TIME ebola

CDC Issues New Guidelines for Returning Health Workers

Tom Frieden
Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, speaks at a news conference in Atlanta on Oct. 12, 2014 John Amis—AP

Travelers coming to the U.S. from Ebola-affected countries who do not require mandatory quarantines upon arrival will undergo voluntary at-home isolation and could be placed on “do not board” lists, according to new guidelines released by the Centers for Disease Control and Prevention (CDC) on Monday.

The CDC’s new guidelines break down travelers’ risk level into categories: high risk, some risk, low risk and no risk.

People who fall into the high-risk category are those who had direct contact with Ebola patients in West Africa, and who may be at a high risk for infection. For instance, they handled bodily fluids without protection. Those individuals will be asked to isolate themselves in their homes for 21 days. They would be allowed to leave and go out on a jog, for example, but they would not be allowed to take public transportation or go to places with high volumes of people or “congregate gatherings.” They will undergo active monitoring.

People who fall under the “some risk” category would have their temperatures checked twice a day, and their travel and public activities will be assessed on a case-by-case basis. This distinction might apply to a health care worker who did not have direct contact with patients, or who had direct contact but used personal protective equipment fastidiously.

These guidelines are a marked departure from the sweeping quarantine mandate that Florida, Illinois, New Jersey and New York implemented over the last week, stirring up controversy after a recently returned nurse who tested negative for the virus protested her forcible detainment in New Jersey.

When asked why CDC recommendations differ from some states, CDC director Dr. Tom Frieden said, “We find that state health departments generally do follow CDC guidelines.” He added that if states wish to be more stringent, they’re within their rights to do so.

Frieden said fewer than 100 people a day are coming into the U.S. from the Ebola-affected countries. So far there have been 807 people, and of those, 46 are health care workers. The CDC has already instituted daily monitoring for travelers coming in from the Ebola-affected countries. Every traveler is given a kit to take their temperatures and must provide local health care officials with contact information to get in touch with them.

“We base our decisions on science and experience,” said Frieden. “As the science and experience changes, we adapt.” Frieden also acknowledged the active monitoring approach that Doctors Without Borders has urged its physicians to follow. Dr. Craig Spencer is the first Doctors Without Borders worker to be diagnosed with the disease in the U.S., but was immediately quarantined after he reported the first sign of an infection (a lower-grade fever). “This is the kind of approach that they will be effective,” said Frieden.

During the press conference, Frieden cited a 1995 study conducted in what is now the Democratic Republic of the Congo that looked at the Ebola infection risk of 173 people living within a household of someone with Ebola. The study showed that only 28 (16%) of the 173 contacts of 27 primary Ebola cases developed Ebola, and those who did develop Ebola had direct contact with a known patient. None of the 78 family members who did not have direct contact later became infected, stressing that Ebola needs very direct contact to spread.

“We will only get to zero risk by stopping it at the source,” said Frieden.

On Monday, New Jersey Governor Chris Christie said health care worker Kaci Hickox was released after being put in a mandatory quarantine despite not having any symptoms for the disease.

TIME Innovation

Five Best Ideas of the Day: October 27

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. In journalism, the ideological middle is fast becoming a myth. Journalists need a point of view if they wish to stay relevant.

By Jay Rosen in the Conversation

2. Shrinking public health resources and the fragmented health delivery system in the U.S. are the real problems with our response to Ebola.

By J. Stephen Morrison in Health Affairs

3. African-American girls are suspended from school at six times the rate of white girls, and this disproportionate punishment has a lasting impact.

By Lucia Graves in National Journal

4. Our war on ISIS is strengthening Iran’s hand in the region — and nudging closed the door on an independent Iraq.

By Paul D. Shinkman in U.S. News and World Report

5. Discovery-focused learning — think of the maker movement and home hacking — can save American education.

By David Edwards in Wired

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME ebola

Here’s What Would Happen if Ebola Was Stolen From a Lab

Biohazard sticker on laboratory window
Adam Gault—OJO Images RF/Getty Images

The virus is considered a bioterrorism agent. But massive fines, jail time and a risk of deadly exposure may be enough of a deterrent

Scientists routinely study deadly pathogens like Ebola in order to find ways to fight them and discover potential cures. But what would happen if a sample of Ebola was taken from a lab illegally?

