IPC, Logistics and Case Detection Assessment at Peripheral Health Unit (PHU) in Kambia District, Sierra Leone

March-April 2015

Masdalina Pane, Baning Rahayujati, Gina SamaanINDONESIA

Objectives

• Baseline data for Logistics, IPC and Case Detection at Peripheral Health Unit (PHU)

• Baseline evaluation process to control ebola epidemic (IPC and Training)

• Strengthening and Involving of PHU as an Existing Health System Against Ebola Epidemic

Background

Bramaia Gbinle Dixon Magbema Mambolo Masungbala Samu Tonkolimba0

2

4

6

8

10

12

14

16

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Number of PHU and Population

# PHU Population

CHC; 13; 19%

CHP; 16; 24%

MCHP; 38; 57%

Type of PHU in Kambia, 2015

Distribution of PHU per Chiefdom

Bramaia Gbinle Dixon Magbema Mambolo Masungbala Samu Tonkolimba0

2

4

6

8

10

12

14

16

2

4

21

34

4 4

10

4

2

6

8

21 1

2

43

CHC CHP MCHP

Position of MCHP, CHC and CHP

Position of MCHP, CHC and CHP base on Population and Case

PART ILogistics Supplies for Ebola Preparedness and

Baseline Functioning

Methods

• 67 out of 68 PHU visited on 26 March – 7 April 2015.

• Respondent : Health Care Workers • Methods : Check the logistics in the practice

room, in ward, laboratory, cold chain and warehouse.

• Check number of patients through General Record book, Maternal book (ANC and Delivery), Under Fives Record book

IPC Screening and Isolation for Ebola# IPC Screening and Isolation Yes % No %1 Light PPE on screener 34 80.9% 8 19.1%

2 Hand washing facilities/hand rub solution at all point

19 86.4% 3 13.6%

3 Hand washing facilities/hand rub solution in all Rooms with inpatients beds

33 49.2% 34 50.8%

4 Hand washing facilities/hand rub solution Consultation room

45 68.2% 21 31.8%

5 Hand washing facilities/hand rub solution in Delivery room

52 77.6% 15 22.4%

6 Hand washing facilities/hand rub solution in the latrines

20 30.3% 46 69.7%

7 Sharp containers at all points of care 17 94.4% 1 5.67%

8 Sharp containers in rooms with inpatients beds 47 70.1% 20 29.9%

9 Sharp containers in consultation rooms 57 85.1% 10 14.9%

Waste Management

# Waste Management Yes % No %1 Pit protected barrier 37 61.7% 23 38.3%2 Autoclave to sterilize surgical instruments 35 53% 31 47%3 4 bucket system for decontamination 52 78.8% 14 21.2%4 HCW describe to make 0.5% and 0.05% chlorine

solution correctly64 96.9% 2 3.1%

Non-Ebola Basic Infrastructure# Non-Ebola Basic Infrastructure Yes % No %1 Cellphone coverage zone, provider :

Airtel, Africell, Sieratel100% 30% poor signal

2 Functioning water sourceType of Water Source : Borehole, Hand Pump

34 52.3% 31 47.7%

3 Electricity at the PHU,Source of Power : Solar, Generator

14 21.2% 52 78.8%

4 Cold chain 41 64.1% 23 35.9%

Health Work Force # Health Work Force (Definition??) Yes % No %1 Senior Registered nurse 1 1.6% 62 98.4%2 Midwife (#MCHP : 38) 11 17.2% 53 82.8%3 Senior Enroll Community Health Nurse 15 22.7% 51 77.3%4 Community Health Officer 13 20.6% 50 79.4%5 Community Health Assistance 4 6.5% 58 93.5%6 Cleaners 100% All PHU have cleaner7 Traditional Birth Attendance 62 95.4% 3 4.6%8 Other staff 100% All PHU have staff9 IPC focal person 36 6.1% 23 39%

Non-Ebola Medications and Supplies# Supplies Yes % No %

Medicines1 IV artesenute treatment 17 25.4% 50 74.6%2 ACT 200 41 63.1% 24 36.9%3 ACT 100 62 93.9% 4 6.1%4 ACT 50 66 98.5% 1 1.5%5 ACT 25 64 95.5% 3 4.5%6 Amoxi or Cotri 58 86.6% 9 13.4%7 ORS 37 55.2% 30 44.8%8 Zinc 24 36.4% 42 63.6%

Equipment and Supplies9 ARI Timer or Timer for RR 51 22.7% 51 77.3%

10 MUAC Tape 64 95.5% 3 4.5%11 Baby scale for weighing 49 73.1% 18 26.9%12 Clean up and clean spoon to prepare treatment 52 77.6% 15 22.4%13 Drinking water to prepare treatment 62 92.5% 5 7.5%14 Syringes or needles for IV severe malaria treatment 55 82.1% 12 17.9%15 Vaccination fridge 40 59.7% 27 40.3%

