Ebola Virus Training: A Needs Assessment and Gap Analysis

Abstract

In response to the 2014 Ebola virus disease outbreak, the Worker Training Program embarked on an assessment of existing training for those at risk for exposure to the virus. Searches of the recent peer-reviewed literature were conducted for descriptions of relevant training. Federal guidance issued during 2015 was also reviewed. Four stakeholder meetings were conducted with representatives from health care, academia, private industry, and public health to discuss issues associated with ongoing training. Our results revealed few articles about training that provided sufficient detail to serve as models. Training programs struggled to adjust to frequently updated federal guidance. Stakeholders commented that most healthcare training focused solely on infection control, and there was an absence of employee health-related training for non–healthcare providers. Challenges to ongoing training included funding and organizational complacency. Best practices were noted where management and employees planned training cooperatively and where infection control, employee health, and hospital emergency managers worked together on the development of protective guidance. We conclude that sustainable training for infectious disease outbreaks requires annual funding, full support from organizational management, input from all stakeholders, and integration of infection control, emergency management, and employee health when implementing guidance and training.

In response to the 2014 Ebola virus disease outbreak, the National Institute of Environmental Health Sciences Worker Training Program embarked on an assessment of existing training for those at risk for exposure to the virus.

The Ebola virus disease (EVD) outbreak of 2014-15 caused concern over the health and safety of healthcare providers and workers who might be exposed while performing their daily job responsibilities. Initial protective guidance was directed toward those with the highest risk: healthcare providers. It quickly became apparent that other workers were at risk for exposure, including hazardous waste workers, cleaning staff, and transportation professionals. Training workers on how to function safely in the EVD workplace environment became a high priority in the United States as volunteer healthcare providers began returning from West Africa; in one case a traveler with EVD was hospitalized in Texas, with his care resulting in EVD in 2 nurses who cared for him.¹

The National Institute of Environmental Health Sciences (NIEHS), an institute of the National Institutes of Health, received funding to develop a training program for workforces determined to be at risk of exposure to EVD in the course of their employment. To inform the development of the program, named the Ebola Biosafety and Infectious Disease Response Training Program, NIEHS performed an analysis of the training needs for front-line workers and the state of existing infectious disease training. The NIEHS effort commenced with an assessment of existing infectious disease training, including that which was carried over from previous outbreaks such as severe acute respiratory syndrome (SARS) and the 2009-10 H1N1 pandemic. Training needs were assessed through discussion with representatives of healthcare organizations and providers, professional organizations, professional unions, and public health officials. NIEHS then performed a gap analysis of the estimated training needs and the current training available necessary to protect workers in future infectious disease outbreaks. This article describes the process by which the gap analysis was conducted and its results.

Methodology

The needs assessment and gap analysis consisted of a literature search of existing infectious disease training; review of key federal guidance; a search of web-based training; and meetings with focus groups who represented key EVD stakeholders. All studies, searches, and focus groups occurred between April and July of 2015. Focus groups were conducted in June and July of 2015 at 3 locations around the country. Literature reviews examined articles prior to April 2015. Internet reviews searched courses in existence since 2004 and posted before April 2015.

Literature Search

A literature search of PubMed and Web of Science was conducted to highlight the latest research and lessons learned related to Ebola and communicable disease outbreaks, occupational health, and biohazard training. Key search terms were broken into 3 areas—health and safety, training, and communicable disease—and included topics such as occupational health, teaching/methods, communication, health and safety, communicable diseases, Ebola, pandemic, SARS, and influenza. A proximity search was conducted in Web of Science for specific diseases. Only articles from each category that had undergone peer review were included, thus excluding opinion pieces and editorials from the past year that do not present data or best practices. Because the number of publications on Ebola before 2014 was limited, peer-reviewed publications from the past 10 years were included. A bibliography from each search engine was created and combined, and following a review of all abstracts, articles focusing exclusively on the delivery of patient care or of relevance only to locations outside the United States were excluded. Additional articles specific to US Department of Defense installations or deployments were also excluded. A total of 38 articles met inclusion criteria and were reviewed. Abstracts and full-text documents that met inclusion criteria were accessed via the NIEHS library system.

Review of National Guidance

A review of the guidance issued from national public health and worker safety agencies—the Centers for Disease Control and Prevention (CDC)² and the Department of Labor, Occupational Safety and Health (DOL/OSHA)³—available in April 2015 was conducted for content and consistency in the context of establishing training requirements for EVD workers. Guidance was examined for gaps in addressing EVD threats based on its transmissibility, consistency with other related regulations, applicability to all at-risk end-user populations, and usability by frontline workers.

Internet Search for Training Courses

A search of the internet for existing training courses for infectious diseases and EVD was conducted. The following inclusionary criteria were used:

• • Sponsor/developer: academic center or response, professional, or government organization

• • Date of course creation within the past 15 years

• • Content has documented specific learning goals and objectives

• • Focus on biosafety or infectious diseases

Courses were categorized by level of training (awareness, operations, comprehensive) (Figure 1), audience, delivery methods, duration, and cost.