Under federal regulations, Ebola is considered a “select agent and toxin” that has the “potential to pose a severe threat to public health and safety,” and it’s illegal to possess, use or transfer a deadly pathogen to another individual without a certificate from the U.S. Department of Health and Human Services, says John Kraemer, an expert on infectious diseases and the law at Georgetown University’s Department of Health Systems Administration. Obtaining that certificate requires meeting a set of biosafety and biosecurity requirements. And the penalties for failing to do so can be steep.

The government has levied fines of hundreds of thousands of dollars to laboratories that have violated the select agent regulations. In 2008, HHS docked Texas A&M University $1 million for safety violations at its biodefense lab. Individuals who steal a disease sample could face similarly steep fines and time behind bars. Under federal law, HHS can fine a person up to $250,000 for each violation and can recommend imprisonment of up to five years.

But there is an additional layer of sensitivity to handling Ebola. The CDC considers viral hemorrhagic fevers, which includes Ebola, a Category A bioterrorism agent. And since 2001, several bioterrorism laws have strengthened criminal penalties against those who attempt to commandeer them. The Patriot Act in 2001 created a provision banning the transfer of a select agent like Ebola, and the Bioterrorism Act of 2002 gave more authority to the HHS to regulate those agents and diseases.

In September, the Obama administration issued new regulations for federally funded labs that work with contagious diseases like Ebola. Some researchers have criticized the guidelines as not being strong enough over fears that the pathogens, which are often made stronger in a lab, could potentially be used as bioweapons.

Kraemer says two scenarios could likely play out if Ebola samples fell into the wrong hands. If a researcher acquired Ebola for misguided research, for example, then they would likely get fined by HHS and could be sentenced to five years in prison.

“If however someone broke into a hospital to steal Ebola for some other reason, it’d be at least 10 years,” Kraemer says. “If someone acquires Ebola with an intent to weaponize it, then they can get life in prison. And, of course, if you actually use Ebola as a weapon, you can be prosecuted under federal anti-terrorism laws, with penalties up to the death penalty.”

Given the security required at labs authorized to handle potential biological weapons, as well as the risk that someone stealing a pathogen may also become infected by it, those latter scenarios are highly unlikely.

“Stealing an Ebola sample would be extremely dangerous because the thief would face a significant risk of exposure,” says Robert Field, a professor of law at Drexel University. “Other pathogens would be safer to steal because protection is easier.”

Like, for instance, anthrax.

TIME ebola

All Travelers Coming to U.S. From Ebola-Hit Countries Will Be Monitored

New York's JFK Airport Begins Screening Passengers For Ebola Virus
People arrive at the international arrivals terminal at New York's John F. Kennedy Airport (JFK ) airport on October 11, 2014 in New York City. Spencer Platt—Getty Images

Travelers will be monitored for 21 days upon arrival in the U.S.

All travelers entering the United States from Liberia, Guinea, and Sierra Leone will now be actively monitored for Ebola-like symptoms by state and local health officials for 21 days upon landing in the U.S., the Centers for Disease Control and Prevention announced on Wednesday. Those three West African countries are the hardest-hit by a recent outbreak of the deadly disease, and about 150 people travel from them to the U.S. every day.

CDC Director Dr. Tom Frieden announced the new program as the U.S. began requiring travelers from those three countries to arrive in the country through one of five airports performing intensive screening procedures. The new monitoring program will start on Monday in New York, Pennsylvania, Maryland, Virginia, New Jersey and Georgia, the six states where most travelers from the three countries end their trips.

When travelers from the three West African countries arrive in the U.S., they will be given an explanatory kit that includes a thermometer and will be asked to provide two email addresses, two telephone numbers, a home address and an address for the next 21 days. They will also need to provide the same information for a family member or friend. Travelers will be asked to report to a public health worker from a state or local health department daily, providing a temperature as well as well reporting any symptoms. They must also inform officials if they plan to travel, and if so, they must coordinate their tracking their symptoms with health officials.

“We have to keep up our guard against Ebola,” said Frieden, adding that it’s the “CDC’s mission is to protect Americans.”

