Defeating Ebola in Democratic Republic of the Congo Requires Strengthening its Health Systems and Infection Prevention and Control Programme in Particular: Lesson Learnt from the Current 2018-2020 DRC Ebola Virus Disease Outbreak

Boniface Hakizimana^1,2*
*Correspondence: Boniface Hakizimana, Academic Unit for Infection Prevention and Control, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 19063, Tygerberg 7505, Cape Town, South Africa, Tel: 250788594903, Email:

Keywords

Infection prevention and control • Health systems strengthening • WHO hand hygiene improvement strategy • Hand hygiene audit • Hand hygiene compliance • Hand hygiene self-assessment framework • Hospital IPC level • Hand hygiene level • Infection Prevention and Control Assessment Framework• Core components of IPC programmes • Alcohol-based handrub • Handwashing basin • Healthcare-associated infections • Community engagement

Introduction

The current 2018-2020 outbreak in eastern DRC started with four cases who had tested positive for EVD in the eastern region of Kivu in the DRC [1-3]. This is the tenth epidemic of EVD in the Democratic Republic of the Congo and it was declared by the Ministry of Health on 1 August 2018. The outbreak is centred in the northeast of the country, in North Kivu and Ituri provinces. The number of cases having surpassed 3,400, it is the country's largest Ebola outbreak. It is also the second-biggest Ebola epidemic ever recorded, behind the West Africa outbreak of 2014-2016. On 14 July 2019, the first case of Ebola was confirmed in Goma, the capital of North Kivu, and a city of one million people. On 30 July 2019, a second person in Goma was diagnosed with Ebola, he died the next day and two more cases were announced from the same family. In reaction to the first case found in Goma, on 17 July 2019, the World Health Organization (WHO) announced that the current Ebola outbreak in DR Congo represents a public health emergency of international concern (PHEIC). In mid-August 2019, the epidemic spread to neighbouring South Kivu province, and it became the third province in DRC to record cases in the ongoing outbreak and the cases have been found in Mwenga, 100 kilometres from Bukavu, the capital of the province. The national laboratory (INRB) confirmed on 7 August 2018 that the current outbreak is of the Zaire Ebola virus, the deadliest strain and the same one that affected West Africa during the 2014-2016 outbreak.

The International Health Regulation (2005) gives significant weight to Infection Prevention and Control as a central strategy for dealing with public health threats of international concern [4]. Improving IPC and hand hygiene through multimodal strategies implementation reduce healthcare-associated infections (HAI) rates including EVD [5,6]. Failure to perform appropriate hand hygiene is considered to be the leading cause of HAI and the spread of multiresistant organisms, and has been recognized as a significant contributor to outbreaks [5].

Transmission of healthcare-associated pathogens through contaminated HCWs’ hands is the most common pattern in most settings and require five sequential steps: (i) organisms are present on the patient’s skin, or have been shed onto inanimate objects immediately surrounding the patient; (ii) organisms must be transferred to the hands of HCWs; (iii) organisms must be capable of surviving for at least several minutes on HCWs’ hands; (iv) handwashing or hand antisepsis by the HCWs must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (v) the contaminated hand or hands of the caregiver must come into direct contact with another patient or with an inanimate object that will come into direct contact with the patient [5-7]. Adherence of healthcare workers (HCW) to recommended hand hygiene procedures has been reported as variable, with mean baseline rates ranging from 5% to 89% and an overall average of 38.7% [12]. Defective hand cleansing (e.g. use of an insufficient amount of product and/or an insufficient duration of hand hygiene action) leads to poor hand decontamination. Obviously, when HCWs fail to clean their hands during the sequence of care of a single patient and/or between patients’ contact, microbial transfer is likely to occur. Contaminated HCWs’ hands have been associated with endemic HAIs and also with several HAI outbreaks [8-10]. The aim of this study was to evaluate whether the implementation of infection prevention and control programme in healthcare facilities improves the level of EVD preparedness and response.

The infection Prevention and Control programme consists of eight core components that require to be implemented in each acute healthcare facility, especially in each hospital [11-15]. Those core components are:

(1) Setting up IPC programme with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing healthcare-associated infections (HAI) and combating antimicrobial resistance (AMR) through IPC good practices, Stand-alone, active national IPC programmes with clearly defined objectives, functions and activities for the purpose of preventing HAI and combating AMR through IPC good practices should be established. National IPC programmes should be linked to other relevant national programmes and professional organizations.

