Transcript IPC, PHU and Case Detection Assessment in Kambia, March

IPC, Logistics and Case Detection Assessment at Peripheral
Health Unit (PHU) in Kambia District, Sierra Leone
March-April 2015
Masdalina Pane, Baning Rahayujati, Gina Samaan
INDONESIA
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
Number of PHU and Population
Type of PHU in Kambia, 2015
16
80,000
14
70,000
12
60,000
10
50,000
8
40,000
6
30,000
4
20,000
2
10,000
CHC, 13, 19%
MCHP, 38,
57%
CHP, 16, 24%
-
0
Bramaia
Gbinle Dixon
Magbema
Mambolo
Masungbala
Samu
Tonkolimba
Distribution of PHU per Chiefdom
16
14
12
8
10
10
6
8
6
3
4
4
4
4
2
4
1
2
2
2
2
Bramaia
Gbinle Dixon
0
4
2
1
1
Magbema
Mambolo
CHC
CHP
4
MCHP
Masungbala
Samu
3
Tonkolimba
Position of MCHP, CHC and CHP
Position of MCHP, CHC and CHP base on Population and Case
PART I
Logistics 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
4 Hand washing facilities/hand rub solution
Consultation room
5 Hand washing facilities/hand rub solution in
Delivery room
6 Hand washing facilities/hand rub solution in the
latrines
7 Sharp containers at all points of care
33
49.2%
34
50.8%
45
68.2%
21
31.8%
52
77.6%
15
22.4%
20
30.3%
46
69.7%
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
#
1
2
3
4
Waste Management
Pit protected barrier
Autoclave to sterilize surgical instruments
4 bucket system for decontamination
HCW describe to make 0.5% and 0.05% chlorine
solution correctly
Yes
%
No
%
37
35
52
64
61.7%
53%
78.8%
96.9%
23
31
14
2
38.3%
47%
21.2%
3.1%
Non-Ebola Basic Infrastructure
#
Non-Ebola Basic Infrastructure
1 Cellphone coverage zone, provider :
Airtel, Africell, Sieratel
2 Functioning water source
Type of Water Source : Borehole,
Hand Pump
3 Electricity at the PHU,
Source of Power : Solar, Generator
4 Cold chain
Yes
%
No
%
100%
30% poor signal
34
52.3% 31 47.7%
14
21.2% 52 78.8%
41
64.1% 23 35.9%
Health Work Force
#
Health Work Force (Definition??)
Yes
1
2
3
4
5
6
7
8
9
Senior Registered nurse
Midwife (#MCHP : 38)
Senior Enroll Community Health Nurse
Community Health Officer
Community Health Assistance
Cleaners
Traditional Birth Attendance
Other staff
IPC focal person
1
11
15
13
4
100%
62
100%
36
%
No
%
1.6%
62 98.4%
17.2%
53 82.8%
22.7%
51 77.3%
20.6%
50 79.4%
6.5%
58 93.5%
All PHU have cleaner
95.4%
3
4.6%
All PHU have staff
6.1%
23
39%
Non-Ebola Medications and Supplies
#
Supplies
Yes
%
No
%
Medicines
1
2
3
4
5
6
7
8
IV artesenute treatment
ACT 200
ACT 100
ACT 50
ACT 25
Amoxi or Cotri
ORS
Zinc
17
41
62
66
64
58
37
24
25.4%
63.1%
93.9%
98.5%
95.5%
86.6%
55.2%
36.4%
50
24
4
1
3
9
30
42
74.6%
36.9%
6.1%
1.5%
4.5%
13.4%
44.8%
63.6%
22.7%
95.5%
73.1%
77.6%
92.5%
82.1%
59.7%
51
3
18
15
5
12
27
77.3%
4.5%
26.9%
22.4%
7.5%
17.9%
40.3%
Equipment and Supplies
9
10
11
12
13
14
15
ARI Timer or Timer for RR
MUAC Tape
Baby scale for weighing
Clean up and clean spoon to prepare treatment
Drinking water to prepare treatment
Syringes or needles for IV severe malaria treatment
Vaccination fridge
51
64
49
52
62
55
40
Non-Ebola Medications and Supplies
Emergency Obstetric and Neonatal Care
16
17
18
19
20
21
22
IM/IV ampicillin
IM/IV Gentamicin
Magnesium Sulfate
Calcium Gluconate
Ergometrine
Oxytocin stored in a cold place
Chlorodexine (4%)
Yes
51
49
62
41
39
45
49
%
76.1%
73.1%
92.5%
61.2%
58.2%
67.2%
73.1%
No
16
18
5
26
28
22
18
%
23.8%
26.9%
7.5%
38.8%
41.8%
32.8%
26.9%
56
52
49
30
37
58
67
10
10
58
51
84.9%
78.8%
73.1%
44.8%
56.9%
87.9%
100%
15.6%
15.2%
86.6%
78.5%
10
14
18
37
28
8
0
54
56
9
14
15.1%
21.2%
26.9%
55.2%
43.1%
12.1%
0%
84.4%
84.8%
13.4%
21.5%
Supplies and Equipment
23
24
25
26
27
28
29
30
31
32
33
Syringes and needles
IV cannulas (assorted)
Blood pressure cuff
Sutures (assorted)
Penguin suction device
Stethoscope
Fetoscope
MVA kit
Manual Vacuum Extractor
Neonatal Ambu Bag