 

TIME ebola

More Than 5,000 Health Care Workers Attend Ebola Training

CDC and Mount Sinai health workers demonstrate how to put on and off Ebola personal protective equipment at an Ebola education session in New York City Alexandra Sifferlin

"We are having a family meeting"

More than 5,000 health care and hospital infection control workers gathered at the Javits Center in New York City for an Ebola education session amid growing concern among hospital workers over Ebola preparedness.

“We are having a family meeting,” Kenneth Raske, president of the Greater New York Hospital Association (GNYHA) told TIME. “The turnout is spectacular. We may not answer every question [today], but we are committed to finding the answers.”

The event, which was streamed live nationwide, featured Centers for Disease Control (CDC) experts offering live trainings on how to safely care for patients with Ebola. It was hosted by the Healthcare Education Project from GNYHA/1199SEIU and Partnership for Quality Care.

New York governor Andrew Cuomo helped kick off the event, touting New Yorkers’ resilience and ability to always “rise to the occasion” from 9/11 to Hurricane Sandy. “We have a new challenge we must meet today,” said Cuomo. New York City Mayor Bill de Blasio also made an appearance, thanking health care workers.

“Regardless of immigration status, we will help them all,” said de Blasio, referring to the possibility of patients with Ebola coming into a New York City emergency room.

The session included a hands-on demonstration of personal protective equipment (PPE) led by Dr. Bryan Christensen of the CDC’s domestic infection control team for the Ebola response. On Oct. 20, the CDC revised its guidelines for Ebola-related care, recommending full-coverage PPE and supervision while taking PPE on and off.

Christensen supervised registered nurse Barbara Smith of Mount Sinai Health System as she demonstrated how to put on and take off all the pieces of PPE: sanitizing her hands, putting on her first set of gloves, sitting in a chair to put on her foot covers, donning her suit—and finally doing a little jig, to audience laughter, once she was completely suited. Afterward, she took off each piece, sanitized her gloves numerous times and checked for any holes. The entire process took 15 to 20 minutes, which the CDC said cannot be rushed.

Over 5,000 health care workers gather in the Javtis Center in New York City to attend an Ebola education session. Alexandra Sifferlin

CDC officials also reviewed Ebola care protocols in detail, from what to wear and how to discard linens (they can’t be washed) to the way hands should be washed and how to use an alcohol rub to clean gloves before removing them, something that is not usually part of standard procedure. For respiratory protection, the CDC recommends either a powered air purifying respirator (PAPR) or a disposable respirator like N95. Emory University Hospital uses the former; the Nebraska Medical Center uses the latter. “When we use equipment we are not used to, it makes it difficult,” said CDC’s Dr. Arjun Srinivasan. “The way we address this is practice, practice, practice.”

Massive education sessions like this have been held before over health threats like anthrax, H1N1 and smallpox. “We had to have this in a convention center to accommodate folks,” George Gresham, president of 1199SEIU United Healthcare Workers East told TIME. “Back in the 80s when the AIDS epidemic first started, I was a health care worker myself, and it was the unknown that was the mystery, and the fear, and I think that’s the same here. “

The massive number of health care workers that crowded into the conference center proves that they crave more education about caring for potential Ebola patients. Even though some states, including New York, are identifying specific hospitals that will take in any Ebola patients for actual care, all health facilities have to be prepared for the possibility that a patient like Thomas Eric Duncan could walk through their doors.

The hope is that the session was helpful and positive. “I think this is another moment we can calm the public and reassure the public of health care workers’ commitment,” Gresham said.

TIME ebola

Why Ebola Isn’t Really a Threat to the U.S.

Members of Bellevue Hospital staff wear protective clothing as they demonstrate how they would receive a suspected Ebola patient on Oct. 8, 2014 in New York City.
Members of Bellevue Hospital staff wear protective clothing as they demonstrate how they would receive a suspected Ebola patient on Oct. 8, 2014 in New York City. Spencer Platt—Getty Images

Ebola will not likely spread within the United States

Give us this—when Americans overreact, we do it all the way. Over the past week, in response to fears of Ebola, parents in Mississippi pulled their children out of a middle school after finding out that its principal had traveled to Zambia—a nation that is in Africa, but one that hasn’t recorded a single Ebola case. A college sent rejection notices to some applicants from Nigeria because the school wouldn’t accept “international students from countries with confirmed Ebola cases”—even though Nigeria has had less than 20 confirmed cases and the outbreak is effectively over.

