Download DETERMINANTS OF EBOLA VIRUS DISEASE INFECTION AMONG

Determinants Of EVD Infection Among
Health Care Workers In Montserrado
County, Liberia
By: Nicholas N.C. Blidi
Resident Cohort 8, GFELTP
Outline
• Background
• Objectives
• Methods
• Results
• Discussion
• Conclusion
• Recommendations
• Acknowledgement
Background
• Ebola Virus Disease (EVD) is a zoonotic and fatal illness,
outbreak hit West Africa, 2014 with many deaths
• The fatality rates in outbreaks have ranged from 25 to 90%
• EVD infection among healthcare workers in Montserrado
County was devastating
• Knowledge gap and poor practice of “good” occupational
safety measure are critical
• Montserrado County accounted for over 90 cases among
health careworker
Objectives
General objective:
• To determine risk factors associated with the infection of EVD
among healthcare workers in Montserrado County, Liberia
Specific objective:
• To determine healthcare workers’ behavioral risk factors for EVD
infection
• To determine health facility-based risk factors for EVD infection
• To determine non-health facility based risk factors for EVD
infection
• To determine which healthcare worker function is a high risk
factor for EVD infection
Methods 1/3
• Study design
• A matched (1:3) Case-Control study design was employed.
• Study area
• Study was conducted in Montserrado County, Liberia
• Variables :
Dependent Variables:
• Exposure of healthcare workers to Ebola Virus Disease
Independent Variables
• Socio-demographic factors (Sex, Age, Profession/Occupation, Place of
work)
• Organizational factors (Availability of IPC guidelines & equipment)
• Behavioral factors [Hand hygiene, Extra-occupational activities (e.g.
funeral attendance), wearing of PPEs (including gloves, mask, etc)]
Map of Liberia and Montserrado County (R – L):
Showing distribution of health care facilities 3/3
Methods 2/3
• Study population – Health workers during the EVD
epidemic in Montserrado County (May 2014-2015)
• Sample size – 168 participants (cases 42, controls
126)
• Sampling methods – census for cases, random
selection of control using number table
• Data entry and analysis – Epi info version 3.4.5,
Descriptive statistics (Percentage and frequency)
• Cross tabulation to determine association (odds
ratio)
Result 1/5
• Epi-Surveillance database reported over 90 confirmed cases of EVD
among health care workers in Montserrado County and approximately
60 deaths
• An equal proportion of male and female cases interviewed
• Mean age was 31.6 years (std. dev 7.1); with the highest proportions of
participants between ages 24-28 for both case and control
• Nurses accounted for the highest number of infection
• Meanwhile, most of the infections occurred in clinics compared to other
health facility types
RESULT 2/5:
Demographics of Health care workers (Case and Controls) in
Montserrado County, May 2014-May 2015
Category
Sex
Case Number(%)
Controls Number (%)
Male
Female
21(50)
21(50)
61(48.4)
65(51.6)
0
11(26.2)
7(16.7)
9(21.4)
9(21.4)
0
44(34.9)
36(28.6)
17(13.5)
3(2.4)
1(2.4)
6(14.3)
12(28.6)
1(2.4)
2(4.8)
9(21.4)
2(4.8)
8(19.0)
3(2.4)
18(14.3)
36(28.6)
3(2.4)
6(4.8)
27(21.4)
6(4.8)
24(19.0)
24(57.1)
17(40.5)
1(2.4)
72(57.1)
51(40.5)
3(2.4)
Age
19 - 23 years
34 - 28 years
29 - 33 years
34 -38 years
44 years - above
Occupation
Doctor
Physician Assistant
Nurse
Midwife
Lab technician
Healthcare intern
Ambulance staff
Auxiliary health worker
Health Facility Type
Clinic
Hospital
Ebola Treatment Unit
RESULT 3/5:
Non-Health Facility-based Exposure of Health care workers to EVD in
Montserrado County, May 2014-May2015
Case
Number
(%)
Controls
Number
(%)
Odds Ratio
Confidence
Interval
Lower Upper
Funeral Attendance
8(19.0)
13(10.3)
2.0
0.82 - 5.31
Participation in burial rites
9(21.4)
18(14.3)
1.6
0.72 – 3.93
Confirmed EVD family member
16(38.1)
33(26.2)
1.7
0.83 - 3.62
Confirmed EVD close neighbor
21(50.0)
51(40.5)
1.5
0.74 - 2.93
Categories
Health Facility-based Exposure of Health care workers to EVD in
Montserrado County, May 2014-May2015 (4/5) Facility-based Risk
functions of Health care workers to EVD in Mon County, May
2014-May 2015
