On Wednesday, ten days after he was admitted to a Dallas hospital and tested positive for the Ebola virus, Liberian national Thomas Eric Duncan died from the disease.
Duncan contracted the hemorrhagic fever that is devastating West Africa while escorting an infected and pregnant neighbor to a hospital in Monrovia, prior to traveling to the US on September 19. He was admitted to the hospital eight days later, becoming the first person to be diagnosed with the virus in the US, a situation that has sparked controversy and criticism.
In a statement following Duncan's death, his partner Louise Troh, who he was visiting in Dallas, said his passing "has dramatically changed our lives, and we will be grieving for a long time." She expressed sorrow that the 42-year-old had not been able to see his son before passing away.
"My family is in deep sadness and grief, but we leave him in the hands of God," she wrote, thanking communities in Dallas and Liberia for their support. "I trust a thorough examination will take place regarding all aspects of his care."
Commenting on Duncan's death, US Centers for Disease Control Director Tom Frieden said, "He is a face that we associate now with Ebola."
The case has put hospital preparedness in the US to the test. While it has shown the CDC's ability to quickly mobilize control efforts and keep the public informed, it has also highlights shortcomings in communications, readiness for outbreaks, and decontamination capabilities.
Among a string of widely publicized missteps, a major hospital oversight occurred when Duncan first sought treatment on September 20 with symptoms commonly linked to Ebola. Despite telling a nurse he had been in West Africa, a communication breakdown led to the 42-year-old Liberian being sent home. He was admitted to the hospital four days days later on Wednesday, September 24 after his second attempt to seek care.
There are a number of healthcare factors that can — and almost certainly will — be analyzed in the months following Duncan's death. Supplies of an experimental serum known as ZMapp, which has been given to other US patients, had run out by the time he fell ill. He also did not receive a blood serum transfusion from a survivor, as has also been done in the past, but he did receive another experimental drug called Brincidofovir. Unapproved treatments aside, one thing that public health officials across the board have stressed throughout the outbreak is that the earlier someone with Ebola receives proper supportive care, the more likely they are to survive.
"We don't know if [Duncan] would have died had he been treated when he first showed up at the hospital," Alan Card, a global communicative disease expert and risk assessment consultant, told VICE News, agreeing that the earlier someone receives care for Ebola, the better. Card said it's important for healthcare staff to be aware of proper measures for handling and mitigating the virus.
While the effect of the four-day gap on Duncan's health is unknown, it was enough to put dozens of people at risk of contracting the disease. The same hospital where Duncan received treatment reported today that a deputy who had entered his family's apartment had been admitted for treatment with Ebola-like symptoms.
"There were some obvious lapses at the beginning, which was a true missed opportunity," Dr. Steve Morse, a professor of epidemiology at Columbia University Medical Center told VICE News. He said that, while we don't know whether Duncan would have survived if he had received care sooner, "we wouldn't have had to worry about all the contact tracing."
As Card pointed out, this kind of misstep is not exclusive to Ebola, saying, "It's a problem we see everyday in health care."
According to Morse, the potentially deadly error "shows the need, as I say, to listen to the patient, sometimes they do know something." He pointed to concerning trends in which healthcare workers in the US now have less time to spend with their patients, and administrative systems that do not streamline communication between nurses and doctors.
As much as public health experts agree that Ebola is unlikely to spread in the modern healthcare systems that are in place in the US and Western Europe, a similar gap in responding to Ebola symptoms in a patient occurred in Spain this week when a nurse reportedly informed her hospital of Ebola-like symptoms three times before she was taken seriously and eventually tested positive for the virus. Even after the nurse, Teresa Romero-Ramos, who had played a role in the treatment of two Ebola-infected Spanish priests at the hospital in recent months, was admitted to the hospital located outside of Madrid, she was allegedly kept in the main emergency room while awaiting test results.
Among those who might have come in contact with Romero-Ramos, probably the most high profile case is not a person, but her pet dog Excalibur. Deciding to stay safe and heed the warning of a study from a previous outbreak that found dogs could be infected with Ebola, the Spanish government obtained a court order to euthanize the family pet. Animal activists and sympathizers around the globe took to social media, and even the streets outside of the hospital, to express their concern for Excalibur. Despite the global show of support, and a petition with more than 300,000 signatures, Spanish authorities confirmed that Excalibur was put down Wednesday evening.
While it may seem unnecessary to focus prevention efforts on a dog, University of Reading virologist Ben Neuman told VICE News that, in this case, it was the right call. He explained that quarantining the dog is not really an option as it would likely mean taking a spot in an Ebola ward that a person might need.
"The Spanish health service have their priorities straight," he said. "At some point you just have to draw the line and say 'It's a dog, not a person.'"
Beyond the canine drama, the fact that the nurse contracted the virus has unsurprisingly been cause for alarm. Romero-Ramos said she believes she could have been infected by touching her gloves to her face while taking off a protective suit she was wearing. The hospital has said the healthcare workers had proper supervision while removing their gear.
Morse pointed out that people are at their most vulnerable to Ebola infection when taking off their Personal Protective Equipment (PPE) since they are potentially covered in virus at that point. Unfortunately, he said that healthcare workers can become complacent and comfortable in the suits. More importantly, Morse explained that the suits are typically removed at the end of the day when the workers are, "Very tired, never are you more tired then when you're taking it off."
According to Card, the Romero-Ramos case and some ways in which the Dallas infection was handled show that "we're doing very poorly at managing contamination." He believes that it's necessary to come up with a better design for PPE, one that doesn't leave so much room for error.
"You're relying on people to be perfect every time, you screw up one time and you can be dead with Ebola," he said, adding that getting product designers and biologists together to design a better model would be ideal.
Equally alarming, as both Morse and Card pointed out, was the way the Dallas apartment of Duncan's family was decontaminated, and the fact that they were quarantined in the virus-covered space for days. It took several days for a crew to come and clean the apartment and throw away contaminated sheets. Duncan had also threw up on the sidewalk outside of the apartment, and the highly-contagious vomit was cleaned away with a pressure washer operated by a man in minimal protective gear.
"We locked them with a house that was contaminated. It's immoral, I think, that we quarantined them in that house — We're asking them to get sick," Card said, adding that pressure washer is not the ideal way to clean up what could have been live virus. "That seems like the exact opposite of anything you'd want to do."
The World Health Organization emphasized in a statement today that, while sporadic cases are 'unavoidable' in Europe due to international travel, the probability of Ebola spreading widely across the continent remains "avoidable and extremely low."
"All countries have protocols and procedures that must be implemented when a case is suspected and it is important that these are followed diligently," the WHO said.
Card noted that it's crucial for hospitals around the US to ensure that they not only have response plans — as most already do, at least on the books — but that the protocols are communicated to anyone who might be involved in infectious disease treatment, from doctors to nurses to janitors. He explained that simply having a plan on paper is not helpful. According to Card, it's important for hospitals to invest the time in performing drills, and then fixing any problems or gaps that arise in these exercises.
"Everyone everywhere needs to take a lesson from these two cases, you need to risk assess your plan before it happens," Card said. "You don't want to learn from experience, you want to have it done before we experience something."
Follow Kayla Ruble on Twitter: @RubleKB