(2) Evidence-based guidelines: Evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and AMR. Education and training of the relevant health care workers on guideline recommendations and monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation.

(3) Education and Training: At the facility level, IPC education should be in place for all health care workers by utilizing team and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR. The national IPC programme should support education and training of the health workforce as one of its core functions.

(4) Surveillance: Facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance with timely feedback of results to health care workers and stakeholders and through national networks. National HAI surveillance programmes and networks that include mechanisms for timely data feedback and with the potential to be used for benchmarking purposes should be established to reduce HAI and AMR.

(5) Multimodal strategies: At the facility level, IPC activities should be implemented using multimodal strategies to improve practices and reduce HAI and AMR. National IPC programmes should coordinate and facilitate the implementation of IPC activities through multimodal strategies at the national or sub-national level.

(6) Monitoring, audit and feedback: Regular monitoring/audit and timely feedback of health care practices should be undertaken according to IPC standards to prevent and control HAIs and AMR at the health care facility level. Feedback should be provided to all audited persons and relevant staff.

A national IPC monitoring and evaluation programme should be established to assess the extent to which standards are being met and activities are being performed according to the programme’s goals and objectives. Hand hygiene monitoring with feedback should be considered as a key performance indicator at the national level.

(7) Workload, staffing and bed occupancy: In order to reduce the risk of HAI and the spread of AMR, the following should be addressed: (a) bed occupancy should not exceed the standard capacity of the facility; (b) health care worker staffing levels should be adequately assigned according to patient workload.

(8) Built environment, materials and equipment: At the facility level, patient care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR, including all elements around the water, sanitation and hygiene (WASH) infrastructure and services and the availability of appropriate IPC materials and equipment. At the facility level, materials and equipment to perform appropriate hand hygiene should be readily available at the point of care [11-14].

The Multimodal Hand Hygiene Improvement Strategy consists of five key elements that are (1) system change to ensure access of healthcare workers to hand hygiene facilities with emphasis on availability of alcohol-based hand rub (ABHR) formulations at the point of care, (2) ongoing training and education, (3) evaluation of practices and feedback, (4) reminders at the workplace, and (5) providing a climate of safety through institution [12].

Methods

This quasi-experimental intervention study was conducted in ten hospitals of Goma EVD sub coordination, North-Kivu Province between April and October 2019. We implemented Infection Prevention and Control Programme as defined by World Health Organization in its recently published Guidelines on core components of IPC programmes at the acute health care facility level4 in the 10 following hospitals: North Kivu Provincial Hospital, Heal Africa Hospital, Charité Maternelle General Reference Hospital, Kyeshero Hospital, Virunga General Refence Hospital, Goma Regional Military Hospital, Kirotshe General Reference Hospital, Rutshuru General Reference Hospital and Pinga General Reference Hospital. Our focus was the implementation of WHO's Multimodal Hand Hygiene Improvement Strategy in each hospital. The entire project included five steps: (1) facility preparedness, (2) baseline evaluation, (3) implementation, (4) follow-up evaluation, and (5) ongoing planning and review cycle [12].

The main activities were the following: baseline assessment of infection prevention and control programme, baseline assessment of hand hygiene programme, baseline assessment of hand hygiene practices (direct observation) for frontline healthcare workers, setting up hospital Infection prevention and control committee and nomination of hospital infection prevention and control focal point, briefing of the IPC committee members and IPC focal point on their roles and responsibilities, a 5 day IPC training workshop for hospital senior managers, IPC committee members and IPC focal point. The training emphasized on basic IPC, leadership and management of IPC programme. At the end of the training, the Medical director of each hospital signed a pledge to own and sustain IPC programme. We also organized a five (5) day IPC training workshop for frontline healthcare workers focusing on basic infection prevention and control considering both Ebola and usual contexts. We, then organized a three (3) day infection prevention and control training workshop for healthcare facility hygienists. The training took into account three contexts (usual, Ebola and Cholera). The first day is devoted to theory, the second day focuses on practical sessions. The third day is devoted to internships in healthcare facilities. Each hospital received IPC kit composed by IPC equipment, materials and supplies including consumables. A supportive supervision with well-trained IPC supervisors was established whereby coaching and mentorship methods were used to help trained healthcare workers translate their knowledge into practice.

