Non-Ebola Health Facilities
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Together with Médecins Sans Frontières and the World Health Organisation, we hosting a two day conference on the global response to Ebola. By pulling together and sharing the collective knowledge, we're working hard to ensure that, as a team, we have a head start on any future epidemics This presentation was by Erin Polich
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Non-Ebola Health Facilities
- 3. What Happened? • 39% decrease in < 5s treated for malaria 1 • 2013: during same period, this increased by 20%. • 50% decrease in total malaria cases 2 • 60% decrease in treatment of diarrhea 2 • 20% decrease in vaccinations for < 12mo 2 • 18% decrease in ANC visits 3 • 22% decrease in PNC visits 3 • 11% decline in the number of women delivering at facilities 3 • Corresponding rise in the maternal case fatality rate1 May to September 2014. UNICEF Health Facility assessment, October 2014. 2 December 2013 to December 2014. ACAPS Ebola Outbreak in West Africa Impact on Health Service Utilisation in Sierra Leone, March 2015 3 HMIS Jan-Dec 2013 to Jan - Dec 2014. VSO. Exploring the Impact of the Ebola Outbreak on Routine Maternal Health Services in Sierra Leone, 2015
- 4. What Happened? • Healthcare Worker infections • Without proper training, HCWs became infected largely at non-Ebola facilities • Retrospective Study May to Dec 2014 1 • 47.4 % of the infected HCWs believed that their exposure occurred in a hospital setting. • 19 % believed that they were exposed at home • 17.8 % at health centres • 5.1 % at other types of health facilities • Only 10.7 % of all HCW infections were associated with Ebola virus disease (EVD) isolation units. 1 Olu et al. Epidemiology of Ebola virus disease transmission among health care workers in Sierra Leone, May to December 2014: a retrospective descriptive study. BMC Infectious Diseases (2015)
- 5. Why? • The health system did not collapse • Despite worries, the vast majority of primary health facilities remained open • Oct 2014: 4.1% of PHUs closed; 4% had previously been closed but reopened. • HCW deaths affected the availability of qualified personnel (particularly the specialists in hospitals), however did not close facilities • HCWs did not stop working (although some moved to ETCs) • Reported clinics with fewer patients • Continued to treat despite risks, but did so without sufficient training or supplies
- 6. Why? • Health seeking behaviour changed • Fear and Misinformation • Fear of infection • Fear they would be taken away to an ETC • Traditional Healers vilified • Politics & Governance • Government not trusted by communities • Non-Ebola facilities largely ignored by initial interventions • For months, facilities lacked basic supplies and training
- 7. Interventions • National IPC trainings • PHUs • 1,118 PHUs trained in IPC from October – December 2014 • Full supplies of PPE delivered to all facilities • Mentorship approach, rather than trainings • Supportive supervision and facility monitoring • Hospitals • WHO/CDC/MOHS conducted periodic assessments throughout Ebola, but no consistent support • 22 hospitals trained in IPC beginning April 2015 • Mentorship approach, embedded in hospitals • Supportive supervision, ward monitoring • MOHS IPC Directorate established • Every district now has an IPC focal point • Every hospital has an IPC focal point and mentor
- 8. 14% 70% 61% 66% 70% 78% 76% 79% 75% 79% 77% 82% 83% 84% 0% 20% 40% 60% 80% 100% PHUs meeting Minimum IPC Structure Scores 31% 82% 67% 62% 70% 77% 78% 77% 68% 69% 71% 72% 76% 79% 0% 20% 40% 60% 80% 100% PHUs meeting Minimum IPC Practice Scores
- 9. 85% 80% 58% 76% 79% 79% 61% 90% 87% 63% 78% 80% 89% 52% 92% 87% 71% 83% 88% 91% 61% 94% 88% 72% 86% 90% 94% 62% 93% 91% 80% 82% 89% 93% 70% 96% 93% 90% 95% 86% 94% 79% 0% 20% 40% 60% 80% 100% IPC Supplies WM and EH Cleanliness Hand Hygiene PPE Use Sharps Management Screening Inpatient Monitoring for Ebola Average Hospital Ward Assessment Section Scores October November December January February March
- 10. Key Lessons Learned • The health system did not collapse. The initial support to it did. • Ignoring non-Ebola health facilities and staff perpetuated the outbreak and led to further infections. • Political intervention is crucial.
