Ebola Infection Prevention and Control Guideline: Ambulance & House Decontamination Project in ...

172 Pages·2017·4.28 MB·English

Practical guide
Ebola Infection Prevention and Control Guideline:
Ambulance & House Decontamination Project in
Sierra Leone
Emergency Technical Unit
2016

PG 25
Coordination
Gaëlle Faure (Ebola Technical and Operational Advisor)

Contributors
Julio Martinez Aniceto, Priscilla Vaast and Jody Clouten (IPC managers of the
Ambulance and House decontamination project)
Pauline Lavirotte (Project Manager of the Ambulance and House decontamination project)
Gaëlle Faure (Ebola Technical and Operational Advisor)
Pierre Mercier (Ebola Programme Officer)
Jérôme Besnier (Emergency Response Manager of the Humanitarian Division (DAH) from
Handicap International)

Validation
Marie Leduc, Head of Emergency Technical Unit, Technical Resources Division (DRT) from
Handicap International

Edition
Stéphanie Deygas
Handicap International
Innovation and Knowledge Management Unit

Rights and Permissions

This work is available under the Creative Commons Attribution-NonCommercial-
NoDerivatives 4.0 International license (CC BY-NC-ND 4.0). Under the Creative Commons-
NonCommercial-NoDerivatives license, you are free to copy, distribute, and transmit this
work, for noncommercial purposes only, under the following conditions:
Attribution-Please cite the work as follows: FAURE Gaëlle; MARTINEZ ANICETO Julio;
VAAST Priscilla; CLOUTEN Jody; LAVIROTTE Pauline; MERCIER Pierre ; BESNIER Jérôme.
Ebola Infection Prevention and Control Guideline: Ambulance and House Decontamination
Project in Sierra Leone. Lyon: Handicap International, 2016. License: Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0).
Noncommercial-You may not use this work for commercial purposes.
No Derivative Works-You may not alter, transform, or build upon this work.
1
Table of contents

1 Introduction - IPC Definition and Principles ................................................................. 5

2 Set up of Hastings Ambulance & Decontamination Platform ..................................... 9
2.1 General set up of Hastings by Risk Zone ............................................................................... 9
2.2 Detailed set up of Hastings ...................................................................................................... 10
2.3 A rigorous circuit of staff, cars and material ....................................................................... 11

3 Water & Sanitation in Hastings ..................................................................................... 12
3.1 General set up of water distribution system ....................................................................... 12
3.2 Colour code and identification of the water ......................................................................... 13
3.3 Water supply ............................................................................................................................... 14
3.4 Water storage ............................................................................................................................. 14
3.5 Water distribution ...................................................................................................................... 15
3.6 How to operate the specialized water system of Hastings site ...................................... 16
3.7 Chlorination ................................................................................................................................. 17
3.8 Daily check of the water in Hastings ..................................................................................... 21
3.9 Sanitation ..................................................................................................................................... 21

4 Organizations and Rules in the different Zones in Hastings .................................... 23
4.1 General Dressing code in Hastings ....................................................................................... 23
4.2 Red Zone ..................................................................................................................................... 24
4.3 Green Zone ................................................................................................................................. 26
4.4 White Zone .................................................................................................................................. 30

5 Human Resources (HR) ................................................................................................. 32
5.1 IPC Organization Chart ............................................................................................................ 32
5.2 Job descriptions of the IPC Team ......................................................................................... 32

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6 Daily work in Hastings ................................................................................................... 33
6.1 Ambulances ................................................................................................................................ 33
6.2 Decontamination Van ............................................................................................................... 35
6.3 Dirty Car ...................................................................................................................................... 35
6.4 Washing Station......................................................................................................................... 35
6.5 Waste Management .................................................................................................................. 36
6.6 Laundry ....................................................................................................................................... 36
6.7 IPC Store Management ............................................................................................................ 37
6.8 Collaboration with ADRA ......................................................................................................... 38

7 Daily work in Outreach .................................................................................................. 39
7.1 Ambulance Team ....................................................................................................................... 39
7.2 Decontamination Team ............................................................................................................ 39
7.3 Dirty Car ...................................................................................................................................... 40
7.4 Clean Car ...................................................................................................................................... 41
7.5 In the community ....................................................................................................................... 41

8 Conclusion ....................................................................................................................... 53

Annexes .................................................................................................................................. 54
Annex 1 - Standard Operating Procedures (SOPs) ......................................................................... 55
Annex 2 - Job descriptions IPC team ................................................................................................ 110
Annex 3 - WataTest user guide ..........................................................................................................138
Annex 4 - AquaChek® High Range Chlorine Test and protocol ................................................ 140
Annex 5 - PPE & IPC ITEMS SPECIFICATION ................................................................................ 146
Annex 6 - Dispatch process & supporting documents................................................................... 151
Annex 7 - Worker’s health issue protocol ....................................................................................... 167