The assessment of IPC programme was conducted using WHO Infection Prevention and Control assessment framework at the facility level [14], WHO hand hygiene self-assessment framework 2010 [16] was used to assess hand hygiene programme, and WHO direct observation form [17] used to evaluate hand hygiene practices among healthcare workers in different in-patient wards. Well-trained IPC supervisors who demonstrated competencies in performing hand hygiene direct observation of practices conducted the observation of hand hygiene practices in different in-patient wards. A two days training workshop was organized to each hospital IPC committee members, IPC focal point and other senior hospital clinical managers and it was made of 2 sessions. The first session consisted with theoretical knowledge transfer, whereby WHO's training Power Point slides for observers were taught during a period of one day and it covered WHO Multimodal Hand Hygiene Improvement Strategy and direct observation of hand hygiene practices. The second session was the practical exercises to enable trainees to develop skills on how to conduct both hand hygiene self-assessment of the hospital and how to conduct hand hygiene audit by using direct observation method.

The WHO's direct observation form is based on “My Five Moments for hand hygiene” that consists of the following: before patient contact, before aseptic procedure, after body fluid exposure risk, after patient contact, and after contact with patient surroundings as hand hygiene indications [6]. A positive or negative HH action, whether hand washing or hand rubbing, was recorded provided that it related to an indication. Opportunity is defined as the time hand hygiene should happen and it must relate to at least one hand hygiene indication. The compliance is calculated by dividing positive actions by opportunities. Hand hygiene practice of healthcare workers was monitored in 60-minute sessions. All categories of HCWs present in a ward at the time of the audit were observed for hand hygiene practice. These included nurses, doctors, Allied Health Professionals and Auxiliaries including Hygienists and cleaners. Performance feedback was given to the In-charges and Managers in each in-patient ward at the completion of the audit and a final report was consolidated and a power point presentation prepared and presented to the hospital management, heads of departments, heads of services and in-charges. Table-round discussions were held in each hospital and an improvement plan developed.

The improvement program was implemented. Infection prevention and control (IPC) kit was provided to each hospital. The composition of IPC kit is as follows: Personnel Protective Equipment (nitrile clinical examination gloves, nitrile domestic gloves, surgical three layers surgical masks, plastic apron, flexible or rigid goggles, plastic boots, plastic eye-shields, fluid-resistant coveralls, hoods, N-95 respirators and surgical water-proof gowns); hand hygiene consumables (alcohol-based handrub sanitizers 1 litre and 100 ml bottles, liquid soap 500 ml bottles, 20 litres handwashing basins devices, disposable paper towels); triage materials (plastic table, plastic chairs, thermoflash, umbrellas); waste management supplies (plastic bins, plastic bin liners, biosafety boxes, burners/ Montfort incinerators), supplies for environmental cleaning (powder soap, chlorine HTH 70%, dosing spoon for chlorine, 135 litre plastic container for mixing chlorine, sprayers) , reminders at the workplace (different posters such hand washing, hand rubbing, EVD case definitions, triage and isolation, EVD transmission, waste segregation, waste disposal, injection safety). Visual hand hygiene colour posters in different sizes were provided that showed the five moments for hand hygiene and right techniques. Posters were placed in the most visible places in wards (in front of nursing stations) and next to each handwashing basin (poster for hand washing).

The impact assessment was conducted 6 months later (after the intervention period). A hospital-wide roundtable presentation of the results, discussion on how to address the gaps and improvement plan has been organized in each of the ten hospitals. Data was analyzed using Ms Excel.

