Infection prevention and control training and capacity building during the Ebola epidemic in Guinea

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Abstract

Background

During the 2014–2016 Ebola epidemic in West Africa, a key epidemiological feature was disease transmission within healthcare facilities, indicating a need for infection prevention and control (IPC) training and support.

Methods

IPC training was provided to frontline healthcare workers (HCW) in healthcare facilities that were not Ebola treatment units, as well as to IPC trainers and IPC supervisors placed in healthcare facilities. Trainings included both didactic and hands-on components, and were assessed using pre-tests, post-tests and practical evaluations. We calculated median percent increase in knowledge.

Results

From October–December 2014, 20 IPC courses trained 1,625 Guineans: 1,521 HCW, 55 IPC trainers, and 49 IPC supervisors. Median test scores increased 40% (interquartile range [IQR]: 19–86%) among HCW, 15% (IQR: 8–33%) among IPC trainers, and 21% (IQR: 15–30%) among IPC supervisors (all P<0.0001) to post-test scores of 83%, 93%, and 93%, respectively.

Conclusions

IPC training resulted in clear improvements in knowledge and was feasible in a public health emergency setting. This method of IPC training addressed a high demand among HCW. Valuable lessons were learned to facilitate expansion of IPC training to other prefectures; this model may be considered when responding to other large outbreaks.

Related collections

Most cited references 4

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Ebola Virus Disease in Health Care Workers — Sierra Leone, 2014

Peter Kilmarx, Kevin R Clarke, Patricia Dietz … (2014)

