Introduction
During the 2013-2016 Ebola outbreak in West Africa, the lack of infection prevention and control (IPC) measures in health care facilities and in the community was one critical element that amplified human-to-human transmission and contributed to the magnitude of this humanitarian disaster. Health care workers in particular were highly vulnerable and disproportionally affected by the Ebola virus disease. It is estimated that they were between 20- and 30-times more likely to get infected than the general population. 1 However, when appropriate IPC measures are applied, the risk of being infected with the Ebola virus at the workplace can be drastically reduced. 1
Throughout the outbreak, the main challenges in establishing IPC activities were to quickly address the specific needs for those caring for Ebola patients, and in parallel, to establish and support the basic IPC activities in non-Ebola health facilities.Reference Cooper, Fisher, Gupta, MaCauley and Pessoa-Silva 2 In this context, hand hygiene is the single most effective initial step for infection control and safe care. In health care settings where frequent disinfection is required, hand hygiene is best obtained with alcohol-based hand-rub solution (ABHRS). 3
In August 2014, the Geneva University Hospitals (HUG; Geneva, Switzerland) implemented local production of ABHRS in non-Ebola health facilities in West Africa in collaboration with the Ministries of Health (MoH) and the World Health Organization (WHO; Geneva, Switzerland). This was the first attempt in a disaster context. Local production of ABHRS has been implemented in low- and middle-income countries world-wide over the last 20 years with positive impact.Reference Allegranzi, Sax, Bengaly and Richet 4 – Reference Djientcheu 7 In this report, the implementation challenges are discussed, as well as the lessons learned in building local capacity in the production of ABHRS in Liberia and Guinea.
Case Report
Following a field assessment on IPC needs in non-Ebola health facilities in Liberia and in Guinea, a training of pharmacist personnel on the production of ABHRS based on the WHO formula 8 was developed, adapted to the emergency context. The initial steps included the validation of the WHO formula by the MoH and the registration of the hand-rub solution as pharmaceutical product in the country. The MoH selected the production sites based on the following criteria: sites should be located in a hospital with a maternity department to increase safety in providing care to mother-and-child populations; and they respected a balance between rural and urban health facilities. In addition, each site had to provide a dedicated clean space that could be safely locked at night, composed of two rooms minimum, with windows for aeration and a sink with runnable water. The training included a mix of didactic and hands-on sessions provided by international experts. The training was adapted from previous experience in sub-Saharan African countries where local pharmacists from different African countries were successfully trained in ABHRS production in 2010 and 2013 through a program from the WHO African Partnerships for Patient Safety (APPS). 9 Given the impact of the epidemic on the local trade, all necessary materials were provided through the project. The materials included laboratory equipment, reusable 100 ml bottles for personal use, chemical products, and bioethanol based on the WHO recommendations 8 to produce ABHRS (Table 1). Materials were in enough quantity to produce ABHRS for approximately one year.
Table 1. List of Materials Provided by the Project, Per Kit
a PP = Polypropylene.
Resources and Partnership
The Swiss Agency for Development and Cooperation and the Humanitarian Aid Unit (SDC/HA; headquarters [Bern, Switzerland] and in-country offices) and the HUG provided financial and logistical support for the implementation of the intervention. The main partners were the MoH of Liberia and Guinea; the WHO headquarter in Geneva, and their country office in Liberia and Guinea; the SCD/HA headquarter in Bern, and their local office in Liberia; the division of tropical and humanitarian medicine, and the hospital pharmacy at the HUG; and the private Addax BioEnergy Company (Makeni, Sierra Leone) that facilitated the purchase of bioethanol in Sierra Leone.
