There may be a couple of problems here - and not just that somebody breached protocol (although that remains the strongest possibility IMO).
Frist - it tells me (based on my own experience writing up SOPs and Work Instructions and providing hands-on training) that there has very likely been a failure in training and documentation.
A properly trained, properly equipped, staff should not have two significant failures resulting in infection in that short a period of time. These people (nurses and doctors) that provided care to Mr. Duncan were put into a situation by the CDC and by their own State Health regulators that they were inadequately prepared for.
Step 1 for the CDC has reportedly already been taken (belatedly) in that they have expert staff on hand in TX now directing and monitoring the process. This should have been done one Day One. Period.
Second - the fact that two people, who were reportedly taking significant precautions to try and avoid infection, now have Ebola suggests that there is something different going on in TX than in Liberia or Guinea.
One possibility - that there is something being done in TX in this hospital that is not being done in West African clinics. Despite the better equipment and staff,.... 'we' may be doing something obvious incorrectly here than those more experienced in working with the disease in Africa know not to do. A direct comparison of methods used here and there needs to be done to get to a potential root cause - if one exists.
A second possibility - the particular Ebola strain(s) that Mr. Duncan brought in could be relatively easier to transmit than most Ebola strains in the African epidemic. Perhaps his variant persists better in suspended water droplets in the air, or has an easier time causing infection with smaller initial exposures. This would need to be followed-up upon by laboratory testing of the "Duncan" strains compared to controls.
A third possibility - North American (and European) populations of humans have not been typically exposed to Ebola/Marburg viruses. African populations likely have been more regularly exposed to viruses in this group. African populations may have more resistance to these viruses based on past selection in their ancestors, or have some better immunological reaction once infected due to exposure to similar viruses in their native environment.
All interesting possibilities. Here's hoping we don't end up running the big, uncontrolled, North American 'natural' experiment to generate the data needed to compare an outbreak in the USA to what is happening in Africa.
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