Health care workers (HCWs) are at increased risk for infection in outbreaks of Ebola virus disease (Ebola) (1). To characterize Ebola in HCWs in Sierra Leone and guide prevention efforts, surveillance data from the national Viral Hemorrhagic Fever database were analyzed. In addition, site visits and interviews with HCWs and health facility administrators were conducted. As of October 31, 2014, a total of 199 (5.2%) of the total of 3,854 laboratory-confirmed Ebola cases reported from Sierra Leone were in HCWs, representing a much higher estimated cumulative incidence of confirmed Ebola in HCWs than in non-HCWs, based on national data on the number of HCW. The peak number of confirmed Ebola cases in HCWs was reported in August (65 cases), and the highest number and percentage of confirmed Ebola cases in HCWs was in Kenema District (65 cases, 12.9% of cases in Kenema), mostly from Kenema General Hospital. Confirmed Ebola cases in HCWs continued to be reported through October and were from 12 of 14 districts in Sierra Leone. A broad range of challenges were reported in implementing infection prevention and control measures. In response, the Ministry of Health and Sanitation and partners are developing standard operating procedures for multiple aspects of infection prevention, including patient isolation and safe burials; recruiting and training staff in infection prevention and control; procuring needed commodities and equipment, including personal protective equipment and vehicles for safe transport of Ebola patients and corpses; renovating and constructing Ebola care facilities designed to reduce risk for nosocomial transmission; monitoring and evaluating infection prevention and control practices; and investigating new cases of Ebola in HCWs as sentinel public health events to identify and address ongoing prevention failures. For this report of Ebola in HCWs in Sierra Leone, data were analyzed on laboratory-confirmed cases in the national Viral Hemorrhagic Fever database, which was created to capture and analyze data from the 2014 Ebola outbreak. Surveillance officers used a standardized case investigation form to collect information from patients with suspected or probable Ebola (2) and their family members. Information collected included age, sex, address, occupation, date of onset of symptoms, and potential exposures to other Ebola patients. “Health care worker” was one of the choices listed under a patient’s occupation and included clinicians such as doctors and nurses, as well as members of other cadres, including ambulance drivers, hospital cleaners, and burial team members. Vital status and laboratory information were entered into the patient’s case record as results were reported to the surveillance team in each health district. District data were merged at the national level. Whole blood from live patients and oral swab specimens from corpses were sent to one of several laboratories in Sierra Leone. Reverse transcription–polymerase chain reaction assays were used to confirm Ebolavirus infection. Select characteristics of HCW and non-HCW cases were compared using chi-square tests. P-values <0.05 were considered significant. To inform infection prevention and control efforts and surveillance of Ebola in HCWs, unstructured interviews concerning HCW infections were conducted with HCWs and health facility administrators in the course of site visits to health care facilities in eight districts during August–October 2014. During May 23 through October 31, 2014, there were 3,854 laboratory-confirmed cases of Ebola reported in Sierra Leone in the Viral Hemorrhagic Fever database, including 199 cases in HCWs (5.2%). Seven additional cases in HCWs and 949 cases in non-HCWs had dates of symptom onset that were missing or outside of May 23 (date of the first documented case) to October 31 and were excluded from analysis. According to the National Health Strategic Plan 2010–2015, published in 2009 (3), Sierra Leone had a total health workforce of 2,402 persons. Using this denominator, the cumulative confirmed Ebola incidence in HCWs was 8,285 per 100,000. This can be compared with the 2,806 confirmed Ebola cases in non-HCWs in a national population of 3.49 million persons aged ≥15 years, with a cumulative incidence in adult non-HCWs of 80.4 per 100,000 population. Therefore, the confirmed Ebola incidence was 103-fold higher in HCWs than that in the general population in Sierra Leone. Among confirmed cases in HCWs, 54.8% were in males, compared with 48.2% in non-HCWs (p=0.09). Of 183 (92%) confirmed Ebola cases in HCWs with recorded age, two (1.1%) were reportedly in persons aged <15 years, 82.0% were in persons aged 15–49 years, and 16.9% were in persons aged ≥50 years. There were no confirmed Ebola cases in HCWs reported in May. The number peaked at 65 cases in August and declined to 36 in September and 42 in October (Figure 1). The highest percentage of confirmed Ebola patients that were HCWs was in August (9.2%); this declined to 3.5% in October (Figure 1). The number of confirmed Ebola cases in HCW per district ranged from zero in two districts to 65 cases in Kenema District (Figure 2), which also had the highest