Country readiness strengthening workshop on infection prevention and control for Ebola and Marburg disease outbreak: workshop report, 4–8 December 2023

Country Readiness Strengthening workshop on infection prevention and control for Ebola and Marburg disease outbreaks Workshop report: 4–8 December 2023 Country Readiness Strengthening workshop on infection prevention and control for Ebola and Marburg disease outbreaks Workshop report: 4–8 December 2023 Country readiness strengthening workshop on infection prevention and control for Ebola and Marburg disease outbreak: workshop report, 4-8 December 2023 ISBN 978-92-4-009440-6 (electronic version) ISBN 978-92-4-009441-3 (print version) © World Health Organization 2024 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover page photo: Group photo of participants partaking in the Country Readiness Strengthening workshop on IPC for EBOD and MARD outbreaks. © WHO/Devika Dixit. III Contents Acknowledgement iv Abbreviations v 1. Introduction 1 1.1 Background 2 1.2 Objectives 2 1.3 Methodology 3 1.4 Country and participant selection 3 2. Overview 5 2.1 Day one 6 2.2 Day two 6 2.3 Day three 7 2.4 Day four 7 2.5 Day five 7 3. Results and outputs 9 3.1 Evaluation of the workshop 10 3.1.1 Pre- and post-tests 10 3.1.2 Workshop survey 11 4. Workshop follow-up 13 5. Recommendations from workshop 15 5.1 Workshop structure and outputs 16 5.2 General organization of the workshop 17 6. Conclusion 19 Annexes 21 Annex 1. Agendas 21 Annex 2. Simulation exercises 27 Annex 3. List of participants 37 Annex 4. Pre and post test results 39 Annex 5. Workshop evaluation 49 Annex 6. Country Roadmaps 53 IV Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Acknowledgements The World Health Organization (WHO) gratefully acknowledges the individuals and organizations who contributed to this workshop on the infection prevention and control (IPC) for Ebola and Marburg disease outbreaks. WHO thanks the Ministry of Health of Liberia for hosting this event. WHO also thanks the UK Public Health Rapid Support Team for the contribution to this event. The development of this report was coordinated by April Baller, who also led the writing together with Devika Dixit, and Victoria Willet of the Department of Country Readiness Strengthening, WHO Health Emergencies Programme and Zainab Sirleaf, WHO Country Office Liberia. Other contributors are listed below: UK Health Security Agency, UK Public Health Rapid Support Team Emilio Hornsey WHO Country Offices, Regional Offices and Headquarters Hannah Hamilton, Landry Kabego, Julius Monday The World Health Organization (WHO) is grateful for the financial contributions it has received from the United States Agency for International Development (USAID) and the United States Centers for Disease Control and Prevention (US- CDC) in support of this workshop on the infection prevention and control (IPC) for Ebola and Marburg disease outbreaks. VAbbreviations GDG Guideline Development Group HQMU Healthcare Quality Management Unit IPC Infection prevention and control MoH Ministry of Health NPHIL National Public Health Institute of Liberia PPE Personal Protective Equipment US CDC Centers for Disease Control and Prevention (of the United States of America) USAID United States Agency for International Development WASH Water, sanitation and hygiene WHO World Health Organization

Introduction 1 2Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks 1. Introduction A workshop to enhance sub-regional IPC readiness for Ebola and Marburg disease outbreaks was held in Monrovia, Liberia from 4–8 December 2023. This workshop was the result of collaboration between the Ministry of Health of Liberia, and the three levels of WHO. The 56 participants who attended the complete 5-day workshop included representatives from Ministries of Health (MoH) and WHO country offices of Ghana, Liberia, Sierra Leone, South Africa and United Republic of Tanzania. Countries were selected based on being English speaking and having prior experiences with Ebola and Marburg disease outbreaks, except for South Africa which was chosen to enhance readiness. Funding for this workshop was received with thanks from United States Agency for International Development (USAID) and Centers for Disease Control and Prevention (of the United States of America) (US CDC). This report describes the main goals and achievements of the workshop and concludes with recommendations and proposed next steps. Annexes with supplementary information are also included. 1.1 Background In recent years, Ebola and Marburg disease outbreaks have been occurring with increasing frequency in Africa. These outbreaks are associated with high morbidity and mortality and can generate fear and mistrust about response activities within the communities affected. In 2021, The World Health Organization Health Emergencies (WHE) Programme, Health Care Readiness (HCR) Unit, Country Readiness Strengthening (CRS) Department, Infection Prevention & Control (IPC) and Water, Sanitation and Hygiene (WASH) Team, identified a need to re-evaluate and update guidance for IPC practices, given that much had been learned since publication of the prior guidelines. Hence, a Guideline Development Group (GDG) was convened, and an updated guideline was developed. This update consists of a consolidated WHO guideline that follows the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and evidence to decision methodology. The WHO Infection prevention and control for Ebola and Marburg disease guideline was published in August 20231. Nine recommendations from previous guidance have been integrated (carried forward) into this new guideline, which also contains 11 new recommendations and 10 new good practice statements. This five-day workshop included presentations from the countries, review of new guideline recommendations as well as implementation considerations, and interactive sessions including a full-day simulation exercise held concurrently at two health facilities in Monrovia. The simulation exercise included four scenarios experienced during an Ebola or Marburg disease outbreak: i) screening, triage and isolation of suspect Ebola/Marburg cases ii) inpatient surveillance and patient management iii) waste and linen management in the context of Ebola and Marburg disease outbreaks iv) health and care worker exposure risk management. These scenarios provided an opportunity for participants to gain valuable hands-on experience and apply new tools and knowledge such as putting on and taking off personal protective equipment (PPE) and setting up an appropriate screening and triage area and safe waste management processes. There was opportunity for discussion and knowledge sharing after each session as well as a pre- and post-test. The workshop concluded successfully with each country presenting their roadmap for inclusion of IPC in contingency plans for emergencies and in particular, adoption of the WHO IPC guideline and key activities for Ebola and Marburg disease outbreaks. 1.2 Objectives The overarching goal of this workshop was to prepare and support participants to be operationally ready to respond to Ebola or Marburg disease outbreaks by reviewing the new IPC recommendations for Ebola and Marburg disease, knowledge sharing amongst countries present and participating in interactive sessions and familiarising themselves 1 For more information, refer to Infection prevention and control guideline for Ebola and Marburg disease, August 2023 available: https://www.who.int/ publications/i/item/WHO-WPE-CRS-HCR-2023.1, August 2023 (who.int). Accessed 2 April 2024. 3with the new tools available to support IPC measures during outbreak management. Toward that end, specific objectives included: 1. To develop an action plan for an Ebola and Marburg disease outbreak readiness and response based upon current contingency plans which includes the updating national guidelines to reflect the new WHO Ebola/ Marburg IPC guideline recommendations. 2. To describe the new WHO Ebola and Marburg IPC guideline recommendations. 3. To identify tools and resources available to support implementation of the IPC Ebola/Marburg recommendations. 1.3 Methodology The 5-day workshop used a variety of adult learning methods, including formal presentations with discrete objectives, interactive table-top exercises, country presentations on past Ebola/Marburg outbreaks and future plans, post-test assessments as well as field simulation at one of two sites (see Annex 1 for agendas and Annex 2 for more information on simulations). 1.4 Country and participant selection Liberia was selected as a pilot host for this workshop based on its experiences and risk of future Ebola or Marburg disease outbreaks; willingness to host training; and motivation for implementation of IPC activities. Participants in this workshop included IPC focal points representing Ministry of Health (MoH), partners and WHO country office focal points for Liberia and five additional sub-regional countries: Ghana, Sierra Leone, South Africa and United Republic of Tanzania. Except for South Africa, each country sent an IPC representative from its MoH and a representative from the WHO country office. In South Africa, there was no IPC focal person available from the MoH so only a WHO country office representative attended. Participants from Liberia included health officers and IPC focal persons, national IPC officers, national surveillance officers and national emergency preparedness and response officers. Also in attendance were Dr. Thelma Nelson, Director of Global Health, National Public Health Institute of Liberia; a representative of Last Mile Health, an organization that partners with governments to build strong community health systems in remote communities; and a representative of Jhpiego, a non-profit organization for international health that is affiliated with Johns Hopkins University in Baltimore, Maryland. Nadoris Nador from the US CDC IPC unit attended the workshop from the beginning to the end of the meeting. Workshop participants were encouraged to adopt the IPC guidelines into their national plans for readiness and response to Ebola and Marburg disease outbreaks. The workshop also highlighted the need for the development of an IPC action plan that would include operational elements, implementation tools and training to support IPC activities and ensure a timely response to any outbreak. A list of participants is available in Annex 3.