The American public is following its leaders, who’ve come down with a bad case of Ebola hysteria. That’s how you get even-tempered politicians like New York Governor Andrew Cuomo musing that the U.S. should “seriously consider” a travel ban on West African countries hit by Ebola, while some of his less restrained colleagues raise the incredibly far-fetched possibility of a terrorist group intentionally sending Ebola-infected refugees into the U.S. It’s little surprise that a Washington Post/ABC News poll found that two-thirds of Americans are concerned about an Ebola outbreak in the U.S.

They shouldn’t be—and two events that happened on Monday show why. WHO officials declared Nigeria officially “Ebola-free.” And in Dallas, the first wave of people being monitored because they had direct contact with Thomas Eric Duncan, the first Ebola patient diagnosed in the U.S., were declared free of the diseases.

Nigeria matters because the nation’s is Africa’s most populous, with 160 million people. Its main city, Lagos, is a sprawling, densely populated metropolis of more than 20 million. Nigeria’s public health system is far from the best in the world. Epidemiologists have nightmares about Ebola spreading unchecked in a city like Lagos, where there’s enough human tinder to burn indefinitely.

Yet after a few cases connected to Sawyer, Nigeria managed to stop Ebola’s spread thanks to solid preparation before the first case, a quick move to declare an emergency, and good management of public anxiety. A country with a per-capita GDP of $2,700—19 times less than the U.S.—proved it could handle Ebola. As Dr. Faisal Shuaib of Nigeria’s Ebola Emergency Operation Center told TIME: “There is no alternative to preparedness.”

But Nigeria’s success was also a reminder of this basic fact: If caught in time, Ebola is not that difficult to control, largely because it remains very difficult to transmit outside a hospital. For all the panic in the U.S. over Ebola, there has yet to be a case transmitted in the community. The fact that two health workers who cared for Duncan contracted the disease demonstrates that something was wrong with the treatment protocol put out by the Centers for Disease Control and Prevention (CDC)—something CDC Director Dr. Tom Frieden has essentially admitted—and may indicate that the way an Ebola patient is cared for in a developed world hospital may actually put doctors and nurses at greater risk.

“You do things that are much more aggressive with patients: intubation, hemodialysis,” National Institute of Allergy and Infectious Diseases head Dr. Anthony Fauci said on CBS’s Face the Nation on Sunday. “The exposure level is a bit different, particularly because you’re keeping patients alive longer.” But now that U.S. health officials understand that additional threat, there should be less risk of further infection from the two nurses who contracted Ebola from Duncan—both of whom are being treated in specialized hospitals.

Even the risk of another Duncan doesn’t seem high. For all the demand to ban commercial travel to and from Ebola-hit West Africa, this region is barely connected to the U.S. in any case. Only about 150 people from that area of Africa come to the U.S. every day—less than a single full Boeing 757—and many airlines have already stopped flying. But there have been relatively few spillover cases even in African countries that are much more closer and more connected to Guinea, Sierra Leone and Liberia. Besides Nigeria, only Senegal has had cases connected to the West African outbreak—and that nation was declared Ebola-free today as well. (There have been cases in the Democratic Republic of Congo, but that’s considered a separate outbreak.) The worst Ebola outbreak ever is raging in three very poor nations—but it seems unable to establish itself anywhere else.

None of this is to deny the scale of the challenge facing Guinea, Sierra Leone and Liberia, where the Ebola has fully taken hold and the disease is still outpacing our efforts to stop it. But West Africa is where our fear and our efforts should be focused—not at home, where Ebola is one thing most of us really don’t have to worry about.

TIME ebola

Ebola Vaccine Testing Could Start Soon

WHO hopes for clinical trials to begin in January

An Ebola vaccine could begin testing in the next few weeks and be ready for clinical trials in West Africa by January, the World Health Organization announced Tuesday.

Still, questions remain about when the drug may be available for the public at large and how many doses will be available, according to CNN.