Editor's Notes
- On average, the number of OPD consultations per 1,000 persons decreased by 29% Why did Tonkolili increase? (Have seen this answered somewhere but can’t find… need to investigate) Guinea also saw a 31% decrease from 2014 in their outpatient visits across the board.
- Main point: Utilization rates fell across the board. Thought – probably could replace this slide better with a chart or graph and then just say outloud the above stats. Vaccination rates fell from 70% to 50% in Need to explain the seasonality of HC seeking behaviour – there are always decreases in visits and morbidity in rainy season (June – Sept) however the comparisons to the year before show this was far more acute in 2014 to 2013. Additionally, things like malaria which should have risen after the initial 2 month dip period did not, which is very alarming. UNICEF Facility assessment: Routine services provided through health facilities were affected across all districts as the EVD outbreak progressed. Nonetheless, health systems in Kailahun and Kenema (the two original epicentres of the outbreak) appear to be performing better and have exhibited their capacity to bounce back. On the other hand, in other districts such as Kambia where health systems were very weak prior to the Ebola outbreak, the utilization of essential maternal and child health services started declining even before the EVD outbreak hit the district directly. This might be because of the already low trust people had in the health system in those districts, compounded by the news of outbreak from neighbouring districts (or even across the border in the case of Kambia), resulting in people shunning health facilities altogether. Outcome and health coverage data according to the Demographic and Health Survey 2013 clearly suggests that these two districts (Ken/Kail) have stronger health systems than in the rest of the country, which likely aided in their quick recovery. Malaria: This decline took place at the height of the malaria season which normally witnesses a spike in malaria cases HIV & TB nonadherence Increased rates of teenage pregnancy Anticipated associated MNCH complications Vaccination coverage decrease Current measles outbreak Long term distrust of health system Measles vaccination rates in 2013: 59.6% Guinea 79.4% Sierra Leone 71.2% Liberia Mass vaccination campaigns were postponed in 2014 to avoid public gatherings in the midst of the EVD outbreak Other consequences: Huge increase in teenage pregnancy (schools closed) which will have an impact on maternal and child health. HIV infections were not able to be treated as people feared facilities. XX% (50%?) of inpatients in Connaught from month X to Y were for opportunistic infections associated with HIV. Predicted: Reducedvaccination and the risk ofmeaslesandotherchildhood infections post-Ebola Saki Takahashi,1 C. Jessica E. Metcalf,1,2 Matthew J. Ferrari,3 William J. Moss,4 Shaun A. Truelove,4 Andrew J. Tatem,5,6,7 Bryan T. Grenfell,1,6 Justin Lessler4 .We project that after 6 to 18 months of disruptions, a large connected cluster of children unvaccinated for measles will accumulate across Guinea, Liberia, and Sierra Leone.This pool of susceptibility increases the expected size of a regional measles outbreak from 127,000 to 227,000 cases after 18 months, resulting in 2000 to 16,000 additional deaths (comparable to the numbers of Ebola deaths reported thus far).There is a clear path to avoiding outbreaks of childhood vaccine-preventable diseases once the threat of Ebola begins to recede: an aggressive regional vaccination campaign aimed at age groups left unprotected because of health care disruptions.
- All focus went to ETCs. None to those providing the majority of the work Huge implication on non-Ebola HCW infections. According to data on patients collected as of 21 October 2014, hospitals accounted for 10% of EVD infections nationally, up to 17% in Bo, 18% in Kenema and 13% in Western Area Urban. This situation has undermined the confidence in the health system reportedly prompting people to stay away from health centers.