Overview 2 6Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks 2. Overview A 5-day workshop was conducted for which a detailed workshop agenda is provided in Annex 1. In the following sections, a summary of highlights from each day is provided. 2.1 Day one The day commenced with opening remarks and introductions of all participants and facilitators as well as officials. Opening remarks were delivered by Ms. Jane Macaulay, Director General, National Public Health Institute of Liberia, Dr. Musu Duworko, Family Reproductive Health Coordinator, on behalf of the WHO country representative, followed by Dr. Francis N. Kateh, Chief Medical Officer, Liberia. Dr. Duworko acknowledged the government of Liberia through its MoH for agreeing to host this WHO-supported meeting. She stated that strengthening country readiness with emphasis on IPC is a key component of quality of care in the context of health systems strengthening. She added that IPC cuts across the spectrum of health services delivery and requires bold actions to institutionalize, implement and monitor it. She highlighted the importance for health facilities and health and care workers to always maintain vigilance and be ready to respond. Dr. Kateh noted the 10-year milestone for the 2014-2016 West African Ebola outbreak, in particular Liberia’s experience and the profound effect it had on Liberia’s health system. Key points included the history of the Ebola disease outbreak in Liberia; the establishment of the Incident Management System; the innovative and creative response activities; the roles of surveillance, case management and IPC; the construction of Ebola treatment units; the health workforce training programme; and resource mobilization efforts. During the outbreak, high numbers of health and care workers became infected. In the outbreak response, IPC played a pivotal role and has subsequently been integrated throughout the health system. On 4 December 2023, Dr. Kateh stated, “We had over 300 health workers that got infected during Ebola. Of that, 192 died. And so we have been able to improve our method of safely guiding ourselves. To provide services, you have to be alive. And so, IPC is keeping them alive and doing what they love to do. Now, I want to welcome you all and declare this historic workshop open.” Day one set the stage for the week and aimed to foster discussion among the participants by sharing experiences. Representatives from Ghana, Liberia, Sierra Leone, South Africa and United Republic of Tanzania each presented their experiences with Ebola or Marburg outbreaks. Countries also presented on IPC status in their country from recent Joint External Evaluation or after-action reviews that were conducted. Uganda presented on Day two due to logistical issues. WHO headquarters presented on the roles of IPC and WASH in the context of emergencies. A pre-test of questions related to general IPC and IPC for emergencies, including Ebola or Marburg disease outbreaks, was completed by 56 participants who were in attendance for the entire five days. See Annex 4 for pre- and post-test results. 2.2 Day two This day started with a presentation on key activities for IPC in the context of an emergency. The focus then shifted to a review of IPC, including a review of standard precautions and transmission-based precautions. Updated evidence on the modes of transmission for Ebolavirus and Marburgvirus was provided. Participants were introduced to some of the guideline recommendations, starting with the IPC ring approach and supporting tools and IPC recommendations for screening and triage of patients with Ebola and Marburg disease. The sessions were interactive – with games, group work and group presentations – to engage participants. 72.3 Day three On this day, participants reviewed the remainder of the IPC recommendations, including IPC recommendations for direct/indirect contact with patients, environmental cleaning and disinfection, dead body management and linen management. Lastly, participants were introduced to the health and care worker exposure protocol and risk assessment form. Adult learning principles were again incorporated into these sessions. These included time for discussion and sharing of experiences, discussion of implementation and challenges foreseen, review and feedback of tools shared, group work and practical sessions. 2.4 Day four On Day four, field simulation exercises were held at the two hospitals (ELWA and 14 Military) that had been prepositioned to support this activity. The participants were divided into eight groups, four of which were taken to each facility, where they spent the day. Participants were given four scenarios that reflected the guideline recommendations and encouraged them to apply the recommendations to “real-life” situations. The scenarios addressed the following topics: 1) Screening, triage and isolation of suspect or confirmed patients; 2) In-patient surveillance, isolation of identified suspect or confirmed cases, contact management in the health facility; 3) Laundry and waste management for suspect or confirmed patients with Ebola or Marburg disease; and 4) Assessment of health and care worker exposure risk. Annex 2 provides more information on simulation exercises. Figure 1. Photographs from simulation exercise and practical session. Left: Waste management. Middle: Hand hygiene demonstration. 6 and 7 Dec 2023. Right: Screening. © WHO/Devika Dixit. 2.5 Day five Main activities on the fifth and final day of the workshop included a debrief from the field simulation exercises; a post- test, including review of results and comparison to pre-test results; and country presentations, which outlined their plans to update their contingency plans for IPC specific to managing future outbreaks of Ebola or Marburg disease. Each country presented its plans for the next year (Uganda presented a five-year plan). These are available in Annex 6. A closing ceremony with certificates concluded the workshop. An evaluation of the workshop was also conducted. See Annex 5 for more information.

