On February 11, 2004, the night of Kelly’s needlestick accident, while still in the lab, she called her colleague Dianne Negley in a panic and left a message on her answering machine. Dianne has short brown hair and appears equally comfortable tanned in her running clothes or in a blue space suit. When she returned home, she heard Kelly’s horrifying message: “I’ve had an accident and got stuck with a needle.”
Diane immediately thought, Ah shit. She knew that Kelly had gone into the lab to work on Ebola-infected mice. She had a sinking feeling in her stomach, she recalls, “Because I knew how bad the outcome would be.” She returned to the institute to help out.
Back in 2001 I had a difficult initiation my first week as the newly minted Medicine Division chief at USAMRIID. One of our virology lab technicians was working with Ebola-infected mice when he realized his laboratory space suit was partially unzipped about six inches. He reported to our clinic as a potential exposure. We considered whether he might have inhaled Ebola from the mice or their bedding. Should we put him in the Slammer? I believed the risk was too low and argued with my commander and the outgoing division chief against Slammer admission. I lost the battle. The commander decided to put the technician in the Slammer overnight.
The next morning, the Virology Division chief and a virology senior scientist confronted me in the hallway and backed me up against the wall, blaming me for the bad decision. I didn’t want to throw the commander under the bus, so I took their criticism. They stirred up an internal firestorm, and the commander relented, so my team arranged for the tech’s release and worked out a monitoring plan as an outpatient instead, which was what I had originally intended. He never became infected and did well in follow-up.
The episode left me a bit shaken, but I had learned some important lessons. I would never pull the trigger to put anyone in the Slammer without strong justification. I also learned to bring the relevant decision makers into the conversation early, before making a decision, and to stick to my guns if I believed I was right.
Now, three years later, Dr. Kelly Warfield had been stuck with a needle while working with Ebola-infected mice. I had the strong justification to pull the trigger. Kelly needed to go into the Slammer.
Kelly wasn’t happy about getting locked up in the Slammer, “but it was the right thing to do,” she said.
Despite the heart wrenching realization that she might never hug Christian, her three-year old son again, Kelly called her mom, described what had happened, and asked her to pick him up from daycare. She didn’t want to risk giving him Ebola. She worried most about what would happen to Christian if she died.
When she got home, Kelly knocked on her neighbors’ door. “Hi,” she said. “I’ve just been exposed to Ebola and have to go into quarantine. Can you watch my cats for a while?” That’s a great way to meet the neighbors.
A friend came over and kept her company, while Kelly stayed up all night on the phone with one of her friends and her husband, Jeremy, who was still in Texas.
After we released Kelly for the night, with a plan for her to return at 8:00 a.m. the next day, I had a heated discussion with my colleagues.
“What will Kelly do? What if she decides to skip town? How should we respond if she returns tomorrow and refuses admission to the Slammer?”
She had every right to. She was not in the military. We had no authority to retain her against her wishes.
“Would we call the police? Would the health department forcibly quarantine her?” I had no answers for any of these questions.
Before leaving USAMRIID near midnight that evening, I drafted an executive summary (EXSUM), an emergency notification for the USAMRIID commander to transmit up the army chain of command. By morning senior leaders all the way to the army surgeon general would choke on their eggs and bacon when they read it:
UNCLASSIFIED
EXECUTIVE SUMMARY
11 Feb 2004
(U) Potential Exposure (USAMRIID). (U) A 28-year-old female NRC fellow, with a history of rheumatoid arthritis, on multiple immunosuppressive medications, presented to the SIP clinic after sustaining a needle stick injury this afternoon while working in room AA-5 in building 1425 (BSL-4 laboratory) injecting antibody into mice that had been infected two days prior with a mouse-adapted strain of Ebola virus. After injecting antibody into four mice, she grazed the base of her left thumb with the 25-gauge needle that had been used for the prior injections. The local site bled, and she immediately decontaminated the local area with microchem [a disinfectant], saline, and betadine [an antiseptic]. The risk of exposure is categorized as probable. The risk of infection is considered low, due to the low amount of organisms thought to be present in the animals at this time with a relatively lower number of organisms that would be expected in the peritoneal tissue [the lining covering the bowel inside the abdomen], the superficial nature of the wound and the rapid wound cleansing. Special testing is being conducted on the mice to determine the levels of virus in different tissues. Based on the anticipated incubation period of the virus, there is no immediate risk to family or community contacts. The risk will be reassessed on a daily basis and the patient will be followed closely in the SIP clinic with twice daily assessments.