Results

The baseline assessment of IPC and hand hygiene programmes was conducted in each of the above-mentioned ten hospitals in North-Kivu in DRC between April and May 2019. The results from IPC programme baseline assessment demonstrated that 8 out 10 (80%) hospitals were at inadequate level, 2 out of 10 (20%) hospitals were at basic level (Table 1). None of the 10 (0%) hospitals were at intermediate nor advanced level. when looking at each core component, lower performance was observed on the following core components: Core component no 2 (IPC guidelines), core component no 4 (surveillance of healthcare-associated infections), core component no 5 (multimodal strategies for implementing of IPC interventions, and the core component no 6 (Monitoring/audits of IPC practices and feedback) (Table 1). For hand hygiene programme, 80% (8/10) hospitals were at inadequate level while 20% (2/10) hospitals were at basic level (Table 2). When looking at each hand hygiene strategy, lower performance was observed on the following strategies: strategy no 2 (Training and education), strategy no 3 (Evaluation and feedback), strategy no 5 (Institutional safety climate for hand hygiene) (Table 2). Overall hand hygiene compliance among healthcare professionals was 33.1% (898/2713) (Tables 3 and 4). In terms of five moments for hand hygiene, the compliance was: Before touching patient: 35.5% (289/814), before clean/aseptic procedure: 37.7% (116/308), after body fluid exposure: 44.4% (91/205), after touching patient: 38.7% (273/705), after touching patient surrounding: 18.9% (129/681) (Table 5). Hand hygiene practice by categories of healthcare professionals was: medical doctors: 45.0% (514/1141), nurses and midwives: 28.3% (296/1047), medical students: 19.8% (25/126), nursing students: 16.0% (59/369), physiotherapists: 40.0% (2/5), radiology technicians: 0.0% (0/1), intern nutritionists: 10.0% (1/10), nutritionists: 12.5% (1/8), hygienists: 0.0% (0/6) (Table 4). Hand hygiene practice per in-patient ward was the following: Surgical: 34.8% (117/336), Emergencies: 17.1% (49/287), Paediatrics: 33.2% (182/549), ICU: 25.2% (51/202), Neonatology: 39.6% (40/101), Internal medicine: 46.9% (201/429), Gynaeco-obstetrics: 30.8% (143/464), Clinic: 31.8% (35/110), Outpatient consultation: 33.1% (59/178), Resuscitation: 36.8% (21/57) (Table 6). Hand hygiene compliance by hospital was: HOPITAL PROVINCIAL DU NORD KIVU: 28.9% (152/526), HGR CHARITE MATERNELLE: 31.3% (121/387), HGR NYIRAGONGO: 50.0% (53/106), HOPITAL MILITAIRE REGIONAL DE GOMA: 12.2% (18/148), HOPITAL HEAL AFRICA: 43.1% (93/216), HGR VIRUNGA: 34.5% (89/258), HGR RUTSHURU: 42.7% (253/593), HOPITAL KYESHERO: 34.9% (80/229), HGR KIROTSHE: 15.5% (39/252), HGR PINGA: 0.0% (there was no water nor alcohol-based handrub available during the baseline assessment) (Table 6).

Table 1: Baseline assessment of IPC programme in 10 hospitals in North-Kivu Province, DRC: April - May 2019.

Table 2: Baseline assessment of hand hygiene programme in 10 hospitals in North-Kivu Province, DRC: April - May 2019.

Table 3: Baseline and impact assessments of hand hygiene practices in 10 hospitals of North-Kivu Province, DRC by five moments of hand hygiene in clinical settings: April - May 2019 and October 2019.

Table 4: Summary of hand hygiene practice from the direct observation conducted in 10 hospitals in North-Kivu Province in DRC from April to May 2019 and October 2019, by categories of healthcare professionals.

Table 5: Summary of hand hygiene practice from the direct observation conducted in 10 hospitals in North-Kivu Province in DRC from April to May 2019 and October 2019, by five moments of hand hygiene.

Table 6: Summary of hand hygiene practice from the direct observation conducted in 10 hospitals in North-Kivu Province in DRC from April to May 2019 and October 2019, by in-patient ward.

The impact/post intervention assessment for both IPC and hand hygiene programmes was conducted in October 2019. Both programmes improved significantly in each hospital. 10 hospitals improved IPC programme from inadequate level (8 hospitals) and basic level (2 hospitals) to intermediate level. None of these hospitals achieved advanced level (Tables 7 and 8). The following core components require more attention in the future: Healthcare-associated infections (HAI) surveillance, workload, staffing and bed occupancy as well as Built environment, materials and equipment for IPC at the facility level. For hand hygiene programme, all the 10 hospitals made a significant improvement as well. 4 hospitals achieved advanced level (HGR CHARITE MATERNELLE, HOPITAL HEAL AFRICA, HGR VIRUNGA, HOPITAL KYESHERO), 5 hospitals achieved intermediate level (HOPITAL PROVINCIAL DU NORD KIVU, HGR NYIRAGONGO, HOPITAL MILITAIRE REGIONAL DE GOMA, HGR RUTSHURU, HGR KIROTSHE), while HGR Pinga achieved basic level (Tables 8 and 9). All the strategies require more attention, most importantly the strategy no 5 (Institutional safety climate for hand hygiene). There is a need to engage patients and community in hand hygiene programme. Hand hygiene should become a habit and be considered as the most effective method in the prevention of infections.