Delivery kit
Laboratory Equipment
#
Supplies
Yes
%
No
%
1
2
3
4
5
6
2 Boxes (25 test per box) of RDT’s (not expired)
RDT’s using regularly since EVD was confirm
Rapid HIV/AIDS test kit
Pregnancy test (at list 25)
Urine Analysis test strip PH, glucose, protein, bottle 50
Urine Analysis test strip PH, glucose, protein, ketone,
blood, bilirubin bottle 50
Ability to check Hb (strips or hemocube)
Working microscope
100%
29
35
36
14
9
43.3%
52.2%
53.7%
20.9%
13.6%
38
32
31
53
57
56.7%
47.8%
46.3%
79.1%
86.4%
9
11
13.4% 58
16.7% 55
86.6%
83.3%
7
8
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 Practice
Methods : 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
3
4
2 pairs of googles
25 Face Masks
2 pairs of rubber boots
66
66
65
100%
100%
98.5%
0
0
1
0
0
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
2
3
Handwashing poster at the handwashing station
Extended PPE Poster at PHU
Removing Extended PPE poster in PPE removal area
56
59
59
84.9%
83.4%
89.4%
10
7
8
15.1%
10.6%
10.6%
#
Screening Area
Yes
%
No
%
64
54
58
55
All
64
64
46
98.5%
83.1%
89.2%
84.6%
100%
98.5%
69.7%
69.7%
1
11
7
10
0
0
1
20
1.5%
16.9%
10.8%
15.4%
0
1.5%
1.54%
30.3%
1
2
3
4
5
6
7
At least one designated screener
Patients and visitor screened before entering
All staff screened daily before beginning their shift
Screening flowchart in screening area
Chlorine washing station available
Station marked with 0.05% chlorine
Chlorine water changed in the last 24 hours
Total PHU have appropriate screening area
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%
52
81.2%
12
18.8%
57
86.4%
9
13.6%
9
Screener inform patient on whether or not they met ebola case
definition
10 Patient sent to appropriate area of PHU if suspected
Waste Management (Training Evaluation)
#
Waste Management (Cleaner)
1 Human bodily fluid dispose pour
down the latrine
2 Used PPE dispose use incinerator or
burn pit
3 The way to clean body fluid spills on
the floor
Yes
%
No
%
62 93.9%
4
6.1%
65 98.5%
1
1.5%
60 90.9%
6
9.1%
PPE worn by Staff in Isolation Area
#
PPE worn by Staff in Isolation Area
Yes
Cleaner
% No
1 One layer of examination gloves and heavy reuseable RGlvs
2 Two layer of examination gloves
60
100%
0
3 Face mask and googles
56
91.8%
5
4 Rubber gum boots
57
93.4%
5 Gown
56
6 Apron (cleaner only)
%
Health Care Workers
Yes % No %
0%
57
90.5%
6
9.5%
8.2%
57
90.5%
6
9.5%
4
6.6%
56
88.9%
7
11.1%
91.8%
5
8.2%
56
88.9%
7
11.1%
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, disposable 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
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%
INFORM Frequency
Percent
No
31
46.27%
Yes
36
53.73%
Total
67
100.00%
Information from : Paramount, Community and HCW
Or Must Ask to DHMT
Date
9/9/2014
9/9/2014
9/9/2014
9/9/2014
9/9/2014
9/12/2014
9/20/2014
9/23/2014
9/23/2014
9/25/2014
10/18/2014
10/19/2014
11/23/2014
11/24/2014
12/2/2014
12/3/2014
12/29/2014
1/5/2015
2/27/2015
Status
Alive
Dead
Alive
Alive
Alive
Alive
Dead
Alive
Alive
Dead
Alive
Dead
Alive
Dead
Alive
Alive
Alive
Alive
Alive
Epi
Non Ebola Case
Confirm Case
Non Ebola Case
Confirm Case
Non Ebola Case
Probable
Confirm Case
Non Ebola Case
Non Ebola Case
Confirm Case
Non Ebola Case
Non Ebola Case
Confirm Case
Confirm Case
Non Ebola Case
Confirm Case
Non Ebola Case
Probable
Confirm Case
PHU
Miles 18
Macoth
Rokupr
Kasserie
Rokupr
Tawaya
Barmoi Luma
Mange
Mange
Kukuna
Kasserie
Mambolo
Gbonkomaria
Madina
Barmoimunu
Rokel
Masunthu
Modia
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 Ebolalike 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 Ebolalike 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
Conclusion
1. 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)
Recommendation
1. 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 !!!