percentage of all confirmed Ebola patients that were HCWs (12.9%). District of residence was missing in seven cases in HCWs (3.5%). The surveillance form included questions on potential sources of infection, specifically attendance at a funeral or contact with a person with known or suspected Ebola, with an ill person, or with a corpse in the month before onset of symptoms. Among 159 (80%) confirmed HCW Ebola cases with data on funeral attendance, 13.8% had attended a funeral, compared with 32.3% in non-HCW (p <0.001). Data on contact with a known or suspected Ebola patient or ill person or a corpse was available for 143 (72%) confirmed HCW Ebola cases; 18.2% were in persons who had contact with a person with known or suspected Ebola or an ill person, compared with 12.3% in non-HCWs (p = 0.05); 30.1% had contact with a corpse, compared with 34.3% in non-HCWs (p=0.3). Among confirmed HCW Ebola patients, 12.1% were dead at the time of surveillance recording, compared with 15.0% among non-HCW patients (p=0.3); other data on vital status, including numbers with missing data at time of surveillance recording and final outcome, are not consistently available in the Viral Hemorrhagic Fever data. Site visits and unstructured interviews with HCWs and health facility administrators revealed a broad range of circumstances potentially leading to Ebola in HCWs. These included a lack of standard operating procedures and clearly assigned responsibilities for infection prevention and control; overall staff shortages and lack of infection prevention specialists; limited availability of safe transport vehicles for patients and corpses; incorrect triage or recognition of potential Ebola in patients and corpses, including no reassessment of admitted patients to identify new symptoms of Ebola (especially children aged <5 years); delayed laboratory diagnosis of Ebola cases because of long turn-around time for specimen transport and reporting of results; inadequate control of Ebola patient or HCW movement within health facilities; and lack of delineation between high-risk and low-risk Ebola zones. Other findings included limited availability of appropriate personal protective equipment and hand washing facilities, including lack of water and sufficient chlorine supplies; no or inadequate training about and monitoring of personal protective equipment use and hand washing; lack of equipment and materials and no or inadequate training about and monitoring of decontamination of transport vehicles and care facility spaces; limited capacity and no or inadequate training about safe management of contaminated waste; and limited capacity and no or inadequate training about safe management and burial of corpses. Discussion Analysis of the national Viral Hemorrhagic Fever database found 199 cases of Ebola in the Sierra Leone health workforce. Using the number of HCWs reported in 2009 (3) as a denominator for HCWs and comparing with infection rates in the general population aged ≥15 years, the estimated confirmed Ebola incidence rate was approximately 100-fold higher in HCWs than in non-HCW adults in Sierra Leone. The number and proportion of all confirmed Ebola patients that were HCWs peaked in August. The subsequent reductions might be attributable to concurrent implementation of infection prevention and control measures, including training and availability of personal protective equipment, and could reflect a closure of many health facilities and reduction in availability of health care services and HCW exposure as the outbreak progressed. However, many Ebola cases in HCWs continued to be reported in October. The highest number of confirmed Ebola cases and the proportion of all confirmed Ebola case that were HCWs occurred in Kenema District. There were 43 Ebola cases in HCWs in Kenema District in July and August, mostly among Kenema General Hospital staff. Inquiries about breaches of infection prevention and control at Kenema General Hospital indicated, among other problems, challenges with overall site management and administrative controls, such as correct and consistent triage and isolation of Ebola patients. Although some districts, such as Kenema, were more heavily affected, confirmed Ebola cases in HCWs have been reported in 12 of 14 districts in Sierra Leone, including all districts that have reported more than 35 confirmed Ebola cases. Also, although most cases in HCWs occurred in facilities operated by the Ministry of Health and Sanitation, including both general care facilities and those designated for Ebola care, there were a small number of confirmed Ebola cases in HCWs at Ebola care facilities established and managed by international implementing partners. These findings underscore the widespread challenges with infection prevention and control in Sierra Leone. Compared with non-HCW patients, HCW patients were less likely to have attended a funeral and were more likely to have had contact with a live Ebola patient or ill person in the 30 days before symptom onset. However, a substantial proportion of both HCW and non-HCW Ebola patients reported funeral attendance or contact with a corpse, highlighting the overall importance of transmission