Table 7: Impact assessment of IPC programme implemented in 10 hospitals in North-Kivu Province in DRC: October 2019.

Table 8: Comparison of the findings from the baseline and impact assessment of IPC and hand hygiene programmes in 10 hospitals in North-Kivu, DRC.

Table 9: Impact assessment of hand hygiene programme implemented in 10 hospitals in North-Kivu Province in DRC: October 2019.

The findings from direct observation of hand hygiene practice among healthcare professionals conducted in October 2019 as a measurement of impact of the intervention demonstrated a significant improvement in terms of hand hygiene practice. 4368 hand hygiene actions over 6197 hand hygiene opportunities were observed in the 10 hospitals and the overall compliance of hand hygiene practice was 70.5% (Table 10). When looking at the five moments for hand hygiene in clinical settings, the compliance was: Before touching patient: 81.1% (1505/1855), before clean/aseptic procedure: 92.8% (874/942), after body fluid exposure: 94.0% (455/484), after touching patient: 69.2% (1039/1501), after touching patient surrounding: 35.0% (495/1415) (Table 5). Hand hygiene practice among categories of healthcare professionals was: medical doctors: 80.2% (2010/2507), nurses and midwives: 79.5% (1751/2202), medical students: 40.5% (175/432), nursing students: 38.8% (317/816), physiotherapists: 70.8% (34/48), intern nutritionists: 41.2% (14/34), nutritionists: 84.3% (43/51), hygienists: 22.4% (24/107) (Table 4). Hand hygiene practice per in-patient ward was: Surgical: 69.1% (706/1021 opportunities), Emergencies: 55.5% (311/560), Paediatrics: 72.8% (917/1260), ICU: 89.0% (317/356), Neonatology: 84.2% (255/303), Internal medicine: 69.5% (674/970), Gynaeco-obstetrics: 68.6% (738/1076), Clinic: 69.3% (201/290), Outpatient consultation: 64.7% (185/286), Resuscitation: 85.3% (64/75) (Table 6). When looking at the hospital level, hand hygiene compliance was: HOPITAL PROVINCIAL DU NORD KIVU: 72.3% (875/1211), HGR CHARITE MATERNELLE: 82.4% (535/649), HGR NYIRAGONGO: 72.2% (268/371), HOPITAL MILITAIRE REGIONAL DE GOMA: 60.4% (382/632), HOPITAL HEAL AFRICA: 75.8% (454/599), HGR VIRUNGA: 71.4% (299/419), HGR RUTSHURU: 77.4% (741/957), HOPITAL KYESHERO: 62.1% (381/614), HGR KIROTSHE: 51.2% (234/457), HGR PINGA: 69.1% (199/288) (Table 10). When looking at procedures of hand hygiene procedure (washing hands with soap and water or chlorine solution 0.05% and alcohol-based handrub): before intervention handwashing with soap and water or chlorine 0.05% solution represented 38.1% of all hand hygiene performed actions and alcohol-based handrub (ABHR) was 61.9% (Table 10). After intervention, handwashing practice represented 16.1% while ABHR represented 83.9% of all hand hygiene performed actions (Table 10). Making available readilyaccessible alcohol-based handrub solution (ABHR) at the point of care, posting hand washing veronica buckets in all in-patient wards and clinical areas, and regularly filling them with clean water and regularly supply of liquid soap, hand towels and posters for reminding for hand hygiene action coupled to the training of all categories of healthcare professionals helped in improving hand hygiene practice from 33.1% to 70.5%.

Table 10: Situational analysis of hand hygiene procedures during baseline and impact assessment of hand hygiene practice from the direct observation conducted in 10 hospitals in North-Kivu Province in DRC during April and May 2019 and October 2019.