LTC Mark G. Kortepeter/MRMC-UIM-R/343–4994/mark.kortepeter@amedd.army.mil
I didn’t sleep well that night, haunted by images of what might happen to Kelly—feverish, disoriented, prostrate, glowing red eyes from subconjunctival hemorrhage, purpuric rash, vomiting, impending shock. In African outbreaks 100 percent of victims stuck with an Ebola-contaminated needle died. Very few infections kill a healthy person so quickly—or so efficiently.
Kelly could be the first Ebola victim ever in the United States. We really had no road map or clue how to proceed and didn’t know whether anything we did could make any difference.
As I considered Kelly’s near-certain death, I also wondered whether someone would blame me for letting her go home. In the government someone always takes the blame.
Fortunately, we never had to deal with Kelly skipping town. One of her friends picked her up, and she arrived, surprisingly bright and fresh the next morning at 8:00 a.m., as requested.
That was the good news, but it came with a surprise. On their way in, the women had stopped at Starbucks for coffee.
Starbucks?! Shit!
I considered the timeline. We were fifteen hours from the needlestick. Should I worry? Could she have infected anyone?
Probably not.
The shortest incubation period for Ebola is generally considered two days, but could we be sure? Convincing the public not to worry could be a challenge. This could easily go viral if word got out, and it would be hard to squelch a fear bonfire if the media fanned the flames. I decided to deal with that later if I had to, because we had enough to deal with at the moment.
We had prepared the Slammer overnight for Kelly’s admission, setting up the room, testing the air-handling system and decon shower, and arranging round-the-clock nursing care and frequent virology lab testing. The critical care team from Walter Reed Army Medical Center arrived and filled the hallway as they unloaded boxes of equipment.
The Slammer had two patient rooms and a surgical room, as well as an anteroom. Kelly would occupy one room, another would hold equipment we would need if she got sick, and we set the third room up as a lab.
I sat down again with Kelly and the deputy commander in my office. We told her that the plan had not changed. We would admit her to the Slammer.
We arranged for military lawyers to meet with Kelly to complete a will and advanced directives to guide life-support decisions if she was dying. Kelly took it all in stride with an upbeat and hopeful demeanor. I admired her steadiness in the face of such grave decisions.
Right after our meeting, I notified the Frederick County health officer on duty about the situation. She called me back to set up a time for a conference call with the county and state health department chiefs.
Great, I thought. Time for a beating.
I was suddenly a popular guy. The ringing of my office phone bore through my skull like a bad migraine. Reporters and bureaucrats in high places with titles I had never heard of managed to find my number. Like a good soldier, I referred them to our public affairs officer, Caree Vander Linden. Caree has short blond hair with little spikes, and she runs, reads, and teaches yoga in her spare time. She has a wry sense of humor, which is a job requirement after raising two teenagers and dealing with media queries for nearly a quarter century. Occasionally the reporters would call back after Caree had briefed them, begging for more details, but I felt some sinister pleasure in hanging up amid their protests, citing patient confidentiality.
Some scientists dropped by my office to argue for other home follow-up options instead of quarantining Kelly in the Slammer. I started to doubt whether I had made the right call. Should we have quarantined Kelly at home instead?
In the early afternoon, I came back to my office and noticed the message light flashing on my phone. I punched in the number to retrieve messages and heard Peter Jahrling’s gravelly, Humphrey Bogart–like voice on the machine. Peter was USAMRIID’s senior scientist and a top Ebola scientist. He had been at USAMRIID for over thirty years—enough to have seen multiple prior Slammer admissions. He was returning from a meeting in Boston, but he had heard about Kelly and called me from the airport.