Non-Ebola Medications and SuppliesEmergency Obstetric and Neonatal Care

Yes % No %16 IM/IV ampicillin 51 76.1% 16 23.8%17 IM/IV Gentamicin 49 73.1% 18 26.9%18 Magnesium Sulfate 62 92.5% 5 7.5%19 Calcium Gluconate 41 61.2% 26 38.8%20 Ergometrine 39 58.2% 28 41.8%21 Oxytocin stored in a cold place 45 67.2% 22 32.8%22 Chlorodexine (4%) 49 73.1% 18 26.9%

Supplies and Equipment23 Syringes and needles 56 84.9% 10 15.1%24 IV cannulas (assorted) 52 78.8% 14 21.2%25 Blood pressure cuff 49 73.1% 18 26.9%26 Sutures (assorted) 30 44.8% 37 55.2%27 Penguin suction device 37 56.9% 28 43.1%28 Stethoscope 58 87.9% 8 12.1%29 Fetoscope 67 100% 0 0%30 MVA kit 10 15.6% 54 84.4%31 Manual Vacuum Extractor 10 15.2% 56 84.8%32 Neonatal Ambu Bag 58 86.6% 9 13.4%33 Delivery kit 51 78.5% 14 21.5%

Laboratory Equipment# Supplies Yes % No %1 2 Boxes (25 test per box) of RDT’s (not expired) 100%2 RDT’s using regularly since EVD was confirm 29 43.3% 38 56.7%3 Rapid HIV/AIDS test kit 35 52.2% 32 47.8%4 Pregnancy test (at list 25) 36 53.7% 31 46.3%5 Urine Analysis test strip PH, glucose, protein, bottle 50 14 20.9% 53 79.1%6 Urine Analysis test strip PH, glucose, protein, ketone,

blood, bilirubin bottle 509 13.6% 57 86.4%

7 Ability to check Hb (strips or hemocube) 9 13.4% 58 86.6%8 Working microscope 11 16.7% 55 83.3%

Summary and Recommendation• Hand washing facilities/hand

rub solution insufficient• Half till 75% of PHU did not

have Basic infrastructure • Supplies to non ebola

medication not equipped, it needed to screen the suspect of ebola cases

• PHU has the capacity to be prepared to screen the suspect ebola as an existing system at the same time CCC, Holding centre and ETU closed.

• Hand washing facilities/hand rub solution must be given in sufficient quantities• Basic Infrastructure in PHU

should be cultivated built (Electricity, water source, waste management and communication)•Medication and Laboratory

Supplies need to be equipped• Donor and international

organization must be involved to help DHMT improve the facilities to strengthen PHU

PART II

Infection Prevention and Control (IPC) and Screening for Suspected Ebola QA at PHU

Objectives and Methods• To assess the capacity of PHU’s to practice IPC • To ensure that appropriate IPC structure are in

place for HCW protection• To assess personnel adherence to IPC

procedures and PracticeMethods : Visit 67 PHU’s, interview and evaluate HCW and cleaner for IPC’s practice.Observe 1 cleaner and 1 HCW (randomly selected) to demonstrate take off contaminated PPE use posters or sign for guidance.

Missing of Minimum Supplies for IPC at PHU

# Supplies Yes % No %1 2 Boxes of Examination Gloves 63 96.2 2 3.8%

2 2 pairs of googles 66 100% 0 03 25 Face Masks 66 100% 0 04 2 pairs of rubber boots 65 98.5% 1 1.52%

5 10 Gowns 64 96.9% 2 3.1%

6 10 Aprons 64 96.9% 2 3.1%

7 2 pairs of rubber gloves 65 98.5% 1 1.5%

8 1 week supply of powder/liquid chlorine 65 98.5% 1 1.5%

9 10 pairs of elbow gloves 57 86.4% 9 13.6%

10 10 disposable towels 61 92.4% 5 7.6%

11 1 infrared thermometer 63 96.9% 2 3.8%

Facility IPC Signage and Screening Area

# Facility IPC Signage Yes % No %

1 Handwashing poster at the handwashing station 56 84.9% 10 15.1%2 Extended PPE Poster at PHU 59 83.4% 7 10.6%3 Removing Extended PPE poster in PPE removal area 59 89.4% 8 10.6%