Liberia - Case Study 1
Need Assessment
At the peak of the epidemic, in September 2014, on the request of the SDC/HA, the HUG assessed the possibilities to participate in the Ebola response based on their expertise and experience, particularly in IPC. Highlighting the needs and taking into account that there were no specific vaccines at the time and numerous on-going activities by the local and international response teams, the SDC/HA decided to support preventive aspects with immediate and long-term impact on IPC, more specifically to create the local capacity for production of hand-rub solution and its use for hand hygiene as part of the minimum standard for IPC. The project was in line with national and international effort to support the re-opening of the health sector in Liberia, including the Keep Safe Keep Serving initiativeReference Cooper, Fisher, Gupta, MaCauley and Pessoa-Silva 2 to prevent further exposure to Ebola for the staff and patients in health services and the community.
Intervention
The training was given over a two-day period. A Malian pharmacist, trained at the HUG and currently responsible for the ABHRS production in Bamako, Mali, gave the training.
Materials and Infrastructure
The sites received the materials prepared and packed at the HUG with the exception of the bioethanol (Table 1). The kits contained the chemical reactive ingredients for the quantitative quality control of the solution. 8 ,10 The bioethanol (>96%) was purchased in Makeni (Sierra Leone) at the Addax BioEnergy Company and transported by road to Monrovia. All sites met the requirements in terms of infrastructure.
Achievements
Twenty-one licensed pharmacists and one laboratory technician from 10 sites attended the training in November 2014, which was provided in two sessions. The MoH chose initially three public hospitals near Monrovia as pilot sites for starting the ABHRS production. The project was then expanded to seven other hospitals to allow a good nation-wide coverage (Figure 1). All sites had maternity departments. In the pilot sites, the production started in February 2015, and a few months later in the additional sites. In the space of one year (March 2016), more than 6,000 bottles were produced in the 10 sites and 4,000 distributed (Table 2). Pharmacists in eight of the 10 sites were able to produce ABHRS after the training. Results from quantitative quality control performed on various samples from initial batches of ABHRS were done at the HUG in Geneva and showed satisfactory results.
Figure 1 Sites.
Table 2 Summary of Training Program on ABHRS Production
Abbreviations: ABHRS, alcohol-based hand-rub solution; HUG, Geneva University Hospitals.
Guinea – Case Study 2
Need Assessment
In the spring of 2015, Guinea was experiencing a different outbreak curve. The country was one year into the Ebola epidemic with cyclical patterns of intense transmission interspersed by misleading declines and persistent foci of cases across the whole country. Efforts to control the epidemic were starting to be effective. The project in Liberia caught the attention of the Guinean government as a relevant response to increase safety of care within health facilities in the country. The HUG experts visited Guinea at the request of the MoH to discuss the possibility and feasibility of local production of ABHRS. When the project started in the fall of 2015, the number of cases had fallen in a sustainable manner and the Guinean MoH was in the process of developing the health system recovery plan with IPC as one of the pillars of the new strategy. 11 During the Ebola outbreak, hand hygiene was required within and outside the health care setting and became routine practice for safe care. The moment was then timely to create local capacity of ABHRS production.
Intervention
The training was given over a three-day period to allow more time for hands-on activities, and an assistant pharmacist from the HUG helped in supervising the practical session. A new objective was to train pharmacist as local facilitators to build the local capacity in training.
Materials and Infrastructure
The sites received the materials from the HUG. Five sites with less capacity to perform the highly technical procedures for the quantitative quality control of hydrogen peroxide received instead in their kits the Quantofix peroxide test strips, a semi-quantitative quality control method. 12 Alike in Liberia, bioethanol was purchased in Makeni (Sierra Leone) and transported by road to Conakry. In terms of infrastructure, only one site did not meet the requirements and had to designate another space before starting production.
