In Spain, Ebola Finds a Country Where Wounds Are Self-Inflicted

A health worker on Sunday at an isolation ward on the sixth floor of the Carlos III hospital in Madrid.
By JIM YARDLEY
October 14, 2014

MADRID — The scene conveyed a First World precision: An elderly Spanish priest, stricken with Ebola in Liberia, arrived in Madrid on a special military jet. A helicopter buzzed overhead as ambulances transported him for treatment. Expressing confidence in the preparations, a Spanish health official said the risk of the virus spreading was “virtually nil.”

There was just one problem: the city’s infectious disease center had been mostly dismantled as part of a government cost-cutting plan and a temporary Ebola ward would have to be hurriedly constructed.

After the priest died on Aug. 12, the unit was closed again, and the same exercise repeated when a second Ebola-infected priest was airlifted from West Africa in September. He died two days later, and last week an auxiliary nurse who changed his diaper and helped clean his bed was found to have the disease.

That ad hoc, improvisational response to a deadly virus that has already killed more than 4,000 people in West Africa has underscored holes in the West’s readiness to confront a wider outbreak. The infection of the Spanish nurse, Teresa Romero Ramos, was the first case of the disease being transmitted outside Africa — arising even before a nurse in Dallas was given an Ebola diagnosis after caring for a patient there.

Together, the cases have raised urgent questions about the risks of the disease spreading even in developed countries, particularly among health care workers, and the role that the smallest of human errors may play in subverting elaborate safety measures.

Both of the nurses had been wearing protective suits, which can pose extreme risks of infection if removed improperly. Officials are investigating whether the Spanish nurse may have inadvertently touched her face while taking her suit off.

A team of European Union investigators has found fault in the layout of the Ebola ward, while Ms. Romero’s co-workers have said they were forced to remove their gear in a very small space, with limited room to maneuver, even as temperatures rose quickly inside the suit.

Interactive Feature | More Ebola CoverageThe latest developments on Ebola along with stories and videos that put the outbreak in context.

“You are sweating more and you are anxious to get it off,” said Manuel Torres, a nurse who joined Ms. Romero in treating the first priest and is now a member of the team treating her.

Recriminations in Spain, like in the United States, have been loud and swift, with blame aimed variously at cost cuts, inadequate training and safety protocols, government officials, and the nurse herself.

Protesters stood outside the Health Ministry on Monday chanting for the resignation of Ana Mato, the national health minister. Facing complaints that the national government acted too slowly, Prime Minister Mariano Rajoy created a special commission on Friday to oversee readiness and investigate how Ms. Romero became infected.

“This is an incredibly important moment, not just for Spain but for Europe and the United States,” said Dr. Julián Ezquerra, general secretary of Amyts, a large union of physicians in Madrid. “This is the first case of Ebola that has been generated outside Africa. We need to know what went wrong.”

Graphic | How Hospital Workers Are Supposed to Treat Ebola SafelyA look at the C.D.C. guidance on protective clothing for workers treating the disease.

For now, Ms. Romero, 44, remains in critical condition, if showing tentative signs of improvement, housed on the sixth floor of the same hospital, Carlos III, where the two priests were cared for.

Her husband and 14 others are quarantined on a floor below, with none yet showing any symptoms of Ebola. In all, 83 people who came into contact with Ms. Romero are being monitored.

Beyond the uncertainty over how the infection occurred, much of the public confusion, and anger, is focused on the seemingly loose monitoring of Ms. Romero for more than a week after the death of the second priest. Even as she called in complaining of a low-grade fever and of feeling queasy, she was never told to return to Carlos III.

“She was considered a low-risk contact,” said Dr. Fernando Simón, the health ministry official now leading the government investigation, in an interview.

Ms. Romero’s own actions are being closely examined, too, to determine whether she put people at risk as her symptoms began to emerge.

Javier Rodríguez, Madrid’s regional health minister, initially blamed Ms. Romero for her infection, saying she also may have lied to doctors, remarks that drew angry criticism. He also later seemed to mock the importance of training workers to remove their protective suits.

