Evaluation of infection prevention and control practices in Lassa fever treatment centers in north-central Nigeria during an ongoing Lassa fever outbreak

Abstract

Background:

Outbreaks of Lassa fever (LF) in Nigeria have become more frequent, with increasing more healthcare worker infections. Prevention of infection is dependent on strict compliance to infection prevention and control (IPC) practices in treatment centres where patients are managed.

Objective:

To evaluate IPC practices during an ongoing LF outbreak in the two major tertiary hospitals serving as the referral LF treatment centres in the north-central region of Nigeria.

Methods:

This cross-sectional survey was carried out by the IPC subteam of the National Rapid Response Team of the Nigeria Centre for Disease Control (NCDC) deployed to Plateau State, north-central Nigeria during the 2019 LF outbreak. Information on IPC in these facilities was collected using the NCDC viral haemorrhagic fevers (VHFs) isolation and treatment facility IPC survey tool.

Results:

Both treatment centres had national VHF IPC isolation guidelines and few health workers had received IPC training. In both centres, there were no clearly demarcated entry points for staff going into clinical areas after putting on personal protective equipment, and there were also no standard operating procedures in place for reporting occupational exposure of staff to infected blood or body fluids in both centres.

Discussion:

The LF treatment centers located in Plateau State during the 2019 LF outbreak were not fully implementing the national VHF IPC guidelines. Periodic assessments of IPC are recommended for proper management of cases and effective control of LF in the State.

Introduction

Lassa fever (LF) is a viral haemorrhagic infection that is endemic in Nigeria, where it has been reported to result in perennial outbreaks with seasonal spikes (World Health Organization, 2018).

Between 1 January and 28 April 2019, a total of 554 laboratory cases of LF with 124 deaths were recorded in 21 states of the 37 states/Federal Capital Territory in Nigeria (Dan-Nwafor et al., 2019). The 2019 LF epidemic in Nigeria was, however, unique in the sense that three states—Plateau, Bauchi, and Taraba—recorded historically high numbers of cases for their individual states, and this was one of the factors that led to the decision to declare the 2019 LF epidemic an emergency on 22 January 2019 (Dan-Nwafor et al., 2019).

Nigeria has a number of LF treatment centres (TCs) that operate in association with specialist teaching hospitals (Dan-Nwafor et al., 2019). During the 2019 LF outbreak in Nigeria, the Nigeria Centre for Disease Control (NCDC) intensified efforts to contain the outbreak by supporting states in assessing the readiness of TCs to safely isolate and manage patients with LF and strengthen their preparedness (Dan-Nwafor et al., 2019).

According to the national guidelines on infection prevention and control (IPC) for viral haemorrhagic fevers (VHF), during an outbreak, healthcare facilities are expected to have a well-equipped screening area at the entrance of the facility to identify any potential suspected patient; suspected patients should be immediately isolated and the proper authorities (Local Government Area/State Disease Surveillance and Notification Officer, or State Epidemiologist) should be notified (NCDC, 2020). Other specifications in the guideline include that the VHF TCs should be fenced off, and the design should be based on a unidirectional flow of staff, solid wastes, patients and dead bodies from low-risk to high-risk zones, use of strict barrier nursing (personal protective equipment [PPE]), appropriate hand hygiene techniques and use of correctly constituted disinfectants for specified purposes (NCDC, 2020).

Breaches in IPC practices are largely responsible for healthcare worker (HCW) infections with VHFs. Ensuring compliance with standard precautions and national IPC guidelines for VHFs is expedient among HCWs, especially during an outbreak (NCDC, 2020). In 2018, NCDC developed a standard assessment tool based on the national IPC guideline for VHFs, with the aim of facilitating continuous improvement of IPC in VHF TCs in Nigeria (NCDC, 2020).

The aim of the present survey was to assess IPC capacities and practices in order to identify action plans and priorities for improvement during the 2019 LF outbreak.

Methods

This was a cross-sectional study carried out in Plateau State in March 2019 by the IPC sub-team of the National Rapid Response Team deployed to the State during the ongoing 2019 LF outbreak as part of the response activities by the national LF Emergency operation centre (EOC).