Achievements
From the start, the MoH decided to cover the entire country by selecting the main public hospitals of the seven administrative regions (districts) as production sites. In Conakry (considered as the eighth administrative region), the main public hospital being in renovation, two large hospitals (one public and one semi-public), as well as a community medical center, were chosen (Figure 1). All sites had maternity departments. Twenty pharmacists (the head pharmacist and an assistant from each facility) attended the training provided in three separate sessions and two visits (September and November 2015). In addition, the heads of the central pharmacy of Guinea and of the national laboratory of drug quality control, both pharmacists by training, were invited to the initial training. Their participation had the purpose of developing a supply chain and local capacity in quality control for ABHRS in the long run. Four selected pharmacists from the initial training session served as facilitators (trainers) for their colleagues in subsequent sessions. In the space of one year, 1,800 bottles were produced and 800 distributed (Table 2). Pharmacists from five sites that had received the bioethanol at the time of training or shortly after were able to produce ABHRS. In the remaining sites, they received the bioethanol months after the training and underwent a refresher course (September 2017). Samples of ABHRS from initial batches were analyzed using the quantitative quality control procedure at the HUG in Geneva and showed satisfactory results.
Discussion
In the early phase of the Ebola outbreak, health care facilities in the affected regions lacked the basic standard precautions such as hand hygiene practices and the use of appropriate personal protective equipment to prevent nosocomial infections due to common pathogens. 1 , Reference Cooper, Fisher, Gupta, MaCauley and Pessoa-Silva 2 In this susceptible context, a pathogen such as the Ebola virus transmitted by direct contact can disseminate quickly. The international response teams carried out massive efforts to improve the IPC activities in health care settings, both at the individual and environmental level. The tasks were major and the actions were focused on setting up facilities to safely care for Ebola patients and improving basic IPC measures across non-Ebola health care facilities and in the community.Reference Cooper, Fisher, Gupta, MaCauley and Pessoa-Silva 2 , Reference Matanock, Arwady and Ayscue 13 – Reference Nyenswah, Massaquoi and Gbanya 17 Hand hygiene was established everywhere and people were asked to wash and disinfect their hands as often as possible. Building entries were equipped with water and soap or with 0.05% chlorine solution; the use of personal bottles of ABHRS spread rapidly in health care facilities. In this environment, building capacity in ABHRS production was appropriate, rational, and timely. Expected benefits were significant in the short-term, resulting in increased safety of care in health care facilities and trust in the health care system, and in the long-term by decreasing the dependence on foreign donations and by locally producing a solution cheaper than imported ones. 3 , Reference Bauer-Savage, Pittet, Kim and Allegranzi 6 , 18 In addition, ABHRS has recently been added to the WHO essential list of drugs.
The implementation of ABHRS production was successful in both countries. Followed are the main challenges and lessons learned at an immediate operational level and in terms of sustainability.
Operational Challenges
Disaster Context
The initial challenge was inherent to the on-going Ebola outbreak that disrupted the everyday life of the people in the affected countries, the commerce, and the traveling in-to and out-of the country. To address these issues, the project provided all raw materials to support the production of ABHRS and covered the trainees’ costs (eg, lodging, food, and transports). Under these conditions, it was feasible to train pharmacists and to locally initiate production despite the emergency context. Trainees had sufficient knowledge and experience in basic pharmacy to learn this new skill and displayed strong commitment during the training. The MoH in both countries supported the project by facilitating the venues and authorizations and providing dedicated MoH personnel to assist with the implementation. The project complemented the efforts by local and international partners involved in IPC activities.
Learning by Doing
Trainees asked for more than practice before doing it independently and to have supervision during their first production. In Guinea, the project integrated this need by adding one training day and a refresher course. This approach had the advantage to select participants to serve as local trainers in subsequent training sessions. The later was key for the sustainability of the project and in the perspective of enlarging the training offer to peripheral health facilities.
The first kits were packed in big cardboard boxes and arrived at the destinations with some damage after the transport by boat. The kits following were packed in a wooden structure and breakable laboratory material was replaced by polypropylene equipment whenever possible to insure durability.
The quantitative quality control procedure to assess the level of hydrogen peroxide in the solution required technical skills and expertise and could not be performed in every site. Experts from the WHO and the HUG validated a semi-quantitative quality control method 12 to overcome this issue. A method using filter paper (ie, Quantofix peroxide paper test strips) was distributed to a few sites, and an agreement with sites performing quantitative analysis was set up to send samples with dubious results for confirmation as well as random samples on a regular basis.