3
Table of acronyms

AA Ambulance Attendant
ADRA Adventist Development & Relief Agency
CMS Central Medical Store
D/U Dressing/Undressing
DDU Driver / Dresser Undresser
DSO District Surveillance Officer
ETC Ebola Treatment Centre
EVD Ebola Virus Disease
GZ Green Zone
HC Holding Centre
HI Handicap International
HP Health Promoter
HTH High Test Hypochlorite
IPC Infection Prevention & Control
NaDCC Sodium Dichloroisocyanurate
PPE Personal Protective Equipment
PPM Parts per Million
RZ Red Zone
SOPs Standard Operating Procedures
TL Team Leader
WHO World Health Organisation
WZ White Zone
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1 Introduction - IPC Definition and Principles

IPC stands for INFECTION PREVENTION AND CONTROL of a communicable disease.

IPC Objectives
1. Breaking the chains of transmission of a communicable disease within communities,
families, health facilities,
2. While ensuring frontline workers’ own safety.
“Failure to apply infection control measures favours the spread of pathogens, and health-
care settings can act as amplifiers of disease during outbreaks, with an impact on both
hospital and community health.”1

Ebola Virus Disease transmission
Viral Hemorrhagic Fevers (VHFs), and specifically the Ebola Virus, are human-to-human
transmitted through direct contact with body fluids of an affected patient.
“Evidence from outbreaks strongly indicates that the main routes of transmission of VHF
infection are direct contact (through broken skin or mucous membrane) with blood or body
fluids, and indirect contact with environments contaminated with splashes or droplets of
blood or body fluids. […] Infection prevention and control is key to the reduction of spread
of infection from patients to health workers, health workers to health workers, and from
the patient to the rest of the community2.
“Ebola is not a fecal-oral pathogen and there is no reported transmission via water”3.

Ebola Virus in the environment
“The characteristics of the Ebola virus indicate that it is likely to be fragile in the
environment; its infectivity and virulence will decline rapidly under conditions found in
tropical climates” 3.
Survival of the Ebola virus in the environment is depending of the surfaces or body fluids in
which it is located but is relatively short: from 2 days in tropical settings on stainless, glass
or plastic surface to 6 days in laboratory conditions. Until 3 days in faeces in tropical
conditions 4.

1 WHO source http://www.who.int/csr/bioriskreduction/infection_control/background/en/
2 WHO Clinical management of patients with VHFs – March 2014
3 WHO Rapid Guidance on the decommissioning of Ebola Care Facilities – March 2015
4 WHO Rapid Guidance on the decommissioning of Ebola Care Facilities – March 2015
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Susceptibility to disinfectants
Ebola virus is quite fragile and easily inactivated by the sun and by some chemicals:
“A wide variety of disinfectants can be used for the rapid and complete inactivation of
Ebola. Filoviruses in general and the Ebola virus specifically are highly susceptible to a wide
variety of disinfectants and other chemical agents. Some of these include: 3% acetic acid
(vinegar); 2% peracetic acid; 1% glutaraldehyde; quaternary ammonium compounds;
phenolics; hydrogen peroxide; ethanol-based products; 0.5% and 0.05% chlorine-based
products (e.g., domestic bleach, sodium hypochlorite, calcium hypochlorite); and organic
solvents”4.

Main IPC principles during an Ebola Outbreak
Because of the above scientific knowledge (human-to-human transmission of Ebola,
survival of Ebola virus in the environment and its susceptibility to some chemical agents);
IPC encompass a large scope of processes and Standard Operating Procedures (SoPs)
based on several principles. The main principles are listed below and must be applied within
communities, health facilities or Ebola Treatment Centres5:
• Activities are segregated into zones according to risk of contamination, defining
as such risk zones:
- High Risk zone (also called Red Zone) are areas where patient or
potentially contaminated environment or material are located.
- Low risk Zone (also called Green Zone) included areas were activities
link to the running of the Red Zone are taking place (chlorine mixing,
laundry area, changing rooms, ambulance car wash).
- Very Low Risk Zone (also called White Zone) where all other activities
are located: logistic, office.

• Movements in the different risk zones are restricted and organized:
- There is a pre-defined circuit for staff, vehicles, material, patient or
families throughout risk zones (for example equipment & materials must
not be shared between the different risk zones).
- Access to certain zones is restricted to certain category of people/staff.
There is one entrance and one exit point for each zone that must be
strictly monitored. Zones are well delimited with proper fencing.