“It will be deployed in the form of trials,” said WHO official Marie Paule Kieny, noting the number of available trials would be in the tens of thousands, not millions.

Initial tests will be available in countries like the United States and England before moving to West Africa, CNN reported.

Currently, there is no vaccine for Ebola, which has killed more than 4,500 people, almost entirely in West Africa, in the latest outbreak. Health officials have been working on a vaccine for years, and now have expedited their efforts in the face of the current crisis.

[CNN]

TIME ebola

CDC Changes Ebola Guidelines

CDC EBOLA TRAINING
Licensed clinician Hala Fawal practices drawing blood from a patient using a dummy on Monday, Oct. 6, 2014, in Anniston, Ala. Brynn Anderson—AP

Now recommending full-coverage for health care workers

Health care workers treating Ebola patients must now wear full-body coverage suits with no skin showing and must undergo significant training prior to treating patients, U.S. health officials said Monday.

“We may never know exactly how [the Dallas infections happened], but the bottom line is the guidelines didn’t work for that hospital,” Dr. Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), said during a news conference announcing the new guidelines for caring for Ebola patients and wearing personal protective equipment (PPE). Prior to the three Ebola infections in Dallas, including two health care workers, the CDC did not recommend full body coverage for Ebola, but instead recommended at least gloves, a gown, eye protection and a face mask. That has changed, in light of the two health care worker infections at Texas Health Presbyterian Hospital.

The new guidelines have three additions:

1. Prior to working with Ebola patients, health care workers must be repeatedly trained and demonstrate competency in treating a patient with Ebola, especially putting on and taking off PPE. “Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment,” the CDC said in a statement.

2. When wearing PPE, no skin can be exposed. The CDC is providing two options for the PPEs, since the University of Nebraska Medical Center and Emory University Hospital, which have both successfully treated Ebola patients, use different versions. Googles are no longer recommended. The recommendations for PPE are now the following:

  • Double gloves
  • Boot covers that are waterproof and go to at least mid-calf or leg covers
  • Single use fluid resistant or imperable gown that extends to at least mid-calf or coverall without intergraded hood.
  • Respirators, including either N95 respirators or powered air purifying respirator (PAPR)
  • Single-use, full-face shield that is disposable
  • Surgical hoods to ensure complete coverage of the head and neck
  • Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea

3. Every step of putting on and taking off PPE must be supervised by a trained observer. There should also be designated areas for where PPE are taken on and off.

“It’s hard to care for Ebola, so every aspect… needs to be overseen,” said Frieden in the press conference, adding that hospitals should limit personnel in health care rooms and should limit procedures to only those that are essential.

The CDC is increasing health care worker training across the country as well as sending out training videos, but Frieden argues that there is no alternative for hands-on training, especially taking on and off PPEs. “We agree with the concern of health care workers,” said Frieden citing anxiety from health care workers nationwide that they felt unprepared for treating patients with Ebola. The new recommendations will be effective immediately, though the CDC does not have the regulatory authority to make hospitals follow the guidelines, Frieden said. The recommendations should be available online later Monday evening.

Earlier on Monday, a Dallas County Judge confirmed that 43 of 48 contacts of Thomas Eric Duncan were considered no longer at risk after the 21-day incubation period passed, and Nigeria was declared Ebola-free.

TIME Laws

The CDC Has Less Power Than You Think, and Likes it That Way

Ebola isn’t likely to lead to a widespread quarantine but it certainly raises interesting constitutional questions

Director of the Centers for Disease Control and Prevention Tom Frieden has come under fire in recent days for what some charge is the agency’s stumbling response to the appearance of Ebola in America. This week, reporters and lawmakers alike grilled Frieden over how two nurses in Texas contracted the virus and how one of them was able to board an airplane even after she reported a raised temperature.

Breakdowns in good practice notwithstanding, it’s important to remember that Ebola in the U.S. is largely contained and very unlikely to lead to any kind of significant outbreak. Still, the charges leveled against Frieden raise a question that leads to a surprisingly complicated answer: just what, exactly, can—and should—the CDC do?

