Ebola in Europe: What Went Wrong

ROME, Italy — When Teresa Romero Ramos, the Spanish nurse now afflicted with the deadly Ebola virus first felt feverish on September 30, she reportedly called her family doctor and told him she had been working with Ebola patients just like Thomas Eric Duncan who died today in Dallas. Her fever was low-grade, just 38 degrees Celsius (100 degrees Fahrenheit), far enough below the 38.6-degree Ebola red alert temperature to not cause alarm. Her doctor told her to take two aspirin, keep an eye on her fever and keep in touch, according to Spanish press reports quoting Romero’s husband Javier Limón Romero. He says she didn’t initially exhibit any of the other Ebola symptoms: vomiting, diarrhea, nausea, and she certainly didn’t feel sick enough to stay in bed.

Less than a week later, Romero tested positive for the virus – news she learned not from her doctor but from watching a Spanish Europa Press news report on her smartphone from her hospital bed. Her husband and a second nurse’s aide who treated the same Ebola patients were immediately put under quarantine when Romero’s diagnosis was confirmed. Now a third nurse who also worked with the same Ebola patients who infected Romero is exhibiting the same low-grade fever. This time, authorities acted quickly to isolate her. Had they had the same response to Romero’s slight fever, they could have stopped the spread of the deadly virus. Instead, scores of people in Madrid who used the same public transportation, restaurants, and grocery stores as Romero wait anxiously to see if they, too, will get sick.

Romero noticed her fever when was on holiday leave from her work at the Carlos III Hospital in Madrid and she and her husband were scheduled to go on a short vacation, but he hurt his leg and they decided to stay close to home instead. She used her time off work to run errands and catch up with friends. She also sat a government civil service exam with 20,000 other people to try to win a better job placement at the hospital, according to Spain’s El País newspaper, which also reports that Romero discussed her slight fever and how she was feeling sick with friends and colleagues.

According to El País, she talked incessantly about what the Ebola threshold was and, since she was far below it, they assured her not to worry—advice she apparently wanted to hear. In retrospect, it would seem, standard thresholds don’t apply to people who were in direct contact with the disease like Romero, who was on the treatment team for two Spanish priests who were repatriated to Spain from Sierra Leone in August and September. Romero attended to Father Manuel García Viejo, 69, who died on September 25. Romero was in his room just twice: once to change a soiled diaper and another time after he died to remove his belongings that were set to be destroyed.

Now Europe is grappling with its worst fear—the threat of an Ebola outbreak. And even the authorities can’t argue it won’t happen. Zsuzsanna Jakab, the Europe director for the World Health Organization, told Reuters that more cases of Ebola in Europe were “most likely” to happen. “Such imported cases and similar events as have happened in Spain will happen also in the future, most likely,” he told Reuters by phone from her Copenhagen office. “It is quite unavoidable.” He blamed the inevitable outbreak on both extensive travel between Europe and the affected African countries, and the increasing number of victims being brought to Europe for treatment.

It is highly likely that Romero will have infected at least one other person, probably her husband, because she was not isolated immediately. Even in African nations with limited resources hardest hit with the epidemic, isolation is well known to be the first line of defense against the virus that has killed more than 3,400 people so far and infected 7,500.

That Romero was allowed to mingle in public after reporting a fever when she was within the known incubation period for the virus is unacceptable. But what makes Romero’s case particularly troubling is that Spanish health authorities and the hospital where she worked appear complicit in not immediately isolating her.

Spain’s health minister Ana Mato says “all possible measures” are in place to stop the spread of the virus, assuring the public that Romero “was not contagious” because her fever wasn’t high enough. That will do little to calm the fears of the more than 50 people now under surveillance who were in contact with her before she was finally taken out of circulation. European Commission spokesman Frederic Vincent told reporters on Tuesday that the Spanish authorities have a lot to answer for. “Spain told us all the protocols have been followed, but obviously something wrong happened,” he said at a press conference.

According to Spanish press reports quoting the Spanish nurses’ union, Romero called Carlos III hospital several times between September 30 and October 2 when her fever finally hit the 38.6 threshold. Still, it took until October 6 when she had become so deathly ill she was begging for an Ebola test before anyone at the hospital where she worked reportedly reacted. Then, rather than immediately isolating her and rushing her to the special ward used to treat the previous Ebola patients, they told her to go to the nearby emergency room at Alcorcón, where press reports say she sat in the public waiting room for several hours absent of any protective gear. “I think I have Ebola,” she reportedly told anyone who would listen. But no one took notice until her first test came back positive. By then, dripping with fevered sweat, she would have been inarguably contagious.

Spain’s El Mundo newspaper was able to reach Romero by cellphone from her hospital bed on Tuesday, from where she uttered monosyllabic responses to their questions until she was too tired to hold up the phone. “Yes,” she told the paper she followed protocols put in place. “No,” she said, she had no idea how she got the disease. She is being treated with the antibodies of Ebola patients who survived, which has become a standard WHO approved treatment for the virus, which has no known cure.

El Mundo was also able to reach Romero’s husband, who is in isolation in the same hospital. He complained that not only has their house been cordoned off and “fumigated” but most of the neighbors have fled in fear. He also said police intend to put their beloved family pet, a Staffordshire bull terrier named Excalibur, to sleep. He even launched a Facebook campaign on an animal welfare page from his hospital room to try to save the pet. “I won’t give permission, and they said that if I don’t they will get a court order to kill the dog,” he told El Mundo. “What next, will they sacrifice me, too?”

Romero’s husband says that his wife followed all available protocols to keep herself safe while she treated the two Spanish priests who both died of Ebola in the hospital where she worked, but he implied the hospital did not offer enough protection.

Carlos III director Yolanda Fuentes told El País that the biohazard suits they provided did indeed conform with safety protocols established by the World Health Organization and the Spanish Ministry of Health. On Wednesday, German Ramfrez from the Chief Medical Internal Hospital in La Paz said it was Romero who erred when she touched her face with her infected glove as she undressed. Ramfrez told reporters at a news conference meant to quell panic that it was Romero's "oversight"—not the Spanish medical community that has been blamed for its preparation for fighting the virus.

But the Spanish press report that the hospital was underequipped to handle cases and that rather than the Level IV suits they require, the Carlos III hospital only had Level II gear. The World Health Organization requires that hospitals taking Ebola patients wear impermeable gloves, goggles, biohazard suits with closed wrist openings and head gear with breathing apparatuses. Even in the African nations where supplies are at a premium, medical workers know to use duct tape to close the sleeves of their suits.

According to El Pais the Carlos III hospital did not make those suits available and instead they were given latex gloves and adhesive tape. They also reported that the human waste from the Ebola patients was transported to the medical incinerator in the same elevators used by unprotected staff. The BBC reports that Spanish health workers have staged a demonstration waving signs in their inadequate biohazard suits to protest the apparent safety failures. For Romero and the scores of people she may have infected before she was isolated, those failures could prove to be fatal.