Results and outputs 3 10 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks 3. Results and outputs 3.1 Evaluation of the workshop Evaluation of the workshop was done in three different ways: 1. Pre- and post-test – to assess baseline knowledge and any knowledge gains/losses of the participants 2. Simulation and table-top exercises observation – to assess hands-on problem-solving 3. Survey of the overall workshop – to assess how to improve the workshop for future iterations 3.1.1 Pre- and post-tests A pre-test was distributed on Day one of the workshop. The test consisted of 15 multiple-choice questions addressing core IPC principles such as standard and transmission-based precautions, Ebola and Marburg disease and IPC response during emergencies. Participants were encouraged to complete the tests independently, although facilitators were avail- able to answer any questions or provide clarifications as needed. Answers that were left blank and those with multiple answers selected were marked as incorrect. A total of 56 pre-tests and 52 post-tests were completed. It is not clear which four individuals did not complete a post-test, despite having participants sign-in daily. Overall, 52% of the questions were answered correctly on Day one and 66% were answered correctly on Day five (figure 1) at the end of the workshop, suggesting an increase in overall knowledge. Questions that were consistently addressed incorrectly on Day one and Day five were reviewed during the post-test presentation on Day five to provide additional clarification. A detailed breakdown of each question pre- and post-test is available in Annex 4. Some lessons from the pre-tests and post-tests were identified and modifications will be made for future workshops: • Best answer format not well understood. Participants often ticked an imperfect but not totally incorrect answer (e.g. Q11 and Q6 screening and patient placement questions). • Indication that many participants did not read the answers fully before responding. The training team needs a better understanding of normative styles of testing in different education systems. • Pieces of information that were delivered only once (i.e. in a presentation but not during simulation) were not well comprehended by many. • Concepts that, to some participants, were new, such as risk assessment and hierarchy of controls, were not fully understood after being introduced and may need to be allotted more time for discussion and practical applica- tion. • Many participants did not attend all the sessions; attendance dropped off during the afternoon on most days, which may explain some gaps in knowledge gain. We were not able to monitor every individual person’s attend- ance in each session, despite having a daily sign-in system. • Some outliers were identified. For example, only four out of 15 participants correctly answered a question that more participants had answered correctly in the pre-test. That invites questions about who took the test. Because test takers were anonymous, we could not identify whether all those who completed the post-test had completed the whole workshop. 11 Distribution of correct answers pre and post 16 14 12 10 8 6 4 2 0 Figure 1. Pre- and post-test results (distribution of correct answers pre and post) 3.1.2 Workshop survey On Day five of the workshop, participants were requested to complete a brief survey to evaluate the content and deliv- ery modalities of the workshop. The survey was provided online using a QR code and paper copies were available for individuals who were unable to access the online version. The graph below depicts the results of the 51 completed evaluations (figure 2). Results for “strongly agree” and “agree” were combined, as were “strongly disagree” and “disagree.” In summary, there was general agreement that the work- shop content and modalities were effective. Participants had the opportunity to provide comments to the following questions: • Which elements of the workshop were particularly well done or that you found most useful? • Which elements of the training could be improved? • OPTIONAL: Did you have any remaining technical questions about certain parts of the presentation that were not clear? Responses to the first question indicated that participants generally enjoyed the practical sessions and simulations. Some examples: “Content is simple, well understood, easy to transform the content into our settings; The PowerPoint presentation[s] were good, content of the presentations as well as the groups interactions and simulation.” The main suggestions for improvement included reviewing time allotment for presentations and sessions as well as reviewing content on the slides so that they are not too detailed. There were also some requests for more videos. One participant stated “Time management; Theoretical sessions [were] more than practical therefore I think more practical session[s] would be necessary to quickly adapt to new guidelines and settings; I think the PowerPoint slides need to be worked on. Some slides we[re] too bulky and hard to follow during the presentation”. Detailed breakdowns for each question are available in Annex 5. 12 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Figure 2. Workshop survey results by percentage Q1. The time allocated for the sessions was appropriate (i.e. not too fast and not too slow). Q2. The practical sessions and group work were successful in increasing my knowledge/understanding of the topic(s). Q3. The table top exercise was useful in increasing my understanding of the role of IPC in readiness and response for Ebola and Marburg disease outbreaks. Q4. The simulation exercises were clear and provided an in depth understanding of IPC activities for Ebola and Marburg disease outbreaks. Q5 The content level of the workshops was appropriate (i.e. appropriate depth and breadth; not too difficult and not too easy). Q6 I can directly apply the knowledge gained from the workshop in my work (i.e. developing or updating country readiness/response action plan. 0% 20% 40% 60% 80% 100% ■ Strongly agree/Agree ■ Undecided ■ Disagree/Strongly disagree Workshop follow-up 4 14 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks 4. Workshop follow-up Given that the workshop goals include helping attending countries develop an action plan and update contingency plans for Ebola or Marburg disease outbreaks, a follow-up plan with the country MoH IPC representative and WHO Coun- try Office IPC focal person has been developed in collaboration with the WHO Regional Office for Africa IPC Focal Point. After the workshop, participants were sent a reminder email outlining the key activities that were agreed upon during the workshop: 1. Adoption, adaptation and dissemination of the Ebola/Marburg IPC guidelines by the MoH. 2. Integration of key IPC activities into all the infectious diseases contingency plans, as well as into the multi-haz- ard plan. 3. Consideration of organizing a follow-up workshop within two years. This session would focus on the second part of the Ebola/Marburg IPC guidelines, especially addressing IPC consideration in community settings. For this, please get back to us if it proves feasible to integrate this into the 2024–25 workplan or, if not, in another place. In the coming months, follow-up meetings will be arranged to check on progress made towards achieving these goals and to identify any further support needed from WHO Regional Office for Africa or WHO headquarters. Considering the extensive participation from Liberia it was decided that the country office IPC focal point will be sup- ported over six months to ensure implementation of recommendations and next steps from the workshop. A follow-up workshop in 1–2 years is anticipated providing availability of funding to update on progress to date and continue with peer-to-peer learning which the participants identified as one of the most valuable components of the workshop. Recommendations from workshop 5 16 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks 5. Recommendations from workshop In addition to recommendations specific to the workshop’s content, structure and organization, some broader themes emerged from the workshop for consideration. 1. The responsible individual(s)/institutes for IPC in the context of health service delivery (IPC programme) and IPC activities during emergencies/outbreaks are often different persons/ institutions (e.g. MoH vs Public Health Agencies/national CDCs). Consequently, IPC may not be part of national preparedness and response plans and/ or disease specific plans. It’s critical to have collaboration at the national level to ensure IPC resources are avail- able both during routine service delivery and during emergencies. 2. Countries continue to experience challenges with insufficient resources for IPC at the ministry and WHO Country Office levels. These challenges affect countries’ ability to implement IPC programmes and activities, which af- fects their ability to develop contingency plans that include IPC activities for readiness and response. Resource mobilization for IPC is critical. The new Global IPC strategy may be an entry point for this. 3. In countries that have experienced Ebola/Marburg outbreaks, health and care workers may have significant psychological trauma. This should be acknowledged at the beginning of any workshop. 4. Countries appreciated the value of learning from each other’s experiences, and specifically requested an op- portunity to share progress and have more peer-to-peer learning opportunities related to IPC for emergency readiness and response annually via an online format and in-person on a biennial basis. Additional recommendations are provided specific to the content of the workshop, logistics and organization. 5.1 Workshop structure and outputs 1. This workshop was a pilot, which should be replicated for use in other English-speaking countries and translat- ed for use in French-speaking countries. Countries at risk of Ebola/Marburg disease outbreaks should be encour- aged to include this workshop in their next biennial workplans. 2. Although this workshop included representatives from five countries aside from Liberia, these countries could also benefit from individualized workshops that would include simulations in their own medical facilities. Each country has its own considerations, e.g. South Africa, which has had no cases of Ebola/Marburg disease, and Uganda or Sierra Leone, whose experiences with Ebola/Marburg disease may not be in line with the updated recommendations. 3. Overall, more time needs to be allotted for countries attending to present and share as well as for general discussion and clarification of the content. This may mean prioritizing recommendations and content to be included in the workshop. Some content – such as the health and care worker exposure risk assessment tool and the IPC rapid assessment tool – need to be allotted more time for participants to understand and apply the information. This may require the practical exercise to be conducted immediately after the presentation rather than included only as part of the simulation exercise. In addition, more time is needed for participants to review terminology updates so that they can differentiate between screening and triage definitions and new terminolo- gy of Ebola disease/Marburg disease versus old terminology of Ebola virus disease/Marburg virus disease. 4. The co-presentation format involving WHO headquarters, WHO Regional Office for Africa and host country was determined to have been useful in promoting engagement and buy-in from participants. This format recog- nizes country expertise and builds capacity within the country. However, in the future, we recommend that co-presenters be identified earlier. Now that slides are available; presentations can be shared beforehand with presenters in the country. 17 5.2 General organization of the workshop 5. Ensure well-functioning IT equipment is available. Country offices may not have sufficient equipment available to devote to a workshop that lasts several days, nor may they have the ability to project visuals and sounds as called for in workshop presentations. A proposed solution would be to put together a kit containing a laptop, projector and speakers and give priority for its use to workshops. 6. Ensure that the workshop is properly documented. A dedicated rapporteur or notetaker would help do that, since facilitators find it difficult to manage and coordinate the workshop presentations while taking the notes needed for follow-up reports. Resources to hire such a person should be included in the budget. 7. Ensure that facilitators have enough in-country lead-in time to set up the workshop properly. This time would allow for on-site planning and support to resolve any logistical issues, such as those that might require site visits before the start of the simulations, and to finalize coordination with the country representatives. This additional time, which is critical to carrying out activities necessary to ensure that the workshop succeeds, needs to be reflected in budget planning as well.

