
 
 Health workers attend a protest outside Madrid's La Paz Hospital calling for the national health minister's resignation after a Spanish nurse contracted Ebola. (Andrea Comas/Reuters) 
 
 The first case of Ebola transmission outside of West Africa has raised questions about how a nurse at a Spanish hospital contracted the virus and whether sufficient protocols were in place to protect health workers there. 
 
 The nurse became infected at Madrid's Carlos III hospital while treating Manuel Garcia Viejo, a priest who contracted the virus in West Africa. The woman, a "sanitary technician," entered Garcia Viejo's room only twice, according to Spanish officials. 
 
 In one case, she entered the room to change his diaper; another time, after he had died, she entered to collect his belongings, according to Mercedes Vinuesa Sebastian, Spain's public health director. Both times, the nurse wore personal protective equipment. 
 
 Spanish officials said they do not know what went wrong and are investigating. 
 
 "We are working to verify the exact source of contact to see if all strict protocols were followed," Spanish Health Minister Ana Mato said at a news conference on Monday, according to NBC News. 
 
 European Union officials have issued a letter to Mato asking for clarification about how the nurse became infected even though all EU member states were required to take measures to avoid transmission. 
 
 “There is obviously a problem somewhere,” European Commission spokesman Frédéric Vincent said, according to the Guardian. 
 
 [RELATED: Spanish case highlights the risks and benefits of repatriating Ebola patients] 
 
 Health workers at the Carlos III Hospital protested on Tuesday, and others have raised concerns that the protective suits used by workers treating Ebola patients at the facility are not adequate. According to the Spanish newspaper El Pais, hospital staff provided photos of protective suits that use latex gloves attached using tape. Hospital staff members told the paper that the protective equipment should have been completely impermeable, but that it was not. The workers also said that the suits did not allow for autonomous breathing. 
 
 Hospital officials denied that World Health Organization recommendations were not followed in the treatment of both Garcia Viejo and another Spanish priest, 75-year-old Miguel Pajares, who died of Ebola after being flown from West Africa to Spain, where he received the experimental drug ZMapp. 
 
 “The suits used perfectly meet protocol, as well as the mandatory protection requirements for this disease," said Yolanda Fuentes, the deputy director of Carlos III hospital, according to El Pais. 
 
 [EXCLUSIVE: How the world failed to stop the Ebola epidemic] 
 
 The WHO recommendations detail, in general terms, the types of equipment that are appropriate for treating a patient with hemorrhagic fevers, including Ebola. The WHO also outlines procedures for entering and exiting an infected patient's room, removing protective equipment and decontaminating surfaces inside and outside a patient's room. Failure to follow any of the steps in those procedures could potentially lead to infection. 
 
 Hospital staff also alleged that waste from the patient's room was removed using an elevator that was shared by all hospital personnel, according to the Guardian. 
 
 [RELATED: Dallas patient: I would have preferred to die in Liberia rather than expose my fiancée to Ebola] 
 
 The nurse who contracted Ebola began experiencing symptoms on Sept. 30, five days after Garcia Viejo died. Tests confirmed on Monday that she had contracted Ebola. 
 
 After treating both Garcia Viejo and Pajares, the woman went on a vacation but remained in Madrid, officials said, according to Reuters. 
 
 On Tuesday, 22 people who came into contact with the nurse were being monitored, but not isolated, according to Rafael Perez-Santamaria, head of the Carlos III Hospital. 
 
 The nurse's husband, who is not showing symptoms, and another health worker who is experiencing diarrhea but not fever, have been hospitalized. Early signs of Ebola infection include fever, diarrhea and headaches. 
 
 A Spanish man who recently returned from Nigeria has also been hospitalized, though the first test came back negative for Ebola, according to the Associated Press. 
 
 Officials "even announced plans to euthanize the woman's pet dog" in an effort the contain the virus, the AP reported. 
 
 Madrid's regional government even got a court order to euthanize and incinerate their pet, "Excalibur," against the couple's objections. The government said available scientific knowledge suggests a risk that the mixed-breed dog could transmit the virus to humans, and promised to use "biosecurity" measures to prevent any such transmission. 
 