from corpses in this outbreak. HCW patients were not significantly less likely than non-HCW patients to be dead at the time their cases were recorded by the surveillance system. The finding that 12% of HCW patients were dead at the time of recording indicates shortcomings in contact tracing, early case identification, and access to medical care, even in HCWs, who might have been expected to have better awareness and access to health care. The findings in this report are subject to at least four limitations. First, public health surveillance data were incomplete, especially in the context of a health emergency in a resource-poor setting. It has been estimated that overall case numbers represent only one third to one half of all cases (4). Second, data on key information such as occupation was missing or might have been incorrect on many case investigation forms, and many cases were not included in the analysis because of missing or out-of-range dates of onset of symptoms. Third, members of some cadres, such as ambulance drivers, burial team members, and community health workers, might not have been consistently recorded as HCWs on case investigation forms or in the Ministry of Health and Sanitation 2009 report on the health workforce (3), and the number of health workers might have changed since 2009. As a result, these findings likely undercount the number of Ebolavirus-infected HCWs in Sierra Leone. However, Ebola reporting might be more complete for HCWs than non-HCWs, so the ratio of the Ebola cumulative incidence in HCWs compared with non-HCWs might be an overestimate. Finally, data on exposures are also likely to be incomplete. For example, the finding that contact with an Ebola patient or ill person was reported for only 19% of HCWs with Ebola is likely an underestimate. A broad range of potential problems with infection prevention and control were reported at both general care facilities and those designated for Ebola care. The Ministry of Health and Sanitation, together with Sierra Leonean and international partners, are implementing a wide range of interventions, including policies, training, procurement, renovation, construction, and monitoring and evaluation, in accordance with established recommendations (5). As is the case with prevention of nosocomial transmission of tuberculosis (6), many observed breaches of infection prevention and control practices appeared to be attributed to failures of administrative controls, such as incorrect triage, or infrastructure limitations of renovated facilities, such as lack of barriers separating Ebola wards, rather than personal protective equipment failures; particular attention to these issues is recommended in the control of Ebola. Cases of Ebola in HCWs are currently being investigated as sentinel public health events. An infection in an HCW might represent transmission from an Ebola patient in a health care facility, but might also be a signal for transmission to and from HCWs in the community, and for facility-based transmission from patient to patient and from HCWs to patients or to other HCWs. New, high-quality, dedicated Ebola treatment units are being established by international partners in Sierra Leone, but because the number of these beds does not meet the need in high-transmission areas, other, less well-resourced facilities, including Ebola care, holding, and isolation centers, are being established by the Ministry of Health and Sanitation. Given the high risk of nosocomial transmission of Ebolavirus (5), health authorities must be vigilant in implementation of strict infection prevention and control measures in all health care settings and alert to the possibility that less well-controlled settings might inadvertently act to propagate rather than interrupt transmission. Prevention of Ebola in HCWs is also critical to sustain the health workforce to address all causes of morbidity and mortality in Sierra Leone. What is already known on this topic? Health care workers (HCWs) are at increased risk for infection in outbreaks of Ebola virus disease (Ebola). Adherence to good infection prevention and control practices are required to prevent Ebola in HCWs. What is added by this report? As of October 31, 2014, of the total of 3,854 laboratory-confirmed Ebola cases reported from Sierra Leone, 199 (5.2%) were in HCWs. This was estimated to be a much higher cumulative incidence of confirmed Ebola in HCWs compared with non-HCWs. A broad range of breaches of good infection prevention and control practices were reported, and Ebola cases in HCW continued to be reported in October. What are the implications for public health practice? In Ebola outbreaks, comprehensive programs to reduce the risk for Ebola in HCWs in all health care settings are needed, including development of standard operating procedures (including safe triage), recruiting and training staff, procuring needed commodities and equipment, renovating and constructing safe Ebola care facilities, monitoring and evaluating infection prevention and control practices; and investigating new cases of Ebola in HCWs as sentinel public health events to identify and address ongoing prevention failures.

