E b o l a Back to basics: Hand washing Commonwealth Health Partnerships 2015 63 Could the Commonwealth Secretariat have done more? Yes, of course. All international bodies could have done more. The message from front-line health workers in Sierra Leone was that they were dying because of a lack of personal protective equipment, and a lack of knowledge about correct infection prevention and control procedures. In our view, the Commonwealth could have played a leading role in mobilising the donation and delivery of such equipment from member countries, and in identifying and supporting the delivery of training in infection prevention and control. The major strategies for managing an EVD outbreak are outlined in the WHO Ebola Response Roadmap, released 28 August 2014, and include: • Early identification of infection • Isolation until confirmation of infection • Confirmation by laboratory testing • Appropriate care and treatment, including rehydration, strict infection control and use of personal protective equipment • Contact tracing • Safe disposal of waste and safe burials • Ongoing surveillance • Community education and engagement Ebola in Sierra Leone Following the brutal civil war (1991–2002), a decade of relatively stable government did not give Sierra Leone sufficient time to develop resilient health or other systems, or to repair country-wide infrastructure (water, sanitation, education) that impacts on population health. For example, in 2014 only 42 per cent of the population of Sierra Leone living in rural areas had access to improved drinking water and only seven per cent had access to improved sanitation. It is almost impossible for people to observe strict hand washing procedures when there is no safe water supply or there is only one tap in the main street servicing several thousand people. Electricity supplies are rationed on a daily basis, particularly in rural areas, which impacts on boiling water to provide safe water and maintain hygiene, and also on maintaining communication. The population of Sierra Leone is around six million with a median age in 2014 of 19 years of age. Two-thirds of the population in 2014 were under the age of 25 years, however, the literacy rate was only 43 per cent (CIA, 2015). Sierra Leone was not equipped to respond to such a virulent epidemic. The challenges included a limited capacity to provide and maintain a safe practice and care environment in health facilities; inadequate human resources, both in quantity and quality; maldistribution of the existing health workforce; weak disease surveillance and response systems that were not yet integrated across the country; a poorly developed emergency preparedness plan; inadequate health technologies, including medicines, supplies and laboratory services; weak supply chain management; an ineffective referral system; and weak co-ordination across the country because of inadequate roads, transport and communication. Sierra Leone reported its first laboratory confirmed case of EVD on 25 May 2014 from the Kailahun District, located in the eastern region of Sierra Leone near the shared border with Liberia. The Ministry of Health and Sanitation responded quickly, declaring an epidemic, implementing a national response and seeking external support. Over the next nine months, confirmed cases totalled 10,740 with 3,276 deaths, according to the WHO Ebola Situation Report on 4 February 2015. In addition to the external support, guidance, construction of isolation centres, and provision of equipment and laboratory services, the Nursing Directorate, with technical support from the WHO, developed guidelines on the use of personal protective equipment and around 1,000 front-line nurses were trained and deployed into Ebola facilities to support the response. A monitoring and supervisory team was formed using personnel from the Nurses and Midwives Board of Sierra Leone to visit all Ebola facilities. Then, 100 senior nurse supervisors were deployed to all health facilities across the country to monitor, mentor and supervise junior staff. Large numbers (296) of health care workers in Sierra Leone became infected with EVD and 221 died; a much higher proportion than in the general community. Most (152) of them were nurses (two registered nurses; three midwives; two nurse anaesthetists; one student nurse; 76 enrolled nurses; 33 maternal child health aides; 26 nursing aides; and nine traditional birth attendants). There is a thin line between care and fear. Nurses were not only concerned for their own health and safety in caring for people infected with EVD, but they also experienced hostility from members of the community and often from their own family members, who were concerned the nurses were spreading the infection. Many nurses were afraid to go to work. Many nurses who came to work were not permitted to return to their own homes and communities. Ebola survivors – those people who tested positive and survived the illness and then tested negative for the virus – also faced discrimination and were frequently refused re-entry into their homes and communities. Certificates were given verifying that they were Ebola free, however, often that was not enough. Watching people suffer and die, watching their colleagues suffer and die, struggling with heavy workloads and inadequate equipment and resources, and fearing for their own safety was a heavy burden for the nurses to bear. Care was provided in an environment of mutual mistrust between patient and health care worker: is this person going to save me? Is this person going to infect me? In Sierra Leone, the most important and basic prevention strategy – hand washing – has been infrequently or incorrectly practiced. Health workers had poor knowledge about infectious diseases and EVD in particular. Their knowledge, skills and practices in infection prevention and control were inadequate, and there were no national standards or guidelines. Health workers lacked basic personal protective equipment (impermeable gloves, waterproof boots, goggles, fluid resistant mask or respirator mask, impermeable coveralls and aprons, head cover). Health facilities were poorly and inadequately maintained – including water and waste management – and wards were overcrowded with limited physical space.
Commonwealth Health Partnerships 2015
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