“Mark,” he greeted me. “I know some of my colleagues think Kelly should go home. I disagree. I firmly believe she belongs in the Slammer.”
I respected his opinion, which made me feel a lot better about my decision.
My deputy chief and I held a conference call with the county and state health departments, and I walked them through the current situation and tried to reassure them that we had things under control. My primary goal was to ensure they would stay out of our way and not sharpshoot us when the media contacted them.
“I think we have everything covered,” I said, trying not to reveal my own misgivings.
The call went smoothly—mostly. When they asked me whether Kelly had gone anywhere after leaving the institute the night before, I hesitated. Should I tell them? I wondered.
Then I gagged out the words, “On the way in this morning, she stopped off at Starbucks.”
“Aagghhh,” an anguished male voice said. I don’t know who said it. It was quick but unmistakable. I braced for a string of expletives and beratement.
None came, so I ignored the sound and just drove on. “I don’t think the CDC needs to be involved,” I said. The last thing I needed was a bunch of armchair quarterbacks swooping in and stirring things up. They didn’t agree or disagree. I don’t know whether they ever called the CDC, but the CDC never called me.
I promised to keep them informed of any changes.
My colleague Colonel Jim Martin, an infectious disease doctor, agreed to serve as Kelly’s primary doc while she was in the Slammer. Jim had previously jumped out of airplanes with special operations units, so he was no stranger to danger and accepted this new challenge willingly.
Kelly felt that an early care provider had avoided her like a leper, as if she already had Ebola, so now she would have a physician whom she trusted dedicated to her care. This freed me up to handle the mounting challenges outside the Slammer.
Although the Slammer was equipped with the same blue space suits as the BSL-4 laboratories, Jim and I decided that the medical team should wear standard hospital barrier protections: gowns, gloves, face shields, and an N-95 (HEPA-filtered) mask at first. Even though her risk of spreading the infection before she got sick was low, we wanted to ensure everyone followed the appropriate precautions habitually before Kelly got sick. The last thing we needed was for someone’s careless error to force us to give Kelly a roommate. Also it was still cold and flu season, so I feared that someone could give Kelly the flu. Any fever would spell disaster, whether from influenza or some other cause, because it might force our hand to treat her for Ebola unnecessarily. We planned to upgrade to space suits if and when the time came.
We made other preparations to autoclave linens, handle garbage, and test Kelly regularly for Ebola.
Just before she entered the Slammer, Kelly emailed an invitation to her closest friends in the institute:
“Come visit (I am afraid it will be quite lonely there). . . . Please come by tonight, tomorrow, this weekend. . . . Your thoughts and prayers are MUCH appreciated.”
Watching the nervous medic in the Slammer drawing her blood the first day upset Kelly. She wanted another quarantined roommate even less than we did. At her insistence her friend, Diane Negley, a medical technician with hospital experience, did all her future blood draws.
At the end of the first day of quarantine, I reflected in my office on the days’ events. I thought things had gone as smoothly as I could have hoped. Starbucks seemed a distant memory.
Before I left for the day, I took a three-feet-by-four-feet piece of white art paper and drew perpendicular grid lines on it with a red magic marker. Then I taped it on my office wall and filled it in like a calendar with the days of the week for a full twenty-one days—the length of time we planned to quarantine Kelly. The day of exposure was “Day 0.” Today was “Day 1.”
I drew my first big red X on the February 12 square, indicating that Kelly had survived one day without a fever.
20 days to go.
As each day began, I had this horrible feeling of doom—like we were prisoners marching in slow motion toward the gallows. Each day we came closer to that inevitable outcome, and I felt more scared and tense as it approached.
This morning as I entered the Medical Division wing, I noticed the Slammer door sitting wide open and medics mopping the floors inside. It took me a second to realize the disconnect.
Wait—it was closed yesterday. What the hell?
I marched down the hallway to Jim Martin’s office.
“Jim, what the hell is going on? Why is the Slammer door open?” I asked. “I don’t know,” he said.
