International Nurses Day 2020: Case study of the week
28 April 2020
COVID-19 and lessons learned from the dealing with the Ebola virus: Liberia
Contributor: Aaron K Sonah
I work as a nurse anaesthetist and epidemiologist at the Bong Ebola Treatment Unit in Bong County, Liberia. Lessons we learned during the Ebola epidemic, including about how to be resilient in the face of difficult circumstances, may be useful during the COVID-19 pandemic.
When the Ebola virus arose in the West African countries of Liberia, Sierra Leone and Guinea in 2014, it took us by surprise. But whereas Ebola affected only a few countries, the COVID-19 pandemic has reached almost every part of the world.
It has produced a similar situation to the Ebola outbreaks, which means people, including nurses, are in fear of exposure to a life-threatening disease, often with few resources, including a lack of personal protective equipment (PPE).
Today we again have to cope with social distancing, which is unusual for most of us nurses, and with regarding everyone we meet as a potential source of infection, which understandably makes us feel nervous, just as it did during the Ebola outbreak.
At the onset of the outbreak, many Liberians denied the existence of Ebola, and there was lots of misinformation about the infection. As the number of cases increased, more nurses became infected and the death rate increased, we all became suspicious of everyone we met because, just as today, we were afraid of taking the infection home to our families. With the arrival of COVID-19, we have gone back to not shaking hands, washing our hands frequently, avoiding crowded places and keeping our distance, and looking for ways to protect ourselves.
Following these rules during the Ebola outbreak was not easy at first: the lack of information about the disease, and misinformation from many sources, made it difficult for health workers. As more information was shared about cases and deaths, there was a change in people’s behaviour.
Nurses and other health workers, in collaboration with community leaders, were able to help communities focus on stopping the spread of the infection. Many people who suspected they had Ebola refused to go to hospital because of unhelpful rumours that were circulating. But as the number of cases increased health workers worked with community leaders and pressure groups to ensure that everyone followed the guidelines set by the government about isolation and treatment.
Ebola caught us unawares, but with the help of the international community we learned and were able to start managing outbreaks with less international input. The last Ebola outbreak in Mambah-Kaba District, Margibi County, was contained with little international input.
Infection Prevention and Control
Since the Ebola outbreak, Liberia now has screening and isolation units in every health facility, where patients and visitors are screened before entering. Everyone, including staff, visitors and patients, must wash their hands before entering. Once inside the units, patients are asked questions based on the case definition of an outbreak or for other contagious diseases. Anyone suspected of infectious disease is isolated in the screening and isolation unit. Patients who are suspected of having an infectious disease are taken via a separate exit and then by ambulance to a hospital or treatment center, depending on the services provided locally.
During the Ebola outbreak we kept a one metre distance rule and used risk-appropriate PPE for all clinical procedures, including taking the patient’s blood pressure. The rationale for this was to avoid airborne and droplet infection, while ensuring that PPE was used appropriately to conserve supplies.
With Ebola, we followed a checklist that was developed to ensure no one got infected while caring for the Ebola patient, which is also important when caring for patients with COVID-19. To avoid the stress of getting infected, it is also very important that nursing and other healthcare staff rest properly, get enough sleep, keep positive thinking, talk more about the people who recover than those who have sadly died, use appropriate protective equipment, accept the situation as it is when you do not have the power to change it, focus efforts on what can be changed, foster a spirit of fortitude, patience, tolerance and hope.
During the Ebola in Liberia, we were careful to discuss each patient and plan their care. We also reminded ourselves and each other to keep safe and follow guidelines. It was important to caution each other that, whenever you feel you are getting tired, leave the treatment centre and remove your protective equipment before you lose your last strength and risk getting infected. To keep us together as a team we were constantly interacting with our colleagues, discussing our concerns and the treatment we were delivering. We tried our best for each patient, even if we were expecting a poor outcome.
In times like these, nurses should be supportive of each other and recognise that people will have different levels of strength and abilities to cope. We worked as a team and we were for each other till the outbreak came to an end.
The mortality rate of Ebola in the treatment unit I worked was about 50%, whereas for COVID-19 it appears to be between 3% to 5% depending on the country and other factors. When we are faced with a situation like these, our strength will usually come from seeing patients recovering and leaving our care. My strength came from seeing children, maybe our future leaders, mothers, fathers and grandparents being cured and going back to join their families.
I always felt that it could have been my child, my mum or dad. I used to take fruit in for the children because I had promised to if they took their medications, and I felt happy holding them in my arms without a PPE when they had recovered.
It was also great when adult patients who had recovered were going home and we were able to touch them without a PPE and let them see our faces. They recognised us by our voices and could immediately call us by names, which were written on our PPE.
The coping strategies we developed during the Ebola outbreak are still just as valid during this COVID-19 pandemic. I am making sure I have enough rest, following the precautionary guidelines and getting as much information about the virus as I can.
By the end of the Ebola outbreak in Liberia, all healthcare workers did Safe Quality Service (SQS) training about the management of Ebola. We also established Epidemic Preparedness Response Teams at all levels of the country, which encourage local people to report unusual illnesses to healthcare workers. Similar teams and training schemes can be set up in most areas of the world, including in middle- and low-income countries where resources are scarce.