Some doctors and healthworkers have contracted the Ebola Virus Disease (EVD) while treating patients. OYEYEMI GBENGA-MUSTAPHA and WALE ADEPOJU write on the World Health Organisation (WHO) requirements for them to stay EVD-free.
The risk of Ebola transmission is low. One can only be infected through direct physical contact with the body fluids – vomit, faeces, urine, blood, semen, etc – of patients and those who died of Ebola Virus Disease (EVD). Avoiding contact is a guaranteed way of staying EVD-free.
Those at higher risk of infection are health workers, their family members and others in close contact with anyone infected with EVD or who has died of it. Those who have Ebola require expert care at designated facilities. Ebola can destroy families and communities, but the infection can be controlled through the use of recommended protective measures.
For health personnel, the World Health Organisation (WHO) requires that they put on a Personal Protective Equipment (PPE). PPE consists of double gloves; fluid-resistant, impermeable laboratory gown, over the lab coat; either a combination of approved particulate respirators (e.g., N95, or higher filtering face piece respirator, e.g, N100) and eye protection (e.g. goggles/face shields/shroud), or powered air purifying respirators (PAPRs).
Sources said infection control staff, healthcare epidemiologists, administrators, nurses and persons responsible for developing, implementing, and evaluating infection control programmes for healthcare settings across the continuum of care should be kitted from contracting any infection, “because the Occupational Safety and Health Administration (OSHA) defined PPE as specialised clothing or equipment worn by an employee for protection against infectious materials.”
In Nigeria, health workers may not have the ability to prepare for potential exposures. For example, in some places, care may be provided in clinics with limited resources (e.g. no running water, no climate control, no floors, inadequate medical supplies), and workers could be in those areas for several hours with a number of (suspected, unconfirmed) Ebola infected patients. In addition, certain job responsibilities and tasks, such as attending to dead bodies, may also require a different PPE than what is used when providing care for infected patients in a hospital. But, many private hospitals, clinics and funeral homes have been carrying on their business as usual.
The late Dr. Iyke Enemuo, who died of EVD in Port Harcourt, Rivers State, contracted the disease when he treated an Ebola patient secretly. Enemuo died of Ebola at the Good Heart Hospital in Port Harcourt on Friday, August 22. Before his death, he practised at the Sam Steel Clinic on the East West Road in Rumuokoro. He was infected with the disease by an ECOWAS diplomat whom he treated in a hotel. The ECOWAS diplomat was infected after he came in contact with the Liberian-American, Patrick Sawyer, the index case. The unidentified diplomat escaped quarantine in Lagos and travelled to Port Harcourt. The diplomat recovered from the disease and returned to Lagos but the doctor died. Enemuo’s wife, also a doctor, had shown symptoms of the disease and has been quarantined. The couple’s three month old baby has also been quarantined.
The late Dr Stella Adadevoh was said to have contracted the EVD from the index case, the late Sawyer, when he went wild and splashed his bodily fluids, including his blood on her and other nurses on duty. These health workers were not adequately protected, with the right apparatus despite that the hospital had a high suspicion of EVD in the Liberian-American; and had sent his specimen for laboratory investigation.
With the deaths, and more EVD suspected cases, the Lagos State and the Federal Governments set up the Case Management Centre at the Infectious Disease Control Hospital (IDH), Yaba.
According to the WHO, there are basically two categories of people involved in the treatment of any infectious disease: front-line health workers and secondary-line health workers. Both must, however, observe the protocol for handling suspected cases.
The WHO is explicit on steps to putting on PPE and removing them; safely collect blood samples from persons suspected to be infected with highly infectious blood-borne pathogens and safely ship human blood samples from suspected Ebola cases.
For clinical management of patients with viral haemorrhagic fever (VHF), a pocket guide for frontline health workers is available. But how many of such personnel have availed themselves of the information?
Laboratory workers involved in EVD screening are yet to record any casualty, perhaps they have observed to the letter WHO recommendations that: personnel entering the laboratory must remove street clothings, including undergarments, and jewelery, and change into dedicated laboratory clothing and shoes, or don full coverage protective clothing (i.e., completely covering all street clothing). Additional protection may be worn over laboratory clothing when infectious materials are directly handled, such as solid-front gowns with tight fitting wrists, gloves, and respiratory protection. Eye protective covering must be used where there is a known or potential risk of exposure to splashes.
Ebola outbreaks can be contained using available interventions like early detection and isolation, contact tracing and monitoring, and adherence to rigorous procedures of infection control. While some individuals, organisations and governments at different levels are getting the prevention of EVD in Nigeria, right, some are yet to.