# Screening Area Yes % No %1 At least one designated screener 64 98.5% 1 1.5%2 Patients and visitor screened before entering 54 83.1% 11 16.9%3 All staff screened daily before beginning their shift 58 89.2% 7 10.8%4 Screening flowchart in screening area 55 84.6% 10 15.4%5 Chlorine washing station available All 100% 0 06 Station marked with 0.05% chlorine 64 98.5% 0 1.5%7 Chlorine water changed in the last 24 hours 64 69.7% 1 1.54%

Total PHU have appropriate screening area 46 69.7% 20 30.3%

Reviewed Process for IPC# Reviewed Process Yes % No %

1 Isolation area for suspected ebola patients only 60 95.2% 3 4.8%

2 Isolation area separate from other patients area 57 90.5% 6 9.5%

3 Suspect patients avoid all clean areas 59 93.7% 4 6.3%

4 Isolation area was secure (any barrier between suspect to other 57 90.5% 6 9.5%

5 Designated space to take off PPE 49 84.5% 9 15.5%

6 Take off PPE space separate from other areas 46 82.1% 10 17.9%

7 Bucket for strong chlorine solution available for google wash 34 61.8% 21 38.2%

8 Disposable towels available 16 28.1% 41 71.9%

9 Rubbish bin with plastic garbage bag 39 72.2% 15 27.8%

10 Strong chlorine (0.5%) foot bath available 37 67.3% 18 32.7%

11 Chlorine hand washing station after PPE removal area 44 73.3% 16 26.7%

12 Station marked with 0.05% chlorine hand washing only 46 76.7% 14 23.3%

13 Chlorine water change in the last 24 hours 46 76.7% 14 23.3%

IPC Practice (Training Evaluation)# Screening Patients Yes % No %1 Screener remains 1.5 m away from patients, not face to face 59 90.8% 6 9.2%

2 Screener is wearing gloves 59 89.4% 7 10.6%

3 Screener is wearing gloves AND face mask OR face shield 58 87.9% 8 12.1%

4 Screener evaluated if patient well/unwell 58 87.9% 8 12.1%

5 Screener took temperature with thermometer at temple 60 90.2% 6 9.1%

6 Screener asked about all symptom of ebola 52 81.2% 12 18.8%

7 Screener asked about potential ebola exposure 51 78.5% 14 21.5%

8 Screener did not touch patient 61 92.4% 5 7.6%

9 Screener inform patient on whether or not they met ebola case definition

52 81.2% 12 18.8%

10 Patient sent to appropriate area of PHU if suspected 57 86.4% 9 13.6%

Waste Management (Training Evaluation)

# Waste Management (Cleaner) Yes % No %1 Human bodily fluid dispose pour

down the latrine62 93.9% 4 6.1%

2 Used PPE dispose use incinerator or burn pit

65 98.5% 1 1.5%

3 The way to clean body fluid spills on the floor

60 90.9% 6 9.1%

PPE worn by Staff in Isolation Area

# PPE worn by Staff in Isolation AreaCleaner Health Care Workers

Yes % No % Yes % No %1 One layer of examination gloves and heavy re-

useable RGlvs60 100% 0 0%

2 Two layer of examination gloves 57 90.5% 6 9.5%

3 Face mask and googles 56 91.8% 5 8.2% 57 90.5% 6 9.5%

4 Rubber gum boots 57 93.4% 4 6.6% 56 88.9% 7 11.1%

5 Gown 56 91.8% 5 8.2% 56 88.9% 7 11.1%

6 Apron (cleaner only) 54 88.5% 7 11.5%

7 Ability to remove gloves properly 47 77.1% 14 22.9% 47 77.1% 14 22.9%

8 Someone else checked the person’s PPE removal 49 81.7% 11 18.3% 50 80.6% 12 19.4%

Summary

• All PHU (100%) need Urgent Action Required for completed Inventory minimum supplies

• For IPC health facility and patients care : 22.2% PHU need to urgent action required and 41.3% action needed

• For the IPC Practices 22.7% urgent action required to improve, and 10% action needed

Recommendation• Complete the minimum supplies, especially for the

gloves, rubber boots, gowns, aprons, chlorine, dispos-able towels and infrared thermometer.

• Check all the minimum supplies regularly using supplies mechanism.