Conclusion 6 20 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks 6. Conclusion This workshop was deemed a success by both participants and organizers. Participants were engaged throughout and expressed their satisfaction not only with the presentations but with the opportunities that were provided for peer-to peer learning. The atmosphere was relaxed and the rapport between the facilitators and participants was respectful, which fostered an environment conducive to learning. Although time management was sometimes an issue, facilitators were flexible with the agenda, which they adjusted accordingly so that participants were able to seek clarifications and further discussion, as needed. On Day five, participants presented detailed plans for follow up actions and timelines to achieve the objectives and activities described. During the workshop, participants were introduced to a number of tools and resources; they were also provided with USB sticks containing the updated guidelines; and with other resources needed to support their implementation at national and county levels. While some newer concepts will take time for countries to more formally adopt and embed into practice, participants demonstrated during simulations and in the post-test that they had increased their knowledge of many key IPC recommendations from the new Ebola and Marburg disease guidelines. Overall, the objectives of the workshop were successfully met. Annex 1. Agendas Annexes 22 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Annex 1: Agendas Day one - 4 Dec 2023 Time Presentation 08:00 Breakfast and registration 09:00 Opening prayer Workshop opening session • NPHIL (Welcome remarks-Dr Thelma Nelson, DG NPHIL) • US CDC (Dr. Rachel T. Idowu) • WHO (Dr. Peter Clement) • MoH: Setting the Scene: Ten-year milestone of 2014-2016 West African Ebola outbreak: Liberia experience- Then and Now. Opening of the workshop- Dr. Francis N. Kateh) 10:00 Group photo 10:15 Participant introductions 11:00 WHO presentation on PRSEAH, security briefing and other housekeeping/administrative issues 11:15 Intro to the workshop including expectations and expected outcomes of workshop 11:30 IPC Knowledge assessment pre-test 12:00 Country presentations for Ebola or Marburg, contingency plans and After Action Review. • Q&A 13:15 Lunch 14:15 Country presentations for Ebola or Marburg, contingency plans and After Action Review (continued). • Q&A 16:00 Coffee break 16:15 IPC and WASH role with Health Emergencies • Global strategy and emergencies • Organization structure for ESRF • Outlining IPC roles and responsibilities • IPC framework and toolkit Key partnerships and networks 23 Day two – 5 December 2023 Time Item 08:00 Breakfast and registration 09:00 Recap Day one 09:15 IPC response plans for Ebola and Marburg disease outbreaks 10:00 Country presentation-Uganda and Q&A 10:45 Review of modes of transmission of Ebolavirus/Marburgvirus 11:30 Review of standard and transmission-based precautions and Interactive game 12:30 Lunch 13:30 Overview of guideline 13:45 IPC ring and IPC Rapid Assessment Tool (RAT) 14:45 IPC Ring table-top exercise 15:45 Coffee break 16:15 Recommendations for screening and triage and direct/indirect contact • Screening: key elements • Isolation referral pathway and set up • Risk based PPE recommendations · Screening without touch and >1 metre distance · Screening with touch · Triage 17:00 Wrap up 24 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Day three – 6 December 2023 Day four - Simulation – 7 Dec 2023 Time Item 08:00 Breakfast and registration 09:00 Opening prayer/ Recap Day two 09:15 PPE recommendations for direct/indirect care: (35 min) • Review appropriate PPE items and steps for putting on/removing PPE • Special considerations for hygienists/cleaners, mortuary workers 10:00 Hand hygiene and glove disinfection recommendations and discussion • Demonstration/Practical 10:45 Survivability of Ebolavirus or Marburgvirus in the environment (35 min) Effectiveness of disinfectants • Wiping versus spraying 11:30 Guideline recommendation: linen and laundry in HCF and in the community and implementation considerations 12:00 Guideline recommendation: Waste management in the context of Ebola/Marburg disease outbreak-HCF and community site and implementation considerations 12:30 Guideline recommendation: safe management of dead body 14:00 Health and care worker exposures including risk assessment 15:30 Instructions for Day four and wrap up 15:45 Review of template for presentations for Day five Time Item 08:00 Breakfast and groups 09:00 Depart 10:00 Begin scenarios- 4 groups- 1 group per scenario and rotate through Complete 2 scenarios then break for lunch 12:30 Lunch 13:00 Complete final 2 scenarios 16:00 Instructions for Day four and wrap up 25 Day five – 8 December 2023 Time Item 08:00 Breakfast 09:00 Debrief from Day four simulation 10:00 Post test 10:30 Finalize presentation for IPC contingency plan for Ebola/Marburg disease 11:00 Presentation on contingency plans • South Africa • Uganda • Sierra Leone • United Republic of Tanzania • Ghana • Liberia 13:00 Lunch 14:00 Evaluations 14:15 Post-test review 14:30 Summary of the information shared and future direction Toolkit overview 14:45 Presentation of certificates, Per diem 16:00 Closing remarks

Annex 2. Simulation exercises Annexes 28 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Annex 2: Simulation exercises Objective This simulation exercise aims to explore, develop and assess functional capacities specific for infection prevention and control (IPC) in the context of an outbreak of Ebola or Marburg disease. Timeline for the day Serial Time Activity Lead Comment 1 08:00 Breakfast and registration At Sinkor Palace, brief participants and break down into group allocations. Assign group leader for each of the 8 groups. 2 08:35 Load onto buses Participants onto buses for travel to sites. Get 14 MH bus departs first. 3 08:45 Depart Sinkor Palace 4 09:15 Arrive at ELWA Break into the 4 groups. 5 09:45 Arrive at 14 Mil Hosp (MH) Break into 4 groups. 6 10:00 Start first round of simulations 7 11:20 End and transfer for second simulation 8 11:30 Start second round of simulations 9 12:40 End and transfer to lunch Chapel at ELWA and Café at 14MH. 10 13:10 End lunch and transfer to third round of simulations 11 13:20 Start third round of simulations 12 14:40 End and transfer to fourth simulation 13 16:10 End and transfer to buses 14 16:20 Depart from hospital locations. 15 17:00-17:30 Arrive at Sinkor Palace Exact arrival time dependent on distance and traffic. Participants may disperse on arrival at Sinkor Palace. 29 Group rotation for simulation day ELWA groups 14 MH groups Scenario 1 Scenario 2 Scenario 3 Scenario 4 A B C D B C D A C D A B D A B C Scenario 1 Scenario 2 Scenario 3 Scenario 4 E F G H F G H E G H E F H E F G Serial Time in minutes Activity Lead Comment 1 0–10 Explain scenario Facilitator 2 10–15 Assign roles Facilitator 3 15–65 Run scenario Facilitator 4 65–100 Debrief Facilitator From facilitators and participant observers Note: Simulation facilitators stay static (do not move) and rather the groups move between each scenario. Scenario timeline Detailed breakdown of timeline of each simulation session, total time 1 hour and 20 minutes Scenario guidance for facilitators 1. A pre briefing for the facilitators will be held on Wednesday afternoon to discuss the logistics and scenarios 2. Each facilitator will stay at the same scenario all day while the groups rotate around. 3. Scenarios will be allocated at the pre briefing. 4. A total of 8 facilitators will cover 4 scenarios at 2 sites. Facilitators should have the following supplies on hand on the day: 1. Scenario description of assigned scenarios and debrief discussion points 2. Any supplies needed to drive the scenario (detailed in the scenario notes). 