Some state governments have gone ahead to screen citizens’ temperatures on the roads; banks are also screening for exceptionally high temperature in customers, before they can come in for business; citizens have gone from eating garcinia kola; drinking salt water to using sanitiser, where water and soap are not easily accessible. The government is paying attention to airports, but land and sea borders are yet to be properly monitored.
A fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhoea, abdominal pain, or unexplained hemorrhage are basic signs and symptoms of EVD.
Given that ignorance is rife in the country’s health sector on EVD, health personnel that have no need for PPE, where they are available, are donning same.
For instance, at the Lagos University Teaching Hospital (LUTH), Idi Araba, the fear of contracting Ebola has made most personnel, including security officers, to turn the hospital into a ‘masquerade-like’ premises, by putting on PPEs, full body suits, face masks and elbow size gloves, among others.
The Chief Medical Director (CMD), Prof Akin Osibogun, said: “It is not every case of fever or vomiting that is Ebola. People should not panic anytime they see such cases. Though we have a high index for suspicions. We had a patient brought in from the International Airport. Every confirmed case will be managed only at the State-designated Case Management Centre in Yaba. We still exercise precautions on all cases, so nobody should panic. The two patients are being investigated and until we have our results we cannot say they are positive.
“Our challenge is that we have PPE and other requirements but they are being used by the wrong personnel. It is only doctors and other healthcare givers who are attending and may have close contact with a patient that should ordinarily use those. We are trying to now carry out enlightenment programme for our workforce. Simple hand washing with soap and water, maintaining a reasonable distance of few metres away from people or patients, as the case maybe is all that are basically needed not to contract the Ebola. We have taken specimen of the patients and we are awaiting the results.
“There is a protocol for handling suspected cases. LUTH staff has over used the PPE. What are required at the A and E are gloves; aprons that are water resistant. It is limiting physical contact where those cases are isolated that must be emphasised. Why would the hospital expose its workforce, like 20 people, to isolated suspected patients?
“In a bid to prevent the disease, even security personnel are putting on PPE. This is gross misuse of those materials. Such create more panic. The hospital has strategic stock of PPE for doctors, nurses and others. But if everybody in the hospital is using it, won’t we run out of stock? I repeat it is only those in close contact with suspected cases that can use those materials. Anyone that has been putting on the PPE in the hospital is creating fear, they are looking like masquerades. What is happening with these two cases is just ultra high suspicion.”
The Nation gathered that the two patients were brought in and quarantined, at the Hold bay, for further observations because they presented with high fever, vomiting and diarrhoea. The patients’ specimens were being taken for screening but they were negative.
Pandemonium broke when one of the patients died, “and blood was coming out from the orifices. And because the personnel at the Accident and Emergency (A and E) unit did not have basic precautionary universal tools to protect themselves, they left the patient unattended to. And there the news spread like wildfire that the patient died of Ebola,” stated a source who claimed to be at the scene of the incident.
To ensure their members are protected against all forms of hazard, especially EVD, the executives of the hospital’s Joint Health Sector Unions (JOHESU) took up the matter.
According to the Vice Chairman, National Association of Nigerian Nurses and Midwives (NANNM), LUTH branch, Comrade (Mrs) Oluyemisi Adelaja, ‘when doctors called off their strike, work peaked yesterday at the hospital and patients were being admitted and taken care of by the health workers. Some of the staff came up complaining that most of the things, such as protective gadgets they should work with were not available, especially the universal basic precautions kits. We then as responsible representatives went to the concerned departments (Store) that should supply those things. The routine is that each unit makes a request for what are needed. Some units have and some don’t. This is because of the doctors’ strike; we have not been having many patients.
“Then two patients came overnight with suspicious signs of Ebola. They both had history of vomiting, high fever and diarrhoea of over three weeks. One was said to be bleeding from the orifices. They were admitted in the Spill over. Then one of them died. Because of the apprehension in the country over Ebola, nobody thought it safe to move near the corpse. But the hospital has not established it as Ebola case. Investigation results are yet to be out. Workers are only agitated because, due to the doctors’ strike we have not been coming in contact with many patients. Now in the face of Ebola, nobody thinks it safe to get that close, majority think it safe to put on personnel protective equipment (PPE). But that is not possible. It is only personnel that will have close contact with many patients that can put on PPE. There is provision for A and E.