We quickly found the chief nurse and pulled her aside. She said that because Kelly looked fine this morning, she figured they could leave the door open.
“True, she might look fine,” I said, “but that’s not the point. The objective here is not to wait until she spikes a fever before sealing the door.” That was like closing the barn door after the cows have left. We had no idea when Kelly would get sick, so we had to proceed as if it would happen any day.
Jim and I pulled the staff together and reeducated them about the plan. It was a sobering reminder about the challenge of communicating even among our team. We closed the door, with a plan to seal Kelly inside for nineteen more days.
That day the USAMRIID commander sent out a note to the institute to remind us to protect Kelly’s privacy—a huge challenge in a close-knit institute. We had had press leaks previously.
By sheer coincidence the NIH was holding a meeting in Washington DC that week to plan a new containment laboratory to be built on Fort Detrick next to USAMRIID. I asked Colonel Scott Stanek, another division chief, to arrange a conference call with experts at the meeting. I led the call seated at the center of a large conference table surrounded by around twenty clinicians and scientists.
Although we had our own cadre of Ebola experts—Tom Geisbert, Lisa Hensley, and Peter Jahrling (who had returned from his meeting in Boston by then)—it never hurts to “phone a friend.”1
We were desperate. We had no approved treatments. Nothing. I welcomed anything they might offer to exhaust all possible options to give Kelly the best chance of survival. The consultants on the phone included an Ebola “Who’s Who.” Karl Johnson and C. J. Peters were USAMRIID alumni and the “elder statesmen” in hemorrhagic fevers. Karl led the first field investigation and named Ebola for the Ebola River in northern Zaire. C.J. had helped discover the Ebola Reston virus, which was the subject of the bestseller The Hot Zone. Pierre Rollin from the CDC had run down numerous Ebola outbreaks in Africa. Heinz Feldmann led an Ebola research team at the Canadian containment laboratory.
Ebola outbreaks at that time occurred in remote African villages and never lasted long enough to test treatments in humans. A report from the 1995 outbreak in Kikwit, Zaire, noted that giving victims whole blood from Ebola survivors may have saved some, but the data wasn’t convincing, and we had no survivor blood anyway.
During the discussion, though, Tom Geisbert mentioned that he had just completed a study treating Ebola-infected monkeys with an experimental worm protein called “rNapC2.” A third of them survived, compared to the usual near-universal death rate. This was our only possible option—everything else previously tested in monkeys had failed.
Although we didn’t have the magic bullet for Kelly that I would have liked, our phone conference reassured me that we hadn’t missed anything. We would focus on providing the best intensive care available and just hope and pray that it might make a difference.
I was really impressed by the outpouring of support. Over the next day, I received multiple phone calls about possible treatments. The CEO of Dendreon (maker of rNapC2) called me and then shipped his product to USAMRIID.
Later that day Sina Bavari, one of our other scientists, swung by my office to discuss an “antisense” product from AVI Biopharma that had promise.2 Ironically, Kelly had met its senior scientist at a seminar the day of her accident. The compounds were small pieces of DNA with complementary genetic sequences that attach, like Lego blocks, to the virus genes and shut down replication. The company tailor-made some against Ebola and shipped them to us.
At the end of the day and a few steps closer to the gallows, I made my second red X on my calendar for February 13.
Nineteen days to go.
That evening during my drive home, Peter Jahrling called me. “Mark. Tony Fauci wants to talk to you.” “Tony Fauci? Are you kidding me?”
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) at the NIH and one of the most powerful and well-regarded scientists in the field of infectious diseases wanted to speak with me? The idea of talking to Tony prompted a visceral fear of being called to the principal’s office. What was I going to tell him? Would he second-guess me?
Nevertheless, after I got home, I sat down at my desk, drafted a couple of preparatory notes, and called him at home. To my surprise he put me at ease immediately—like talking to another physician on hospital rounds. In his characteristic Brooklyn accent, he offered assistance with possible use of an Ebola DNA vaccine that the NIAID was testing. He referred me to the head of its clinical trials unit, who gave me some additional information about the vaccine, which was undergoing early safety (phase 1) testing in humans, but it had a long way to go before testing whether it worked in humans.
