Ebola Outbreak Updates & The Role of Nosocomial Transmission

In the face of continued transmission and security issues, the Ebola outbreak in the Democratic Republic of the Congo (DRC) has challenged response efforts in new ways. On May 18, 2019, the DRC reported 15 new confirmed cases, bringing the total to 1728, with 1121 deaths.

Over the past week, 40% of the new cases were community-related and, of the total deaths, 68% occurred outside Ebola treatment centers. This leaves the community increasingly at risk, as it is the time when patients are most likely to spread infection. Safe burial has long been a challenge when it comes to Ebola outbreaks, not only because the body is contagious, but it also poses a problem for maintaining infection prevention efforts during dignified burials. Moreover, response efforts have been challenged with a “stop and go” pattern where response efforts are active for a day or 2 and then halted due to violence or security threats. Outside of the challenges for maintaining response and prevention efforts in a conflict zone, we’re also seeing a worrisome trend in Ebola cases—infection of health care workers.

During the 2013-2016 outbreak, health care workers in West Africa were 32 times more likely to be infected with Ebola. Earlier this week, a nurse was reported as the latest case in this trend, bringing the total of health care worker infections to 99. On Friday, the World Health Organization situation report noted that this number had increased to 101 and now accounted for 6% of the cases. Of these health care worker cases, there have been 34 deaths. The continued need for more health care workers, especially in the wake of frequent threats and violence, makes the possibility of nosocomial transmission that much more real. The enhanced personal protective equipment (PPE) alone is difficult for a novice and can be a considerable source of exposure. Bringing in local health care workers and staff is critical to maintaining local engagement and earning trust in this rapidly evolving environment, however, the tacit knowledge of caring for an Ebola patient is complicated on the best of days.

The continued trend of health care worker infections provides insight into the challenges of training new staff, but also highlights how there is little room for mistakes in managing Ebola outbreaks. From the perspective of this infection preventionist, even with all the resources available and the time to don/doff the PPE appropriately, infection control is extremely difficult and patient care is inherently complicated by the burden of PPE. In an environment with limited resources and the challenges of a community already timid to outside agencies swarming in to help, it’s not surprising that health care workers are stressed. These are not intuitive processes and it takes considerable practice to establish a level of comfort. The training of health care workers and community partners is critical as a decentralized approach in hospitals, the lack of which breeds poor infection control, and thus nosocomial transmissions.

Overall, this outbreak has challenged public health and health care response in new ways. We already struggle to combat nosocomial infections, especially in health workers, but when you add in the stress of security threats and violence, it’s not surprising that case counts continue to grow. The virulence of Ebola and the infectious nature of the disease means that health care workers are inherently more at risk. Invasive medical procedures and continued close contact with patients in their peak infectivity only makes the importance of PPE and infection control efforts that much more dire. As this outbreak continues and more cases of health care worker infections are reported, we should continue efforts to make their work safer and help translate these lessons to the community.

Infection control is not limited to health care settings, but there are strategies that can be taught to families and the community to help reduce the rapid spread of disease. Efforts are underway to help community members facilitate safe burial practices and reduce transmission at home. One thing this outbreak has taught us is that just when we think we’ve got Ebola containment down to an art, we realize that we’re just barely learning the complexities of disease management.