The current Ebola (filovirus) outbreak in West Africa has focused attention once again on the detection of and response to the disease. By late March some 60 people had died in Guinea the first recognised outbreak of the virus in the country with suspected cases reported in neighbouring Sierra Leone and Liberia.
In Sub-Saharan Africa, when a medical professional suspects Ebola disease, the patient’s blood sample is typically sent elsewhere in the country or abroad to a biosafety level-4 (BSL-4) laboratory for diagnostic confirmation. If positive, an outbreak is declared and an international response initiated, consisting of case identification and contact tracing, with isolation and treatment of suspected and confirmed patients in a filovirus ward.
While waiting the days or weeks it takes for diagnostic confirmation and a prospective international response, first-line medical professionals, often supported by medical and humanitarian aid organisations, establish a makeshift filovirus ward, a crucial component of early and effective outbreak response. Yet in resource-limited settings where filovirus outbreaks occur, treatment and infection control equipment and protocols have typically not yet been established. Moreover, despite lessons learned from past experiences, first-line medical professionals often lack written and readily available guidance for best practice in case management in filovirus wards. Thus, patients hospitalised on makeshift wards often endure adverse conditions.
In recent years I have contributed to multiple international responses to filovirus outbreaks and have observed many of the adverse conditions that some makeshift filovirus ward patients have experienced. If first-line medical professionals and medical and humanitarian aid organisations are well-informed about these adverse conditions, they will be able to anticipate some of the challenges and implement measures to improve patient health and safety. What follows is an amalgamation of actual scenarios and challenges experienced by patients in makeshift filovirus wards from recent outbreaks in Sub-Saharan Africa (not including the current outbreak in Guinea), all of which could feasibly happen in future outbreaks.
Scenarios and challenges
Once medical professionals suspected a filovirus infection, the patient and caregiver (when available) were hospitalised on an unoccupied ward of the health facility (i.e. the makeshift ward) while the patient’s blood sample was sent to a BSL-4 laboratory. Health facility staff feared direct patient contact, and some fled the premises. As patient numbers were initially low, several medical professionals wearing latex gloves continued to enter the makeshift ward to draw blood for diagnostic testing, administer intravenous (IV) fluid drips and dispense paracetamol, antimalarials, antibiotics and oral rehydration solution (ORS).
Soon thereafter, patient numbers increased, including health care workers from the hosting medical facility. Medical professionals continued to draw blood samples and send them for biological confirmation and accompany patients to the entrance of the makeshift ward. However, as they feared the disease, its apparent transmission within the hospital and the increased patient numbers, medical professionals greatly reduced their presence on the ward. In one instance, medical professionals stood at the entrance to the ward and provided a caregiver with a box of IV fluid drips and verbal instructions on how to administer them. Despite wearing latex gloves and frequently washing his hands with bleach, the caregiver was too afraid of contracting filovirus to establish direct contact with patients other than his loved one. Instead, he demonstrated his newly learned IV administration procedures to conscious and capable patients, some of whom managed to self-administer. In the meantime, medical professionals placed bottles of bleach and boxes of latex gloves, paracetamol, antimalarials, antibiotics and ORS at the ward entrance, and instructed conscious patients on medication administration procedures, frequency and dosage. Shouting through an open window, local authority staff outside the ward told patients that anyone attempting to leave the ward would be shot.
Health and safety conditions on the makeshift ward then deteriorated further. Not understanding that the bleach was intended for the disinfection of materials, a patient-caregiver poured a bottle over her unconscious daughter’s body and face in hopes of killing the filovirus. Other patients contemplated drinking bleach, citing rumours of its effectiveness in killing filovirus circulating in the body. Meanwhile, medication, bleach and latex gloves quickly ran out and were not replaced, and food and drinking water were provided only intermittently. Mattresses were provided for some but not all patients; those without slept on a concrete floor. Mops, brooms, bed sheets, pillows, mosquito nets, a change of clothing, shower facilities and bathing water were typically not provided (albeit they were not typically provided on other wards either). Latrines were clogged with human faeces (with blood), which were likely to be contaminated with highly infectious filoviruses.
Eventually a number of the patients on the makeshift ward died. Fearing contagion from the unshrouded corpses and from the ward itself, the remaining patients moved to an area immediately outside the ward and, in at least one instance, near the clogged latrine. Medical professionals, flanked by armed police, then entered the ward and removed the corpses for immediate burial. Patients re-entered the ward days later after an infection control team arrived to spray the ward and douse the latrine with a 0.5% chlorine solution.
Soon afterwards international clinicians entered the ward and were immediately confronted by patients incensed by the health and safety conditions they faced. During the verbal aggression that ensued, a disoriented patient walked back and forth on the ward’s central walkway from her sleeping area to the latrine with diarrhoea and vomit dripping from her body onto the floor. Other patients tried to protect themselves from her by placing a wooden stick in the handles of the back double-door to prevent her from re-entering the ward after using the latrine. The patients, some of whom had a laboratory confirmation for filovirus, were distressed at not being provided with a bucket of water, a mop and additional bleach so that they could disinfect the floor, particularly as some of them were sleeping on it.
Patient fear and unsanitary conditions were exacerbated when patients from a local prison were admitted to the makeshift ward with suspected filovirus. Their hands were cuffed and the police took their shoes away to discourage them from fleeing. The patients eventually tested negative for filovirus but had now been placed at risk of contracting it on the ward by being obliged to walk barefoot on the contaminated floor. An unidentified elderly male without an admission record had died and remained unshrouded on the floor of the ward for over 48 hours before his corpse was removed for burial.
Improving patient health and safety
Considering filovirus’ potential for transmission within a health facility, it is commendable that first-line medical professionals were extremely vigilant during clinical assessments and understood the importance of acquiring and sending blood samples for biological confirmation. Their prompt establishment of a makeshift filovirus ward was a crucial component of early and effective outbreak response, and the establishment of such a ward will remain essential in future outbreaks. Past experience from other filovirus outbreaks suggests several action points to help medical professionals and medical and humanitarian aid organisations improve patient health and safety on makeshift filovirus wards:
- Employ barrier-nursing techniques while maintaining continual presence and patient care on the ward.
- Directly provide patient care and medicine; never transfer this responsibility to the patients themselves.
- Ensure that medicine is available and is replenished as needed.
- Ensure that floors and other surfaces are disinfected with water and bleach. It may be desirable to provide water, buckets, mops and bleach to the patients themselves so that they can respond to spills of body fluids when medical personnel are unwilling to enter a makeshift ward.
- Together with local authorities, employ an information, education and communication campaign to encourage potentially infected patients to accept isolation and treatment on a filovirus ward. Patients, whether infected with filovirus or not, should never be threatened with deadly force.
- Provide each patient and caregiver with continuous access to drinking water and at least two meals a day.
- Provide each patient and caregiver, when possible, with a mattress, pillow, sheet, mosquito net, shower area, bathing water, soap and a change of clothing.
- Prohibit the use of a latrine that is likely to be a source of filovirus contamination, such as one that is clogged with accumulating human faeces. Latrine holes for safe deposit and cover of faeces and urine should be provided.
- Remove corpses from the ward in a timely manner and conduct, together with family members, safe and culturally sensitive burial rites and procedures.
- As highlighted in previous outbreaks, collect high-quality clinical and epidemiological patient data.
Paul Roddy is an independent epidemiology consultant.
This is an article in HPN’s Online Exchange. To read other Exchange articles, please visit http://www.odihpn.org/humanitarian-exchange-magazine.
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