Category
Case Number (%) Control Number
(%)
Odds ratios
CI
Lower Upper
Taking Vital signs
24(57.1)
38(30.2)
3.1
1.52 – 6.31
Performing P.E
12(28.6)
24(19)
1.7
0.81 – 3.82
Drawing blood
4(9.5)
5(4)
2.5
0.73 – 9.94
Changing linen
6(14.3)
7(5.6)
2.8
0.92 – 8.94
Bathing patient
9(21.4)
4(3.2)
8.3
2.43 – 28.7
Feeding patient
10(23.8)
4(3.2)
9.5
2.84 – 32.4
Lifting and
positioning
patient
7(16.7)
8(6.3)
2.9
0.92 – 8.72
RESULT 5/5:
Preventive Measure against EVD by Health care workers in the Health
Facility, Montserrado County-May 2014-May2015
Categories
Cases Number (%)
Controls Number
(%)
5(25.0)
0(0)
2(10)
13(65.0)
42(77.8)
5(9.3)
0(0)
7(13.0)
13(65.0)
7(35.0)
0(0)
49(38.9)
4(3.2)
72(57.1)
27(64.3)
19(45.2)
16(38.1)
18(42.9)
48(38.1)
45(35.7)
30(23.8)
29(23.0)
7(16.7)
3(7.1)
3(7.1)
4(9.5)
36(28.6)
34(27.0)
21(16.7)
20(15.9)
Hand hygiene (WHO 5 moment)
Always (100% of time)
Often (>50% of time)
Infrequent (<50% of time)
Unsure
Hand hygiene(after removing PPEs)
Always (100% of time)
Not always
Never
Close Contact with Patient
Gloves
Gown
Eye protection
Medical mask
For Patient room entry
Gloves
Gown
Eye protection
Medical mask
WHO Specialist providing training for health
care workers
IPC specialist (WHO), providing support to health care worker on effective triage
and isolation at a hospital in Montserrado Couty
DISCUSSION 1/2
•
Equal proportion of male and female as cases
• A study in Sierra Leone showed males were more prone to EVD infection
than female - Odds 0.62 (95% CI: 0.44, 0.88) (Fang et al., 2016)
•
The odds of cases being exposed in a health facility compared to controls
were 5.3 (2.2-12.9)
• Healthcare facilities play an amplifying role in the evolution of Ebola
outbreaks according to Shears & O’Dempsey, 2015 on EVD in Sudan
•
Funeral attendance had an odds of 2.0 for exposure of study participant
outside the health facility
• Victory et al., 2015 study in Guinea showed that funeral attendance was a
major media through which EVD is spread outside the health care facility
Discussion 2/2
• Placing Urinary Catheter, emptying bed pans, providing
medications, conducting surgery and caring for dead bodies
were major risk factors.
• Infection of a healthcare worker may result from a breach in
the strict application of the infection control measures
(ECDC 2014)
• When caring for an infectious patient, when involved in
waste management or when removing personal protective
equipment (PPE) (ECDC, 2014)
• Health care workers were 21-32 times more likely to be
infected with EVD than people in the general population
(WHO, 2015)
• Nurses and nurse aids accounted for more than 50% of all
health worker infection (WHO, 2015)
Situation of EVD in Liberia
Conclusion
• EVD infection among health workers in Montserrado County
can be attributed to both health facility based and non-health
facility based risk factors
• Health facility based risk factors (poor hand hygiene and
wearing of PPEs) during service provision are cardinal
preventive measure
• Administering IV/IM and Oral medications and waste disposal
were procedures of higher risk among the cases
Recommendations
Based on the aforementioned, the following recommendations were made:
• Ministry of Health of Liberia must strengthen infection prevention and control
• intervention in all health facilities
•
•
Health facility administrations must to ensure infection prevention and control
interventions are properly implemented
•
•
•
Ministry of Health and health facility authorities to ensure the provision of
regular in-service training for health care workers, especially in detection of
infectious diseases like EVD and infection prevention and control
•
•
Health care workers must adhere to preventive measures against infectious
diseases both in the health facility and at home or in the community
Training of Trainers on IPC in Liberia
Acknowledgement
• Faculty members of Ghana Field Epidemiology & Laboratory Training
Program, University of Ghana, especially Drs. Sackey and Donne
• EPI-Surveillance Unit, Ministry of Health, Liberia
• Fulton Q. Shannon
• Mr. Joseph Asamoah-Frimpong
• Mr. Robert Kpoto
• Mr. Sekou Kromah