Figure 1.

Definitions of course types

Focus Groups and Questionnaires

The Worker Training Program (WTP) conducted 4 stakeholder meetings: 2 in Washington, DC; 1 in Oakland, California; and 1 in New York City. These sites were selected for their geographic diversity, as well as for being proximally near to national healthcare organizations, union headquarters, and federal agencies. Participants represented labor unions (nursing and other healthcare staff, teachers, and airlines), academic research and medical centers, government agencies (federal, state, and local) responsible for health care and labor, healthcare facilities and organizations, safety and health trainers, private industry representatives (including clean-up workers and waste handlers), professional organizations, and labor advocacy groups

Participants were asked to provide input into their training requirements, best practices, challenges, barriers, and gaps. Comments from participants were not for attribution, and each session lasted between 2 and 3 hours. Participants were provided an agenda and a list of potential discussion topics prior to sessions. A total of 80 people participated in the 4 meetings. An experienced facilitator led the discussions at all sites.

To inform meeting discussions, in advance of the meeting, stakeholders were provided an optional on-line form that asked a series of questions about any training they had conducted for their workers. This 24-question document asked about training characteristics, audiences, challenges in performing training, and best practices. Responses were anonymous and were used to formulate discussion during the in-person meetings and to allow further discussion of issues raised and area-specific topics.

Stakeholders who were unable to attend any of the meetings were afforded the opportunity to participate in individual interviews to discuss the same issues as discussed in the larger stakeholder meetings.

Results

The literature search produced 38 articles that met the inclusion criteria (Figure 2). The majority of articles focused on outlining the need for training, how to evaluate training, or innovative training methodologies, such as simulations and interactive Web training.^4-6 Few described curricula or competencies, and only 2 addressed mental health resilience training.^7,8 Of the training components described, most addressed the use of personal protective equipment (PPE).

Figure 2.

Primary focus of reviewed articles

The internet search produced 71 courses that met the inclusion criteria; 52 courses were classified as awareness level, 9 as operations, 6 as comprehensive, 3 as train the trainer, and 1 was a clinical course. Table 1 illustrates key characteristics of the courses.

Table 1.

Course characteristics

	Average Duration	Shortest	Longest	Delivery method
Awareness	3.28 hours	0.25 hours	40 hours (web series)	Web-based (31)	Classroom (15)	Hands-on (8)
Operations	15.9	4	32	Hands-on (9)	Classroom (9)	Lab-based (1)
Comprehensive	28	24	40	Hands-on (6)	Classroom (6)
Train the trainer	8	8	16
Clinical	5.4	NA	NA

Courses were delivered through a variety of media, depending on whether the course required hands-on training with equipment or procedures. Most courses were offered as a single course and not on a continuing basis. Most courses were directed to healthcare providers; 1 course was directed to laboratory workers.

Stakeholders were given opportunities to provide input through face-to-face meetings and a web-based form. They provided qualitative information representing a broad spectrum of professional organizations and disciplines from management and labor. Recurring themes from the focus groups included:

• • Infectious disease training developed during previous outbreaks has not been sustainable.

  • ○ Federal guidance continues to be disease-specific as opposed to developing a universal framework of worker safety and health.

  • ○ Training also needs to focus on general worksite preparedness and assessing worksite hazards.

• • Federal guidance was confusing and changing frequently, resulting in training that could not reflect the most current guidance.

• • Hospital training focused on infection control and not on worker health and safety.

  • ○ Integration of these 2 important functions is essential for preparations for future outbreaks.

• • Those facilities where labor and management worked cooperatively were considered to be the most successful in providing training to potentially at-risk workers.

• • Workers who received EVD training felt stigmatized by other workers who thought that they could possibly transmit EVD to others.

A total of 55 stakeholder meeting participants completed the web-based form, representing a wide spectrum of professional associations and disciplines. In their responses, 38 training programs were described, with 17 (45%) classified as awareness, 16 (42%) classified as operations, and 5 (13%) as train the trainer. Twelve (32%) courses were delivered online or were computer based, with the remainder delivered in a classroom setting. Awareness training was generally less than 2 hours; operations training ranged from 2 to 40 hours. Train the trainer courses generally added training onto operations-level training and ranged from 2 to 4 hours. The most commonly reported target training audiences were environmental service workers (11), health workers with potential contact with EVD (9), health workers with contact with EVD (8), and laboratory workers (7). Other target audiences included airport/aircraft workers, environmental remediation workers, mass transit workers, and public health responders. Half of the respondents noted that training was not ongoing, and 50% noted that, as of July 2015, their courses had been revised since initial development. None reported offering continuing education credits. Survey responses identified key challenges to training, including lack of funding, time off to attend the training, getting new workers trained, classroom logistics, finding qualified trainers, and finding an appropriate curriculum.