5 These underlying principles are drawn from WHO Interim IPC guidance for care of Patients with
suspected or confirmed Filovirus Hemorrhagic fever in health-care settings, with focus on Ebola –
December 2014; Médecins Sans Frontières filovirus haemorrhagic fever guideline- -2008

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- In Red zone, staffs always enter by team of two. One stays “clean”: not
touching anything and spraying the environment or his colleagues’ hands;
the other one is “touching” the environment with his gloved hands
(opening doors, removing waste, carrying items).

• Protective clothes in Red and Green Zone:
- All people entering Red Zone must wear appropriate Personal Protective
Equipment (PPE) and all people leaving Red Zone must remove protective
clothing according to a strict protocol, and be disinfected. Due to the
tough conditions when wearing PPE, staffs stay only a limited time in Red
Zone (one hour, not more).
- All people entering Green Zone must wear at least scrub and boots.

• Use of chlorinated water with 0.5% and 0.05% concentration:
- 0.05% for disinfection of bare hands, skin and for use in laundry.
- 0.5% for disinfection of body fluids (excreta, vomit, etc.), corpses,
environment in Red Zone (soiled items of the patients, house
decontamination of a patient, toilets and bathrooms, ambulance, reusable
items of the PPE, footbath).

• Safe Waste Management: No waste is allowed to leave the Red Zone. Waste must
be managed in the zone where generated. If this is not possible Waste always goes
from White Zone to Green Zone or from Green Zone to Red Zone. This is a one way
movement. No return is possible.

IPC principles
IPC principles, if strictly respected and rigorously followed could have a direct impact on
the epidemic curve by breaking the transmission chains.

The following guideline is describing IPC organizational processes and Standard Operating
Procedures (SoPs) that have been set up, carried out and monitored during the HI
Ambulance and House decontamination project in Western Area (Freetown) in Sierra Leone
in 2015 (during the 2014-2015 West Africa Outbreak). It represents choices made in terms
of protocols at a certain point of time. This guideline would be a starting point should HI be
involved again in a frontline Ebola project: it will be completed as appropriate by guidelines
to be released by relevant international stakeholders.

This Ambulance and House decontamination project funded by DFID, through a specific
mechanism called DEERF (DFID Ebola Emergency Response Fund), was the first Ebola
“frontline project” carried out by Handicap International.
Western Area was the main affected district. Within the coordinated national and
international response in this district, HI was in charge of:
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1) Transportation of any suspected or confirmed Ebola patient in ambulance from his
house to an isolation or treatment centre,
2) Decontamination of the houses of the patients transported and evacuation of
her/his material potentially contaminated (inclusive of intervention within slums
area or under specific conditions like Wet Weather conditions),
3) Decontamination of the ambulances and other decontamination vehicles after the
intervention in community.

In this view, an ambulance platform inclusive of a decontamination site was set up in
Western Area Peninsula, in Hastings precisely. Another site (Fire Station), more central,
closer to Freetown was used for departure of teams and parking but not as a
decontamination site.

From December 2014 to November 2015, more than 3800 patients have been transported
and more than 1800 houses have been decontaminated. During the first weeks of the
project, transportations reached their highest average of 64 per day. This project
employed not less than 250 staffs - among them 5 expatriates (FTE). No staff
contamination occurred during this project.

Additionally to this guideline, in order to get more insight on this project and HI work in
Ebola Context, other resources are now available:
• A video displaying the Ambulance and House decontamination project made in
October 2015 by HI USA: https://www.youtube.com/watch?v=n7-qppnHWRU
• An article from “Alternatives Humanitaires” describing the Ambulance and House
decontamination Project challenges and the story of its deployment: “Breaking the
transmission chains of the Ebola virus within a community: the story of a
deployment in Sierra Leone” by Gaëlle Faure, Pauline Lavirotte, Jérôme Besnier,
Magalie Vairetto and Jean-Baptiste Richardier
http://alternatives-humanitaires.org/en/2016/01/12/breaking-the-transmission-
chains-of-the-ebola-virus-the-story-of-a-deployment-in-sierra-leone/
In French: http://alternatives-humanitaires.org/fr/2016/01/12/rompre-les-chaines-
de-transmission-du-virus-ebola-lhistoire-dun-deploiement-en-sierra-leone/#more-
248
• A “Staff Safety Package in Ebola context” has been developed; it gathers all the
elements, documents, processes set up in order to ensure safety of national and
expat staff. It encompasses pre and post mission protocol, HR package, prevention
measure set up on the field, medevac process and institutional organization
necessary for implementation of these measures.
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2 Set up of Hastings Ambulance & Decontamination Platform

2.1 General set up of Hastings by Risk Zone

Figure 1: General Set Up of Hastings site
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