WHO Ebola diaries: Changing the health worker culture

Cota Vallenas

Dr Cota Vallenas talks about her experiences in the early days of the Ebola outbreak as an expert in infection prevention and control. She reminds us that health-care workers are among the most vulnerable and a cultural change is needed around self-protection to ensure these frontline workers don’t become infected.

It was Spring Break in the United States and WHO infection prevention and control (IPC) expert Dr Constanza (Cota) Vallenas was visiting her sons in New York. In late March 2014, she began seeing emails from WHO epidemiologist, Dr Pierre Formenty, about an outbreak of Ebola virus disease (EVD) in Guinea. Although a French-speaking IPC specialist had been deployed, more were needed. On 4 April, she was deployed to Guinea to train health-care professionals in IPC practices that would prove critical to the health and safety of hundreds of frontline workers.

Trainings on infection prevention and control

When she arrived in Conakry, she recalls a patient who arrived there and was treated in Kipe Hospital. "Unfortunately, they were unaware of the Ebola outbreak in their country. When the patient arrived, the doctors and nurses treated him without personal protective equipment (PPE). There was no culture among health workers of self-protection." As a result of this case and lack of awareness, a number of health-care workers became infected.

In an effort to address IPC needs, WHO team helped set up a triage system in Donka Hospital. These efforts were difficult by multiple entry points, numerous buildings and hundreds of people coming to the hospital every day. At one point, a doctor in this hospital also died. A number of his colleagues had been involved in his care. When they learned he was Ebola-positive, they were scared and many of them disappeared into the community. It became impossible to contact or follow them to ensure they did not become ill.

Because health-care workers were fearful, they began applying IPC and PPE measures inappropriately. For example, when hand washing solutions are made, they usually have .05% chlorine in them. In some places in Guinea, workers were using pure chlorine bleach or water mixed with a 2% solution. This increased their risk of exposure through dry, cracked hands. They also used PPE for any circumstance that brought them into contact with patients – Ebola-positive or not.

It became clear that IPC training was urgently needed. "We knew that Ebola would appear in other hospitals and treatment centres," Cota recalled. "There wasn’t a sense of infection control, so I spent the next 12 days going to the main hospitals and health centres in Conakry explaining and demonstrating infection control: how the disease is transmitted, how workers could protect themselves, and so on. It was tough."

At the end of her deployment, Cota returned to Geneva and continued working not only on IPC and PPE guidelines, but also in a new area - occupational health and safety. In November 2014, she returned to Conakry to help train members of the Cuban brigade in the proper use of PPE and patient clinical management.

During the training, she noted that even though "these were doctors, nurses, administrators and coordinators with solid experience in international deployments, [they] really needed to be trained urgently on how to manage patients inside an Ebola treatment unit (ETU)". The training was successful, only 1 doctor out of the entire brigade of 400 health-care professionals became infected.

Delivering compassionate care while ensuring safety

Cota believes that WHO’s trainings on IPC and PPE practices, as well its approach to patient care, not only saved the lives of health workers, but also lowered the mortality rate among patients. "The general approach with Ebola treatment is to isolate patients and reduce contact with health workers." The clinical management teams became "very dynamic in finding solutions for treating patients with compassion while also ensuring their own safety."

This included finding ways for doctors to communicate with their patients without entering isolation areas (Red Zones) in the ETUs or donning PPE. In some ETUs, when a doctor enters the Red Zone, they attach a photo of themselves to their PPE so their patients have "some sort of recognition that this astronaut or whatever is that person I’ve already met, with whom I’ve talked."

For Cota, one of the biggest lessons learned was the "need to focus more on routine care and protecting health workers. This is a total change in culture. There hasn’t been a culture of self-protection, and changing that won’t be easy." She believes no cost should be spared in finding innovative clinical management tools and PPE that ensures the safety of workers while delivering compassionate care.

"I realized these health workers are very vulnerable. Many are poor people — professionals, of course — but just from the community. No one is taking care of them. They know about protective measures, but they didn’t have the training nor the PPE. They didn’t have the resources to practice self-protection."

Cota hopes that the work she and others have done around IPC, PPE and occupational health and safety have made a difference and saved lives. More than anything, though, she hopes it is the beginning of shifting the health worker culture to one of self-protection and good care.