“We then moved to the Store to verify what the Management told us on Friday, which was to collect certain items, and our members’ allegation that they don’t have those items. The Joint Health Sector Union (JOHESU) discovered that out of 11 items, that are supposed only three were available at the Store. The personnel at the Procurement Department told us that some companies are expected to make some supplies, and they are expecting those deliveries. That approval had been given before now, but that it was done late yesterday.”
The Secretary of the LUTH branch of the Senior Staff Association of Universities, Teaching Hospitals, Research Institutes and Associated Institutions (SSAUTHRIAI) of Nigeria, Comrade Johnson Shaba said: “While doctors were on strike, we as health sector stakeholders were monitoring the news on Ebola as it is ravaging neighbouring countries. So we as partners in progress were consulting with the management on how lives, be it those of patients or the hospital’s staff, won’t be lost to EVD.
“We mapped out how to manage it should there be cases here in LUTH. Not that we will become panicky and be running helter skelter. The management appreciated our being proactive and promised, along with the Ministry of Health, to get those things ready; that before doctors called off the strike they would have made available those things. The hospital equally created a place called, the Observatory section, where suspected cases of Ebola would be monitored and screened, and if positive would be transferred to the Mainland Hospital, set up by the Lagos State Government.”
Comrade Shaba gave further insight on the Ebola scare in the hospital: “Then, this morning, our members said Ebola has entered LUTH and that they were no longer safe because there is nothing to protect them. We told them that the patient had not been confirmed as Ebola case. And that we should not heat up the hospital unnecessarily. Based on our members concern, we moved into action. It was found out that some units, such as the Staff Clinic; Medicine had been equipped. Only few units are remaining.
“Based on circular, we moved to find out why and the Procurement Personnel explained the delay in logistics. And that once deliveries are made, such will be distributed according to the requests. We are happy to discover that reputable pharmaceutical companies would supply those things and not that contract was awarded to some people, who may end up bringing in inferior things, which will jeopardise our health.”
Comrade Shaba appealed to the Management that: “Water is important and highly crucial now and everything must be done to ensure its constant flow as against what is happening now. Likewise, constant supply of soap, sanitisers and PPE, at no time should there be break in supply as that could lead to loss of life. The agitation of members that had contact with those two spills over patients is understandable. We have enlightened them and should they be negative or positive, the results would not be hidden from them. Should they (the patients) be positive, they will be handled by the procedure as laid down by the Federal Government and being implemented but the Lagos State Government. What normally kills is not the disease or the causative agent but the fear. We appeal to all stakeholders not to panic.”
According to a Pharmacist, Remi Adeseun, there are standard requirements for containing or managing EVD cases. Such include: “Elbow length gloves; Level four overalls with hood, knee booths, goggles, medical masks, anti-viral sanitisers, rubber aprons, respirators and bags of hair-nets for female health workers. For the frontline health workers, the items include elbow length gloves, medical masks, and anti-viral sanitisers, level three overalls with hood; rubber aprons and thermal scanners.”
According to the Centres for Disease Control and Prevention (CDC), in hospital settings, Ebola virus can be killed by any brand of bleach or disinfectants.
It stated: “Ebola virus is susceptible to three per cent acetic acid, one percent glutaraldehyde, alcohol-based products, and dilutions (1:10-1:100 for 10 minutes) of 5.25 per cent household bleach (sodium hypochlorite), and calcium hypochlorite (bleach powder). The WHO recommendations for cleaning up spills of blood or body fluids suggest flooding the area with 1:10 dilutions of 5.25 per cent household bleach for 10 minutes for surfaces that can tolerate stronger bleach solutions (e.g., cement, metal). For surfaces that may corrode or discolour, they recommend careful cleaning to remove visible stains followed by contact with a 1:100 dilution of 5.25 percent household bleach for more than 10 minutes.”
According to Infection Control Officer, LUTH, Dr (Mrs) Oyin Oduyebo: “To get this WHO recommendation right at the household level, get a bottle of household bleach (sodium hypochlorite) (any brand is ok). The starting concentration is 3.5 per cent of hypochlorite or sodium hypochlorite (i.e one bottle of the product). Pour the whole content into a cup. One cup of bleach to six cups of water will give 0.5 per cent. From this take another one cup and add to nine cups of water, so you end up with 0.05 per cent for hand washing. If it is two per cent concentrated it will burn the hands.”
Prof Osibogun said Nigerians should be wary of the kind of sanitisers they buy: “Any good one should contain 70 per cent of alcohol. Use 70 per cent alcohol-based sanitiser where there is no water and soap and keep a safe distance of one metre from when interacting with people. The screenings being done by banks and others is a phase, borne out of panic. It will pass. One must do constant hand washing with soap and water.”
