CDC update on Dallas Ebola Response, 10-12-2014

OPERATOR: Welcome and please stand by. Your lines have been place on a listen-only mode. During the question and answer session, press star one on your phone. Today's conference is being recorded. If you have objections, you may disconnect. I start would like to turn today’s meeting to Barbara Reynolds.

BARBARA REYNOLDS: Good morning. You're joining CDC's update on the Ebola response in Dallas. We'll have two speakers today and then take questions, both in the room and on the phone. For those of you asking questions in the room, would you please give your name and affiliation. Our first speaker today is CDC director Dr. Tom Frieden.

TOM FRIEDEN: Good morning, everyone. And thank you for joining us. We're deeply concerned by the news that a health care worker in Texas has tested preliminarily positive for infection with Ebola virus. Confirmatory testing is under way at CDC and will be completed later today. We don't know what occurred in the care of the index patient, the original patient in Dallas, but at some point there was a breach in protocol and that breach in protocol resulted in this infection. The health care worker developed symptoms on Friday. They were assessed last night and this morning. Today is Sunday; they were assessed Friday and tested yesterday. And the laboratory response network laboratory in Austin, Texas tested their result preliminarily positive. That result came in late last night, about exactly 12 hours ago, and I will outline the steps that we have been taking before, since, and in the future to address this. The individual was self-monitoring and immediately on developing symptoms as appropriate she contacted the health care system, and when she came in, she was promptly isolated. The level of her symptoms and indications from the test itself suggest that the level of virus that she had was low. There are four things that we're doing at this point. First, to make sure we do everything possible to care safely and effectively for this individual. Second, assessing her possible contacts from the moment she developed symptoms. And the CDC team lead has investigated her. It appears at this time there's only one contact that may have had contact with her while she may have been infectious. That individual is under active monitoring. Third, we are evaluating other potential health care worker exposures because if this individual was exposed, which they were, it is possible that other individuals were exposed. We know that this individual did provide care to the index patient on multiple occasions and that care included extensive contact. Fourth, we will undertake a complete investigation of how this may have occurred. That's so important so we can understand it better and intervene to prevent this happening in the future. I want to go into a little bit more detail first on what we are doing to promote safe and effective care and then on the investigation. In terms of safe and effective care, we had already begun several days ago to ramp up the education and training of health care workers at this facility. The care of Ebola can be done safely, but it is hard to do it safely. It requires meticulous and scrupulous attention to infection control, and even a single inadvertent innocent slip can result in contamination. Second, we are recommending to the facility that the number of workers who care for anyone with suspected Ebola be kept to an absolute minimum. Third, we recommend that the procedures that are undertaken to support the care of that individual be limited solely to essential procedures. Fourth, we're 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. And fifth, 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. CDC has sent additional staff to Texas to assist with this response and we will continue to work closely with them. In the investigation itself we look at three different phases. What happens before someone goes in to an area where someone with suspected or confirmed Ebola is being cared for, what happens in that space, and what happens when they leave. The two areas where we will be looking particularly closely is the performance of kidney dialysis and respiratory intubation. Both of those procedures may spread contaminated materials and are considered high risk procedures. 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 gone into 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. We will do that over the coming days. Before I turn it over to Dr. Lakey, commissioner of Texas department of health and human services, I want to make two final points. The first is that unfortunately it is possible in the coming days that we will see additional cases of Ebola. This is because the health care workers who cared for this individual may have had a breach of the same nature of the individual who appears now to have preliminary positive tests. That risk is in the 48 people who are being monitored, all of them have been tested daily, none of whom so far have developed symptoms or fever, and in any other health care workers who may have been exposed to this index patient while he was being cared for. We're still determining how many health care workers that will be. That is an intensive investigation. It takes many hours of tracing steps. We'll always cast the net wider. There is no risk to people outside of that circle of the health care workers who cared for the individual patient and the initial 48 patients or contacts who had definite or possible contact with the index patient, who we've already identified. The second point I want to make is that what we do to stop Ebola is to break the link of transmission, to break the chains of transmission. And we do that by making sure that every person with Ebola is promptly diagnosed, that they're promptly isolated, that we identify their contacts, and that we actively monitor their contacts every day for 21 days. And if they develop symptoms or fever, we do the same process again. That's how we have stopped every Ebola outbreak in history except the one currently in West Africa. That's how we stopped it in Lagos, Nigeria. That's how we will stop it in Dallas. So breaking the link in the chain of transmission is the key to preventing further spread. Now I would like to turn it over to Dr. Lakey.