30 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Scenario descriptions Descriptions include introductory statement to be given to participants to set the scene. Injects to add in during the simulation and occasional prompts. Scenario 1: Screening, detection and Isolation Start location At the front of the hospital (ELWA or 14Military) Roles • IPC team • Screener • Patient • Persons (2) to transport patient to isolation • Observers Supplies needed for scenario 1 • Hand hygiene materials • Screening questionnaire • Thermometer • Waste bins • Selection of PPE items • Marker tape Objective of this scenario • Participants set up a screening process and transfer to isolation area (can consider triage) • Participants determine an isolation referral pathway • Demonstrate PPE ((put on and take off) (2 participants)) Background scene setting for participants There have been rumours in the local community that there may be cases of Ebola/Marburg disease, but this is not yet confirmed. You are getting your facility ready for the possibility that suspected cases might arrive and need to set up screening, triage and a space for isolation of any suspected cases. Please proceed with your actions to prepare for a patient screening 31 Inject 1: A patient arrives to the screening area with a caregiver. Screen the patient as you would for real and take any appropriate actions. Inject 2: The patient needs to be moved from the screening to the isolation area. One group member should put on PPE to escort the patient to the designated isolation area and bed. Any staff who have put on PPE should be allowed to remove the PPE. Points for discussion at the debrief. • Was there a clearly marked screening area? • Were there barriers to promote minimum 1 metre distance e.g., table chairs, fencing, is there shade? • What is the referral isolation pathway within the facility and to treatment centre? • What kind of PPE did the participants indicate would be needed (recall: no PPE need if >1 metre and no touch)? • What should be done in the screening /triage areas? • Did participants indicate the need for routinely cleaning and disinfection of the area? • What challenges did you see with setting up the process for screening/triage/isolation? • Will adaptations be required depending upon the size of the facility? • Should staff come through the same screening area as patients? • Was management of non-suspected patients considered? How are the patients being managed while waiting for screening • What do you do about the caregiver? Scenario 2: In patient surveillance Start location Female medical wards nurses station. Roles • IPC focal points • Health and care worker • Patient • Observers Supplies needed for scenario 2 • Hand hygiene materials • Screening questionnaire 32 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks • Non-contact thermometer • Waste bins • Selection of PPE items Objectives of this scenario • Implement a process for in patient surveillance • Identify isolation pathway if suspect case within a ward • Identify and management of contacts within the facility (consider quarantine) • Putting on and taking off PPE - Minimum 1 person to perform this task (others if time/resources permit) Background scene setting for participants. The community where your health facility is located, has an ongoing declared outbreak of Marburg disease. Admission screening has just started at the entrance to the facility but so far no ongoing surveillance is happening. You are in the female medical ward and need to create a plan for inpatient surveillance and transfer to isolation if there is a suspect case. Inject 1: Group member identified as the nurse checks the patient who notes a headache, fever, abdominal pain and diarrhoea -conduct screening. Nurse notices that the patient wasn’t screened on entry into the health facility nor when she was admitted yesterday. Inject 2: Result of the test for Marburg comes back positive. There is no isolation capacity in the isolation pod. Inject 3: The patient’s mother, who was admitted to another ward for a routine procedure, came to the female medical ward last night to see her daughter. Scenario 3: Waste and Linen management Start location Start behind the isolation pod on the covered way towards the waste and laundry area. Roles • IPC team • Person to transport the waste (may wear PPE) • Observer(s) Supplies needed for scenario 3 - Waste • Hand hygiene materials • Mock up full contaminated waste and laundry bags. 33 • Waste bins • Selection of PPE items (heavy duty gloves) • Alcohol based hand rub Objectives • Identify safe transport of infectious waste to the waste management area • Develop plan for final disposal of infectious waste • Appropriate PPE for waste handlers (put on and take off) Scenario 3a: Waste Background scene setting for participants. There is a confirmed outbreak of Ebola disease. Your facility has isolation capacity for suspected patients who are then transferred to another facility if they test positive. Meanwhile all IPC protocols for Ebola are followed in the isolation area. As the IPC focal point’s, you are concerned about how the environmental decontamination, infectious waste and contaminated linen is being managed and decide to check the waste management and laundry area to ensure IPC meas- ures are in place. The rest of the facility is continuing to treat general patients. Health and Safety point: None of the group should stray from paths at any point as there may be sharps or other hazards in the waste area. Inject 1: Now collect, transfer and store the waste as you would if it was contaminated with Ebola. Scenario 3b: Linen Start location Near the laundry facilities of the hospital Roles • Linen/laundry workers • IPC focal point(s) • Observer(s) Supplies needed for scenario 3b -Linen • Hand hygiene materials • Mock up full contaminated waste and laundry bags • Waste bins 34 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks • Selection of PPE items (heavy duty gloves) • Alcohol based hand rub Objective Identify procedures for safe management of infectious linen. Show the group the linen reprocessing area and describe the system as it now happens. Ask the group to come up with a plan for managing the contaminated linen. Inject 2: Now collect and transfer the linen for reprocessing as you would if it were contaminated with Ebola. This should be discussion only. Scenario 4: Assessment of health and care worker exposure Start location Dedicated room within the hospital Roles (applies to 4a and 4b) • Health and care worker • IPC focal person or designate to do the assessment • Observers Supplies needed for scenario 4a and 4b • Health and care work protocol copies • Health and care worker algorithm copies • Health and care worker risk assessment form copies Objective • Assess the health worker exposure using the tool • Determine the risk level of the exposure • Strategies to manage the health and care worker Case scenario 4a: (30 min) Aminata is a nurse who works on the Maternity ward at a Regional Referral Hospital. She is working night shift and is attending to three patients. She is sitting and eating her dinner when a pregnant woman starts to scream for assistance. The pregnant woman has fallen out of her bed and is having trouble getting up from the floor. Aminata puts on gloves and goes and helps the pregnant woman back to bed. As Aminata is assisting the pregnant women, the woman tries 35 to grab her hand because she feels herself falling again. As she grabs Aminata’s hand, the pregnant women accidently tears Aminata’s glove and scratches her hand. It is a simple scratch with just a small amount of blood. Aminata settles the pregnant women back to bed and goes to wash her hands. She puts a plaster on her hand, and she returns eating her dinner. Two hours later, Aminata receives a notification from the laboratory that the pregnant woman is positive for Marburgvirus. Utilize the health and care worker risk exposure protocol and assessment form to answer the following questions. 1. What is the first thing Aminata should do? • Facilitator answer: do not panic, perform first aid (including hand hygiene for several minutes), should notify occupational health/IPC as appropriate so she can be assessed properly for Marburgvirus disease and also other blood borne viruses. 2. Interview Aminata using the risk exposure form. 3. What risk exposure category would you put Aminata in? (No exposure, low exposure, high exposure)? • Facilitator answer: high risk 4. Explain why you would put her into that above category. • Facilitator answer: non-intact skin, physical contact with patient, patient has confirmed Marburgvirus infection 5. What is the follow-up plan for a health and care worker in this category? • Facilitator answer: follow high risk recommendations found in the algorithm. Case scenario 4b: (30 min) 2 different people should play the roles Richard is a new hygienist working in the isolation area of a Treatment Centre with confirmed patients with Ebola dis- ease. This is his second day on the job. He is working during the day, and he is waiting to clean and disinfect a patient room who has been discharged an hour ago. He puts on his scrubs, boots, coveralls, 2 pairs of gloves (outer pair is heavy duty), medical mask, and goggles. He goes into the patient area and starts cleaning. He starts to clean, when in the cor- ner of the room, he sees a big spill of blood. He doesn’t touch the blood. None of his PPE touches the blood, and he was able to keep 1 metre distance. Regardless, he becomes scared because this is the first time he is cleaning blood in the Treatment Centre. He leaves the patient care area and goes to take off his PPE. He worries he is potentially infected with Ebolavirus. Answer the following questions 1. What is the first thing Richard should do? • Facilitator answer: stay calm, ensure PPE removal is done properly with the appropriate hand hygiene steps in between. Ask support from occupational health/IPC. 2. What risk exposure category would you put Richard in? (No exposure, low exposure, high exposure)? • Facilitator answer: no exposure. 