I appreciated the offer, but I was reluctant to use it because it had failed to protect monkeys from Ebola. Kelly’s situation set a much higher bar—trying to prevent illness after she had already been infected. Kelly had rheumatoid arthritis, and I feared the vaccine might rev up her immune system and worsen her disease or cause other unexpected side effects. I didn’t want to give her something that we might later regret, unless it showed great promise. I decided, though, to let Jim Martin and Kelly make the final decision as doctor and patient.
Even if we wanted to, we couldn’t just pick something and give it. We had to establish an “emergency IND” with the FDA and convince the agency that any unlicensed products promised to help the patient with a low risk of harm and that it really was an emergency. Fortunately, that was not too difficult. We drafted a couple of short experimental protocols and consent forms, and we conferred with the FDA officer on call. Within hours, we had the approvals for using any of the products, if needed.
While I dealt with administrative and regulatory hassles on the outside, Kelly sweated it out inside the Slammer. To compound her fear of Ebola and being cut off from the world, Kelly had personal issues to deal with. Her husband, Jeremy, flew in hastily from Texas, where he had been doing army training for several weeks. The army had transferred him the prior year to Georgia. He had received promises of returning eventually to Walter Reed Army Medical Center in Washington DC, but things were not going as planned. I was really impressed when our commanding general met with Kelly and Jeremy in the Slammer fully garbed in protective gear. He offered a sympathetic ear and promised to contact someone regarding Jeremy’s assignment.
It really helped having a knowledgeable patient who could make informed decisions about her treatment. On the day of her admission, Kelly plunked down a stack of Ebola articles on Jim Martin’s desk for him to read as her physician. Once we had collected information on the three possible products, Jim and Kelly conferred. The vaccine was taken off the table as unlikely to provide benefit. We decided to wait on giving either of the other products until Kelly showed signs of infection, like a fever or abnormal labs. This way we stood by one of medicine’s oldest promises to patients: “primum no nocere” (first do no harm).
The night of Kelly’s accident, Diane Negley had returned to the institute to help collect the mice that Kelly had worked on for urgent harvesting and testing. We needed to know whether Kelly’s mice had Ebola virus growing in them at the time of her needlestick.
“There were a lot of unknowns,” Diane says. “The probability [of infection] was lower end, but you still didn’t know until you tested the animals.” Using initial PCR testing, only one of the ten mice Kelly had worked with tested positive at low levels—and none of the four mice Kelly had injected had detectable virus. So far so good.
However, in a second round of more sensitive tests, four of the mice had detectable virus. We had a legitimate cause for concern. It was no longer theoretical.
We took some grief when others were shocked, shocked that Kelly had been working in BSL-4 while on medications for her rheumatoid arthritis, but that eventually blew over. As word spread up the chain, though, the commander and I were summoned to the Pentagon to meet with the deputy assistant secretary of defense (DASD) for safety and occupational health. As we passed by a sea of offices in the Pentagon searching for the right one, I felt increasingly annoyed at wasting several hours just to hold some bureaucrat’s hand when I had a patient to worry about.
We finally shuffled into a small, austere room with about ten people seated around a small conference table. I couldn’t fathom why any of them had any business being there.
I barely had a chance to pull up the chair of “honor” next to the overweight secretary with the Fred Flintstone face when he said, “Why did you let her go home?”
I didn’t feel like taking any crap and went into offensive mode, firing back, point by point, the reasons for our decision. I emphasized that we took appropriate steps to minimize risk to the public, and our actions had to stand up to scrutiny from the scientific and the medical communities, not to rumor and innuendo. I conveniently left out the visit to Starbucks. I was pleased that my commander chimed in several times and defended me. The DASD seemed satisfied, and the meeting didn’t last long.
At this point, three days into the incubation period, we had the possible treatments in the freezer. Now began an excruciating period of waiting, crossing our fingers, hoping, and praying.