“You don’t need a master’s degree to explain to someone how you should put on or take off” a protective suit, he said on a Madrid television program.

On Monday, Ms. Romero’s husband, Javier Limón, had a friend read a statement outside Carlos III in which he demanded Mr. Rodríguez’s resignation and defended his wife, saying she had acted precisely as she had been told to. On Tuesday, Mr. Rodríguez apologized.

In Madrid, unions representing health workers have complained that too little training was provided on how to properly remove the suits, with some people being shown a 20-minute video and others saying they got no instruction.

Without admitting any fault, health officials have sent work crews into Carlos III in recent days to expand the size of the changing areas used by health workers. On Tuesday they also announced that all health care workers would receive training courses from the military and Doctors Without Borders, the international aid group.

Unquestionably, the Ebola crisis has exposed the deep divide between health workers and Madrid’s government. In December 2012, Madrid officials announced a broad plan to cut costs by restructuring the public health system, privatizing some hospitals and closing two others, including Carlos III.

Unions vehemently protested the plan. Ultimately, Madrid officials canceled most of the program but still closed the infectious disease center at Carlos III so that the hospital could be converted for geriatric care.

By late last year, many doctors and nurses were reassigned to the adjacent La Paz Hospital, while the intensive care unit and other departments were dismantled at Carlos III.

“The building was basically empty,” said Elena Morán, an official with one of the major unions representing health workers. “The people were working in La Paz.”

By May, the spread of Ebola in West Africa was raising fears that the virus could reach Europe. Health officials in Madrid designated La Paz as the responsible hospital for any future cases, and staffers and hospital management soon revolted.

It is unclear when, precisely, Madrid officials backed away from that decision. Dr. Simón, the health ministry official, said that the decision to take the infected priest, the Rev. Miguel Pajares, to Carlos III was made in the final days before he arrived in early August.

That decision that alarmed leaders of Amyts, the physician’s union. Representatives from some other unions say the change was made at the very last moment.

“It was the speed, and how quickly it was being done, the improvisation,” said Dr. Ezquerra, the general secretary. “Carlos III was being dismantled.”

Ms. Romero volunteered for the teams that treated both priests. As an auxiliary nurse, her job was to assist the nurses and handle some cleaning tasks.

When the Ebola staff disbanded, she left for time off. As a “low-risk” contact, she monitored herself, and was only supposed to call in if her temperature exceeded 38.6 degrees Celsius (101.5 degrees Fahrenheit). She did not initially demonstrate any symptoms and took a civil service exam on Sept. 27.

Three days later, though, she began to feel vaguely ill. According to Dr. Simón, she went to see local physician on Oct. 2, though she did not mention that she had worked in the Ebola unit. The doctor gave her paracetamol for her low-grade fever.

That same day, Ms. Romero made her first call to the monitoring unit at La Paz, which was tracking the Ebola team. Her temperature remained below the 38.6 threshold and she was advised to continue self-monitoring.

In the next few days, she called a second time, according to Dr. Simón, but, again, her temperature had not topped the Ebola threshold. Again, no one advised her to report to Carlos III. (Now, Spanish officials have changed the protocol so that lower temperatures will trigger concern.)

Finally, on Oct. 6, Ms. Romero called an ambulance service for the closest hospital, Alcorcón, warning them that she had worked on the Ebola team and might be showing symptoms. At Alcorcón, she was quickly quarantined.

After seeing Ebola symptoms, the attending physician, Dr. Juan Manuel Parra, himself now under quarantine, made several requests that she be transferred to Carlos III.

Her transfer was delayed while health officials tried to locate one of the special plastic capsules needed to move an Ebola patient, and while a medical team was scrambled to again prepare the once-empty sixth floor of Carlos III.

“You never think it is going to be Ebola,” Ms. Romero said in one of her media interviews at the beginning of her quarantine. “You never think that.”

Patricia Rafael and Brenda Yastremski contributed reporting.