- While patients avoided facilities, many times they would go to seek treatment when they were very ill, increasing the risk to the HCWs. Mention why HCFs were closed – most were due to lack of patients, some due to quarantine, or lack of staff (if staff didn’t show up, were quarantined themselves, etc). Worth noting that many hospitals – both public and private – did have to close at least temporarily. Don’t think there are stats on this though. Additionally, they were the facilities most frequently plagued by quarantine and full closure or at least skeleton staff when their facilities became closed due to EVD cases on the wards (Lungi, Kambia, PL, Makeni)
- Health seeking behaviour Nationally, 37% of PHUs felt they have not been provided adequate training on Ebola. In 15% of the PHUs, staff identified lack of information about Ebola as a challenge. An overwhelming 90% of PHUs felt fear/conception is the main challenge confronted by the health system in fighting Ebola. 87% of the PHUs reported the lack of protective gear as a large gap. In 26% of the PHUs, the lack of medicines was cited as a challenge. Politics & Governance SL government would not address Ebola nationally. Fostered even further distrust as disease was seen as a political plot to rid political parties of enemies (which is why it was targeted in one geographical area) Traditional healers and private facilities were either initially ignored or vilified, which undermined their contribution as leaders and influence holders in their community. These are often the first point of reference for communities when sick, and yet little attention was provided. Ignoring the importance of traditional healers led to the origin of the outbreak in Sierra Leone – first identified case came from a TH who treated cross border. Punitive measures to this source – bylaws, fines, blaming THs, etc – caused a backlash. Instead of embracing these outlets as important roles in their community, and properly engaging and training them, it caused push back. Already, the communities do not trust the government or outsiders in much of these areas (particularly sierra leone) and by not appropriately engaging with these members (which the soc mob group will go into more tomorrow) they themselves then began fuelling mistrust, and warning communities not to go to facilities because the governements would give them Ebola. Facilities Ignored: During the initial stages of the outbreak, very little attention was paid to non-Ebola health facilitie. This ignorance led communities to hold to a severe lack of distrust and fear of facilities. Lack of PPE quote: “The care that we offer did reduced with the advent of the EVD because we were in fear and we did not have enough PPEs to work with. So we were afraid to conduct most of the services because we were challenged.” Midwife People stayed open, and showed up to work – EVERY DAY – even though they knew they didn’t have the supplies to keep them safe, and even though they watched, every day, as their coworkers got sick and often died around them.
- It was found one off trainings and assessments were not enough, particularly for hospitals. People were trained and provided corrective action, but reverted back even when they saw the detrimental effects (eg, patients and coworkers infected, constant facility quarantine) ERCs IPC project was training, supportive supervisions, supplies provision, establishing screening stations etc. We were the only ones at the height of the outbreak to focus on non EVD facilities. Anecdotes: the HCW in Bombali in October 2015 who identified the case after 169 days without a case. Called 117, didn’t get through. Put the girl on a motorbike to an ETC with 2 survivors, both dressed in PPE
- Also monitored supplies – great across the board except Elbow gloves and disposable towels, which made everyone’s scores drop.
- Ward Monitoring Tool only rolled out to all hosp in Oct, but IPC monitoring had been going on since April/July in various forms
- The obvious: Interventions must include non-Ebola facilities at all levels (PHU, hospital, community) Supplies must be addressed Less obvious: Politics: Communications to combat mistrust from govt IRC Ebola Reader “Unmentioned are relevant political realities: weaknesses in governance, unpaid health workers and a decade of health system strengthening as an apolitical exercise. Mixing politics into public health makes for uncomfortable conversation, but we can’t prevent another catastrophe without having that conversation.” Dr Bicknell - Public health is the art and science of deciding who dies when, and with what degree of misery. You can say it the other way around, that it is about deciding how long people live, and the quality of life they live, but the danger of that is you often forget what happens when you get it wrong. Not acting, or focusing resources in a limited number of areas, can have just as many consequences as acting and making a mistake. Politics is about making choices. The thing that threw everyone with this emergency was that the primary driver was a health problem. This meant we needed a primary health response, as well an additional health response to deal with the secondary health problems, this is what didn’t happen. In any other emergency this is the bread and butter health piece that happens. For future disease driven emergencies, there needs to be 2 health responses, 1 focused on the primary disease, and 2 focused on keeping routine health services functional. Something that is also quite interesting on Ebola comparative to other emergencies is that supply and demand for health services were affected. In many other emergency settings, supply is disproportionately affected compared to demand.