3. Explain why you would put her into that above category. • Facilitator answer: proper PPE used, no issues with putting on/taking off described, no direct contact with 36 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks blood or body fluid exposures, distances maintained. 4. What is the follow-up plan for a HCW in this category? • Facilitator answer: follow no exposure/no risk arm of the exposure algorithm. Annex 3. List of participants Annexes 38 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Participant Name Role/Country Participant Name Role/Country Ngormbu Jusu Ballah Director, Healthcare Quality Management Unit, Liberia Zainab Sirleaf WHO Liberia Thelma Nelson NPHIL, Liberia Julius Monday WHO Liberia Charles T. Caine MoH, Liberia Alpha Tamba WHO Liberia Veraus Torpor MoH, Liberia Gertrude Mulbah MoH, Liberia Comfort K. Gbaie MoH, Liberia Felicia Okwumuo Toe MoH, Liberia Philip K. Bemah NPHIL, Liberia Sumo Nuwolo MoH, Liberia Benjamin T. Vonhm MoH, Liberia Welleh C. Sackor MoH, Liberia Roseline George MoH, Liberia Hawa K. Kromah MoH, Liberia Ralph Jetoh MoH, Liberia Otila W. Moore MoH, Liberia Comfort H. Smith MoH, Liberia Joshua Tengbeh MoH, Liberia Paul Y.S. Quiminee MoH, Liberia Richard B. Nimely MoH, Liberia Anderson Flomo Jr. MoH, Liberia Isatu L. Gbarjah MoH, Liberia Yolaine Waka-Metzger MoH, Liberia Bill Taytuh MoH, Liberia Alvin Corker MoH, Liberia Celestine Yeanay MoH, Liberia Thomas Dahn MoH, Liberia Alfreda S. Kerkula MoH, Liberia Yatta Wapoe MoH, Liberia Marcus Massaquoi MoH, Liberia Advertus N. Mianah MoH, Liberia George S. Dokie MoH, Liberia Meamen M.H. Biea MoH, Liberia Yassah V. Sumo MoH, Liberia John S. Yarngrorble MoH, Liberia Dedesco Gweh MoH, Liberia Darius Dolopei MoH, Liberia Richard B. Nimely MoH, Liberia Peter George MoH, Liberia Mamawah George-Annan MoH, Liberia Thomas D.Siah MoH, Liberia Alfred David MoH, Liberia Jimmy Lawubah MoH, Liberia Rita N. Mcgill MoH, Liberia Joseph N. Topor MoH, Liberia Merline Slebo Wesseh MoH, Liberia Masuah T. Kokro MoH, Liberia Patrick Mawupemor Avevor WHO Ghana Siana Jackson-Mentoe MoH, Liberia Selina Dussey WHO Ghana Ophelia M. Woods MoH, Liberia Ruth Raymond Ngowi MoH, United Republic of Tanzania Merline Slebo Wesseh MoH, Liberia Masuma Janeth Stanislaus MoH, United Republic of Tanzania Haweton Shilling MoH, Liberia Sheriff Bockarie Pharaj WHO Sierra Leone Tarso L. Kollie MoH, Liberia Ramatu Elizabeth Ngauja WHO Sierra Leone Garrison Kerwillain Liberia Patrick D. Moonasar WHO South Africa Blima Sirleaf MoH, Liberia Bahatungire R. Rony MoH, Uganda Abel W.L. Saydee MoH, Liberia Annet Alenyo Ngabirano MoH, Uganda Patience Meannue MoH, Liberia Hawa K. Kromah MoH, Liberia Annex 3: List of participants Annex 4. Pre and Post test results Annexes 40 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Annex 4: Pre and Post test results Note: Facilitator’s version provided below with correct answers in bold. Participant copy does not have correct answers bolded. Each question had four options for answers: A, B, C or D. E was selected if the individual completing the test didn’t answer that question at all or had ticked multiple answers to a single-answer question. Each question is listed below, with the correct answer in bold text. Each figure that follows the question and correct text response indicates the participants that selected each answer A-D (and E for error) both in the pre- and post- test. This correct answer is highlighted with a green arrow. 1. What is the correct order of phases when planning for an outbreak of Ebola or Marburg disease A. Preparedness, Readiness, Response B. Readiness, Preparedness, Response C. Readiness, Response, Preparedness D. Assessment, Response, Readiness Figure A4.1: Question 1 results pre-test (before workshop) and post-test (end of workshop). Figure A4.2: Question 2 results pre-test (before workshop) and post-test (end of workshop). ■ A ■ B ■ C ■ D ■ E Q1 Before Q1 After ■ A ■ B ■ C ■ D ■ E Q2 Before Q2 After 2. Which of the following are all included in standard precautions? A. Respiratory hygiene, Hand Hygiene, Cohorting and Isolation B. Waste management, Handling of laundry and linen, Safe injections and sharps injury prevention C. Safe injections and sharps safety, Disinfection of all surfaces, Food hygiene D. Sterilisation, Environmental cleaning, Hand Hygiene 41 Figure A4.3: Question 3 results pre-test (before workshop) and post-test (end of workshop) Figure A4.4: Question 4 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q3 Before Q3 After ■ A ■ B ■ C ■ D ■ E Q4 Before Q4 After 3. Which of the following is the most effective IPC measure to reduce risk of spread of infections? A. Personal Protective Equipment B. Engineering controls C. Substitution D. Administrative controls 4. What is the preferred method for cleaning hands that are visibly soiled (dirty) in the context of Ebola or Marburg disease? A. Chlorine 0.5% solution B. Chlorine 0.05% solution C. Alcohol Based Hand Rub D. Soap and water 42 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Figure A4.5: Question 5 results pre-test (before workshop) and post-test (end of workshop) Figure A4.6: Question 6 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q5 Before Q5 After ■ A ■ B ■ C ■ D ■ E Q6 Before Q6 After 5. How long can Ebolavirus/Marburgvirus survive on surfaces in the presence of dried blood? A. Less than 24 hours B. Between 24 and 48 hours C. Up to a year D. Around 2 weeks 6. When should screening for symptoms of Ebola or Marburg disease be done in the context of a declared outbreak? A. On entrance to any health facility B. On entrance to any health facility and every day for inpatients C. On admission to inpatient health facilities only D. At the entrance to all markets, churches or mosques and schools 43 Figure A4.7: Question 7 results pre-test (before workshop) and post-test (end of workshop) Figure A4.8: Question 8 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q7 Before Q7 After ■ A ■ B ■ C ■ D ■ E Q8 Before Q8 After 7. Which of the descriptions below, best describes the IPC ring approach during an outbreak of Ebola/Marburg disease? A. A system of locking down areas where cases of Ebola/Marburg v disease have been identified. B. A series of measures that enables provision of intensive IPC support to community locations and health facilities close to where a patient with a case of Ebola/Marburg disease has been identified. C. A method of providing care embedded in communities where a cluster of Ebola/Marburg disease have been identified. D. A tool during preparedness to help prioritise which health facilities should receive additional IPC support should an outbreak be declared as part of readiness. 8. Which of these is a high-risk exposure for a health worker to Ebolavirus or Marburgvirus? A. An eye splash with a body fluid from a confirmed Ebola or Marburg disease patient. B. Worked in the same health facility where a confirmed patient with Ebola or Marburg disease was cared for but had no direct or indirect contact with the patient or patient area. C. Torn PPE that has exposed bare intact skin in the red zone triage area but with no contact with blood or body fluids. D. Treating a patient using standard precautions who subsequently becomes tests positive for Ebola or Marburg virus but is asymptomatic at the time the care was provided. 44 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Figure A4.9: Question 9 results pre-test (before workshop) and post-test (end of workshop) Figure A4.10: Question 10 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q9 Before Q9 After ■ A ■ B ■ C ■ D ■ E Q10 Before Q10 After 9. Which order should environmental surface decontamination be conducted in the context of Ebolavirus or Marburgvirus? A. Initial cleaning followed by disinfection B. Initial disinfection, cleaning then a final disinfection C. Initial cleaning then sterilisation D. Initial cleaning alone is enough 10. Ebolavirus or Marburgvirus is not transmitted from human to human via: A. Sexual transmission B. Respiratory aerosols C. Breast feeding D. Contact with blood or body fluids 45 Figure A4.11: Question 11 results pre-test (before workshop) and post-test (end of workshop) Figure A4.12: Question 12 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q11 Before Q11 After ■ A ■ B ■ C ■ D ■ E Q12 Before Q12 After 11. Which of the following is preferred practise for placement of patients with suspect and confirmed Ebola or Marburg disease? A. Individual isolation of suspect patients and cohort confirmed patients. B. Cohort suspect and confirmed Ebola or Marburg disease patients in separate rooms. C. Cohort suspect patients in one area and individual isolation of confirmed patients in another area. D. Each patient with suspected or confirmed Ebola or Marburg disease should be individually isolated, with suspected persons in one area and confirmed in another. 