The road to redemption: Infection prevention and control in the era of Ebola

August 2015

The road to the 200-bed Redemption Hospital in Monrovia is unpaved. During the rainy season it is full of potholes and mud. Patients may have difficulty arriving, but they come, because Redemption is the only public facility in the area and serves some 90 000 people. In August 2014, the hospital was at the center of the Ebola epidemic in Liberia. It quickly became overwhelmed and, for a time, had to close its inpatient department.

However, after decontamination of contaminated wards, reinforcement of infection prevention and control (IPC) practices, and outbreak response training, the inpatient department was able to reopen. This was made possible due to the leadership of the Ministry of Health of Liberia, the World Health Organization (WHO), and the support of many partners, including the US Centers for Disease Control (CDC), Médecins Sans Frontières (MSF), the International Rescue Committee (IRC), the International Committee of the Red Cross/Red Crescent (ICRC), and the Academic Consortium to Combat Ebola in Liberia (ACCEL).

Redemption Hospital

Redemption Hospital, Monrovia, was at the center of the Ebola epidemic in 2014, Liberia
WHO/S. Saporito

In August 2014, at the height of the Ebola epidemic, Redemption Hospital lacked robust IPC practices and relevant equipment to prevent the spread of Ebola. Both staff and patients were becoming sick and dying in the hospital and the inpatient wards were closed. To prevent further transmission of Ebola virus disease, the sanitary conditions and procedures of the facility were overhauled. Today, the community and its health workers feel safer coming to the hospital, now that adequate IPC measures are in place.

Implementation of screening measures

Every person coming to the Redemption Hospital has their temperature checked, Liberia
WHO/C. Bailey

At all main entrances of the hospital as well as in patient care areas, hand hygiene is performed, along with other IPC procedures and screenings. Under the guidance of the IPC Task Force, a technical group led by the Ministry of Health with support from WHO, the US Centers for Disease Control and Prevention (CDC) and other partners, Liberia is moving away from the use of chlorine to using soap and water or alcohol-based hand rub for hand hygiene. This is due to the complications and occupational hazards posed by repeated use of chlorine.

At the entrance of the Redemtion Hospital, hand hygiene and other IPC procedures are performed, Liberia
WHO/C. Bailey

Assisted by IRC, Redemption Hospital received much-needed renovations to its emergency ward. With proper infrastructure, the hospital is now able to more effectively implement Ebola screening for every person coming into the facility. Once his/her temperature is checked, each person is given a card with the current temperature for reference. A fever will trigger a careful response to isolate the person from patients and further investigation will be done to determine whether Ebola is a likely possibility. Any person suspected of being infected with Ebola is referred to the Ebola transit unit, located next door.

Murals communicate public health messages

The exterior of the Redemption Hospital is lined with murals with public health messages, Liberia
WHO/C. Bailey

The exterior of the hospital is lined with murals with public health messages painted by local artists. This one describes what the community can do every day to create a more hygienic environment that can help stop the spread of disease.

Strategically-placed reminders inspire confidence in safety

Reminder about hand wash at the entrance of the Redemption Hospital, Liberia
WHO/C. Bailey

Reminders about IPC are positioned at strategic points throughout the hospital. These prompters help give patients and health-care workers confidence that this is a safe workplace.

Health worker infections

Behind this door of the Redemption Hospital, the first nurse infected with Ebola in the Liberian outbreak died.
WHO/C. Bailey

Behind this door, the first nurse infected with Ebola in the Liberian outbreak died. Over 800 health-care workers in Guinea, Liberia, Sierra Leone have become infected over the last 18 months. More than 500 died.

When Ebola hit this hospital and its systems broke down, of the few brave health workers who came to work, 8 of them died. The hospital then closed its inpatient departments and became a holding area for those suspected of being infected with Ebola virus disease before treatment centres were built and proper triage, isolation and treatment could be put in place. Once the hospital was thoroughly decontaminated and renovations were complete, WHO along with CDC, IRC, and ACCEL , trained all staff, supplied appropriate IPC equipment and reopened the hospital.

IPC training and equipment

IPC equipment and painted instructions on the wall at the Redemption Hospital, Liberia
WHO/C. Bailey

A year ago, Redemption lacked proper tools, equipment and training to ensure the safety of its health workers and other patients. All of that has changed.

Note the new 'sharps box' on the left for depositing needles and other sharp objects that can lead to accidental exposure. Note the painted instructions on the wall. These are now found throughout the hospital as reminders for all routine IPC procedures. Behind the microscope is a centrifuge to process specimens safely. Also, the lab workers are using personal protective equipment as they are handling biological material.

All of these things were provided by partners in collaboration with WHO and have helped make the hospital a safer place for health workers and patients and gradually helped turn the tide of the disease.

Reducing risks to non-clinical health workers

Cleaning team at the Redemption Hospital, Liberia
WHO/C. Bailey

Non-clinical health-care workers, such as this maintenance woman, have been essential to breaking the infection transmission chain at hospitals, however they are also at risk of becoming infected.

Proper IPC training, personal protection equipment and staff payment systems that account for hazardous conditions are key to motivating the workforce, from doctors to janitors, and keeping them on the job. The slogan on the wall, branded by the Ministry of Health, reads: "Keep safe, Keep serving." Staff report feeling confident and respected now. In turn, they are even more committed to their jobs.

Minimum standards for safe care

The beds are spaced safely part, Redemption Hospital, Liberia
WHO/C. Bailey

Before IPC policies were put in place, beds were very close to each other and patients often doubled up on a single bed or slept on the floor due to overcrowding, supporting the potential for disease spread. Now, the beds are spaced safely 1-metre apart, the ward is clean and uncrowded, and the mosquito netting protects against insects carrying malaria, which causes fever and can be mistaken for Ebola. These measures are now part of Liberia’s minimum standards for safe care provision. The standards were developed by the IPC Task Force for the Ministry of Health with support from WHO and other technical partners and are being implemented by many partners in their respective facilities.

Waste management

Instructions for sorting medical waste, Redemption Hospital, Liberia
WHO/C. Bailey

Proper sorting of waste and its disposal were also crucial to stopping Ebola infections in the hospital. With significant support from IRC, Redemption now has an incinerator, so potentially harmful medical waste does not need to be transported through the crowded city.

Maternal and newborn health

In the age of Ebola, childbirth is one of the most dangerous procedures for a health-care worker, redemption Hospital, Liberia
WHO/C. Bailey

During an Ebola outbreak, pregnant women can have safe assisted delivery if managed appropriately by strict application of IPC procedures. Health-care workers need to be well protected in these circumstances as babies born to women who are positive for Ebola virus disease pose a risk to health workers. At Redemption, the paediatric ward was also temporarily closed. Changes to IPC practices were put in place and workers were trained in the safe, but compassionate care of newborns. Here, a nurse in PPE tends to a baby in the re-opened paediatric ward.

Critical gaps remain

A doctor fixes a file cabinet with a rock, Redemption Hospital, Liberia
WHO/C. Bailey

The hospital has made great strides, particularly with its recent renovations to both its paedatric and emergency wards. However, critical infrastructure gaps remain, such as access to working plumbing and clean water. Here, a doctor fixes a file cabinet with a rock because a hammer is not available. For improvement to be sustainable, in addition to IPC training and equipment, other basic infrastructure and human resources needs have to be met in a way that can be maintained over time.