• Fit out the IPC Structure (health facility and patients care) : Screening station, designated screener, isolation area and process for isolation. Prepare specific latrine for suspected ebola patients

• Re-training to the cleaner and HCW for IPC Practice

PART III

PHU Ebola Case Detection Audit

Background

INFORM

Frequency

Percent

No 31 46.27%

Yes 36 53.73%

Total 67 100.00%

1. PHU (Periphery Health Units) is an Advance Existing Health System 2. Village with PHU which has Epi-case patients (confirm, suspect, and probable) in Village : 47.8%

Information from : Paramount, Community and HCWOr Must Ask to DHMT

Date Status Epi PHU9/9/2014 Alive Non Ebola Case Miles 189/9/2014 Dead Confirm Case Macoth 9/9/2014 Alive Non Ebola Case Rokupr 9/9/2014 Alive Confirm Case Kasserie9/9/2014 Alive Non Ebola Case Rokupr

9/12/2014 Alive Probable Tawaya 9/20/2014 Dead Confirm Case Barmoi Luma9/23/2014 Alive Non Ebola Case Mange9/23/2014 Alive Non Ebola Case Mange9/25/2014 Dead Confirm Case Kukuna

10/18/2014 Alive Non Ebola Case Kasserie10/19/2014 Dead Non Ebola Case Mambolo11/23/2014 Alive Confirm Case Gbonkomaria11/24/2014 Dead Confirm Case Madina12/2/2014 Alive Non Ebola Case Barmoimunu12/3/2014 Alive Confirm Case Rokel

12/29/2014 Alive Non Ebola Case Masunthu 1/5/2015 Alive Probable Modia

2/27/2015 Alive Confirm Case Magbembeh

In 2015, 2 suspect case visited PHU during course of Ebola illness.

Other suspect case visited PHU during course of Ebola illness.

Objectives of Case Detection Audit

• Assess proportion of PHU patients with Ebola-like syndromes not triaged or documented at EVD health facilities (CCC, EHC or ETU).

• Follow up PHU patients with Ebola-like syndromes who were not triaged to an EVD health facility (CCC, EHC or ETU) to exclude Ebola infection

PHU and CCC Visited by Chiefdom

Methods• 22 out of 67 PHU (CHC, MCHP, CHP) and 10

CCC visited include 10 PHU near CCC’s on 26 March – 7 April 2015. Purposive selection: All chiefdoms represented 2-5 PHU per chiefdom . Remote locations and islands targeted

• For 22 PHU visited, 2,300 patient visits were conducted on 7 March – 7 April 2015.

• Different PHU types: 7 CHC, 12 MCHP, 3 CHP (Proportionate to size)

Issue: Which syndromes should be reported by PHU for Ebola screening/testing? Risk of overwhelming the

system and over-riding PHU clinical judgement?

• Malaria (indistinguishable from early Ebola disease phase) • Malaria PLUS complication (gastrointestinal or respiratory) • Typhoid fever • Gastrointestinal illness (diarrhea or vomiting) • Respiratory illness • Gastrointestinal PLUS respiratory illness • Unexplained febrile illness • Unexplained bleeding • Complication during pregnancy • Meningitis / encephalitis

Results

• For 22 PHU visited, 2,300 patient visits were conducted on 7 March – 7 April 2015.

• Of these visits, 962 (42%) were possible Ebola-like syndromes.

• Per week, most outpatient visits were <5 yr olds

• Proportion of possible ebola syndrome patients ranged 31-78%

Patients with Ebola like Symptoms at PHU n=992

Possible Ebola Like Syndrome patients’s seen at PHU and CCC

Issue: Which syndromes should be reported by PHU for Ebola screening/testing? Risk of overwhelming the

system and over-riding PHU clinical judgement

• Malaria (indistinguishable from early Ebola disease phase) • Malaria PLUS complication (gastrointestinal or respiratory) • Typhoid fever • Gastrointestinal illness (diarrhea or vomiting) • Respiratory illness • Gastrointestinal PLUS respiratory illness • Unexplained febrile illness • Unexplained bleeding • Complication during pregnancy • Meningitis / encephalitis

National Existing Surveillance Case Definitions

Different PHU used different Ebola screening algorithms:

lack of standardization

Conclusion1. Large proportion of PHU visits are patients with

possible ebola-like syndromes and a small proportion of possible ebola-like syndromes were referred.

2. Not all patients referred from PHU in locations near CCC were logged in CCC screening register.

3. Use of malaria RDT varied at PHU 4. PHU have a role to play in detection & reporting

Epi Ebola Cases (suspect and probable)

Recommendation1. Clarify syndromes to report and inform PHU staff about:

a. Correct screening algorithm b. Process for reporting persons under investigation.

2. Inform staff at all types of PHU in the screening and reporting protocol.

3. Re-train PHU staff in the syndromes they must refer and process of reporting (especially in context of CCC closure).

4. Since CCC are slowly closing, inform PHU to directly report possible ebola-like patients to 117.

5. Clarify protocol for RDT/Pregnant test use for PHU: a. Target patients for RDT at PHU

b. Needed to be consider whether malaria RDT positives, Thypoid Fever and pregnancy should be referred for Ebola testing?

Thank You !!!