12. When mapping partners supporting a response to an outbreak of Ebola or Marburg disease the IPC taskforce should follow which approach? A. Why, Where, Which, When B. Strengths, Weaknesses, Opportunities, Threats C. Who, What, Where and When D. Local, National, Regional, Global 46 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Figure A4.13: Question 13 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q13 Before Q13 After 13. How should Personal Protective Equipment be decontaminated during the steps for removing PPE? A. Using a low-pressure spray of 0.5% chlorine solution, before removing any PPE B. Perform glove disinfection, between each step of the PPE removal C. No decontamination of any items of PPE is required before taking off D. Rinsing the front part of apron and coverall with a solution of 0.5% chlorine before removal Figure A4.14: Question 14 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q14 Before Q14 After 14. Should visitors or family caregivers be allowed to enter health facilities in areas where there is an active outbreak of Ebola/Marburg disease? A. No, never, during an outbreak all visitors should be discouraged from visiting relatives in health facilities. B. Yes, no change is needed to usual practise, as long as everyone is screened at the entrance of the health facility. C. Yes, access should be facilitated, they should be screened at the entrance and every day they stay with inpatients, also they should be given instructions and support on health protection and IPC. D. Only one visitor per patient should be allowed into the facility, all others should be turned away. 47 Figure A4.15: Question 15 results pre-test (before workshop) and post-test (end of workshop) ■ A ■ B ■ C ■ D ■ E Q15 Before Q15 After 15. Where should people be transferred if they screen positive as a suspected case of Ebola/Marburg disease at a general health facility? A. They should go to an isolation ward and wait to see if they still screen positive later on, if they are still sympto- matic, they should be tested for Ebolavirus or Marburgvirus B. They should be advised to take public transport (e.g. mototaxi) to a testing centre as long as they are well enough with no wet symptoms C. They can be admitted to a general ward if they need urgent treatment but then be transferred for testing as soon as possible D. They should be immediately transferred to an isolation area in the facility, and then reported for transfer to a dedicated testing or treatment centre.

Annex 5. Workshop evaluation Annexes 50 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks Annex 5: Workshop evaluation Participants were requested to complete an online survey prior to receiving their certificates of attendance on Day five. Paper versions were provided for participants who had challenges completing the online version. The paper versions were then transcribed into the online survey. Responses were anonymous. The survey consisted of two parts. A series of questions with a Likert scale evaluation ranging from strongly disagree to strongly agree. The second part provided opportunities for comment on 2 mandatory questions and 1 optional. Questions in part 1 included: A. The time allocated for the sessions was appropriate B. The practical sessions and group work were successful in increasing my knowledge/understanding of the top- ic(s). C. The tabletop exercise was useful in increasing my understanding of the role of IPC in readiness and response for Ebola and Marburg disease outbreaks. D. The simulation exercise was clear and provided an in depth understanding of IPC activities for Ebola and Mar- burg disease outbreaks. E. The content level of the workshop was appropriate (i.e., appropriate depth and breadth; not too difficult and not too easy). F. I can directly apply the knowledge gained from the workshop in my work (i.e., developing or updating country readiness and response action plan). Figure A5.1: Workshop evaluation results. N=51 responses Q1. The time allocated for the sessions was appropriate (i.e. not too fast and not too slow). Q2. The practical sessions and group work were successful in increasing my... Q3. The table top exercise was useful in increasing my understanding of the role of IPC in readiness and... Q4. The simulation exercises were clear and provided an in depth understanding of IPC activities for... Q5 The content level of the workshop was appropriate (i.e. appropriate depth and breadth; not too difficult... Q6 I can directly apply the knowledge gained from the workshop in my work (i.e.developing or updating... 0 5 10 15 20 25 30 35 ■ Agree ■ Strongly agree/Agree■ Undecided■ Disagree■ Strongly disagree 51 Figure A5.2: Workshop evaluation results by percent. N=51 responses Q1. The time allocated for the sessions was appropriate (i.e. not too fast and not too slow). Q2. The practical sessions and group work were successful in increasing my... Q3. The table top exercise was useful in increasing my understanding of the role of IPC in readiness and... Q4. The simulation exercises were clear and provided an in depth understanding of IPC activities for... Q5 The content level of the workshop was appropriate (i.e. appropriate depth and breadth; not too difficult... Q6 I can directly apply the knowledge gained from the workshop in my work (i.e.developing or updating... 0% 20% 40% 60% 80% 100% 120% ■ Strongly agree/Agree■ Undecided■ Disagree/Strongly disagree Workshop evaluation – comments* Although all individual comments are available, for the ease of this report the main comments have been grouped into themes with some example quotes in each section. Question 1 Which elements of the workshop were particularly well done or that you found most useful (e.g. methods/content such as particular PowerPoint slides shown, particular content areas, performance of trainers, practical session elements, videos, etc.): A great number of respondents appreciated the simulations and practical sessions “During the workshop the practical sessions elements were well done and I really got the concepts. Reason being is that hands on activities gives you a clearer picture about what you’re learning.” Many commented on specific sessions they found worthwhile, most commonly waste management, the ring approach table top exercise and response planning. Others reported enjoying the group presentations, risk assessment and PPE/ glove and hand hygiene sessions. Others made general comments about the delivery methods and appreciating the workshop. Question 2 Which elements of the training could be improved (e.g. methods/content such as particular PowerPoint slides shown, particular content areas, performance of trainers, practical session elements, videos, etc.): Most comments related to process issues, including the PowerPoints being too long and including heavy text. 52 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks “I think the PowerPoint slides need to be worked on. Some slides we too bulky and hard to follow during the presentation.” The next most common issue identified was time management. Others reported more preparation for some of the trainers was needed. A few gave specific recommendations to include more practical exercises and videos for new PPE donning and doffing techniques. “IPC is practical, there should be practical at the training session where questions will be answer before going at the facilities for IPC practical” There were a few respondents who gave very short statements, but it was hard to understand what the problem or issue was e.g., just saying ‘practical sessions’, but not saying any more about what the issue was. Others took the opportunity to reiterate that they had no concerns and had enjoyed the workshop. Question 3 OPTIONAL: Did you have any remaining technical questions about certain parts of the presentation that were not clear? Please describe. This was an optional question but the most common answer by far was ‘No’, of those few who did elaborate the most common query was about how to access additional WHO support (ether financial or technical) to facilitate rollout in countries or districts. A very few mentioned specific sessions about types of hand washing solutions, vaccination of health and care workers and waste segregation. Annex 6. Country Roadmaps Annexes 54 Country Readiness Strengthening w orkshop on infection prevention and control (IPC) for Ebola and M arburg disease outbreaks Annex 6: Country Roadmaps On Day five of the workshop, each country presented on the following topics: 1. What new best practices have you learnt from this workshop? (workshop content, country presentations)? 2. What gaps have you identified in your country from what has been discussed in this workshop? 