title: Nosocomial transmission of Ebola virus disease on pediatric and maternity wards: Bombali and Tonkolili, Sierra Leone, 2014.
abstract: 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.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone. Electronic address: ydg8@cdc.gov.
authors.forename: Angela C
authors.initials: AC
authors.lastname: Dunn
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: Tiffany A
authors.initials: TA
authors.lastname: Walker
authors.affiliation: CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: John
authors.initials: J
authors.lastname: Redd
authors.affiliation: CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: David
authors.initials: D
authors.lastname: Sugerman
authors.affiliation: CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: Jevon
authors.initials: J
authors.lastname: McFadden
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: Tushar
authors.initials: T
authors.lastname: Singh
authors.affiliation: Concern Worldwide, Tonkolili District, Sierra Leone.
authors.forename: Joseph
authors.initials: J
authors.lastname: Jasperse
authors.affiliation: Sierra Leone Ministry of Health and Sanitation, Tonkolili District, Sierra Leone.
authors.forename: Brima Osaio
authors.initials: BO
authors.lastname: Kamara
authors.affiliation: Sierra Leone Ministry of Health and Sanitation, Bombali District, Sierra Leone.
authors.forename: Tom
authors.initials: T
authors.lastname: Sesay
authors.affiliation: CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: James
authors.initials: J
authors.lastname: McAuley
authors.affiliation: CDC Sierra Leone Ebola Response Team, Freetown, Sierra Leone.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Kilmarx
mesh_terms: D000328:Adult; D002675:Child, Preschool; D016358:Contact Tracing; D003428:Cross Infection / Q000453:epidemiology* / Q000635:transmission*; D018562:Disease Transmission, Infectious; D005260:Female; D019142:Hemorrhagic Fever, Ebola / Q000453:epidemiology* / Q000635:transmission*; D006801:Humans; D007231:Infant, Newborn; D017053:Infection Control / Q000379:methods; D000067393:Personal Protective Equipment / Q000706:statistics & numerical data; D011247:Pregnancy; D012807:Sierra Leone / Q000453:epidemiology
keywords: Epidemiology; Hospital-acquired infection; Infection control; Outbreak; West Africa