Nosocomial transmission of Ebola virus disease on pediatric and maternity wards: Bombali and Tonkolili, Sierra Leone, 2014

doi:10.1016/j.ajic.2015.09.016

American Journal of Infection Control

Volume 44, Issue 3, 1 March 2016, Pages 269-272

https://doi.org/10.1016/j.ajic.2015.09.016 Get rights and content

Highlights

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We detail two cases where transmission of EVD occurred in health care settings.
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We describe admission and care of two EVD cases–one pediatric and one maternity.
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Delayed EVD recognition and inadequate PPE contributed to nosocomial spread.
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Limiting non-health care worker contact to patients may limit infection spread.
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Routine EVD screening of admitted patients may help decrease EVD transmission.

Background

In the largest Ebola virus disease (EVD) outbreak in history, nosocomial transmission of EVD increased spread of the disease. We report on 2 instances in Sierra Leone where patients unknowingly infected with EVD were admitted to a general hospital ward (1 pediatric ward and 1 maternity ward), exposing health care workers, caregivers, and other patients to EVD. Both patients died on the general wards, and were later confirmed as being infected with EVD. We initiated contact tracing and assessed risk factors for secondary infections to guide containment recommendations.

Methods

We reviewed medical records to establish the index patients' symptom onset. Health care workers, patients, and caregivers were interviewed to determine exposures and personal protective equipment (PPE) use. Contacts were monitored daily for EVD symptoms. Those who experienced EVD symptoms were isolated and tested.

Results

Eighty-two contacts were identified: 64 health care workers, 7 caregivers, 4 patients, 4 newborns, and 3 children of patients. Seven contacts became symptomatic and tested positive for EVD: 2 health care workers (1 nurse and 1 hospital cleaner), 2 caregivers, 2 newborns, and 1 patient. The infected nurse placed an intravenous catheter in the pediatric index patient with only short gloves PPE and the hospital cleaner cleaned the operating room of the maternity ward index patient wearing short gloves PPE. The maternity ward index patient's caregiver and newborn were exposed to her body fluids. The infected patient and her newborn shared the ward and latrine with the maternity ward index patient. Hospital staff members did not use adequate PPE. Caregivers were not offered PPE.

Conclusions

Delayed recognition of EVD and inadequate PPE likely led to exposures and secondary infections. Earlier recognition of EVD and adequate PPE might have reduced direct contact with body fluids. Limiting nonhealth-care worker contact, improving access to PPE, and enhancing screening methods for pregnant women, children, and inpatients may help decrease EVD transmission in general health care settings.

Section snippets

Bombali district

On October 8, 2014, a 29-month-old child presented with vomiting and fatigue to the pediatric outpatient center of the district's government hospital. The patient did not meet the EVD screening case definition and therefore was admitted to the general pediatric ward, where he was treated for malaria. The patient developed diarrhea later that day. On October 10, he developed fever, rash, red eyes, and melena. The patient died October 13 on the pediatric ward. Given the patient's symptoms, the

Tonkolili district

A 25-year-old full term pregnant woman presented with labor pains to her community maternity clinic on October 7, 2014. On October 9, she was transferred to the maternity ward of a general hospital due to prolonged labor where she was observed for 5 days. On October 14, the patient gave birth to a live newborn via an uncomplicated cesarean section for prolonged labor. Two days later, on October 16, she reported feeling febrile and had 1 episode of vomiting. The following day, October 17, the

Discussion

Unidentified EVD patients in non-EVD health care facilities present a significant health risk to health care workers, caregivers, and other patients.⁶ Effective infection prevention and control measures to reduce the risk of nosocomial transmission to health care workers and patients include improved disease screening, isolation of suspect case patients, facility engineering controls, and adherence to recommended PPE.⁴ In the outbreaks we describe, screening at the time of admission did not

References (11)

P. Kilmarx et al.
Ebola virus disease in health care workers – Sierra Leone, 2014
MMWR Morb Mortal Wkly Rep
(2014)
Laboratory Diagnosis of Ebola Virus Disease
(September 2014)
Infection Control and Screening and Isolation of Suspected Ebola Patients at the Peripheral Health Units. Infection Control Guidelines and Training Manual
(2014)
Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Hemorrhagic Fever in Health-Care Settings, with Focus on Ebola
(December 2014)
Sierra Leone Emergency Management Program Standard Operating Procedure for Safe, Dignified Medical Burials.
(October 2014)

There are more references available in the full text version of this article.