DAVID LAKEY: Thank you, Dr. Frieden. This is David Lakey, commissioner of health for the state of Texas. I appreciate all of the support from the CDC that the CDC has given us. Not only overnight but over the last several weeks as we have been working through this unprecedented event. Our staff have been working throughout the night trying to gather more information and as we get more information as appropriate, we will provide that information. As Dr. Frieden noted, we have one health care worker, a health care worker that had extensive contact with our initial patient, who did what was appropriate with early symptoms, came in to be checked and we facilitated getting the blood test done. That test came back at 9:30 last night and as Dr. Frieden noted was positive. The controls were appropriate. The amount of virus in her blood was less than what was there when the first index case came back, but it is a positive test. So our hearts really do go out to this individual and the family. Health care worker who was willing to compassionately care for Mr. Duncan. Again, our thoughts and prayers are with them. We have been preparing for events such as this, put in contingency fines. We are refining those plans and a lot of work is taking place right now. As Dr. Frieden noted, the 48 original contacts continue to be monitored and they continue to do well. We have this one health care worker that now needs our care. And so as Dr. Frieden noted, we are -- we have been and will continue to monitor health care workers, stepping that up to make sure that any health care worker that has any fever or any other symptoms will be quickly identified as with this individual. Continue to work to make sure the infection control practices that are being performed at the hospital are at the highest standards, and fully evaluating what is under way and figure out exactly what happened that allowed this individual to be infected. And we brought in more public health officials, public health staff, and epidemiologists to make sure we have the individuals we need to fully evaluate this situation. And again, appreciate the work from the CDC and their support for Texas now as we work through this situation. Thank you.

TOM FRIEDEN: We will now take questions. We will start in the room and then go to the phone.

STEVE GEHLBACH: Steve Gelbach with WSB TV in Atlanta. This health care worker had multiple contacts with the original patient. In your interviews with her, has she been specifically isolated, a chance where this may have occurred where this breach you say in those interviews with her, talking about why you're investigating, where she's taking off the equipment or anything, why you're focusing on that part in your investigation?

TOM FRIEDEN: We have spoken with the health care worker and that individual has not been able to identify a specific breach. We look at every single interaction, what was the nature of the interaction, look at any information we can gather. I was not mentioning taking on or off or procedures related to the investigation but as a general rule. These are the two areas where we see the greatest risk.

STEVE GEHLBACH: Is this going to change the way health care workers here or Dallas, with patients wearing more gear or what's going to change now?

TOM FRIEDEN: I think 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. The protocols work. We have decades of experience caring for patients with Ebola. But we know that even a single lapse or breach, inadvertent, can result in infection, so figuring out how all of the things that we can do to minimize that risk, such as i went through, reducing the number of health care workers, reducing procedures to essential procedures, having a site monitor there, these are things we will be looking at closely. We will go to the phone for questions.

OPERATOR: Thank you. We begin the question and answer session. If you would like to ask a question, press star one. Unmute your phone and say your name clearly. First question is from Dr. Richard Besser with ABC News.

RICHARD BESSER: Dr. Frieden, you were saying how difficult it is to implement proper infection control, how one slip can be so dangerous. Is there any consideration of moving patients to a system where they are trained instead of treating them in hospitals where they don't have that training?

TOM FRIEDEN: We are going to look at all opportunities to improve safety and minimize risk. We can't let any hospital let its guard down. A patient, American returning or somebody else coming to the country that had exposure, maybe didn't have awareness of that exposure may become ill. So we do want hospitals to have the ability to rapidly consider, isolate and diagnose people who may have Ebola. Again, anyone who has been in guinea, Liberia, Sierra Leone in the past 21 days and has a fever or other symptoms should be immediately isolated and evaluated for Ebola. So I would distinguish that diagnosis needs to be done anywhere, then thinking about what's the safest way to provide that care. That's something we'll absolutely be looking at.

RICHARD BESSER: Thanks very much.

TOM FRIEDEN: On the phone. Next question.

OPERATOR: Thank you; we have Michele Salcedo with AP. Ask your question. Check your mute button. Salcedo? We will go to the next question. Caleb Hellerman with CNN. Your line is open.