My wife’s birthday came and went without any celebration. Sadly, she was used to having my patients come first. Next year would be different I promised.
With each successive square I crossed out on my calendar, I felt better, but the time went by very slowly.
Every day brought new challenges.
The Walter Reed Army Medical Center, fearful of contagion, refused to accept routine labs, despite a long-standing agreement to do so, so we had to spin up a lab system and blood bank quickly inside the Slammer.
How were we to feed Kelly? We worked out a system where Kelly ordered take-out from local restaurants, then one of her friends would pick it up, don protective equipment, and bring the food in to Kelly. She became particularly fond of sushi.
Also we had a plan to clean bed linens, but no plan for her personal laundry. Kelly improvised by washing her clothes in the sink and drying them in the tub. Unfortunately, the stiffened clothes irritated her skin.
Kelly’s rheumatologists recommended that we stop all her rheumatology medications, but doing so caused painful flare-ups in her hands that Jim treated with ibuprofen and acetaminophen with codeine for additional pain control. Ironically, since Ebola triggers a massive, detrimental immune response (known as a “cytokine storm”), we wondered whether Kelly’s usual medications that suppressed her immune system might help by dampening the body’s hyper-response to Ebola. However, we decided not to risk testing that hypothesis.
Kelly had numerous visitors. Although it helped her peace of mind, I was concerned that when she became ill, or if we had a mishap, we might have to lock up more people. We tracked the date and time anyone entered the unit, but on February 15 (Day 4), we cracked down. Kelly was approaching the period of highest risk for spiking a fever from Ebola, so we asked her to choose only six possible visitors, and we would exclude everyone else. She was not happy, but she understood that if we had to quarantine both of her parents, Christian would have no caregiver. She made the heart-wrenching decision to exclude her father.
As I crossed out each daily calendar box, Kelly dealt with her own private hell. She spent the first week on edge, fearful of getting sick, and haunted by images of dying monkeys she had infected. She envisioned having the same fate and didn’t want such a painful, terrible death.
“Just give me morphine, keep me comfortable,” she pleaded with her husband.
Despite her fears she didn’t want her death to be a waste. She wanted the medical team to take a lot of specimens and conduct an autopsy. Maybe knowledge gained from her death could make a difference for someone else.
Kelly also felt as if she were living inside a fishbowl, with multiple people monitoring her every move. She requested Ambien regularly to sleep.
None of Kelly’s early tests showed activation of her immune system, so around the end of the first week, she began to feel hopeful things would be okay. On February 17 (Day 6), Kelly sent a note to her colleagues: “I was PCR negative yesterday and all my other tests look great. . . . I’m feeling great and in good spirits.”
I was not so optimistic. The usual incubation period is about eight to twelve days. I wasn’t ready to pop the champagne cork yet.
Kelly began her next phase: feeling stir crazy. She wanted just to scream, “Let me out of here!”
On February 18 (Day 7) she emailed the deputy commander: “I am using the cards to decorate my room. It’s pretty boring looking at concrete walls all day. . . . However, I am doing great!”
On the same day she emailed her friend Julie Boyer: “We’ll be dancing tonight, if the tests come back clean today.” Julie responded, “Do you remember how badly we dance?”
Nevertheless, after taking a shower the next day, she noticed a rash on her arm. Worried, because rash is an early sign of infection, she called her doctor, Jim Martin, in the middle of the night. Could it be Ebola? He was less concerned because she didn’t have any other new symptoms and nothing else had changed. He examined her the next morning. The rash resolved on its own over the next couple of days.
Another night late in the evening, when no one was around, Kelly told the nurses to contact facilities because she was feeling warm and needed the room temperature changed. When the facilities crew member got the call, he rushed down to the Slammer, afraid that something was wrong, that Kelly was sick or had a fever. It turns out, Dianne Negley explained, “She just wanted to talk to somebody.”