Discussion

As the EVD outbreak unfolded in the United States, it became apparent that there were at-risk populations outside of healthcare providers in direct contact with EVD patients. Available training for workers who were considered at risk but not providing patient care was not well documented. This article summarizes the nature of the training that was available by June 2015.

Our comprehensive approach used literature reviews, web-based searches, and interviews and surveys of key organizations responsible for training workers at risk for exposure to EVD while in the course of executing their job duties. The approach has the advantage of being able to identify training gaps based on the needs of end-users, as noted by their participation in focus groups and through identification of readily available and accessible training. Our approach examined the most accessible sources for training curricula, the internet and peer-reviewed literature, followed by discussions with those who represent the full spectrum of response organizations. The literature revealed a relatively small number of articles, most of which described teaching methodologies and strategies but lacked descriptions of curricula. We did not evaluate the quality of the training. The internet was more productive in that some details about courses were available, such as duration of the course and a general description, but detailed descriptions about the training curricula were difficult to find. The paucity of detailed articles was surprising in light of recent large-scale infectious disease outbreaks, including SARS (2003) and the H1N1 pandemic (2009), and the potential for other outbreaks like Middle East respiratory syndrome (MERS).

Training programs for previous infectious disease outbreaks have not been sustained, as evidenced by the US response to EVD. There are several possible explanations to account for this. The first is that training is time-consuming and expensive, and, in the time between outbreaks, training is not funded. A second explanation is complacency. Without a clear and present infectious disease threat, providers and responders focus on current threats. Yet another explanation is that training is disease-specific, and, when the outbreak passes, the training is no longer useful in the daily functions of providers and workers.

Based on the gaps uncovered in our searches, we turned to focus groups to answer questions related to those gaps. One of the first sentiments expressed by the focus groups was that EVD training needed to address basic worker health and safety issues, such as identifying workplace hazards and understanding the worksite safety structure, issues that have application outside of the infectious disease realm. Finally, workforce turnover in the face of episodic infectious disease training can result in a largely untrained, unprepared workforce.

Infection control training conducted by healthcare facilities was not felt by focus groups to be sufficient to address worker health and safety issues facing workers at risk for exposure to EVD. Those few programs that combined worker health with infection control were those that established joint EVD committees that included representatives from both programs.

The gap analysis identified several key training deficiencies. The first gap is the absence of a mechanism that integrates public health, medical, occupational health, and worker safety activities in a comprehensive approach that incorporates key stakeholder perspectives and provides easy-to-follow risk-based guidance. Infection control, worker safety, and emergency management professionals need to be better connected to manage resources, consolidate guidance, and protect worker health and safety. End-users also require a mechanism to contribute to the development of local practice and policy and into the guidance issued by federal agencies. Protective guidance was felt to be incomplete and difficult to interpret and implement at the user level. As a result, training was often outdated or dismissed as not being sufficient.

The second identified gap is that there is not a systematic mechanism to address the barriers to meaningful and sustained training that addresses overall worker safety in the context of an infectious disease outbreak. Stakeholders related that employers had begun withdrawing support for training very quickly after the US cases were discharged from care. Workers were unable to attend training because of the lack of employer support. Funding for training also rapidly became reduced or withdrawn, resulting in decreased course census. Complacency has a present and future negative impact on infectious disease training.

Finally, the stigma of EVD affected training. Fear and misinformation, in addition to the complexities of the EVD work environment, caused anxiety in workers. None of the training courses had a mental health resiliency module included.

Our gap analysis had several limitations. While we feel confident that our literature and web-based searches were comprehensive, there could be training courses that exist and are not described in the peer-reviewed literature or internet. Our stakeholder groups were limited. While we made every attempt to find representation from healthcare, public health, and worker organizations, there are other groups who may not have been represented at the meetings who may have presented a different perspective. We accounted for this limitation by being inclusive in our invitations and offering multiple avenues by which to participate. Weaknesses associated with focus groups were addressed by using a seasoned facilitator who sought the opinions of all and provided unbiased, open-ended questions throughout the discussions, which were framed by our literature review and internet search.

Response to emerging and reemerging infectious disease outbreaks must address worker safety and be based on their risk of exposure. The recent EVD outbreak revealed the need for a training program for workers who might be exposed to infectious diseases in the workplace, beyond those who provide direct patient care. Now that the outbreak has subsided, the NIEHS Worker Training Program has embarked on developing an infectious disease training program intended to address the needs of workers responding to an infectious disease outbreak.

Acknowledgments

NIEHS would like to acknowledge the outstanding cooperation, support, and leadership of the unions, academic centers, hospitals, stakeholders, and federal institutions that participated in the focus groups and provided invaluable insights and information to our team. Their collaboration and openness greatly contributed to the completion of this project.