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Ebola Virus Disease Cases Among Health Care Workers Not Working in Ebola Treatment Units — Liberia, June–August, 2014

Almea Matanock, M. Allison Arwady, Patrick Ayscue … (2014)

West Africa is experiencing the largest Ebola virus disease (Ebola) epidemic in recorded history. Health care workers (HCWs) are at increased risk for Ebola. In Liberia, as of August 14, 2014, a total of 810 cases of Ebola had been reported, including 10 clusters of Ebola cases among HCWs working in facilities that were not Ebola treatment units (non-ETUs). The Liberian Ministry of Health and Social Welfare and CDC investigated these clusters by reviewing surveillance data, interviewing county health officials, HCWs, and contact tracers, and visiting health care facilities. Ninety-seven cases of Ebola (12% of the estimated total) were identified among HCWs; 62 HCW cases (64%) were part of 10 distinct clusters in non-ETU health care facilities, primarily hospitals. Early recognition and diagnosis of Ebola in patients who were the likely source of introduction to the HCWs (i.e., source patients)* was missed in four clusters. Inconsistent recognition and triage of cases of Ebola, overcrowding, limitations in layout of physical spaces, lack of training in the use of and adequate supply of personal protective equipment (PPE), and limited supervision to ensure consistent adherence to infection control practices all were observed. Improving infection control infrastructure in non-ETUs is essential for protecting HCWs. Since August, the Liberian Ministry of Health and Social Welfare with a consortium of partners have undertaken collaborative efforts to strengthen infection control infrastructure in non-ETU health facilities. Human-to-human transmission of Ebola virus occurs through direct contact with the body fluids of symptomatic or deceased patients. HCWs in Liberia working without adequate infection control equipment and protocols are at high risk for infection given their close physical contact with Ebola patients and potential exposure to body fluids. HCWs have accounted for up to 25% of infected persons during previous outbreaks (1). Isolating infected patients is essential for preventing transmission to others, and historically this has been accomplished by caring for infected persons in specialized ETUs with strict isolation and infection control protocols, including guidelines for patient movement, physical layout, disinfection, and use of PPE designed to protect HCWs and patients (2,3). Ideally, all patients suspected of having Ebola would be triaged and tested at an ETU (1); however, before recognition of Ebola and transfer to an ETU, infected patients often are cared for in non-ETU health care facilities. Treatment of Ebola in non-ETU health care facilities is particularly difficult in Liberia, where the health care system is understaffed and under-resourced (4). Visits to non-ETU health care facilities revealed that basic materials for standard infection control practices such as gloves, soap, and water often were inadequate, and overcrowding in patient care areas plus the lack of physically separated spaces made isolation difficult. Because Ebola is a febrile illness with nonspecific signs and symptoms, differentiating it from many other common febrile illnesses is difficult, potentially delaying isolation. As of August 14, 2014, a total of 810 confirmed, probable, and suspected cases of Ebola† in six of Liberia’s 15 counties had been reported (5). There were two primary epicenters in Liberia: Lofa County in northwestern Liberia, where the outbreak in Liberia was initially detected following movement of infected persons over the border from Guinea; and Montserrado County, which includes the capital city of Monrovia (Figure). Because of the scale and geographic distribution of the outbreak, the lack of staff, beds, and transportation to ETUs, as well as patient resistance to being treated in ETUs, only an estimated 25% of known Ebola patients had been treated at an ETU as of August 14, 2014 (5). At the request of the Liberian Ministry of Health and Social Welfare, CDC collaborated with the ministry to investigate risks associated with working in health care settings and possible sources of exposure among HCWs. Reviews were performed of national surveillance data, including case report forms, health care facility line lists, the national surveillance database, and laboratory results. Clusters were defined as two or more confirmed, probable, or suspected cases of Ebola among HCWs who had dates of symptom onset or, when symptom onset was not available, dates of diagnosis within 21 days of each other and any subsequent chains of transmission. Source patients were identified prospectively in some clusters, and retrospectively in others. Evaluations of the recognized clusters of HCWs were performed using unstructured in-person and telephone interviews with county health officials, hospital staff members, and contact tracers, as well as visits to six of the 10 health facilities with identified clusters of Ebola among HCWs. HCW cases of Ebola not identified as part of the clusters and risk factors outside of health care settings were not evaluated. No patient care was directly observed. Review of national case-based surveillance data and field investigations of clusters of Ebola in HCWs through August 14 identified 97 HCWs with Ebola. Among the 97 HCW cases, the most common occupation was nurse or nurse aide (35%), followed by physician or physician assistant (15%); other occupations included laboratory technicians, cleaners and hygienists, administrators, midwives, dispensers, and security personnel (Table 1). Most of these Ebola cases occurred in HCWs employed at hospitals (60%). However, all types of health care settings (including public and private) experienced cases of Ebola among HCWs, from the smallest clinics, which have catchment areas of <3,500 persons and are open Monday through Friday without inpatient services, to larger regional hospitals, which have catchment areas of three to five counties and are expected to be open 24 hours a day with at least a 100-bed capacity (6). Among the 97 HCW cases, 11 clusters