Access to Raw Resources
The bioethanol, which was not sent from Geneva for safety reasons, could not easily be found locally as it is neither produced in Liberia nor Guinea. Bioethanol had to be purchased in Makeni, Sierra Leone. The transport to both countries required time-consuming paperwork and revealed to be more complicated and slower than anticipated. At the end of the project in March 2016, a few Guinean sites had not received their barrels of bioethanol yet and could not start the production. As a result, when the bioethanol eventually arrived, they felt that they were not ready to start the production without supervision or re-training.
Supply Conflict
The project started at a time where donations of ABHRS from the international community poured into the countries in large quantity, and most hospitals had substantial stocks. Hospitals were instructed to use the donations first. As a result, trained pharmacists were not able to immediately and regularly produce ABHRS after the training and likewise felt that they were partially losing their skills. Low quantity and regular production to maintain the skills was the recommended approach, along with central coordination of the supplies to distribute the stocks to health facilities without the capacity of producing ABHRS. A refreshment training focusing heavily on practical skills took place in Guinea in September 2017 for the pharmacists and for the local facilitators to reinforce their knowledge. Other themes such as ABHRS promotion and adoption by end-users were discussed and solutions shared between sites. At distance of an outbreak, this supply issue would likely not occur. On the contrary, the government would be challenged with the very high price of imported ABHRS compared to locally produced solutions.
Sustainability Issues
Continuous Access to Materials and Equipment
There are general concerns about purchasing locally the materials in the event of loss, damage, or depletion of reserves. Most basic items of the WHO list 8 are proposed in different options and materials (eg, metal, plastic, or glass) based on local availability and are the items most easily find locally. The alcohol meter and the precision scale are the exception to this, but they are expected to last long with normal use.
Regarding the reagents, the glycerol (98%) is available broadly and its purchase would not be an issue. The availability of the hydrogen peroxide (3%) used to inactivate contaminating bacterial spores in the solution is more of a concern. The reagents not being routinely available in the two countries of implementation, its purchase will need some ahead planning and coordination with the central pharmacy or other governmental instance.
The kits contained 100 ml bottles with caps for personal use. The bottles are designed to be reusable after cleaning, but over time, between the ones that would break down or be lost, the need for replacement was part of the discussion with the local authorities. The bottles and caps in the kits are patent protected and have the particularity to be operable with one hand. Options are to use existing local recipients or to create a new market by unifying the needs from Liberia, Guinea, and Mali, and potentially other countries in West Africa, and ordering the bottles ideally from an African producer. This same issue was raised during previous WHO APPS workshops 9 in Mali and Zimbabwe, and discussions could also be engaged with APPS to find common solutions. Options were largely debated between local partners, but discussions were not pursued further due to the fact that production of ABHRS was not yet reliable and substantial and likewise the distribution of existing bottles.
The main supply concern is the impossibility to find pure ethanol (>96%) in enough quantity at a reasonable price in Liberia or Guinea. National authorities discussed the possibilities of local production of bioethanol. There was a real interest for the potential benefits in term of supporting local agriculture, economy, and employment. However, it was clear that this would be an option worthy to explore only if and when the demand for ethanol has proven to be real, reliable, and sustainable in the country. In the meantime, the objective is to purchase the bioethanol from Sierra Leone.
Support by Government and Local Partners
The project itself did not include long-term support, with the exception of technical assistance. Continuous financial support from the local partners, including the MoH, is a crucial challenge. Without financial assistance to cover travel costs and participants allowance, regular training and supervision activities will not occur, as well as replacement of lost or broken materials. From the start, local governments were involved in all aspect of the project implementation and were committed with sustaining the ABHRS production, but they were struggling to re-establish the health care system and were limited in their capacity to offer tangible financial assistance. During project implementation, WHO (in-country office) was a strong partner and was committed to support training activities by extending the training to peripheral health care facilities and supporting the purchase of local materials and equipment. In addition, nongovernmental organizations (NGOs) involved in IPC activities in the same hospitals where the ABHRS production was implemented were solicited to reinforce the promotion and adoption of ABHRS.
