowed to leave.
And in Louisiana, Attorney General Buddy Caldwell plans to seek a temporary restraining order to block the disposal of incinerated waste from Duncan’s personal items at a Louisiana landfill.
“There are too many unknowns at this point, and it is absurd to transport potentially hazardous Ebola waste across state lines,” Caldwell said Sunday.
Is the U.S. prepared?
President Barack Obama wants federal authorities to immediately take further measures to ensure that health care workers are able to follow protocols for treating Ebola patients. He will meet with senior administration members at the White House on Monday afternoon for an update on its response to the Dallas case and the broader effort to make sure the country is prepared to handle an outbreak.
Of the thousands of hospitals in the United States, only four have been training for years to deal with highly infectious diseases such as Ebola: Emory University Hospital in Atlanta, the Nebraska Medical Center in Omaha, the National Institutes of Health in Maryland and Rocky Mountain Laboratories in Montana.
“They have the management, the processes, the implementation in place that if an Ebola patient comes in, just right away they know what to do,” said Gavin Macgregor-Skinner, who teaches public health preparedness at Penn State University.
But if someone with symptoms of Ebola shows up at any other hospital, as Duncan did, the hospital might not be ready.
“It may not be that every single hospital is in fact prepared for this,” said David Sanders, associate professor of biology at Purdue University.
“We may have to think about regional centers that are best prepared to deal with Ebola patients.”
Another step in the battle is screening.
On Saturday, passengers arriving from the three countries hardest hit by Ebola — Liberia, Sierra Leone and Guinea — started getting special screening, including having their temperatures taken, at New York’s John F. Kennedy International Airport.
Washington’s Dulles, Newark, Chicago’s O’Hare and Atlanta airports will begin screening Thursday.
‘The time to act is long overdue’
The country’s largest nursing organization, National Nurses United, surveyed 2,000 members. Of them, 76% said their hospitals hadn’t communicated any policy about how to admit Ebola-infected patients. And 85% said their hospitals hadn’t provided education on Ebola in which the nurses can interact and ask questions.
Nurses “are alarmed at the inadequate preparation they see at their hospitals,” said the group’s executive director, RoseAnn DeMoro.
“The time to act is long overdue,” she said.