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Ebola virus disease nosocomial infections in the Democratic Republic of the Congo: a descriptive study of cases during the 2018–2020 outbreak
2022, International Journal of Infectious Diseases
To describe the characteristics of nosocomial cases of Ebola virus disease (EVD) in the Democratic Republic of the Congo between July 2018 and May 2020 in order to inform future interventions.
Nosocomial cases of EVD were identified during outbreak response surveillance, and a retrospective analysis of cases was conducted according to demographic characteristics and type of health facility (HF).
Of 3481 cases of EVD, 579 (16.6%) were nosocomial. Of these, 332 cases occurred in women (57.3%). Patients and visitors accounted for 419 cases (72.4%), of which 79 (18.9%) were aged 6–≤18 years and 108 (25.8%) were aged ≤5 years. Health workers (HWs) accounted for the remaining 160 (27.6%) nosocomial cases. The case fatality rate (CFR) for HWs (66/160, 41.3%) was significantly lower than the CFR for patients and visitors (292/419, 69.7%) (P<0.001). The CFR was higher among cases aged 6–≤18 years (54/79, 68.4%) and ≤5 years (89/108, 82.4%). Referral HFs (>39 beds) had the highest prevalence of nosocomial EVD (148/579, 25.6%). Among HFs with at least one case of nosocomial infection, 50.0% (98/196) were privately owned.
Nurses and traditional healers should be targeted for infection prevention and control training, and supportive supervision should be provided to HFs to mitigate EVD transmission.
Ebola: A review and focus on neurologic manifestations
2021, Journal of the Neurological Sciences
Ebolavirus disease (EVD) is a severe, highly contagious, and often fatal systemic disease in human and non-human primates. Zoonotic and human-to-human transmission have been well documented. Ebolaviruses are endemic to Equatorial and West Africa and there have been over 20 outbreaks in sub-Saharan Africa since 1976. The largest known outbreak of EVD occurred between 2013 and 2016 across several West African countries. It resulted in 28,646 suspected and confirmed cases and 11,323 deaths. There are 5 species within the genus Ebolavirus with 4 of them being clinically significant. In patients with EVD, neurologic manifestations range from mild symptoms such as confusion to severe neurologic diseases such as meningitis and encephalitis. Altered mental status, from mild confusion to delirium with hallucinations, may also occur. Rare neuropsychiatric manifestations of EVD include psychological or cognitive symptoms, including short-term memory loss, insomnia, and depression or anxiety. Although Ebolavirus RNA has been detected in cerebrospinal fluid, the body of knowledge around the pathogenic mechanisms of neurological disease is not yet fully understood. Studies are needed to understand the acute and chronic neuronal pathologic as well as biochemical cerebrospinal fluid changes in Ebolavirus infection.
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Citation Excerpt :
The third surviving neonate was reportedly alive at 2 months of age, but this report has not been confirmed.17 Screening for Ebola virus disease by the use of case definitions38 was described in eight studies.4,5,15,17,18,29,30,39 The specificity of standard case definitions for Ebola virus disease in pregnant women was 16–29%,15,39 compared with 50% in the general population with Ebola virus disease.40
The outbreaks of Ebola virus between 2014 and 2020 have drawn attention to knowledge gaps related to Ebola virus disease in pregnant women. The aim of this study was to systematically evaluate available data on pregnant and lactating women with acute Ebola virus disease or following recovery. We searched MEDLINE, Embase, Cochrane Library (CENTRAL), Web of Science Core Collection, CINAHL, POPLINE, Global Health, and WHO Global Index Medicus, in addition to grey literature, for relevant articles. Studies of all types and published between database inception and Aug 19, 2019, were eligible (PROSPERO 129335). We identified 1060 records, of which 52 studies met our inclusion criteria. Overall, mortality in 274 pregnant women with Ebola virus disease was 72% (197 women died); mortality for pregnant women with Ebola virus disease were not higher than those in the general population of patients with Ebola virus disease. Nearly all women with Ebola virus disease had adverse pregnancy outcomes. Among survivors, Ebola virus RNA was detected by RT-PCR in amniotic fluid up to 32 days after maternal clearance of Ebola virus from the blood and in breastmilk 26 days after symptom onset. A risk of transmission of Ebola virus from pregnancy-related fluids and breastmilk probably exists, and precautions should be taken.
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: ACD and TAW contributed equally to this work.

: The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the Centers for Disease Control and Prevention or the institutions with which the authors are affiliated.

: Conflicts of interest: None.

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Major articleNosocomial transmission of Ebola virus disease on pediatric and maternity wards: Bombali and Tonkolili, Sierra Leone, 2014

Highlights

Background

Methods

Results

Conclusions

Section snippets

Bombali district

Tonkolili district

Discussion

Ebola virus disease in health care workers – Sierra Leone, 2014

MMWR Morb Mortal Wkly Rep

Laboratory Diagnosis of Ebola Virus Disease

Infection Control and Screening and Isolation of Suspected Ebola Patients at the Peripheral Health Units. Infection Control Guidelines and Training Manual

Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Hemorrhagic Fever in Health-Care Settings, with Focus on Ebola

Sierra Leone Emergency Management Program Standard Operating Procedure for Safe, Dignified Medical Burials.

Major article
Nosocomial transmission of Ebola virus disease on pediatric and maternity wards: Bombali and Tonkolili, Sierra Leone, 2014