Introduction
Sierra Leone experienced an unprecedented epidemic of Ebola virus disease (EVD) from 2014 to 2016. The first case in country was reported on 24 May 2014. By the end of October 2014, 3854 laboratory-confirmed cases were reported, including 199 cases (5.2%) among healthcare personnel.1 Healthcare personnel had one of the highest rates of EVD in the epidemic, with infection 21–32 times more likely than the general adult population.2 General wards, not EVD isolation wards,3 4 were higher risk since unrecognised patients with EVD admitted to general wards exposed other patients, healthcare personnel and caregivers.5
The high frequency of EVD transmission in general healthcare facilities was primarily a consequence of absent infection prevention and control (IPC) infrastructure and systems compounded by gaps in knowledge and practices among healthcare personnel and unavailable supplies and personal protective equipment.6 The high EVD transmission in general healthcare facilities led to a major impact in the national healthcare system. Healthcare facilities were perceived by the community as high-risk settings for EVD.3 As a result, healthcare utilisation dropped dramatically during the epidemic,7 8 and a general perception of healthcare system collapse was widely reported.9 10
Prior to the 2014–2016 Ebola epidemic, Sierra Leone had no IPC programme, as was the case in many countries across Africa. IPC programmes at the national, district and facility level did not exist, nor were there dedicated IPC staff at government healthcare facilities. Since IPC was not subsumed within any other programme, policies, human resources and training programmes in IPC were also absent. A rapid assessment of IPC in six districts in October 2014 identified multiple IPC gaps in facilities.6
Recognising the critical need for establishing IPC capacity, the Sierra Leone Ministry of Health and Sanitation (MoHS) rapidly created a national programme to provide leadership and coordination for IPC activities throughout the healthcare system. Here we describe the first year of implementation and lessons learnt from a national IPC programme in Sierra Leone centred on the development of a national policy, human resources, technical guidelines, training and education, and monitoring during the Ebola epidemic.
Sierra Leone healthcare system
Sierra Leone had an estimated population of 7.1 million in 2015, with over 40% residing in urban areas.11 There are 14 administrative districts across four regions of the country. The health system is composed of public services, private services and traditional healthcare practices. Primary care is provided at peripheral health units (PHUs), which also includes a community health worker extension. Secondary and tertiary care is provided at district and referral hospitals (table 1).
As of 2015, there were 1264 public and private health facilities serving the country, including 40 hospitals.12 The Government of Sierra Leone owned 24 of these hospitals, with the rest owned by a mix of private companies, non-governmental organisations and faith-based organisations. Hospitals owned by the Government of Sierra Leone will be referred to as government hospitals. The national healthcare workforce was estimated at 9900 healthcare personnel as of 2016.13 Given the estimated population, this translates to three physicians per 100 000 population and 50 nurses and midwives per 100 000 population.13
Ministry ownership
Leadership and ownership by the MoHS were identified as essential to the short-term success of IPC promotion during the Ebola epidemic and the long-term success of IPC in routine healthcare delivery during the post-Ebola period. International partners, such as US Centers for Disease Control and Prevention (CDC), WHO and non-governmental organisations, such as Infection Control Africa Network (ICAN), provided technical and implementation support, but the MoHS was responsible for the creation, acceleration and long-term sustainability of the programme. A timeline of significant milestones and activities for the first year of the national IPC programme is presented in figure 1.
Milestones of the Sierra Leone national IPC programme, 2014–2015. The national IPC programme began with formative discussions in fall 2014. By February 2015, a national IPC coordinator was hired, the national IPC unit was established and hospital IPC focal persons were identified at government hospitals. Further milestones including development of framing documents, organisation and human resources, trainings and monitoring. IPC, infection prevention and control.
The MoHS chief nursing and midwifery officer, an IPC ‘champion’,14 aided the development of the IPC programme and provided the overall leadership and vision. This IPC champion provided recommendations for the programme’s organisational structure based on experience in the Sierra Leone government healthcare system, maintained communication with senior leaders at MoHS on decisions and progress and collaborated closely with humanitarian aid agencies and international partners. The IPC champion facilitated the creation of a new MoHS unit for IPC and collaborated with the chief nurse at each government hospital, also known as the hospital matron, to appoint IPC focal persons at government hospitals and district health offices.
MoHS also committed to salary support for IPC staff, both within the national IPC unit (NIPCU) and IPC focal persons at government hospitals and district health offices. Although humanitarian aid funding could have covered salaries given the influx of resources during the Ebola epidemic, MoHS considered it necessary for long-term ownership and financial sustainability that salary funding stay within MoHS.
National IPC policy
A new national IPC policy formalised the organisational structure and requirements of the programme. This policy defined roles, responsibilities, reporting and accountability processes at each level of the healthcare system. International partners assisted MoHS in drafting the national IPC policy. MoHS directorates and other stakeholders reviewed the draft policy document at a 2-day validation workshop, followed by approval from the chief medical officer and Minister of Health and Sanitation.