Plateau State is located in north-central Nigeria, has a population of about 3.5 million people and an average temperature in the range of 18–22 °C (Plateau State Government, 2019). It is one of the LF high-burden states in Nigeria. It has two TCs where cases of LF identified in the State are managed. The two TCs also serve neighbouring states where there are no designated TCs.

This survey was carried out in the two LF TCs in the State using the NCDC VHF isolation and treatment facility IPC survey tool to assess IPC guidance and training, infrastructure, PPE and hand hygiene, equipment and supplies, and staff health. The survey tool was interviewer-administered and observations were made using a checklist. The respondents were the IPC focal persons in the TCs.

Key informant interviews with the IPC focal persons in the TCs were used to obtain information on the reasons for poor compliance with IPC and recommendations to facilitate improvement.

Ethical Considerations

This evaluation was done as part of an emergency outbreak response led by the NCDC. The rapid response team had the permission of the Plateau State Ministry of Health for this exercise. Ethical principles of autonomy and confidentiality were upheld throughout the process. Participation by the respondents was voluntary. Verbal consent was obtained from each participant before the interview. Data from this evaluation will be stored in a password-protected computer for a minimum of five years.

Results

In the two TCs (TC A and TC B) there were 30 HCWs, consisting of doctors, nurses, and porters, with close patient contact roles.

In TC A, only four HCWs (three doctors and one nurse), and in TC B, only two HCWs (one doctor and one nurse) had received formal training on IPC. TC A had staff assigned to strictly work in its VHF treatment centre while TC B did not; therefore, members of staff who rendered services at the TC were also required to carry out services in the general patient wards in TC B.

Both TCs had VHF IPC guidelines but there was no regular onsite training of the staff on IPC practices as recommended in the National Guideline (NCDC, 2020) (Table 1).

Table 1.

IPC guidance and training.

	TC A	TC B
Availability of NCDC VHF guideline	Yes	No
Designated IPC supervisor as part of the team or visiting at least once a week
Triage algorithms and protocols in place	No	No
SOP for safe escorting of patients to/from ambulance in place	No	No
Training
Proportion of staff who had received formal training on IPC	4/15 (26.6%)	2/15 (13.3%)
Regular onsite staff training on IPC practices (minimum once a month)	No	No
Staff trained to perform appropriate screening and use adequate protection when working in triage area	No	No
Staff trained to appropriately perform hand hygiene	Yes	Yes
Staff trained on safe removal of dead bodies	No	No
Staff training on safe sample collection from suspected VHF patients	Yes	Yes

IPC, infection control and prevention; NCDC, Nigeria Centre for Disease Control; SOP, standard operating procedure; TC, treatment centre; VHF, viral haemorrhagic fever.

On assessment of the infrastructure, TC A had a perimeter fence and security to prevent trespassers but TC B did not (Table 2). There were no clearly defined areas for visitors that allowed for close contact between visitors and patients. TC A had clearly defined distinct areas for suspected and confirmed VHF cases while TC B kept suspected cases in the general ward pending the result of laboratory investigations.

Table 2.

IPC infrastructure, waste management and water supply.