CALEB HELLERMAN: I was wondering, Dr. Frieden, or Dr. Lakey, if you could say anything more about the kind of intensive contact, what was the role of this person that's become infected and if you could clarify the monitoring process. You say she was self-monitoring. Are some of the other contacts getting in person visits or just what is the process for taking temperature and reporting in, if you could clarify that? Thank you.

TOM FRIEDEN: I'll turn that over to commissioner Lakey. I want to really thank the Texas and Dallas health authorities who have been working around the clock since diagnose of the first patient, and have monitored all of those patients that are taking their temperature and are addressing the latest development. Dr. Lakey?

DAVID LAKEY: Thank you, Dr. Frieden. The 48 individuals that have been known to have contact or potential contact, those individuals have daily had an on-site visit where they saw one of the epidemiologists, and had a subsequent fever check later in the day. The health care workers where there was no breach in contact were doing self-monitoring. So in light of this case we're looking at the on-going monitoring of all health care workers and looking at going forward having an epidemiologist see them and more active surveillance for these individuals. Again, health care workers with no breach in personal protective equipment had been doing self-monitoring until today.

CALEB HELLERMAN: If I can quickly follow-up. This woman was not in that group of 48 contacts, she was an additional person. Do you have any sense of how many more people this might expand to?

DAVID LAKEY: This individual was not part of the 48 and we're looking at defining what that new number is, working on that pretty hard right now.

CALEB HELLERMAN: Thank you.

TOM FRIEDEN: In order to identify that number, we cast the net wide. We identify first anyone who might have had contact and then we do detailed interviews and record reviews with each and every one of them to identify those who definitely did have contact, those who definitely didn't, and those who we cannot rule out they had contact. Next question on the phone.

OPERATOR: Next question comes from Denise Grady with the New York Times. Your line is open.

DENISE GRADY: Thank you. Dr. Frieden, could you please explain and clarify what you were talking about when you said try to limit things to essential procedures? What does that mean, what's essential and what's not essential, how do you limit procedures and not compromise the patient?

TOM FRIEDEN: So in terms of limiting, first as we do everywhere Ebola patients are cared for, we try to keep to absolute minimum the number of health care workers who enter the area. That reduces risk. Second, we try to ensure that the procedures that are undertaken are kept to the absolute minimum. So for example, a blood draw to monitor electrolytes is very important, but if someone is not having diarrhea and vomiting, maybe it only needs to be done once a day, rather than multiple times a day. I am not saying that was done differently previously, I’m saying an example of how we might limit things to essential procedures. Next question.

OPERATOR: Next question from Betsy McKay with the Wall Street Journal.

BETSY MCKAY: Yes, thank you. Dr. Frieden, I was wondering if you could comment a little bit more on the preparedness of hospitals, regular hospitals that are outside of these bio containment units that have treated the other Ebola patients who have come to the U.S. do you think this incident, what do you think it says about the preparedness generally of hospitals around the country, is it an outlier, are you concerned about hospital preparedness? And the other related question, you mentioned that now an infection control person, official, should be monitoring in hospitals. Is that a guideline for all hospitals or were you talking specifically about this Texas hospital?

TOM FRIEDEN: So let me answer the second question first. In Ebola treatment units in Africa one of the things we identified as a potential contributor to infections that occurred there is the lack of an on-site manager at all times who doesn't have any specific responsibilities other than overseeing and supervising everything that's being done to make sure infection control is being done correctly, that procedures are being done correctly. I was saying we will ensure that that is done going forward in Texas, at this particular hospital. In terms of your first question, very important to distinguish for infection control the physical layout from the procedures and policies and training and staff work. In terms of the first, the demands are not extensive. There are some special demands in place like an anti-room, for example, a room before for people to take off and put on protective equipment. But it is not a disease that spreads through the air, so it doesn't require some of the most intensive infection control, physical procedures. However, on the personnel training, supervision, follow-up, monitoring, it is very clear that the necessity of doing this right 100 percent of the time does require a very intensive training, follow-up, monitoring process. Next question.

OPERATOR: Next question from Eben Brown with Fox News Radio.

EBEN BROWN: Good morning. Thank you for taking the call and doing this this morning. Dr. Frieden and Dr. Lakey, if you could respond to this question. One, how frustrating is this for you after saying we're going to stop Ebola in its tracks to know that a breach of protocol among a professional is what caused this new transmission, and two, is it shaking your faith in hospitals around the country to adequately aid and prepare staff?

