CDC probes Ebola in Sierra Leone health workers, response gaps

An analysis of health workers infected with Ebola found their incidence rate was more than 100-fold higher than in the general population, along with deep infection control gaps, including lack of protocols, training, and supplies, researchers from the US Centers for Disease Control and Prevention (CDC) and their West African partners reported today.

The findings come from one of two CDC reports on infection control problems in Sierra Leone published today in an early online edition of Morbidity and Mortality Weekly Report (MMWR).

'Widespread challenges'

Today's review covers health worker infections reported in Sierra Leone from late May through the end of October. Of 3,854 lab-confirmed Ebola infections in the country during that period, 199 (5.2%) were in health workers. Infections peaked in August, though several cases were still being reported in October.

Healthcare workers were sickened in 12 of 14 of Sierra Leone's districts, but the highest number was from Kenema district, especially Kenema General Hospital. Most infections occurred in facilities operated by the country's health ministry, though a small number were reported from Ebola facilities run by international partners.

"These findings underscore the widespread challenges with infection prevention and control in Sierra Leone," the team wrote.

Investigators found that the Ebola incidence was 103-fold higher in healthcare workers than for the general adult population. Men were infected slightly more often.

Interviews revealed a broad range of problems that potentially led to the Ebola infections in medical settings. They included lack of standard operating procedures for infection prevention and control, staff shortages, limited supply of vehicles to safely transport patients and corpses, unrecognized infections in patients and contamination in dead bodies, delayed lab diagnosis, lack of delineation between high- and low-risk areas, lack of personal protective equipment (PPE) and other supplies, and inadequate training.

The researchers said a decline in cases after August might reflect improvements in the infection control situation or even closures of health facilities along with reduced availability of healthcare services.

Given the broad range of problems found at Sierra Leone's general health facilities and in specialized Ebola care settings, the health ministry and its partners are implementing a wide range of interventions that include training, policy changes, supply and equipment purchases, renovation, construction, monitoring, and evaluation according to established recommendations.

Shortages of supplies, SOPs

In a separate report, the CDC's Ebola Response Team in Sierra Leone described their findings from an infection control assessment that focused on health facility observations and interviews with health staff in 6 of the country's 14 districts during the first week of October. The districts were Bombali, Moyamba, Port Loko, Pujehun, Tonkolili, and Western.

The team identified wide gaps in infection prevention and control in all six districts. None of them had dedicated infection control employees or supervisors in the district health structure, and there were no standard operating procedures for managing suspected or confirmed Ebola patients.

Screening procedures didn't adequately separate suspected Ebola patients from patients with other condition. And PPE supplies weren't sufficient and were especially sparse in rural areas.

Shortages were worsened by health worker deaths, delays in hazard pay, and staff fatigue. The investigators found that one of the biggest staffing barriers was that infection control training and mentoring hadn't been delivered to staff members before the opening of Ebola care facilities.

Delayed lab diagnosis also played a role in infection control problems, with turnaround taking as long as 1 week in some areas.

Based on the group's findings, Sierra Leone's health ministry and international responders have developed infection prevention protocols for care and transport at the district and facility level, the authors said. Officials are also procuring more supplies and prioritizing lab capacity.

Federal declaration for Ebola vaccines

In other Ebola news, Health and Human Services (HHS) Secretary Sylvia Burwell today announced that, under the Public Readiness and Emergency Preparedness (PREP) Act, three drug companies will be granted immunity against claims related to three Ebola vaccines under development.

In a press release, the HHS said the step is intended to streamline the global work on developing a vaccine to assist with West Africa's outbreak and to respond to future epidemics.

Managing liability and compensation issues is one way the nation encourages vaccine development, the HHS said. The PREP Act was designed to ease the development of medical countermeasures to address urgent public health threats such as Ebola.

Burwell said in the statement that she hopes the US declaration will trigger other nations to enact similar liability and compensation steps. "As a global community, we must ensure that legitimate concerns about liability do not hold back the possibility of developing an Ebola vaccine, an essential strategy in our global response to the Ebola epidemic in West Africa," she said.

Today's declaration covers ChAd3-EVOV, developed by the National Institutes of Health and GSK; VSV-EBOV, developed by Canadian researchers and licensed by NewLink Genetics, and the Ad26.ZEBV/MVA-NB-Filo vaccine made by Janssen Corp, a subsidiary of Johnson & Johnson and Bavarian Nordic.

PREP Act declarations have been issued, revised, or renewed 14 times since the act was signed into law in 2005, the HHS said. Previous ones addressed H5N1 pandemic influenza vaccines, products related to the 2009 H1N1 flu virus, and botulism antitoxin.

Other developments

  • The CDC today provided an update on exit and entry screening for Ebola. According to a third MMWR report, as of Nov 10, 1,993 people have been screened for Ebola after arriving in the United States from Guinea, Liberia, or Sierra Leone. Eighty-six were referred to public health officials for further evaluation, seven of whom had symptoms and were referred for medical evaluation. None were infected with Ebola. The CDC said combined exit and entry screening helps maintain confidence that air travel is safe from Ebola.

  • The World Health Organization (WHO) this week is hosting two meetings to discuss issues related to public health emergencies, including the Ebola outbreak. One is a 2-day panel discussion that starts tomorrow on human rights in public health emergencies as they relate to the implementation of the international health regulations (IHR). The WHO will brief reporters at the conclusion of the meeting on Dec 11. The second meeting, slated for Dec 12, is a joint meeting to discuss ways to speed the development of new diagnostic tools for Ebola. The WHO is holding the meeting with the Foundation for Innovative New Diagnostics (FIND).

  • A simulation involving a patient suspected with Ebola presenting to a hospital that was ready for Ebola revealed flaws in the response that would have put both the patient and health workers at risk. Authors from Northwestern University described the drill and the lessons learned in a commentary in the latest edition of AHRQ WebM&M, an online journal of the Agency for Healthcare Research and Quality. The exercise involved a 28-year-old man who presented to the emergency department thinking he had foodborne disease symptoms, but had returned from volunteering in Sierra Leone. Experts who observed the exercise found that the patient was put at risk for a central line–associated bloodstream infection. They also found a group of errors in the isolation unit related to a lack of standardized equipment that was familiar to the staff. Other problems occurred from lack of clear directions on how to safely handle blood specimens. The authors noted that Ebola simulations should ensure that more senior physicians are able to perform procedures that are typically done by medical residents, since, in an effort to reduce the number of health workers exposed to Ebola, care of infected patients from residents and fellows isn't typically recommended.

See also:

Dec 9 MMWR report on healthcare worker Ebola infection in Sierra Leone

Dec 9 MMWR report on Ebola infection control assessment in Sierra Leone

Dec 9 MMWR report on airport exit and entry screening for Ebola

Dec 9 HHS press release

WHO notice on human rights and IHR panel discussion

WHO notice on Ebola diagnostics joint meeting

Dec AHRQ WebM&M commentary

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