IPC infrastructure	TC A	TC B
Isolation area perimeter fence or cordon	Yes	No
Security present	Yes	No
Staff entry area
Clearly demarcated entry point for staff going into clinical areas after putting on PPE	No	No
Area can hold two days of PPE stock for scheduled staff	Yes	Yes
Protocol for putting on PPE clearly displayed	Yes	No
Hand hygiene station	Yes	Yes
Full length mirror mounted	Yes	Yes
Staff exit area
Only option for staff exit	No	No
No crossover into the entry section	No	no
Defined protocol for doffing PPE clearly displayed	Yes	No
Presence of at least three hand hygiene stations	No	No
Infectious waste container for used PPE	Yes	Yes
One infectious waste container for disposable PPE	Yes	Yes
One infectious waste container for reusable PPE	Yes	Yes
Plastic bench to sit for removing overshoes if used	Yes	No
Patient entry point
Staff present to receive patient	Yes	Yes
Well ventilated	Yes	Yes
Hand hygiene material	No	No
Triage algorithm present	No	No
Suspect area
Separate entry for staff and patient	No	No
Single patient rooms	Yes	Yes
Cohorted but at least one meter between patients	Yes	Yes
Suspects with vomiting and diarrhoea separated from others	No	No
Separate rooms for male and female patients	Yes	Yes
Suspect area has observation window	No	No
No mixing of suspect and confirmed cases	No	No
Exit shower area	No	No
Separate toilet and bathroom	No	No
Confirmed area
Separate entry for staff and patients	No	No
Single patient rooms	Yes	No
Cohorted but at least 1 m between patients	No	No
Separate rooms for male and female patients	No	No
Suspect area has observation window	No	No
Separate rooms for male and female patients	No	No
Separate toilet and bathroom	No	No
Ambulance entry
An entry for confirmed cases	Yes	Yes
Stores	Yes	Yes
Waste management
Dedicated area for waste destruction	No	No
Incinerator	No	No
Open barrel for burning	No	Yes
Ash pit	No	Yes
Housekeeping
Laundry	No	No
Water supply
Municipal water supply	Yes	No
Borehole	Yes	Yes
Large storage tanks that can hold up to three days’ supply	Yes	Yes
Water piped to patient areas, kitchen, laundry	Yes	Yes
Power supply
Standby generator with expanded fuel capacity	No	No
Other sources e.g. solar	No	No

IPC, infection prevention and control; PPE, personal protective equipment; TC, treatment centre.

Neither of the TCs had incinerators. TC A disposed of waste by transporting the waste from the isolation centre to the incinerator used for general hospital services located a few kilometers from the isolation centre using an open wheelbarrow, while TC B disposed of waste by burning in a small makeshift open barrel (Table 2).

In both TCs, hand hygiene solutions were readily available (Table 3). All surfaces in the patient care area were always cleaned and decontaminated at least daily and on discharge in both TCs (Table 4)

Table 3.

PPE use and hand hygiene.

	TC A	TC B
Full PPE used by all staff to enter the red zone	No	No
Cleaning staff use full PPE and heavy duty rubber gloves/aprons	No	No
The facility has appropriately located hand hygiene stations	Yes	Yes
Availability of alcohol-based hand sanitisers	Yes	Yes
Availability of 0.05% chlorine solution	Yes	Yes
Chlorine solution is freshly prepared on a daily basis using a recommended formula and from known concentrations	Yes	Yes
Chlorine solution is changed every 6 h	No	No

PPE, personal protective equipment; TC, treatment centre.

Table 4.

Environmental cleaning, disinfection and waste management.

	TC A	TC B
Buckets (with faucet) of 0.5% chlorine solution are available in inpatient areas for disinfection of surfaces and gloved hands	Yes	Yes
The facility has sharps puncture-resistant containers available at the point of care and securely sealed with a lid	Yes	Yes
The facility has a place for routine cleaning and decontamination of reusable equipment using 0.5% chlorine solution	Yes	Yes
All surfaces in the patient care area are always cleaned and decontaminated at least daily and on discharge	Yes	Yes
Toilets are always cleaned and decontaminated twice daily	Yes	Yes
Body fluid waste from patients are always disposed of in the toilet followed by chlorine decontamination	Yes	Yes
Linen from patients after discharge or when soiled is always disinfected safely or incinerated	Yes	Yes

TC, treatment centre.

Face shields/goggles, heavy-duty gloves, examination gloves and gum (rubber) boots were available for all staff, adequate and in good repair (Table 5).

Table 5.

Equipment and supplies.

	TC A	TC B
Disposable fluid-resistant gowns or coveralls are available, adequate specification and in good repair	Yes	Yes
Reusable or disposable plastic aprons are available, adequate and in good repair	Yes	Yes
Respirators are are available, adequate specification and in good repair	Yes	No
Face shields/goggles are available, adequate specification and in good repair	Yes	Yes
Heavy-duty gloves are available, adequate specification and in good repair	Yes	Yes
Examination gloves are available, adequate specification (nitrile) and in good repair and in different sizes	Yes	Yes
Elbow gloves are available	Yes	Yes
Hoods or head covers are are available, adequate specification and in good repair	No	No
Gum (rubber) boots are available for all staff, adequate and in good repair	Yes	Yes
Soap (liquid) is always available and adequate	Yes	Yes
Alcohol-based hand rub solutions (ethanol or isopropanol 60%–80%) are always available and adequate	Yes	Yes
Chlorine (powder or bleach) is always available and adequate	Yes	Yes
Patients have individual thermometers	Yes	Yes
Leak-proof bags for waste disposal are always available, adequate and in good repair	Yes	Yes
Body bags (leak-proof) are available, adequate and in good repair	Yes	Yes

TC, treatment centre.

In both TCs, there was no Standard Operating Procedures (SOP) or system in place for reporting occupational exposure of staff to infectious substances (Table 6)

Table 6.

Staff health.

	TC A	TC B
SOP is in place for managing and reporting exposure of staff to infection	Yes	Yes
There is a system for reporting suspected/confirmed cases of LF in healthcare workers in place	Yes	Yes
There is daily screening of all staff arriving to work including temperature checks, before and after the shift done routinely and recorded	No	No
Have any of the facility staff being infected with LF virus	Yes	No
There is enough drinks for hydration after removing PPE for the staff	No	No
There is a system to track and monitor frequency and length of time staff are in the red zone per shift	No	No

LF, Lassa fever; PPE, personal protective equipment; SOP, standard operating procedure; TC, treatment centre.

On observation by the researchers, it was noted that in both TCs, PPE was not worn at all times by staff when entering highly infectious zones (Table 7).

Table 7.

IPC information obtained by observation.

	TC A	TC B
The triaging/screening tools and equipment (e.g. triaging algorithm, PPE, thermometer, hand hygiene facilities, etc.) can be easily accessed	Yes	Yes
SOP for safe removal of dead bodies of VHF cases are posted in appropriate areas	No	No
According to ad-hoc observation by the assessor, waste is being handled and disposed of appropriately	No	No
There is a unidirectional flow from clean to contaminated areas within the facility for both patients and staff	No	No
According to ad-hoc observation by the assessor, recommended PPE is correctly used for routine activities	No	No
For putting on PPE outside the isolation space/area, there is a dedicated well-organised area (with body size mirror, poster on steps for putting on PPE, hand hygiene station and good stocks of equipment)	Yes	Yes
For removing PPE, there is a well-equipped area separate from the donning area (with body size mirror, poster on PPE removal steps, hand hygiene station, equipment for decontamination and waste bin)	No	No
According to ad-hoc observation by the assessor, procedures to put on PPE (donning) are correctly performed, including supervision by a colleague	No	No
According to ad-hoc observation by the assessor, procedures to remove PPE (doffing) are correctly performed, including supervision by a colleague	No	No
According to ad-hoc observation by the assessor, healthcare workers correctly perform hand hygiene (correct technique and correct duration)	No	No
According to ad-hoc observation by the assessor, gloves are decontaminated and changed between patients	yes	Yes
According to ad-hoc observation by the assessor, sharps are being disposed adequately in a dedicated sharp container (e.g. not on the floor or other surfaces) and containers are less than three-quarters full	Yes	Yes
There is a clock with second hand within sight to count breathing and heart rate	Yes	Yes

IPC, infection prevention and control; PPE, personal protective equipment; SOP, standard operating procedure; TC, treatment centre; VHF, viral haemorrhagic fever.

Key informants reported that the reasons for poor compliance with IPC standards were: lack of funds to renovate/remodel TCs to meet the required specifications; inadequate number of staff; lack of support in the IPC capacity building of HCWs; and poorly functional IPC committee to monitor and evaluate compliance with guidelines. Recommendations to improve IPC in the TCs were: establishment and strengthening existing IPC committees; financial support from the government for renovations/remodeling and equipment; technical support from the government and agencies to sustain regular IPC training for staff; and employment of more staff to meet facility needs.

Discussion

Effective and sustainable implementation of IPC programmes is a reflection of safety and quality in healthcare delivery and is critical in the prevention of healthcare-associated infections (Sunkesula et al., 2015). Occurrence of nosocomial infections may lead to a lack of trust from the public in the capability of the health facility to provide adequate care, and this may result in public avoidance of healthcare facilities during LF outbreaks, facilitating the spread of the infection (Dan-Nwafor et al., 2019).

Findings from this survey showed that one of the centres (TC A) had no IPC committee, while the other (TC B) had an IPC committee that was not functioning appropriately. An adequate IPC governance structure includes an IPC committee whose function is to oversee implementation of IPC in the facility, provide SOPs, conduct surveillance, carry out regular evaluations and mobilise resources for the IPC programme (NCDC, 2020).

In a related survey to identify IPC gaps in hospitals in Rivers State, Nigeria during the 2014 Ebola virus disease (EVD) outbreak, only one of the tertiary healthcare facilities studied had an IPC committee in place with a focal officer in charge, only one hospital had an IPC policy which was not operational and none of the health facilities had a good score for both availability and use of IPC materials (Okwor et al., 2015). This is also similar to the findings in our survey where some critical IPC protocols and SOPs were not available in both facilities. However, the health facilities in Rivers State were assessed in 2014, and improvements may have been made since then.

Research has shown that the availability of technical guidelines is essential in supporting good practices, and having easily accessible protocols and SOPs can enhance compliance to policies by personnel in their daily jobs (United States Fire Administration, 1999); this could also apply to IPC practices among HCWs in Nigeria.

In addition, studies have shown that significant improvement in IPC among hospitals in resource-limited settings is achievable with deliberate coordinated and cooperative efforts by all stakeholders guided by recommended infection control guidelines (Ogoina et al., 2015). Although there is an existing national guideline for IPC for VHFs in Nigeria, the TCs in the State did not fully implement the IPC measures. Researchers have found that the existence of guidelines alone is not enough to ensure their implementation, and that it is important to train relevant HCWs on the importance of adherence to the guidelines and monitor their adherence (Storr et al., 2017).

Evaluation of evidence from 15 studies showed that IPC training was associated with a decline in hospital-acquired infections and recommended IPC training as one of the core components IPC (Storr et al., 2017). Most of the HCWs in the TCs had not received any IPC training. This is a similar finding among HCWs in other low-income countries such as Ethiopia, where only 17.7% of HCWs had received training on IPC (Alemayehu et al., 2016) and in Guinea, where 25% of health facilities had only one trained HCW, 53% had at least two trained HCWs and 22% of the health facilities had no IPC trained HCWs (Keïta et al., 2018). Training HCWS should be prioritised; this was an identified gap in the facilities assessed during an active LF outbreak. A similar study during outbreaks of EVD in Guinea found that health facilities that implemented IPC training of staff were five times more likely to have an IPC score above average (Keïta et al., 2018). Therefore, the provision of necessary IPC infrastructure along with training of HCWs on IPC could be relevant in reducing VHF infections and deaths among HCWs.

This survey also highlighted how IPC can be supported in the TCs. Recommendations to establish and strengthen IPC committees, financial and technical support to TCs, and the employment of more staff to meet facility needs were made by the IPC focal person’s interviewed; based on these, an action plan was developed for the TCs. For better IPC coordination according to the World Health Organization, national plans and budgets should capture and focus effort in the development of health system capacity, including IPC (World Health Organization, 2019).

In conclusion, implementation and adherence to IPC guidelines in health facilities should be made mandatory. This survey discovered gaps in adherence to IPC policies during an ongoing outbreak of LF in TCs in Plateau state. Implementation of existing IPC guidelines in these TCs, periodic assessments of IPC and staff training on IPC with close supervision to ensure compliance is recommended for effective control of LF in Plateau State. Furthermore, these assessments should be carried out routinely in existing TCs and in newly established LF TCs in Nigeria.

Study limitations

The findings from this survey cannot be generalised to every treatment centre in Nigeria and some of the information obtained could not be verified by the researchers.