 The incident has raised fresh concerns that, despite assurances from global public health officials that Ebola cases can be safely managed in developed countries, sufficient precautions have not been taken. 
 
 The WHO's European director told Reuters that additional imported cases in Europe are "unavoidable." 
 
 "Such imported cases and similar events as have happened in Spain will happen also in the future, most likely," said Zsuzsanna Jakab. "It is quite unavoidable ... that such incidents will happen in the future because of the extensive travel both from Europe to the affected countries and the other way around." 
 
 [This post originally cited an AP report that said a Nigerian has been hospitalized in Spain. The AP has updated its reporting to say that the man is Spanish and had recently traveled to Nigeria. This post has been updated as well.] 
 
 RELATED READING: 
 
 U.S. will increase Ebola screenings, but won’t impose travel bans 
 
 Here’s what the Ebola epidemic (still) looks like in West Africa 
 
 Live chat with Post reporters and Ebola expert. Submit questions 
 
 Dallas officials send a message of calm about Ebola risk 
 
 Dallas Ebola patient receives experimental treatment 
 
 Patient may face charges in Texas ||||| Media caption Spanish authorities have been criticised after the nurse contracted Ebola in the country's best-equipped quarantine unit 
 
 A doctor in Madrid says the Spanish nurse infected with Ebola remembers touching her face with her gloves after treating a dying priest. 
 
 The nurse, Teresa Romero, is the first person known to have contracted the deadly virus outside West Africa. 
 
 She had treated two Spanish missionaries who later died from Ebola. 
 
 A World Health Organization (WHO) adviser has warned that more Ebola cases can be expected among medical staff, even in developed countries. 
 
 Ms Romero, a 40-year-old auxiliary nurse, remains in quarantine in the Spanish capital along with her husband and three other people. 
 
 A fifth person, said to be a friend and colleague of Ms Romero, was admitted on Wednesday morning with a slight fever. In all, more than 50 people in Spain are under observation. 
 
 Media caption Dr German Ramirez Olivenza: "She told me that at some point the suit could have touched her face" 
 
 The infected nurse was part of a team of about 30 staff at the Carlos III hospital in Madrid looking after the missionaries when they were repatriated from West Africa. 
 
 Miguel Pajares, 75, died on 12 August after contracting the virus in Liberia, while Manuel Garcia Viejo, 69, died on 25 September after catching the disease in Sierra Leone. 
 
 New figures released by the WHO show that more than 8,000 people have now been infected with the disease and 3,879 have died. The vast majority of deaths have been in Guinea, Sierra Leone and Liberia. 
 
 Nurse 'doing better' 
 
 Ms Romero told the El Pais newspaper that she might have become infected when removing her protective suit after cleaning Mr Garcia Viejo's room. 
 
 "I think the error was the removal of the suit," she told El Pais by phone. "I can see the moment it may have happened, but I'm not sure about it." 
 
 She added that she did not have a fever on Wednesday and was "doing better". 
 
 In another development, the woman's husband, Javier Limon, is reported to be fighting a court order to have their pet dog put down over fears it could be carrying the disease. Animal rights groups have also criticised the move, saying there is no evidence Ebola has been spread by dogs. 
 
 Image copyright AFP Image caption In Sierra Leone, burial teams are reported to have gone on strike because they have not been paid 
 
 Image copyright AFP Image caption Several aid organisations have criticised the global response to the outbreak, saying more needs to be done 
 
 In other developments: 
 
 Meanwhile, the head of Medecins Sans Frontieres (MSF) in Sierra Leone says the rest of the world is not doing enough to combat the outbreak of the Ebola virus. 
 
 Media caption MSF chief says Sierra Leone's Ebola outbreak is "not under control" 
 
 Cristina Falconi, MSF's chief in Sierra Leone, told the BBC that more staff, supplies and facilities were needed immediately to have any chance of halting the spread of the disease in West Africa. 
 
 "We need people, more people on the ground, more means of transport, more facilities, more beds. But also good management of these facilities," Ms Falconi told the BBC's Tulip Mazumdar. 
 
 In Sierra Leone, burial workers have gone on strike this week, leaving the bodies of Ebola victims on the streets of the capital, Freetown. 
 