of Ebola occurred (10 in non-ETU facilities and one in an ETU) during June 9–August 14 in four counties (Bong, Lofa, Margibi, and Montserrado) (Figure). The one cluster involving HCWs who worked primarily in an ETU and triaged patients from an associated hospital has been described previously (7). Among the remaining 10 clusters that occurred in non-ETU health care facilities, the number of cases ranged from two to 22 HCWs per cluster (median = five HCWs). Included in these 10 clusters were 62 (64%) of the 97 HCWs with Ebola identified overall (Table 2). Of the 62, a total of 50 (81%) had confirmed Ebola, and 31 were known to have died. Seven of 10 HCW clusters were primarily associated with hospitals. One cluster included HCWs in two clinics and a hospital; a single source patient visited all three locations while ill. The remaining two clusters occurred among HCWs who worked in two separate clinics. Of the 62 HCWs involved in the 10 clusters, 33 were identified as having cared for the source patient in the cluster. Examples of reported high-risk exposures among the infected HCWs included a spill of infected patient blood onto the uncovered skin of a phlebotomist and medical care provided by HCWs not using adequate PPE when caring for a fellow HCW who was ill with what was thought to be heart failure, but later was diagnosed as Ebola. Additionally, possible high-risk exposure occurred by direct physical contact of two HCWs with an infected patient whom the HCWs had assisted into the hospital. In two of the clusters, the source patients were HCWs who had reportedly cared for infected patients at home, outside of their regular job duties. Four HCWs among three of the 10 clusters had no known or identified unprotected physical contact with patients with Ebola, but worked in health facilities where patients with Ebola had been treated. For example, an HCW who served as the officer-in-charge of an outpatient department was infected. This HCW had no direct contact with the source patient, but had worked closely with many of the HCWs who developed secondary cases. In four of the 10 clusters, the source patients were suspected of having Ebola when initially examined, based on history and clinical symptoms. However, in four other clusters, the source patient was initially thought to have another disease (e.g., dysentery, cholera, Lassa fever, or heart disease). In one of these four clusters, the source patient had a known history of heart disease and did not disclose a history of Ebola virus exposure leading to a delay in diagnosis. In another cluster, details of testing are unclear, but the source patient was not confirmed to have Ebola virus until at least 12 days after developing symptoms. Of the remaining two clusters, a source patient could not be identified in one cluster, and investigation of the other was incomplete because five HCWs had died and the health facility director could not be contacted Visits to six of the 10 non-ETU health care facilities where clusters occurred revealed that materials and setup required for implementing adequate infection control precautions often were not available. These included adequate chlorine, running water, cleaning supplies, hand washing stations, adequate types and supplies of PPE, and isolation areas. In instances where limited PPE was available, equipment was shared or reused. At one hospital visit, it was reported that multiple HCWs consecutively donned and doffed the same pair of single-use gloves to care for a patient with Ebola. Alternatively, some HCWs were noted to be wearing the same PPE throughout their shift while caring for Ebola and non-Ebola patients. Isolation areas existed at five of the six health facilities visited where there were clusters of Ebola among HCWs, but were inadequate. For example, at one hospital, a single occupancy room within the emergency department was used for isolation but was quickly overwhelmed when the facility admitted multiple patients with Ebola in a week. The isolation areas were rudimentary, lacking toilet facilities, running water, and physical separation from other patient treatment areas. Discussion These infections demonstrate the risk associated with caring for Ebola patients without adequate infection control. Individual cases and clusters of Ebola continued to occur among HCWs working in non-ETU health care facilities in Liberia during the period covered by this investigation, reflecting ongoing transmission and the increasing burden of Ebola in the community. Nurses and nurse aides were most commonly infected, although cases of Ebola among HCWs in all occupations, both clinical and nonclinical, were observed. By early August, many of the health care facilities in Liberia were either functionally or officially closed because of inability to maintain staffing as a result of HCW illnesses and departures and patient avoidance of facilities where Ebola patients had been treated. Inadequate infection control infrastructure, including inadequate protocols, training, materials, and setup contributed to Ebola virus exposure in the non-ETU health care settings described in this report. Supplies of PPE were insufficient across Liberia and, when available, often were not adequate or improperly used. During the course of this investigation, many health care facilities closed; however, preparation for reopening closed health facilities was under way, including training for infection prevention and control. As conditions of reopening, HCWs not only requested training, but also a consistent supply of adequate PPE. Early recognition, triage, and isolation of all potential Ebola cases are essential so that adequate infection control measures can be applied and transmission of Ebola virus limited. Ebola symptoms are similar to those of many other diseases, and recognition is difficult when not initially suspected. In Liberia, Ebola should be considered in all patients with fever or other symptoms because of 1) the relatively high incidence of the disease; 2) ongoing opportunities for acquisition through direct contact with body fluids of symptomatic or deceased patients during patient care, handling of a dead body, or environmental contact with body fluids; 3) variable