August 23rd, 2014, Monrovia, Liberia
Liberia is experiencing the worst Ebola epidemic the world has ever seen. One of the most important aspects of epidemic containment is infection control and prevention measures. Over the past month, Dr. Rose Macauley, Chief of Party of the United States Agency for International Development’s Rebuilding Basic Health Services (RBHS) has coordinated the Liberian Ministry of Health and Social Welfare’s (MOHSW) Ebola infection control and prevention trainings for health workers. These trainings have focused on health facility-based case management as well as raising public awareness of Ebola.
Recently, the training was conducted by senior MOHSW and RBHS staff at the SOS Children’s Villages Clinic in Monrovia. Dr. Kumblytee Johnson, a medical officer at Redemption Hospital in Monrovia’s densely populated New Kru Town community, sees many suspected Ebola cases. A designated trainer, Dr. Johnson has attended four trainings as a trainee and ten as a trainer.
During the second wave of the ongoing Ebola epidemic, which started in March 2014, four well-respected health workers from Redemption Hospital, including a Liberian nurse and a physician from Uganda, contracted Ebola and died. When a New Kru Town resident died, hospital staff were verbally attacked and the hospital itself was stoned by community members. Dr. Johnson described the sense of overwhelming fear experienced by health workers—fear of infection as well as fear of community resistance to their work. To a large degree, these fears stemmed from a lack of understanding of the disease, lack of personal protective equipment, and the psychosocial impact of the sudden loss of colleagues. The hospital staff became so gripped with fear that they were unable to focus on their tasks and eventually were too scared to even show up for work, so the hospital, like many others across the country, shut down.
Dr. Johnson said that after several weeks of being closed, health workers agreed to return to work if a set of conditions was met. In addition to having the entire facility decontaminated, staff demanded in-depth training in Ebola case management and the provision of personal protective equipment (PPE). After consulting with staff, the hospital’s medical director and the chief medical officer of the Republic of Liberia developed a plan to re-open the hospital. The strategy involves triaging patients through the emergency room, which has a dedicated holding room for suspected Ebola cases. Patients testing negative for Ebola are directed to the appropriate ward for treatment and services. For patients who test positive, the Ministry of Health is notified and a team dispatched to move the patient to one of the treatment centers in Monrovia. Dr. Johnson emphasized that health worker input informed this new strategy, which she believes will help protect both health workers and patients.
When Redemption Hospital re-opened, procedures changed to prioritize the safety and security of staff through infection control and prevention measures. Emergency room staff now have personal protective equipment, including coveralls, heavy duty aprons, gum boots, shoe covers, face shields, goggles, and gloves. Dr. Johnson is pleased that appropriate PPE is being used as needed and that barrier nursing is being practiced. She added that the ob/gyn department is taking similar precautions, and staff are advocating standardized use of PPE for all deliveries.
Dr. Johnson described a recent case in which a woman experienced postpartum hemorrhage (PPH), the leading cause of maternal mortality worldwide. Initially it seemed to be standard PPH, but the patient became a suspected Ebola case when she started presenting symptoms. The patient died, but because of testing delays her Ebola status has yet to be confirmed. Her family is unsure about how to provide care to the newborn (who may have been exposed to the virus), and anxiously awaits the test result so they can assess their own risk of exposure and gain a sense of closure from the sudden loss of their loved one.
Ebola causes confusion and anxiety in families and communities—in part because of the isolation, stigma, and sudden death associated with the disease. Dr. Johnson emphasized the critical role of health workers in these situations, stressing that they must use their knowledge and interpersonal communication skills to educate and put families at ease as they await test results. Dr. Johnson and her colleagues show affected families how to watch for symptoms, explain the importance of remaining under surveillance for 21 days (the incubation period for Ebola), and maintain communication with families to monitor symptoms and provide emotional support.
Dr. Johnson appreciates the importance of the case management, universal precautions for infection control and prevention, and psychosocial first aid trainings. The knowledge she has gained allows her to serve patients confidently while protecting herself and her colleagues.