 Local media said the teams had abandoned their posts in anger over unpaid wages, but Deputy Health Minister Madina Rahman insisted on Wednesday that the strike had been "resolved" and the staff would soon return to work. 
 
 The BBC's Umaru Fofana in Sierra Leone says burial teams in the eastern district of Kenema remain on strike, saying they are owed four weeks' wages by the government. 
 
 In neighbouring Liberia, health workers say they will go on strike if their demands for more money and safety equipment are not met by the end of the week. 
 
 Ebola virus disease (EVD) 
 
 Symptoms include high fever, bleeding and central nervous system damage 
 
 Spread by bodily fluids such as blood, sweat and saliva 
 
 Fatality rate can reach 90% - but current outbreak has mortality rate of about 70% 
 
 Incubation period is two to 21 days 
 
 There is no proven vaccine or cure 
 
 Supportive care such as rehydrating patients who have diarrhoea and vomiting can help recovery 
 
 Fruit bats, a delicacy for some West Africans, are considered to be natural host of virus ||||| Spain is urgently compiling a list of people who had contact with the nurse who became the first case of an Ebola infection outside Africa when she was diagnosed in Madrid yesterday. 
 
 The government is taking action to keep doctors and staff safe at Hospital Carlos III, and is investigating how the woman became infected, Health Minister Ana Mato said at a news conference yesterday. The nurse treated Manuel Garcia, a priest who died of Ebola last month, at the hospital. Her husband and thirty medical workers are being monitored, officials said. 
 
 The diagnosis adds a new dimension to the outbreak, which has killed more than 3,400 people, mostly in Guinea, Sierra Leone and Liberia. A man is hospitalized with Ebola in Dallas after traveling there from the Liberian capital Monrovia, the first time the virus has been inadvertently carried out of Africa in the almost 40 years since it was discovered. 
 
 The Ebola Scourge 
 
 “The concern in European hospitals where there’s good infection control is minimal,” David Heymann, professor of infectious diseases at the London School of Hygiene and Tropical Medicine, said in a telephone interview. “It may spread to a few people at the start, but it shouldn’t go further. I don’t anticipate any major outbreaks in Europe.” 
 
 Photographer: Gonzalo Arroyo Moreno/Getty Images A Spanish nurse infected with Ebola is moved to Carlos III Hospital from Alcorcon Hospital in Alcorcon, Spain, on Oct. 7, 2014. Close A Spanish nurse infected with Ebola is moved to Carlos III Hospital from Alcorcon... Read More Close Open Photographer: Gonzalo Arroyo Moreno/Getty Images A Spanish nurse infected with Ebola is moved to Carlos III Hospital from Alcorcon Hospital in Alcorcon, Spain, on Oct. 7, 2014. 
 
 Patient Contact 
 
 The European Union has asked Spain to explain what happened in the nurse’s case, Frederic Vincent, spokesman for EU Health Commissioner Tonio Borg, said by telephone. The European Commission will hold a conference call tomorrow on the case with the 28 EU governments, plus Norway, Switzerland, the World Health Organization and the European Centre for Disease Prevention and Control, Vincent said. 
 
 Related: 
 
 Work to identify the nurse’s contacts is “continuous” and “intensive” and is being conducted following World Health Organization recommendations, Spanish public health director Mercedes Vinuesa Sebastian told lawmakers in Madrid today. The nurse went on vacation after treating the priest, with whom she was in contact twice, once before and once after his death, Vinuesa Sebastian said. 
 
 Stocks of Spanish hotel operators fell in Madrid. NH Hotel Group SA fell as much as 4.8 percent and Melia Hotels International SA fell as much as 3.3 percent. 
 