Discussion

The results of this study demonstrated the importance of infection prevention and control programme in improving quality of healthcare delivery and strengthening health system in general. In the context of DRC, implementation of both infection prevention and control and hand hygiene programmes helped in defeating EVD, particularly in the area of Goma where those programmes have been implemented in early 2019. The first and the second cases of EVD in Goma were well controlled and there were neither secondary cases nor EVD nosocomial infections. When looking at the improvement made for both programmes, all the 10 hospitals achieved intermediate level of Infection prevention and control programme from inadequate (8 hospitals) and basic (2 hospitals) levels. All the hospitals improved their hand hygiene programme as well. Four hospitals achieved advanced level, five hospitals achieved intermediate level and one hospital achieved basic level. There was a significant improvement in terms of hand hygiene practice. Overall, hand hygiene compliance improved from 33.1% (898 actions over 2713 opportunities) to 70.5% (4368 actions over 6197 opportunities) with improvement of 37.4%. When looking at the hospital level, each of the 10 hospitals improved its hand hygiene compliance. HOSPITAL PROVINCIAL DU NORD KIVU made an improvement of 43.3% that means from 29.0% to 72.3%, HGR CHARITE MATERNELLE improved from 31.3% to 82.4% with an improvement of 51.1%, HGR NYIRAGONGO improved from 50.0% to 72.2% with an improvement of 22.2%, HOSPITAL MILITAIRE REGIONAL DE GOMA improved from 12.2% to 60.4% with an improvement of 48.2%, HOSPITAL HEAL AFRICA improved from 43.1% to 75.8% with an improvement of 32.7%, HGR VIRUNGA improved from 34.5% to 71.4% with an improvement of 36.9%, HGR RUTSHURU improved from 42.7% to 77.4% with an improvement of 34.7%, HOSPITAL KYESHERO improved from 34.9% to 62.1% with an improvement of 27.9%, HGR KIROTSHE improved from 15.5% to 51.2% with an improvement of 35.7%, HGR PINGA improved from 0.0% to 69.1% with an improvement of 69.1% (Table 6). Some IPC core components such as setting up IPC programme, IPC guidelines, IPC training and education, multimodal strategies for implementation of IPC interventions, monitoring of IPC practices and feedback, were likely to be easy for implementation with local resources whereby others such as healthcare-associated infections (HAI) surveillance, workload, staffing and bed occupancy, built environment, materials and equipment for IPC at the facility level required more expertise and more resources.

In terms of hand hygiene programme, the components such as system change, training and education, evaluation and feedback, reminders in the workplace were easy for implementation at the facility level. The strategy no 5 (institutional safety climate for hand hygiene) was the likely to be more difficult for implementation.

Conclusion

The best way to combat outbreaks including Ebola virus disease (EVD) in any country is to strengthen its health systems with more focus on Infection Prevention and Control (IPC) programme and hand hygiene in particular. The implementation of both IPC and hand hygiene programmes in healthcare facilities in North-Kivu Province in DRC proved the importance of putting more effort on working on the programme including setting up of the IPC programme in the light of the local context. Multimodal strategies remain the best way to be based on when implementing any programme. IPC level in 10 hospitals improved from inadequate level (80%) to intermediate level (100%). Hand hygiene level in 10 hospitals improved from inadequate level (80%) to advanced level (40%), intermediate level (50%) and basic level (10%). Hand hygiene practices among healthcare professionals improved significantly from 33.1% to 70.5%. Medical doctors and nurses/midwives improved their hand hygiene performance from 45.0% to 80.2% for medical doctors and from 28.3% to 79.5% for nurses/ midwives. Low hand hygiene performance continued to be noted among students (medical and nursing) population, where it improved from 19.8% to 40.5% for medical students and from 16.0%) to 38.8% for nursing students. Universities and higher education institutions should integrate IPC and Hand hygiene programmes in the pre-service healthcare teaching curricula.

More efforts, resources and expertise are required for better implementation of IPC programme, especially for the core components such as Healthcare-associated infections (HAI) surveillance, workload, staffing and bed occupancy as well as Built environment, materials and equipment for IPC at the facility level.

There is a need to engage patients and communities in hand hygiene programme. Hand hygiene should be considered as very important and become a habit. For healthcare professionals it should become a second nature as well as for the community members. Hand hygiene remains the cheap and most effective method in the prevention of infectious diseases and outbreaks.

Acknowledgements

The author is grateful for the support from the leaders, managers, medical doctors and nurses of the 10 hospitals in North-Kivu Province, DRC.

The author would like to convey his special gratitude to the Infection Prevention and Control Commission, EVD response sub coordination of Goma and Infection Prevention and Control Supervisors for their active participation in this project.

My acknowledgement goes to Prof. Benedetta ALLEGRANZI, Coordinator, Infection Prevention and Control Global Unit World Health Organization Geneva, Switzerland for her technical support, knowledge and skills transfer during this project.

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