3. What are the priorities/opportunities in your country over the next year for strengthening IPC readiness for Ebola and Marburg disease outbreak? The actions identified by each country form the basis of the follow up plan post workshop. Follow up meetings will be arranged in the coming months to check in regarding progress towards achieving these activities and to identify any support needed from WHO Regional Office for Africa or headquarters. Highlighted below are the roadmaps presented (item#3) by each country. Table A6.1: Liberia S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges Q1 Q2 Q4 1 Advocate for dedicated IPC budget for allotment National HQMU Yes Well crafted IPC budget x x Leadership 2 Mobilize additional resource for IPC programme implementation through Partners National HQMU Yes Well crafted IPC investment case WHO, US CDC Global Fund, World Bank x 3 Support the implementation of national IPC strategic Subnational HQMU No Financial x x x Funding 55 S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges 4 Develop facility based IPC plan Subnational/ national Countries Health Team Yes Program planning technical support & financial WHO, Jhipego x Funding 5 Adopt and validate national HAI surveillance protocol and Implement National HQMU & NPHIL Yes Technical & Financial WHO, US CDC x x x Funding 6 Develop contingency plan with IPC considerations for priority diseases National NPHIL Yes Technical & Financial US CDC & WHO x Funding 7 Provide support for IPC capacity strengthening activities for levels National & Subnational MoH/Partner Yes Technical & Financial US CDC & WHO x 8 Establish/renovate major IPC-WASH infrastructures in key facility Subnational HQMU/NPHIL Yes Financial x 56 Country Readiness Strengthening w orkshop on infection prevention and control (IPC) for Ebola and M arburg disease outbreaks Table A6.2: Sierra Leone S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges Q1 Q2 Q4 1 Adapt, adopt and endorse the IPC guidelines for viral hemorrhagic fever (VHF) on case management and prevention of VHF transmission in healthcare facilities to our specific context National, MoH National IPC Program WHO Technical and Funding support WHO, US CDC x 2 Train healthcare workers (Clinical and non-clinical) on IPC guidelines for VHF National/ Subnational, MoH National IPC Program WHO Technical and Funding support WHO, US CDC x x x x 3 Print and Disseminate the IPC guidelines for VHF National/ Subnational, MoH National IPC Program WHO Technical and Funding support WHO, US CDC x 4 Print and distribute IEC materials on the case definition of Ebola/Marburg disease. National/ Subnational, MoH National IPC Program WHO Technical and Funding support WHO, US CDC x 5 Conduct supportive supervision in both private, public hospitals and peripheral health units National/ Subnational, MoH National IPC Program WHO Technical and Funding support WHO, US CDC x x x x 57 Table A6.3: United Republic of Tanzania S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges Q1 Q2 Q4 1 Review the available IPC EVD guideline and include new recommendations National Health Quality Assurance Unit, IPC subunit, Dr. Joseph Hokororo & Ruth Raymond Yes Technical and financial support WHO, US CDC, USAID etc x 2 Review IPC/MVD training material to incorporate new recommendations National Health Quality Assurance Unit, IPC subunit, Dr. Joseph Hokororo & Ruth Raymond Yes Technical and financial support WHO, US CDC, USAID etc x 3 Update IPC rapid assessment tool that is available electronically to incorporate new recommendations National Health Quality Assurance Unit, IPC subunit, Dr. Joseph Hokororo & Ruth Raymond Yes Technical and financial support WHO, US CDC, USAID etc x 4 To sensitize MoH Management so as to review the available pillars and make IPC/ WASH pillar instead of the available Case Management & IPC Pillar National Health Quality Assurance Unit, IPC subunit, Dr. Joseph Hokororo & Ruth Raymond Yes Technical WHO, US CDC, USAID etc x 58 Country Readiness Strengthening w orkshop on infection prevention and control (IPC) for Ebola and M arburg disease outbreaks Table A6.4: South Africa S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges Q1 Q2 Q4 1 Develop/update Ebola & Marburg contingency/multi- hazard plans to include key IPC activities, including costs National MoH Yes Technical and financial NICD x 2 Adopt, adapt and endorse WHO IPC Ebola guidelines and/or training of health workers on new IPC Ebola guidelines National and subnational MoH Yes Technical and financial NICD/RTC x 3 Secure full- time capacity at WCO and MoH National MoH Yes Financial x 4 Develop/update Ebola & Marburg contingency/multi- hazard plans to include key IPC activities, including costs National MoH Yes Technical and financial NICD x 59 Table A6.5: Ghana S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges Q1 Q2 Q4 1 Formalize and launch National IPC strategy National Quality Management Unit/ MoH No WHO, US CDC, USAID, UNICEF x 2 Establish national IPC TWG for high level leadership for national IPC programme National Quality Management Unit/ MoH Yes Resource mapping, Advocacy, investment case, best practices from other countries GHS, Teaching Hospitals, CHAG, GQHI, Private Health facilities, HTIs, Faith- Based facilities, HEFRA, FDA, EMS x 3 Developing implementation plan and annual workplan for the national IPC strategy National IPC TWG Yes Technical Guidance, best practices from other countries, guidance to align with global/Regional IPC frameworks GHS, Teaching Hospitals, CHAG, GQHI, Private Health facilities, HTIs, Faith- Based facilities, HEFRA, FDA, EMS, WHO, US CDC, UNICEF, etc x x 4 Establish a framework for a national IPC Programme which integrates all relevant agencies National IPC TWG Yes Technical Guidance, best practices from other countries GHS, Teaching Hospitals, CHAG, GQHI, Private Health facilities, HTIs, Faith- Based facilities, HEFRA, FDA, WHO x 5 Review and Strengthen IPC component of national AHF contingency plan National IPC TWG No GHS, NPHEOC, WHO, US CDC, etc x 60 Country Readiness Strengthening w orkshop on infection prevention and control (IPC) for Ebola and M arburg disease outbreaks S/N Priority Actions National/ Subnational Lead/responsible unit Technical expertise needed (Yes/No) If Yes, describe the kind of support needed Implementing partners Timeline Anticipated challenges 6 Incorporate new WHO guidelines in IPC capacity building efforts National and sub- national Quality Management Unit/ MoH Yes Funding, capacity building/training GHS, Teaching Hospitals, CHAG, GQHI, Private Health facilities, HTIs, Faith- Based facilities, HEFRA, FDA, EMS, WHO, CDC, UNICEF, etc X X 7 Actively engage and participate in JEE National IPC TWG No GHS, IHR NFP, IHRSC X X 8 Ensure IPC is prominent in NAPHS and National Multi- hazard preparedness plans National IPC TWG No GHS, IHR NFP, IHRSC, WHO X X 61 Table A6.6: Uganda Uganda provided a detailed copy of their 5 year, costed, National IPC Strategic Framework. The full report is not attached in this report. From the situation analysis and the deliberations at the stakeholders' workshops, six areas emerged as priority areas to focus strategies to deliver the IPC agenda at all levels of the Uganda health sector. These are also aligned with the WHO IPC Core components of the IPC program and include: I. Leadership and governance II. Education and Training III. Hospital-built environment, equipment and supplies IV. Healthcare-associated infection Surveillance V. Research and Innovation VI. Monitoring and Evaluation Workshop content Peer to peer country presentations 1. Appreciating perspective from global strategy through region, country to impact in facility/bedside. 1. The importance of general IPC preparedness that can support response to any threat ( case of Tz that used EVD for Marburg) 2. New guidelines and their rationale. 3. Learning from one another through strong regional IPC networks and conversations. 3. Various training techniques; didactics, table top exercises, simulations, 3. Funding funding funding!! Gaps Identified • Outdated or lack of crucial IPC strategic documents like IPC guidelines, IPC strategic framework and HAI, Guidelines for a safe environment in healthcare facilities, HAI Surveillance plan. • No dedicated IPC budget • No designated IPC staff at all levels • No established IPC M&E plan • No national IPC training curriculum 62 Country Readiness Strengthening workshop on infection prevention and control (IPC) for Ebola and Marburg disease outbreaks From the situation analysis and the deliberations at the stakeholders' workshops, six areas emerged as priority areas to focus strategies to deliver the IPC agenda at all levels of the Uganda health sector. These are also aligned with the WHO IPC Core components of the IPC program and include: I. Leadership and governance II. Education and Training III. Hospital-built environment, equipment and supplies IV. Healthcare-associated infection Surveillance V. Research and Innovation VI. Monitoring and Evaluation