TOM FRIEDEN: I’ll start and turn it over to Dr. Lakey. It is deeply concerning that this infection occurred and our thoughts are with the health care worker who was providing care and appeared to have become infected if that test is confirmed, in the process of that care. That doesn't change the bottom line here which is that we know how to break the chains of transmission. We need to ramp up the infection control for any patient suspected or confirmed as having Ebola, and we need to do what we have been doing with contact tracing and monitoring. If you go back to what happened here, she identified symptoms immediately on their onset. She was isolated promptly. At this point it looks like there's one additional contact potentially from that illness period. That individual does not have fever. So we're looking very closely at that, but it doesn't change the bottom line. The bottom line is we know how Ebola spreads. We know how to stop it from spreading. But it does reemphasize how meticulous we have to be on every aspect of the control measures, from rapid diagnose to effective isolation to effective care with infection control, to scrupulous contact investigation. Dr. Lakey?

DAVID LAKEY: Thank you, Dr. Frieden. I guess I would like to second what Dr. Frieden said. I firmly believe we're going to stop this here. We have to be very careful. We need to closely look at the practice, the infection control practices as they are occurring to be meticulous, to be sure there are no breaches. Is it frustrating or disappointing? Of course it is. Our hearts go out to the health care worker and family that is infected. And she's going to have a rough time. We need to be continuing to be sure she gets the care she needs. I think we have been doing contingency planning for situations like this. One of the things i learned in disaster response, you have to have a little humility in how you approach things. Be very cautious with how we approach things and need to continue to do that and to continue the contingency planning, but do I doubt that we're going to stop this spread here in this one hospital, no. I firmly believe we will stop it. Thank you.

TOM FRIEDEN: Next question.

OPERATOR: Next question is from Katie Dominick with CBS News.

KATIE DOMINICK: Hi, Dr. Frieden, I wonder if there's updated guidance when additional screening will be starting at airports announced last week.

TOM FRIEDEN: Yesterday, we began screening at JFK international airport at New York City. That screening went smoothly. There are a lot of lessons being learned through that to be sure that screening goes smoothly for passengers, other passengers. As we said before, we're anticipating starting screening at the other four airports this week and anticipate that starting Thursday. Next question.

OPERATOR: Next question, Jeffrey Wise with Dallas Morning News.

JEFFREY WISE: Yes. Can you speak to how a health care worker using high precautions apparently caught the Ebola when people who had close contact in that apartment several days did not, and do you have any plans to transfer this new case to one of the specialty hospitals in Atlanta or Nebraska, someplace like that.

TOM FRIEDEN: With regard to the first question, when patients have Ebola, they become progressively infectious the sicker they become, because the amount of virus in their body and in their secretions increases, and people who had contact with this individual, the index patient, in Dallas prior to his isolation are not yet out of their 21 day exposure period, so we're not out of the woods yet with potential additional cases among contacts before isolation. But medical procedures involve dealing with blood, dealing with body fluids, diarrhea, vomit, other things that may have very large quantities of virus, and that's why the personal protective equipment and protocols are so important because as someone gets sicker, they get more infectious also. We will look at all possibilities to ensure the safe care of patients to the greatest extent possible. Next question.

OPERATOR: Next question, Lena Sun, with the Washington Post.

LENA SUN: Hi, Dr. Frieden. I was wondering whether you or Dr. Lakey could clarify this health care worker was not in the initial group of 48. So the earlier this morning Varga said there were 19 hospital employees they were tracking. So is this person part of that 19 or is it part of a larger group? That was one question. And the second question was the hospital by its own track record has not provided the best information. They've had to do a lot of walk backs. I know the hospital initially said this morning there was low grade fever. Are there any other symptoms? Is there any other information we need to pursue further, given the hospital's track record in not providing accurate information initially?

TOM FRIEDEN: I'm sorry; I have forgotten the first question.

LENA SUN: Is this person part of the 19 the hospital is tracking or is it a larger group of people?

TOM FRIEDEN: Thank you. So the 48 contacts identified were individual who had contact up to September 28th, the day he was isolated. This person was not exposed in that period of time. Those 48 as per everything we know are the only people he may have had contact with before he became isolated. In terms of the care in the hospital from the 28th to October 8th, the date he passed away, that's a period of 10, 11 days when there may have been additional contacts, given the fact this individual clearly was exposed then. That's what's being investigated now. So that first contact tracing period identified what we still believe is all 48 who were exposed, up to the time he was isolated. Now we're doing a new investigation given the diagnosis late last night of this individual of anyone else who may have been exposed once he was on what should have been effective isolation. In terms of the clinical status of the patient, i can say that our information is that as of at least some time back, she was showing only mild symptoms and low grade fever. Our team lead did interview her directly and will continue to monitor closely to ensure she gets the best possible care. We will take two more questions on the phone.