reliability of patient reports of their risk factors; and 4) difficulties in contact tracing, including limited availability and timeliness of laboratory testing. After triaging possible cases, patients should be isolated with adequate infection control measures (3). As demonstrated in these clusters, inaccurate illness and exposure histories and difficulties in making a clinical diagnosis can result in additional exposures. These factors make it critical that all HCWs, both clinical and nonclinical, who might encounter infected patients or contaminated environments or materials, have access to and adhere to infection control measures. What is already known on this topic? Human-to-human transmission of Ebola virus disease (Ebola) can occur through direct contact with body fluids of symptomatic or deceased patients. Health care workers (HCWs) are at greater risk for Ebola, accounting for up to 25% of cases in previous outbreaks. These risks can be mitigated by triage protocols, adherence to strict infection control guidelines, and adequate provisions and use of personal protective equipment. Strong infection control is essential to breaking the chain of transmission of Ebola virus. What is added by this report? During June 9–August 14, 2014, a review of national data and field investigations identified 97 cases of Ebola among HCWs in Liberia, 62 of which occurred in 10 clusters in health care facilities not dedicated to treating Ebola patients, primarily hospitals. Individual cases and clusters of Ebola among HCWs occurred most often among nurses, nurse aides, and physicians. However, there were cases of Ebola among HCWs in all occupations and health care settings. Infrastructure for adequate infection control was lacking. What are the implications for public health practice? To avoid the acquisition of Ebola among HCWs, especially in the health care setting, and the subsequent undermining of the epidemic response, a strong infection control infrastructure is needed. Working towards this, the Liberian Ministry of Health and Social Welfare in collaboration with a consortium of partners has initiated a major program to improve infection prevention and control at health care facilities. This program emphasizes rapid recognition and triage, appropriate training in the use of and adequate supply of personal protective equipment, and identification of a structure for the supervision of consistent and appropriate infection control adherence. Direct physical contact with the body fluids of infected patients while at work continues to be a clear risk factor, but exposures outside the health care setting also were noted (i.e., the two HCW source patients who had cared for infected patients at home). With many facilities closed and ongoing community transmission, HCW risks for acquiring Ebola in the community exist. Additionally, although no HCW-to-patient or patient-to-patient transmissions were identified because this investigation was limited to infected HCWs, patients likely also had direct physical contact with other patients and environmental exposures to Ebola virus in these health care settings. The findings in this report are subject to at least four limitations. First, collection of data on exposure history and infection control practices was limited by deaths and illness among HCWs from Ebola (31 deaths at the time of the investigation, with other HCWs critically ill), a lack of coworker proxies to provide history for many of the cases, and the closure of health facilities, which made it difficult to locate HCWs. Second, infection control practices were not systematically observed, and reports might have been affected by recall bias. Third, exposure histories were difficult to evaluate because multiple cases of Ebola were treated simultaneously by individual HCWs and there also was the potential for environmental exposure in the work place and community exposures. Finally, evaluation of exposure and disease transmission contacts was limited by the lack of contact lists in eight clusters and incomplete contact lists in the other two. The immediate consequences of Ebola among HCWs, especially when occurring in clusters at individual facilities, are the closure of health facilities, loss of routine services, grief and fear among HCWs, and public mistrust of HCWs and health facilities, all of which might undermine the epidemic response. The long-term consequences include the loss of a sufficient and experienced HCW work force to provide health services and educate future HCWs. Both the immediate and long-term consequences are likely to result in increased non-Ebola morbidity and mortality. Effective isolation is at the core of a robust Ebola response and cannot be performed without strong infection control in a functioning health care system. Strong infection control is essential to breaking the chain of transmission of the Ebola virus, which is necessary in reestablishing routine health care in Liberia. To begin to accomplish this, there needs to be recognition and triage of potential cases of Ebola, appropriate training in the use of and adequate supply of personal protective equipment, and identification of a structure for the supervision of consistent infection control adherence. Since August, collaborative efforts to strengthen infection control infrastructure in non-ETU health facilities have been undertaken by a consortium of partners working with the Liberian Ministry of Health and Social Welfare. These efforts included developing national guidance for infection control standards necessary to deliver health services. A training program on infection control, including triage and isolation of suspected Ebola cases, appropriate use of PPE, and environmental hygiene, has been initiated for HCWs of all occupational types working in all levels of the health care system throughout Liberia. Importantly, a culture of infection prevention will be emphasized by identifying infection control specialists who will be embedded in non-ETU health facilities to supervise adherence to infection control practices. These efforts to implement, assess, and improve infection control in non-ETU health care settings are an ongoing and essential component of the response.

