The
worst Ebola outbreak in the world is confirmed to have infected 1,305 people in
Sierra Leone to date1 though the actual rates may be higher. Of the
Ebola confirmed cases, around 22% are children between the ages of 0 and 17
years2. Children are not only getting infected with this disease,
but many have either been separated from their parents or been orphaned due to
Ebola and many more children can no longer access basic health services for
non-Ebola illnesses.
The
loss of over 240 healthcare workers due to Ebola infections in the affected
countries of Sierra Leone, Guinea, Liberia and Nigeria, with long-standing
shortages of healthcare professionals, has understandably instilled fear amongst
hospital staff and has led to a demand for more training, sufficient protective
equipment and incentives before they feel confident to proceed with their work
on the front line. This, in combination with a fear amongst the general public
to report at health facilities and the difficulty in identifying suspected
cases when reliable histories are not forthcoming, has resulted in many
health facilities closing or only running outpatient services. Amongst these
health facilities is the Ola During Children’s Hospital (ODCH); the only
government run Children’s hospital in the country, which is now temporarily
closed.
At
ODCH, which Welbodi Partnership has supported for over 5 years now, preparations
were made in collaboration with hospital staff and partnering organisations at
the start of the outbreak for the possible arrival of suspected Ebola cases. This
included setting up a small isolation unit, ensuring the availability of
personal protective equipment in the unit, training of staff and screening of
patients at the entrance of the hospital. It also involved the reinforcement of
using universal precautions on all of the wards.
The
screening questions are based on the case definition for Ebola, which includes specific
symptoms, travel to/from an affected district and contact history with an Ebola
patient. Since the transmission of
Ebola is through contact with bodily fluids of an Ebola patient, the contact and
travel history are important. It is estimated that prior to the outbreak, 80-90%
of children presenting to hospital come with symptoms such as fever, diarrhoea,
vomiting, and weakness; symptoms that not only categorize Ebola, but many other
common diseases such as malaria, typhoid and gastroenteritis. If the case
definition were only to focus on symptoms, this would mean that the majority of
children presenting to the hospital would need to be isolated, which with
approximately 1000 admissions a month at ODCH, would be a daunting task. It
would require a rapid turn around of laboratory results and a large medical and
logistics team on the ground, as frequent entry into the unit would be required
to assure that infants and young children are receiving adequate hydration and
care, particularly as it is not guaranteed that these children could be
isolated with a dedicated caregiver.
The
agreed procedure at ODCH in dealing with suspected Ebola cases was put to the
test in early August: a child arrived at the hospital and was screened at the
entrance. The history revealed fever, vomiting, weakness and a positive contact
and travel history. Since the patient met the case definition, the child was
immediately isolated in the hospital’s isolation unit while testing was carried
out. Two days later when the test result came back positive, the child was
taken to an Ebola treatment centre in the east of the country. All staff that
came into contact with this patient were aware that she very likely had Ebola
and took the necessary precautions. Although this case brought up a few
challenges in the process, it did go according to plan and the hospital
continued with the same procedure.
Only
a week later, however, another child arrived at the hospital. This child had
symptoms of fever, diarrhoea and vomiting, but the father denied any history of
contact with an Ebola patient or travel from an affected district, most likely
because he was afraid to hear that his child might have Ebola. For many, the
diagnosis of Ebola is seen as a death sentence. Since the father withheld
essential information, the child did not meet the case definition and was
admitted to the Emergency Room. It was not until two days later that one of the
doctors found out from another relative that the child had been in contact with
an Ebola case. Alarm bells rang and preparations were immediately made to
transfer the child to an isolation unit for testing for Ebola. All other
patients were moved onto another ward and the Emergency Room was
decontaminated.
As
one can imagine, hospital staff was nervous, having cared for this patient for
two days on a general ward, using gloves and universal precautions, but not
using the full protective suits since the patient was not admitted as a
suspected case. It was decided that all staff in direct contact with this case,
would be quarantined in their homes where they would sit out the 21-day
incubation period with the hope that they had not been infected. Since that day, ODCH has been closed to
new admissions, because without reliable histories during screening it is
impossible to identify a suspected case and isolating all cases arriving at the
hospital was an impossible task due to size limitations of the initial
isolation ward. Over the next few days, most children were discharged from the
hospital. Two days later, the result for the child was announced: positive.
Thankfully,
21 days has passed and none of the staff that came in contact with this case have
shown any signs of Ebola, but to date, ODCH, the country’s only government-run
paediatric hospital, remains closed.
This
story is not unique. Many health facilities across the country and in the
sub-region are in similar situations. The impact of this outbreak on the
already fragile health systems throughout West Africa will be immense. On
average, ODCH admits 1000 patients in the month of August. The fact that ODCH
was shut for the second half of the month means that 500 children who would
normally have access to health care services, did not. What is the fate of
these children? Children with diseases such as malaria, pneumonia, gastroenteritis
and other common diseases may well die. The implications will also be severe
for services such as outpatient paediatric HIV/AIDS and tuberculosis treatment,
as these patients are either afraid to come to the hospital to receive their
medications, or health staff are placed at high risk without proper protective
equipment to allow them to safely conduct consultations. The immunization
programmes will be hindered and many children may not be immunized adequately
during this outbreak. It is fair to say that we will see an increase in both
morbidity and mortality over the next months. Extrapolating data from a Lancet
article in 20133,4 it is estimated that 2,500 women and children die
in Sierra Leone every month. With the current strains on the health care services
this number is inevitably going to increase, and this will never be accounted
for in national Ebola mortality statistics. The closure of the hospital has also
had an impact on the few remaining health facilities in the area, already
overburdened by the demands of the Ebola outbreak, and with limited experience
in paediatric care.
Efforts
are underway to re-open the hospital, but this must be done in such a way to
ensure the safety of both staff and patients. An effective screening method
needs to be put in place so that the hospital is not, once again, forced to
close. With a high level of fear amongst the general public, it could be that
other caregivers will not be forthcoming with the actual history, for fear of
their child being isolated. Finding a safe way to re-open the hospital potentially
means that a large proportion of children presenting to the hospital will need
to be isolated and tested prior to being admitted, since the symptoms of Ebola
mimic that of other diseases. NGOs currently on the ground at ODCH are working
with hospital staff, the Ministry of Health and Sanitation and other agencies
to discuss plans to set up a larger isolation unit adjacent to the hospital for
this purpose. In the meantime, training of hospital staff is ongoing with a big
focus on infection control measures, including the use of personal protective
equipment. Welbodi Partnership is currently providing advice from afar but hopes
to return soon to support the efforts at ODCH.
In
itself, Ebola is a terrible disease, causing suffering and death, but the
impact on the fragile public health systems in the country means that the
morbidity and mortality from more common illnesses will be on the increase. Measures
to stop the transmission of Ebola need to be scaled up to control this outbreak. At the same time, and continuing into
the future, the current health systems need to be strengthened to ensure the availability
of high quality health care in Sierra Leone, as well as to prevent and control
such outbreaks in the future.
1 MOHS
Sierra Leone Situational Report - 9 September 2014 http://health.gov.sl/?p=537
2 UNICEF Sierra Leone - Ebola
Virus Disease - Weekly update (1-7 September 2014)
Written by: Sandra Lako, Welbodi Partnership
