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. 2014 Oct 17;63(41):925–929.

TABLE.

Work responsibilities and clinical information for five health care workers (HCWs) who became infected with Ebola virus while working in an Ebola treatment unit (ETU) or an adjacent general hospital (hospital A) — Monrovia, Liberia, July 2014

Work responsibilities/Clinical information HCW A HCW B HCW C HCW D HCW E
Work location Hospital A ED ETU and hospital A ED triage area ETU and hospital A ED triage area ETU (hospital A ED triage area: unknown) Hospital A ED
Work shift; shift Frequency Night only; 3.5 shifts per week Day and night; ~14 day and 7 night shifts per month Day only; shift frequency not available Night only; shift frequency not available Night only; 3.5 shifts per week
Responsibilities Direct patient care in hospital A ED Direct patient care in ETU; assessment of patients in hospital A ED and triage area; cleaning and disinfection of grossly contaminated surfaces in hospital A triage area; cleaning and disinfection of grossly contaminated surfaces in hospital A ED Disinfecting soiled surfaces and HCWs leaving ETU ward, but inside the ETU containment area; cleaning and disinfection of grossly contaminated surfaces in hospital A triage area Disinfecting soiled surfaces and HCWs leaving ETU ward, but inside the ETU containment area; unknown whether cleaning and disinfection activities were performed in hospital A triage area Direct patient care in hospital A ED
Barrier precaution equipment use in ETU Did not work in this setting As recommended by MSF for this setting* As recommended by MSF for this setting* As recommended by MSF for this setting* Did not work in this setting
Barrier precaution equipment use in hospital A ED Gloves were used when available; use of other equipment unknown Double gloves and gown reported at a minimum for all patient and cleaning encounters; use of additional mucus membrane barrier precaution equipment variable Unknown Unknown Gloves were used when available; use of other equipment unknown
Ill contacts outside of work Unknown None reported None reported Unknown Unknown
Date of symptom onset July 14 July 22 July 22 July 23 July 29
Outcome Died July 26 Recovered Recovered Died July 27 Recovered
Case status Laboratory confirmed§ Laboratory confirmed§ Laboratory confirmed§ Probable Laboratory confirmed§
Additional comments No other HCWs in cluster were reported to have contact with this HCW after July 14 Participated in cleaning and disinfecting surfaces grossly contaminated on July 14 No additional information Died with hemorrhagic manifestations of EVD Had direct, unprotected patient contact with undetected, but infected patient in hospital A ED on July 14
Did not work on July 14 Never worked same night shift as HCW A
Information source Indirect: interview of coworkers, administrators; review of work schedule Direct: interview
Indirect: interview of coworkers, administrators; review of work schedule
Direct; interview
Indirect: interview of coworkers, administrators; review of work schedule
Indirect: interview of coworkers and administrators; review of work schedule Indirect: interview of coworkers and administrators; review of work schedule

Abbreviations: ED = emergency department; MSF = Médecins Sans Frontières (Doctors Without Borders).

*

A description of personal protective equipment use recommended for ETUs can be found in Sterk E. Filovirus haemorrhagic fever guidelines, Médecins Sans Frontières, 2008:34. Available at http://www.slamviweb.org/es/ebola/fhffinal.pdf.

This is not adequate barrier precaution use for caring for patients with Ebola or for cleaning and disinfecting surfaces grossly contaminated with Ebola-containing fluids.

§

Laboratory-confirmed by reverse transcription–polymerase chain reaction.