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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