Kelly had hoped to remain anonymous, but on February 19 someone in the institute leaked the news to the press. Kelly was particularly incensed that the detailed description in the news might allow someone to identify her. We had already drafted a press release just in case, so we launched it immediately. The commander followed up with a second email to the institute: “This is a reminder that all press inquiries should be referred to Ms. Caree Vander Linden or Mr. Chuck Dasey. Violation of our policy in this regard could make you liable for punishment or dismissal. . . . This Command will have a zero tolerance for release of private and sensitive information.”
On that same day, Kelly wrote to some friends: “Information about the Ebola exposure was leaked to the press. Trying to stay positive. I’m almost out of the darkest part of the woods!” and “the last 7 days weren’t that bad because it’s been the waiting game each day. . . . The next 14 are going to be hard.”
The exposure made the local and national headlines, but our army public affairs officers wouldn’t let me talk to the press. This annoyed me because it left a vacuum of information, so the news channels went elsewhere for their information. The CDC supported us. It never hurts to have a vote of confidence from the “big boys.” My decision to talk with the county and state health departments was validated. Without that we probably would have taken more heat for sending Kelly home that first night. ABC News got the story wrong, though, saying the patient was feeling ill the day after the accident. Our public affairs officers sent a corrective note, but I’m not sure whether the network ever issued a correction.
Kelly was determined to use her time in isolation to work, but it wasn’t easy. On February 19 (Day 8), she emailed a friend: “I think that work is the only way I’m going to get through the next 2 weeks. The last week has been tough, just waiting . . . hard to concentrate.”
The highlight of her days became her morning blood draws, when she and Diane Negley would share coffee and breakfast, afternoon visits with PCR results from Lisa Hensley or Elizabeth Fritz, and the evenings, when Diane returned with another friend, Dana Swenson, for dinner.
For Diane and her other friends, the possibility that Kelly might die was on their minds early on because, as she noted, “We all knew one PFU [plaque forming unit] could kill her.”3
Considering the circumstances Diane thought Kelly was dealing with the situation very well. Even though she knew Kelly was feeling bad, Diane said, “You didn’t hear her complain. You could just see in her face and her movements how she was hurting.” Diane spent a lot of time “just being her friend” and letting her “talk about whatever she wanted to talk about.”
As each day passed, watching the rooms in the Slammer fill up with new equipment intended for her care unnerved Kelly: a ventilator; dialysis, ultrasound, and X-ray machines; an on-site laboratory, and a blood bank. She had to climb around equipment just to look out the window.
Using PCR we hoped to identify whether Kelly had virus growing in her blood before she felt any symptoms to give us a head start on treating her. PCR can detect extremely low levels of virus, but this advantage brings a downside risk of a false positive, meaning that the test is positive, but the patient is not infected. As a self-check we ran the tests in two different labs, one in virology and one in diagnostics.
We drew Kelly’s blood every morning, and much to the chagrin of the physicians, Kelly’s friends in the lab bypassed the usual information chain and phoned her or walked down to the Slammer in the afternoon to tell her the lab results, speaking loudly at the window of the Slammer door.
One afternoon in the first ten days, we had a bombshell. Kelly received a call from Lisa Hensley. The test for Ebola in one lab was positive! “Don’t freak out,” Lisa said. The test in the other lab was negative. “We’re re-running the tests.”
This really tightened our sphincters. Was Kelly infected? Split lab results could indicate a low level of virus . . . or contamination in the lab.
Fortunately, on the repeat assessments, both tests were negative.
We all breathed a sigh of relief . . . until we were jolted temporarily by another false positive later.
On February 21 (Day 10) Kelly received an email from the institute commander suspending her laboratory access . . . indefinitely, “pending a review of [her] medical condition.”
She was crushed and angry. Diane said she was “a little furious.” The delivery of the commander’s message by email, rather than on the phone or in person, particularly angered her.
Kelly fired off a note to Nancy Jaax, former Pathology Division chief and a pioneer for women working in BSL-4. “Nan—They’ve pulled my suite access. . . . Gee, he could have waited until a better time, you think? . . . Right now I am freaking out. He just decimated my life in one email.”