Since time immemorial, public health officials’ main weapon against the outbreak of a disease as been to restrict the ability of people to interact with one another, also known as a quarantine. The term comes from the Latin “quadraginta,” meaning 40, and is derived from the 40-day period ships traveling from plague-stricken regions were kept at bay before being allowed to dock in medieval European ports.

Imposing a quarantine—effectively stripping innocent people of the most basic right to move freely in the world—is one of the most serious actions a government can take against its own citizenry. Partly for this reason, in the American federal system (designed from the outset to check the power of the national government) the power to quarantine resides largely with state and local authorities. Should Texas, or any other state, someday face the threat of a true epidemic, the states have broad authority to restrict the movement of people within their own borders. Public health codes granting the state power to impose quarantine orders vary from state to state, of course. Violating a quarantine order in Louisiana is punishable by a fine of up to $100 and up to a year in prison; in Mississippi the same infraction could cost a violator up to $5000 and up to five years in prison.

The federal government does have its own powers. The CDC, as the U.S.’s primary agency for taking action to stop the spread of disease, has broad authority under the Commerce Clause of the Constitution to restrict travel into the country and between states of an infected person or a person who has come in contact with an infected person, according to Laura Donohue, director of the Center on National Security and the Law at Georgetown Law School. Federal quarantine can be imposed, too, on federal property, like a military base or National Forest land. And as the preeminent employer of experts on public health crises, the CDC is always likely to get involved within any affected state in the event of a looming pandemic.

But its power to act is extremely restricted. The agency traditionally acts in an advisory role and can only take control from local authorities under two circumstances: if local authorities invite them to do so or under the authority outlined in the Insurrection Act in the event of a total breakdown of law and order.

And here the picture becomes murkier yet because authority does not always beget power.

“It’s not a massive regulatory agency,” said Wendy Parmet, a professor in public health law at Northeastern University in Boston. “They don’t have ground troops. They don’t have tons of regulators. They’re scientists. Even if the states asked them to do it it’s not clear how they would do it.

Even in the highly unlikely event that the CDC were called to respond to a—let’s reiterate: extremely-unlikely-to-occur—pandemic, quarantine and isolation would be imposed not by bespeckled CDC scientists but by local or federal law enforcement or troops. Most importantly, the CDC is extremely reluctant to be seen as a coercive government agency because it depends as much as any agency on the good will and acquiescence of citizens in order to respond effectively to a public health emergency. When the bright lights of the Ebola crisis are not on it, the CDC will still need people to get vaccinated, to go to the doctor when they get sick, and to call the authorities if they see trouble.

“Our public health system is built on voluntary compliance,” Donohue tells TIME. “If the CDC starts to become the enemy holding a gun to [someone’s] head and keeping them in their house, they lose insight.”

TIME

Here’s Who’s Blaming Who for Ebola

A guide to the Ebola blame game

Correction appended at 8:35 p.m. ET

The Ebola crisis in Texas has resulted in the death of one patient, the infection of two health care workers, and an endless round of finger-pointing—all of which is yielding a flurry of conflicting news accounts and a very confused public.

Here’s a rundown of who has been blaming who, and when.

The player: Centers for Disease Control and Prevention (CDC)
Who they’re blaming: Texas Health Presbyterian Hospital, an infected nurse, and the CDC itself

  • CDC Director Tom Frieden on Sunday blamed a “breach in protocol” for allowing the infection of nurse Nina Pham.
  • Frieden admitted on Tuesday the CDC could have done more: “We did send some expertise in infection control but think in retrospect, with 20-20 hindsight, we could have sent a more robust hospital infection control team, and been more hands on at the hospital on day one about exactly how this [case] should be managed. We will do that from now on any time we have a confirmed case.”
  • Frieden, commenting on the infection of the second nurse, Amanda Joy Vinson, said: “She should not have flown on [a plane].”
  • But a CDC spokesman later explained to TIME that the agency had actually asked Vinson to travel: As officials widened the net of people who needed to be monitored, Vinson was in Ohio and the CDC told her to go back to Dallas. Her temperature was 99.5°F, the spokesperson said. “Most doctors would call that a slight temperature, not a fever,” he said. “At that point, she was asked by CDC to come back to Dallas so she could be monitored, and she came back.”