 Stable Condition 
 
 The nurse had been in contact with other people and those people would have to be followed, Fernando Simon, coordinator of the center of alerts and emergencies at Spain’s health ministry, told Cadena Ser radio today. The virus is spread through direct contact with bodily fluids from an infected person. The nurse was previously treated in Alcorcon Hospital, on the outskirts of Madrid, before being transferred to Carlos III 
 
 Photographer: Pablo Blazquez Dominguez/Getty Images TV trucks at Carlos III Hospital before the arrival of Priest Miguel Pajares on Aug. 6, 2014 in Madrid, Spain. Close TV trucks at Carlos III Hospital before the arrival of Priest Miguel Pajares on Aug. 6,... Read More Close Open Photographer: Pablo Blazquez Dominguez/Getty Images TV trucks at Carlos III Hospital before the arrival of Priest Miguel Pajares on Aug. 6, 2014 in Madrid, Spain. 
 
 “We can’t put a blindfold on,” Simon said, according to comments published by Ser on its website today. “The possibility of contagion exists -- it’s low, but it exists.” 
 
 The nurse is in stable condition, and her life isn’t at risk at the moment, Simon said. It may have been possible to isolate the patient on Sept. 30 when she showed her first symptoms, Simon said. Her husband is in isolation, in good health and “relatively calm,” he said. 
 
 “In the case of a person under monitoring, perhaps an isolation protocol should have been applied,” Simon said. 
 
 Madrid health officials will have have a full list ready today of the people that the nurse had contact with, Simon told Ser, adding that it could include 20 or 30 health workers. 
 
 Missionary Doctor 
 
 “If this spreads and we have another case, I’m out of Madrid,” said Jose Dominguez, a taxi driver in the capital. “I have an apartment on the coast, and I’ll drive there with my wife and daughter until this blows over. I’ll bring 600 cans of food.” 
 
 Photographer: John Moore/Getty Images A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment center in Paynesville, Liberia, on Oct. 5, 2014. Close A Doctors Without Borders health worker in protective clothing carries a child... Read More Close Open Photographer: John Moore/Getty Images A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment center in Paynesville, Liberia, on Oct. 5, 2014. 
 
 Aid workers who have fallen ill in Africa have been evacuated to Spain, France, Germany, the U.S. and Norway for treatment, raising concern that secondary infections will occur in those countries. Garcia, a missionary doctor, died at Carlos III hospital on Sept. 25 after being repatriated from Sierra Leone. Miguel Pajares, the priest who contracted the illness in Liberia, died at the hospital in August. 
 
 Nursing unions in Madrid called on the government to reassure patients and staff and carry out investigations as quickly as possible to find out how the infection occurred. 
 
 “We demand all the information so that the general public and nursing professionals can be assured of their safety,” said Juan Carlos Mejia, secretary of union action at the Madrid branch of the nursing union SATSE. 
 
 For Related News and Information: Fujifilm Jumps as Ebola Patient Given Drug Leaves Hospital (2) 
 
 To contact the reporters on this story: Esteban Duarte in Madrid at eduarterubia@bloomberg.net; Charles Penty in Madrid at cpenty@bloomberg.net 
 
 To contact the editors responsible for this story: Alan Crawford at acrawford6@bloomberg.net; Vidya Root at vroot@bloomberg.net; Phil Serafino at pserafino@bloomberg.net Kristen Hallam, Todd White
– How did a Spanish nurse get the first case of Ebola contracted outside West Africa? Though she treated a priest who was suffering from the virus, she only entered his room twice, Spain's public health head says—once to change the patient's diaper, and once after he had already died, the Washington Post reports via Bloomberg. She was wearing protective gear both times, but some have suggested the suits at the Carlos III Hospital are subpar; latex gloves, for instance, are simply taped to the outfit, according to pictures staffers showed Spain's El Pais newspaper. Another possible explanation being offered up by a Spanish doctor, as per the BBC: that she touched her face with contaminated gloves. The nurse herself—one María Teresa Romero Ramos, per Spanish newspaper El Mundo—doesn't have "the slightest idea" how she became ill, though she now feels "a little better." Some experts on the disease are now suggesting that, contrary to official assertions, this strain of Ebola could spread through the air, the Los Angeles Times reports. "We just don't have the data to exclude it," says a researcher. Amid concerns over Spain's handling of the illness and calls for its health minister to step down, officials are keeping an eye on some 50 people for signs of the illness, the New York Times reports. Another cause of controversy centers on the nurse's dog: International Twitter users have banded together to urge authorities not to put it down as planned, the New York Times notes.