So compounded with the fear of death and feeling isolated, Kelly now faced the end of her professional research career. Her future hung in limbo. Fortunately, she had some advocates in the institute. She received a reassuring note from the deputy commander that he would ensure the situation was handled fairly and impartially. In a subsequent note to Nancy Jaax, Kelly wrote, “My knight in shining armor [the deputy commander] has appeared. . . . At least someone is looking out for me.”
By the time I crossed out Day 14 (February 25) in red marker on my makeshift calendar, I felt the veil of gloom lifting. Kelly felt this as well. Two days later, she sent a note out to the institute inviting everyone to “come celebrate freedom.”
Jim Martin’s note in her medical chart on March 1 (Day 19) notes, “Exam unchanged (except for painted nails).” Clearly, Kelly was getting ready for a “jail break.”
As the mood began to lighten inside the Slammer, Diane brought in some beer one night. As the beer went through the security scanner, the guard said, “Heineken?” “No, Fosters,” Diane said. “Tell Kelly we said hi,” he told her.
Another night, near the end, the women shared some champagne.
I am glad I didn’t know about it, otherwise I might have had to intervene and spoil the celebration. After all it was a government facility and alcohol was not permitted.
After twenty-one days in quarantine, we freed Kelly. We all felt as if we had received a stay of execution. The institute held a party that afternoon, complete with snacks and balloons. She and nurse friend Denise Clizbe put together a mock newsletter with the headline: “Prisoner Released from the Slammer!” featuring a photo of a smiling Kelly looking out through the Slammer door’s window. The day after discharge, she received a medical bill from the army for $267.00. It was later rescinded.
To this day she retains copies of all the emails and cards from well-wishers that she received while in containment.
There were no hugs in front of CNN cameras, however. Kelly could have gone on the talk-show tour and made a lot of money, but she preferred to stay out of the news, fearing potential negative impact on her career or being viewed as exploiting the situation.
Despite her release her ordeal would continue for several more months. I assigned one of my physicians to do a comprehensive medical evaluation, so we could give the commander adequate justification to let her back into the lab. I feel proud that we did it, and the commander eventually approved her return. Barring her from the lab would have been tragic. Kelly’s scientific career continues to thrive in her new role leading research in a private company—still on Ebola. Her husband, Jeremy, was reassigned back to Walter Reed the next year and eventually became chief of Oncology. She has a large family with three stepchildren and two new children, ages two and four. Christian, the three-year-old boy during this ordeal, is now eighteen. It is unlikely that he remembers this scary time.
When I asked her recently, Kelly said that I needn’t have worried about her skipping town that first night before her slammer admission. She never considered it. “Where would I have gone, anyway?” Good question. If she had been infected with Ebola, she would have surfaced somewhere.
After Kelly’s discharge I saw it as a perfect opportunity to turn a negative story into a positive one for USAMRIID. The commander agreed to let us invite in the media. We gave several reporters a good “dog and pony” show describing the institute’s capabilities and research activities and answered all their questions, followed by a tour of the Slammer. They wrote positive stories.
A couple of years later, a group of us from the organizations that had built specialized sites for care of patients with Ebola and other highly hazardous infectious diseases, including USAMRIID, Emory University, and the University of Nebraska, met to draft guidelines on containment care for patients (“biocontainment”).4 Kelly provided a valuable perspective to that discussion. Several new BSL-4 laboratories were popping up in the post-9/11 world, so I wanted to ensure that others could learn from our experience. We published an article, with Kelly as one of the coauthors, that included a list of all historic Slammer admissions.5 I shared this several years later with German colleagues who faced a similar tragedy in their Hamburg lab.
Only two and a half months after Kelly exited the Slammer, we had a very sobering reminder of the gravity of our situation. On May 24, 2004, Russia announced that Antonina Presnyakova, chief lab technician of the Division of Highly Dangerous Pathogens of the Institute of Molecular Biology at the State Research Center of Virology and Biotechnology (“Vector”) in Novosibirsk, had a presumed needlestick injury while working in the lab on Ebola.
She became infected and died.