Access to Technical Support
Pharmacists received digital training materials on a USB key and personal access to the HUG Pharm-Ed 19 web site, which includes all technical documents. Trainers were available by email for specific questions. A step further would be to offer a web-platform or group mobile-messenger system to keep the participants connected with their pairs and the trainers, as well as to stimulate exchanges. To facilitate future training in francophone countries, a manual for the facilitators was developed during the project implementation in Guinea. The manual details the procedures to organize the course and to set up practical activities and compiles the required materials in one document. The manual is currently available in French from the HUG Pharm-Ed web site, along with a didactic video. 19 , 20
From Production to Promotion
In both countries, measures to promote behavioral changes and supervision of the systematic use of ABHRS among health care workers and patients were still lacking. National authorities were finally recognizing IPC as an essential component of safe care and a strong health system. The task of promoting the use of ABHRS within the public hospitals was given to the pharmacists in the absence of a designated IPC team, and most of them did not have time and expertise to engage seriously in these activities. As a result, adoption rate was low among end-users, despite the fact that the majority of health care workers recognized the benefit of using ABHRS for safer care. The NGOs involved in behavioral changes for improved IPC partially filled the gap. During the refresher training course, solutions to increase ABHRS adoption rate by health care workers were specifically discussed and shared among participants.
Social and Cultural Context
Acceptability—The use of ethanol could pose a challenge in countries where there is a fear that ethanol be diverted for other purposes, such as a consumable. To work around this issue, isopropyl instead of ethanol can be used, as explained in the WHO formula. 8 Successful implementation and acceptation were recorded in Middle-East countries. However, in the cases presented, the issue around availability would not be resolved, as both products are not available in either country.
Conclusion - Recommendations
Efficient hand hygiene with hand-rub solution had an impact on health care workers’ confidence in their ability of providing safer care and on the patients’ trust in the health care system. This is particularly critical in an outbreak setting to keep the health care facilities open and to provide the community with continued access to care.
This pilot project showed that building local capacity in ABHRS production is feasible, even in emergency and poor-resource settings when all materials and ingredients are provided. The project evolved during implementation to address operational and immediate challenges. Sustainability of ABHRS production remained, however, an issue as it depends on the government financial and political commitment, the capacity to create the demand for ABHRS within the country, the local purchase of the necessary materials and chemical products, and the availability of continuous local partners’ support. In Table 3, there are a few recommendations for future programs resulting from the lessons learned in this specific project. They are complementing the WHO steps for ABHRS production in resource-limited settings. 8 , 9
Table 3 Summary of Recommendations
Abbreviations: ABHRS, alcohol-based hand-rub solution; APPS, African Partnerships for Patient Safety; HUG, Geneva University Hospitals; IPC, infection prevention and control; MoH, Ministry of Health; WHO, World Health Organization.
Authors’ Contributions
FC, OHa, FJ, and OHe obtained funding and designed the project. FJ and OHe drafted the manuscript with support of FC. FJ, OHe, OHa, BMK, LB, YT, KG, and EIB participated in the course in Liberia and/or Guinea as coordinator, trainer, or national focal point. All the authors contributed to and approved the final version of this article.
Acknowledgements
Numerous colleagues have made extraordinary contributions to the project through tough times, both in Liberia and Guinea. While not specifically contributing to the manuscript, the authors wish to acknowledge their involvement and support (the list is not conclusive):
Pharmacists and pharmacist assistants from Liberia and Guinea; MoH representatives from Liberia, Sierra Leone, and Guinea; Hospital CEOs from the production sites in Liberia and Guinea; video producer (Astar Media); Addax BioEnergy Company; HUG pharmacist Dr. Sandrine von Grünigen (Pharm-Ed); SDC/HA headquarters and Liberian country office; WHO country office in Guinea; WHO collaborative center at the University Hospitals of Geneva; WHAHA (NGO) in Guinea; and Expertise France (NGO) in Guinea.
Supplementary Material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X18000985
