The Protection Gap: Infection prevention and control Adherence and Determinants among SARS-CoV-2 Infected Healthcare Workers in Ethiopia and Implications for Future High-Consequence Pathogen Outbreaks

Abstract Background HCW (Health care workers) infections during outbreaks of high-consequence pathogens, from SARS-CoV-2 to Ethiopia's 2025–2026 Marburg outbreak, highlight persistent Infection Prevention and Control (IPC) gaps. Understanding the settings and determinants of adherence failure is essential to prepare for future outbreaks. Methods This cross-sectional study of 1,152 SARS-CoV-2-infected HCWs in Addis Ababa (March 2020–March 2021) assessed IPC adherence among HCWs with face-to-face or body fluid/surface exposure from suspected/confirmed patients within 14 days pre-diagnosis. Clinical environments categorized via adapted OSHA pyramid: High-Pathogen Designated Areas (HPDA: isolation/treatment), General High-Risk Areas (GHR: ICUs/EDs/ORs), Medium-Risk Clinical Areas (MRCA: inpatient/outpatient), Low-Risk Support Areas (LRS: administrative/non-clinical). Adherence (PPE use/hand hygiene/donning & doffing) defined as practice in >50% of interactions. Chi-square/Fisher’s exact tests and Cramér’s V assessed bivariate associations. Multivariable logistic regression identified determinants for donning/doffing (HCWs with face-to-face contact, N=742) and N95 seal checks (N=350, N95 users). Results Only 19.2% of infected HCWs worked in HPDA. Mask (85.7–97.7%) and glove (68.2–98.0%) adherence was high. Conversely, gowns, face shields/goggles, coveralls, head caps, N95, and shoe covers fell below 50%, except for face shields/goggles (52.8%) and N95 use during Aerosol Generating Procedures (AGPs) (66.5%). N95 seal‑check compliance was 34.9%; fit‑tested N95 use was 1.1%. Hand hygiene increased from 49.3% (before face‑to‑face) to 82.5% (after body fluid exposure). Per chi-square analysis, HPDA and health professionals had significantly better adherence than non-HPDA areas and support staff. For donning/doffing , odds were lower in non-HPDA areas (GHR aOR=0.12 [0.07–0.19]; MRCA aOR=0.08 [0.04–0.14]; LRS aOR=0.07 [0.03–0.17]). Adherence was higher with AGP involvement (aOR=3.61 [2.33–5.58]) and training (aOR=1.59 [1.05–2.41]), but lower among support staff (aOR=0.35 [0.14–0.88]). N95 seal-check odds were lower in non-HPDA areas (GHR aOR=0.53 [0.30–0.93]; MRCA aOR=0.33 [0.16–0.66]; LRS aOR=0.25 [0.08–0.77]). Positive predictors included communal living (aOR=2.37 [1.29–4.35]), IPC training (aOR=1.71 [1.03–2.83]), and AGP involvement (aOR=1.71 [1.05–2.80]), while age >30 (aOR=0.57 [0.34–0.98]) and stress (aOR=0.46 [0.28–0.77]) were negative determinants. Conclusions This study underscores IPC gaps among HCWs especially in non-designated areas, where most infections occurred, highlighting the need for standardized IPC across all healthcare environments.