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Infection prevention and control of the Ebola outbreak in Liberia, 2014–2015: key challenges and successes

Catherine Cooper, Dale Fisher, Neil Gupta … (2016)

Prior to the 2014–2015 Ebola outbreak, infection prevention and control (IPC) activities in Liberian healthcare facilities were basic. There was no national IPC guidance, nor dedicated staff at any level of government or healthcare facility (HCF) to ensure the implementation of best practices. Efforts to improve IPC early in the outbreak were ad hoc and messaging was inconsistent. In September 2014, at the height of the outbreak, the national IPC Task Force was established with a Ministry of Health (MoH) mandate to coordinate IPC response activities. A steering group of the Task Force, including representatives of the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC), supported MoH leadership in implementing standardized messaging and IPC training for the health workforce. This structure, and the activities implemented under this structure, played a crucial role in the implementation of IPC practices and successful containment of the outbreak. Moving forward, a nationwide culture of IPC needs to be maintained through this governance structure in Liberia’s health system to prevent and respond to future outbreaks.

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Author and article information

Contributors

Heidi M. Soeters:

ORCID: http://orcid.org/0000-0002-9415-9340

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Lamine Koivogui: Role: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: Supervision

Lindsey de Beer: Role: Investigation

Candice Y. Johnson: Role: InvestigationRole: Writing – review & editing

Dianka Diaby: Role: Data curationRole: InvestigationRole: Project administrationRole: Resources

Abdoulaye Ouedraogo: Role: InvestigationRole: MethodologyRole: Supervision

Fatoumata Touré: Role: InvestigationRole: Supervision

Fodé Ousmane Bangoura: Role: InvestigationRole: MethodologyRole: Supervision

Michelle A. Chang: Role: InvestigationRole: MethodologyRole: Supervision

Nora Chea: Role: Resources

Ellen M. Dotson: Role: InvestigationRole: SupervisionRole: Writing – review & editing

Alyssa Finlay: Role: InvestigationRole: Writing – review & editing

David Fitter: Role: InvestigationRole: Writing – review & editing

Mary J. Hamel: Role: MethodologyRole: SupervisionRole: Writing – review & editing

Carmen Hazim: Role: Resources

Maribeth Larzelere: Role: Investigation

Benjamin J. Park: Role: ConceptualizationRole: MethodologyRole: ResourcesRole: VisualizationRole: Writing – review & editing

Alexander K. Rowe: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – review & editing

Angela M. Thompson-Paul: Role: InvestigationRole: Writing – review & editing

Anthony Twyman: Role: Investigation

Moumié Barry: Role: ResourcesRole: Supervision

Godlove Ntaw: Role: Funding acquisitionRole: Project administrationRole: ResourcesRole: Supervision

Alpha Oumar Diallo: Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: ResourcesRole: Supervision

Graciela Andrei: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 28 February 2018

Publication date Collection: 2018

Volume: 13

Issue: 2

Electronic Location Identifier: e0193291

Affiliations

[1 ] Centers for Disease Control and Prevention, Atlanta, United States of America

[2 ] Institut National de Santé Publique, Conakry, Guinea

[3 ] Catholic Relief Services, Conakry, Guinea

[4 ] World Health Organization, Conakry, Guinea

[5 ] Hôpital National Donka, Conakry, Guinea

[6 ] Guinea Ministry of Health and Public Hygiene, Conakry, Guinea

Katholieke Universiteit Leuven Rega Institute for Medical Research, BELGIUM

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Competing Interests: The authors have declared that no competing interests exist.

* E-mail: HMSoeters@ 123456cdc.gov

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Heidi M. Soeters http://orcid.org/0000-0002-9415-9340

Article

Publisher ID: PONE-D-16-34147

DOI: 10.1371/journal.pone.0193291

PMC ID: 5831010

PubMed ID: 29489885

SO-VID: 4b375acf-336b-4dae-8c59-548d1c25fd78

License:

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

History

Date received : 25 August 2016

Date accepted : 8 February 2018

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Figures: 1, Tables: 2, Pages: 8

Funding

IPC trainings were supported by the United States Agency for International Development, CDC Foundation, and Rio Tinto Group. CDC staff were provided in kind during the response. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability All relevant data are within the paper and its Supporting Information files.

Infection prevention and control training and capacity building during the Ebola epidemic in Guinea

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Ebola Virus Disease in Health Care Workers — Sierra Leone, 2014

Ebola Virus Disease Cases Among Health Care Workers Not Working in Ebola Treatment Units — Liberia, June–August, 2014

Infection prevention and control of the Ebola outbreak in Liberia, 2014–2015: key challenges and successes

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