Having worked as an RN for sixteen years in a setting where bloodborne precautions are sometimes necessary (dialysis/HepB) I can tell you
that the CDC attributing the infection of the nurse to a breach in protocol is almost certainly correct. However, I have no doubt that the PPE
offered was insufficient to the task, the staff was not correctly trained, and that there was poor oversight during the disrobing when it was
suggested inadvertent contact occured. Having read the guidelines, it would require DAYS of training to begin to feel comfortable and
competent in donning and disrobing the tyvek body suits... so that every step is perfectly adhered to and nothing overlooked.
I'd be willing to bet that few, even in the CDC, have undergone the rigorous field training required. It's a far different animal to read about something
as compared to actually doing it. Finally, you are under constant pressure to perform with the utmost haste in medical settings. I have no doubt this
sense of urgency (and fatigue) contributed to this "breach in protocol."