On Monday, the day before she contacted a hospital about her symptoms, Texas nurse Amber Vinson, the second nurse to eventually be infected with Ebola after treating the first patient with the virus, took a commercial flight from Cleveland to Dallas.
Before she boarded the plane, she called the Centers for Disease Control (CDC) and reported that she had a fever of 99.5 Fahrenheit.
Here's what happened next, according to NBC News:
According to the government spokesperson, when Vinson called in, the staff she talked with looked on the CDC website for guidance. At the time, the category for "uncertain risk" had guidance saying that a person could fly commercially if they did not meet the threshold of a temperature of 100.4.
CDC Director Dr. Tom Frieden said the nurse "should not have traveled on a commercial aircraft."
But she did. And she apparently wasn't told by the CDC that she shouldn't or couldn't.
Now, it's not likely that anyone else on her flight contracted Ebola. "Chances that other passengers were infected were very low because Vinson did not vomit on the flight and was not bleeding," according to Reuters. Even still, it should not have happened. It was a preventable error.
This is the latest in a string of worrisome incidents involving the CDC going back through the summer.
In June, the CDC announced that dozens of workers in its Atlanta facility had been inadvertently exposed to anthrax. The samples had not been properly "inactivated" before being moved. As a result, they were handled without necessary protection.
An internal review of the incident later found that "use of unapproved sterilization technicques," "transfer of material not confirmed to be inactive," and "lack of a standard operating procedure or process on inactivation and transfer" played a role.
In July, the CDC admitted that it had unexpectedly found six long-lost vials in a storage room at the National Institutes of Health in Maryland. Several of those vials contained still-active samples of smallpox, which is deadly.
In the aftermath of those incidents, the CDC temporarily closed two of its labs and stopped many sample transfers. The head of the lab where the anthrax exposure ocurred resigned.
In that incident, "the scientists failed to follow a scientifically derived and reviewed protocol that would have assured the anthrax was deactivated," CDC Director Frieden said, according to CNN at the time. The short version: It "should have happened, and it didn't."
Months later, with the pressure on the agency as the first Ebola cases hit the United States, the CDC does not seem to have improved all of its processes. Things that should be happening clearly aren't happening, and things that should not be happening are.