OPERATOR: Next question from Donna Young with Scripp News.

DONNA YOUNG: Thank you, I wanted to find out specifically with this patient, the new patient, why was she not, you have gone around this, why was she not initially included in the 48 that were monitored. And also I wanted to ask Dr. Frieden when he was over in Africa, did you take special precautions that you normally wouldn't have with putting on the protective equipment? Thank you.

TOM FRIEDEN: So as I just indicated, we monitored all contacts up to the time of the index patient's admission September 28th. Given this apparent infection, we now will be evaluating and monitoring all contacts who may have had exposure during the hospital stay. I'll ask Dr. Lakey to comment further on that or any other issue in a moment, in terms of precautions in Africa, yes, they're very specific for personal protective equipment, taking it off, putting it on, and what happens there. Dr. Lakey?

DAVID LAKEY: Thank you, Dr. Frieden; I don't have much to add besides what you provided. The health care workers that were in full PPE, personal protective equipment, during their involvement in the care of the initial individual were classified as minimal risk and those individuals had guidance to do self-monitoring, but were not in that 48. So this individual was doing that and in the earliest signs of illness checked her temperature and was evaluated. Thank you.

TOM FRIEDEN: We will take the last question.

OPERATOR: Next question comes from Lisa Schnirring with CIDRAP.

LISA SCHNIRRING: Hi, thanks for making such great information available today. I'm wondering how common is it for people to be on dialysis or to be intubated during an Ebola infection, is that something you've seen in other patients treated in western countries? Just wondering how common that is and how often health care workers have had to deal with those situations. Thanks so much.

TOM FRIEDEN: Thank you. I don't know the details of the other patients cared for in other parts of the world, but I’m not familiar with any prior patient with Ebola who has undergone either intubation or dialysis. Certainly it would be very unusual if it has happened before. I do want to clarify one thing. Of the 48 contacts being monitored, including the 10 who are known to have had contact, that does include health care workers who had contact with the index patient before he was isolated on September 28th. But doesn't include anyone after September 28th. Before i make a couple of concluding remarks, just turn it over to commissioner Lakey for anything more you want to say.

DAVID LAKEY: Well, thank you again for your support. Obviously a very trying day, a very busy night, work that's going onto make sure that we fully understand what happened and can make sure that the hospital has the expertise and infection control practices they need to prevent any other individual from being exposed to this virus. Again, appreciate the health care worker on the earliest signs coming in and being cared for appropriately and we're bringing in the resources we need to fully understand this as quickly as possible. So again, my appreciation to the CDC for the work that they continue to do to assist us. Thank you.

TOM FRIEDEN: Thank you, Dr. Lakey, and thank you for the terrific work your team in public health is doing there. We really do appreciate the partnership, your work on the ground makes a really big difference and we're honored to be part of the team doing that with the state and the city and the hospital. Bottom line here, we're very concerned that a preliminary positive has been identified in a health care worker who provided care to the index patient. We will have confirmatory testing later today at CDC. We will identify any additional contacts, both of that individual before they were diagnosed and other individuals who may have provided care for the index patient and similarly may have been exposed and actively monitor those individuals. We will also undertake a thorough investigation to understand how this may have happened and we will ramp up infection control to do whatever we can to minimize the risk that there would be any future infections. And finally, our thoughts go out to the health care worker, their family, understanding how difficult a time this is for them and for other health care workers who now may have been exposed or are known to have been exposed, need to go through that anxiety producing time. These are the individuals who we need to monitor. This is how we break the links of transmission. It is possible that we will see additional cases in those who had contact with either of the two patients. But there is no doubt that we can break the links in the chain of transmission. We have done it before and we will do it here, and the team in Dallas is doing an excellent job making sure that happens. Thank you all so much for your interest in covering this topic.

BARBARA REYNOLDS: Thank you. This concludes our update on the Ebola response in Dallas. For media who have additional questions, they can contact the CDC media through 404-639-3286. Thank you.

OPERATOR: Thank you. Thank you all for your participation today in today's conference. You may now disconnect.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES