Thursday, September 11, 2014

The impact of the Ebola outbreak on child health in Sierra Leone...

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.

MOHS Sierra Leone Situational Report - 9 September 2014
2 UNICEF Sierra Leone - Ebola Virus Disease - Weekly update (1-7 September 2014)
Written by: Sandra Lako, Welbodi Partnership

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