The player: Dallas nurse Amber Joy Vinson
Who they’re blaming: The CDC

  • Vinson said she was cleared by the CDC for travel, which a spokesman later confirmed. She traveled to Cleveland to plan her wedding.

The player: Texas Health Presbyterian Hospital
Who they’re blaming: Texas Health Presbyterian Hospital and National Nurses United

  • The hospital originally released Thomas Eric Duncan, the first patient diagnosed in the U.S., who later died. Later, after his diagnosis, the hospital offered a number of reasons for not treating him immediately. At first, the hospital said a computer glitch was responsible for his travel history not being communicated to staff, and then said a nurse did not provide Duncan’s travel history to a physician. Finally, the hospital admitted it made a mistake.
  • The hospital refuted claims from a nurses’ union that nurses weren’t adequately trained: “The assertions [of National Nurses United] do not reflect actual facts learned from the medical record and interactions with clinical caregivers. Our hospital followed the Centers for Disease Control guidelines and sought additional guidance and clarity.”

The player: Doctors Without Borders
Who they’re blaming: The CDC

  • A Doctors Without Borders representative questioned the CDC’s preparation in the New York Times: “I’ve seen the CDC poster. It doesn’t say anywhere that it’s for Ebola. I was surprised that it was only one set of gloves, and the rest bare hands. It seems to be for general cases of infectious disease.”

The player: Emory University Hospital
Who they’re blaming: The CDC

  • Sean G. Kaufman, who oversaw infection control at Emory University Hospital, told the New York Times that the CDC’s guidelines are “absolutely irresponsible and dead wrong,” and that he tried to warn that they were not stringent enough and “they kind of blew me off. I’m happy to see they’re changing them, but it’s late.”

The player: National Nurses United
Who they’re blaming: Texas Health Presbyterian Hospital, the CDC

  • A statement from the union cites “confusion” and “frequently changing policies and protocols” at the hospital: “No one knew what the protocols were or were able to verify what kind of personal protective equipment should be worn and there was no training.”
  • RoseAnn DeMoro, the union’s head, contested the CDC’s claim that nurses didn’t follow protocol: “The protocols that should have been in place in Dallas were not in place, and that those protocols are not in place anywhere in the United States as far as we can tell.”

The player: Republicans
Who they’re blaming: Frieden, an open border, Democrats, President Barack Obama

  • Mitt Romney, the 2012 presidential candidate: “Look this administration couldn’t run the IRS right, and it apparently isn’t running the CDC right. And you ask yourself what is it going to take to have a president who really focuses on the interests of the American people.”
  • Republican Rep. Thom Tillis, a Senate candidate in North Carolina: “Ladies and gentlemen, we’ve got an Ebola outbreak, we have bad actors that can come across the border. We need to seal the border and secure it.”
  • New Hampshire Senate candidate Scott Brown addressing his opponent’s record: “I think it’s naive to think that people aren’t going to be walking through here who have those types of diseases and/or other types of intent, criminal or terrorist. And yet we do nothing to secure our border. It’s dangerous. And that’s the difference. I voted to secure it. Senator Shaheen has not.”

The player: Democrats
Who they’re blaming: Republicans

  • The Democratic Congressional Campaign Committee, in an ad targeting GOP congressional candidates: “Republicans voted to cut CDC’s budget to fight Ebola.”

The player: Dallas Nurse Briana Aguirre
Who they’re blaming: Texas Health Presbyterian Hospital

  • Aguirre told NBC that she “can no longer defend [her] hospital at all.” She said infection control was far too lax, waste was not properly taken care of, and the hospital didn’t provide any mandatory education or information about Ebola outside of an optional seminar before Thomas Eric Duncan arrived at the hospital.

The player: National Institutes of Health Director Francis Collins
Who they’re blaming: Budget cuts, Congress

  • “NIH has been working on Ebola vaccines since 2001. It’s not like we suddenly woke up and thought, ‘Oh my gosh, we should have something ready here,'” Collins told The Huffington Post. “Frankly, if we had not gone through our 10-year slide in research support, we probably would have had a vaccine in time for this that would’ve gone through clinical trials and would have been ready.”

Read next: U.S. Scrambles to Contain Ebola

The original version of this story misstated the first name of Amber Joy Vinson.

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