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Is Differing Ebola Guidance to Medical Providers a Hole in U.S. Safety Net?

CDC says recent travelers should be isolated if they show fever OR other symptoms, but some cities require both before taking that step.

Some major municipalities are providing guidance to local health facilities for screening and handling potential Ebola cases that differs from that being dispensed by the federal Centers for Disease Control, NBC News has learned.

Health authorities in at least three metropolitan areas – New York City, Las Vegas and Cook County, Illinois, which includes Chicago – have distributed guidelines for local hospitals, health facilities and health workers. Included in that guidance is language advising that patients who recently returned from an Ebola-affected area but exhibited only a fever or associated Ebola symptoms – not both -- could be released, possibly allowing them to infect others, according to documents obtained by NBC News.

That differs from the CDC’s official printed “algorithm” – the agency’s recommended course of action for doctors and nurses to help them identify and manage potential Ebola cases. The CDC advises that if a traveler who has visited an Ebola-affected area within 21 days of the onset of illness presents with “fever … or compatible EVD (Ebola Virus Disease) symptoms,” the facility should immediately isolate the patient, implement infection control measures and notify local authorities.

The difference between patients presenting with fever “and” other symptoms vs. fever “or” other symptoms may appear small, but it could have a big impact for a health care provider carefully following the guidance in those cities – and possibly others.

And there are indications that not all Ebola patients exhibit both fever and other associated symptoms.

That appears to have been the case with a Spanish nurse who on Monday became the first person known to have contracted the disease outside of West Africa during the current epidemic. Spanish health officials said that the nurse, who had cared for an Ebola patient who contracted the virus in Sierra Leone, exhibited only a fever when she was first treated.

Such a case in the U.S. could have serious consequences.

For example, an “Ebola Screening Questionnaire” prepared for Clark County, Nevada, emergency medical services staff, including Las Vegas, specified that, if a patient does not have both a "fever of greater than 101.5 F (38.6 C) and at least one additional symptom, EMS workers do not have to ask “secondary questions” and can “transport as normal.” Only if they have a fever and additional symptoms, it says, do EMS workers need to "proceed to secondary questions," including asking if the patient recently lived in or traveled to "a country where an Ebola outbreak is occurring" or if the patient had "contact with blood or body fluids of a patient known to have or suspected to have Ebola.”

Contacted about the draft by NBC News, a Southern Nevada Health District spokesperson Stephanie Bethel wrote NBC News in an email that that document “is an obsolete draft. The protocol has been revised and distributed to area personnel.”

Bethel noted that Southern Nevada’ Health District’s recently published screening algorithm intended for health workers including emergency medical services personnel, is based on the CDC’s guidance, and directs that “patients are to be asked about travel histories if they have any of the following symptoms: fever or chills, headache, joint or muscle aches, weakness or fatigue, stomach pain, diarrhea or vomiting, or abnormal bleeding.”

The Dallas County Health and Human Services Department -– where the first confirmed case of Ebola on U.S. soil was reported – also closely reflects the CDC’s guidance. It requires isolation, Ebola testing, and reporting to local health authorities whether either fever or additional symptoms are present in a traveler from “an area where (Ebola) transmission is active” –- as long as Ebola is “suspected.”

Despite that recommendation, Thomas Eric Duncan, the first Ebola patient to be diagnosed in the U.S., was released by Texas Health Presbyterian Hospital in Dallas on Sept. 26, after he visited the emergency room. Duncan's death was announced Wednesday by officials at the hospital where he was undergoing treatment.

Responding to an inquiry about the discrepancy, CDC spokeswoman Abbigail Tumpey said that the CDC’s use of the term “or” in its guidance to healthcare providers was intentional.

“We created the algorithm with the term “or” to ensure that local doctors and nurses will be screening the largest possible group,” she said.


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But she also thanked NBC News for bringing the issue to the agency’s attention and said that officials had identified some other discrepancies in their own documents that they are working to fix. She also said that the agency released its latest Ebola algorithm checklist on Wednesday and that it was based on the CDC's earlier guidance on the disease, which was released in late July or early August.

After NBC News brought the differences to their attention, the health departments for both New York City and Cook County said that they are changing their guidance to match the CDC’s.

On Thursday, New York City’s Department of Health and Mental Hygiene issued an official update of its Ebola policies and guidance, which included an updated Ebola “decision” algorithm. In its “Ebola Virus Disease Update” advisory, the agency directed health workers and facilities to “obtain a travel history from all patients presenting with fever OR with other signs or symptoms compatible with EVD (e.g., headache, myalgias, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage).

The new algorithm also eliminates a minimum fever temperature of 101.5 F as one determining factor for isolation. The new algorithm specifies only "measured or subjective" fever -- meaning fever of any amount, either measured by a thermometer device or reported by the patient. (The CDC's posted algorithm, as of Thursday, continues to specify a minimum temperature "(subjective or ≥101.5°F or 38.6°C).")

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Dr. Eric Toner, a senior associate at the University of Pittsburgh Medical Center’s Center for Health Security in Baltimore,said that the risk of an Ebola patient being released would be small, no matter which definition was used.

“Some of the EVD symptoms listed are so general and nonspecific -- headache, weakness, joint pain -- that it would be hard to imagine that anyone with fever would not have at least one of these,” he said.

The CDC issued broader guidance about Ebola, “Guidelines for Evaluation of U.S. Patients Suspected of Having Ebola Virus Disease,” to health authorities and facilities nationwide in early August through its Health Alert Network, and has continued to update it.

One infectious disease specialist who is familiar with CDC’s Ebola protocols told NBC News that the one-page algorithms are a very effective way to simplify and visually represent the CDC’s full guidance, which is more complex and can run to many pages.

“It is by no means intended to be a practice standard,” that individual told NBC News. “And in general most people understand that. It is not meant to be absolute.”

That expert also said that the algorithms were very useful as guidance.

“It’s supposed to be used with the larger CDC guidance,” the source said. “The intent is all good.”

The expert cautioned that criticism of the algorithms may have unintended negative consequences.

“If there’s too much focus on the exact wording and language of an algorithm, I’m worried there will be a general sense that algorithms are not worthwhile and may be dangerous, because they can be misinterpreted as something that’s rigid and absolute.”

Maggie Fox contributed to this report.