The national IPC policy outlined the creation of IPC positions at national, district and facility levels. At the national level, the policy designated a national IPC coordinator to oversee the development, implementation and evaluation of the programme. These activities included developing strategic documents, creating technical and training materials, liaising with MoHS directorates, generating national IPC progress reports and evaluating the implementation of IPC activities. Leadership was central to all improvement efforts, and the national IPC coordinator was appointed to lead the NIPCU, which became the primary coordinating body for MoHS IPC activities during the latter half of the Ebola epidemic. The NIPCU is now the lead unit for all IPC activities across the healthcare sector. The formation of the NIPCU was an essential step in institutionalising a national IPC programme, creating a central hub for IPC leadership, coordination and advocacy.
In each of the 14 Sierra Leone districts, the policy mandated IPC focal person positions to coordinate and implement IPC activities. The policy also specified a district IPC supervisor to provide mentorship and support for facility IPC focal persons. The district IPC personnel were also assigned to oversee IPC at all PHUs15 across 14 districts in Sierra Leone. PHU IPC focal persons were appointed to work under the authority of the district IPC supervisor with responsibility for a geographic cluster of PHUs.
The policy created an IPC focal person position with responsibility for overseeing IPC at each government hospital. The MoHS chief nursing and midwifery officer (ie, the IPC champion) communicated directly with each hospital matron to identify an experienced, respected clinician, most often a nurse, to transition full-time duties to the management of IPC at the hospital. Each of the Sierra Leone government hospitals appointed an IPC focal person in February 2015. Their responsibilities were built around a multimodal improvement approach and included training all facility staff on infection control practices, monitoring IPC practices across the hospital, generating reports for hospital leadership, leading quality improvement initiatives for IPC and liaising with pharmacy, environmental services and other departments. Hospital IPC focal persons reported on action plans, assessments, training and implementation to district-level IPC personnel. As outlined in the national policy, district IPC personnel then reported information to the NIPCU.
National IPC guidelines
Development of the Sierra Leone national IPC guidelines began in May 2015. The guidelines set standards for safe, high-quality patient care and healthcare personnel safety during routine healthcare delivery. The CDC and WHO collaborated on the initial drafting and technical review of the document through the establishment of a guideline finalisation group. The CDC and WHO working group reviewed each draft guideline chapter for technical consistency. A team of two reviewers revised each chapter, which was then reviewed by the NIPCU for context and quality control. The MoHS organised a 2-day validation workshop in August 2015 that provided an opportunity for comment and feedback from MoHS directorates and other stakeholders and was an important step to secure buy-in. The chief medical officer and Minister of Health and Sanitation formally approved the document following revisions from the workshop. As a first step for guideline implementation, the NIPCU developed a standard IPC training package for healthcare personnel. Facilities rolled out the IPC guideline training via international partner support throughout late 2015.
Training and education
Healthcare personnel in Sierra Leone did not receive formal in-service IPC training before the Ebola epidemic. In late 2014, MoHS led a partnership among multiple organisations to cascade national IPC training to over 4200 PHU staff within the context of the ongoing epidemic of EVD.16 PHUs were a first stop for community members presenting with symptoms of Ebola. This standardised training focused on IPC practices to keep healthcare personnel safe and emphasised messaging to screen, isolate and refer suspect cases. International partners conducted supervision visits every 2 weeks, using a structured assessment, to check on IPC practices and supply availability.
After creation of hospital IPC Focal person positions in the national IPC policy and selection at each facility by the chief nursing and midwifery officer and hospital matrons, MoHS organised orientation training. Hospital IPC focal persons were responsible for improving IPC practices to limit Ebola transmission in their assigned hospital and beginning to integrate IPC into routine patient care. Newly appointed hospital IPC focal persons attended an initial 10-day training in March 2015. MoHS held this training with support from the ICAN and CDC. The training oriented hospital IPC focal persons to their roles and responsibilities and taught IPC practices. The focus of the training was preventing Ebola transmission in hospitals during the Ebola epidemic.
Ebola-related IPC training for government hospital staff was cascaded nationally after the IPC focal person training in March 2015. By November 2015, 6448 clinical and support staff at hospitals had received IPC training. Each training roll-out was paired with mentorship or supervision activities. Following the initial IPC focal person training, a mentorship programme was set up through a partner consortium, which is the Ebola Response Consortium. The mentorship programme matched a hospital IPC focal person with a full-time mentor (a clinician from outside Sierra Leone) to guide the transition to full-time duties in IPC.
Formation of IPC committees
The national IPC policy also called for the formation of IPC committees at national, district and facility (ie, hospital) levels (table 2) and provided each committee with terms of reference. The national IPC advisory committee provided input on IPC policy, strategic plans, guidelines, procedures and management issues and reviewed progress towards national goals. This committee was also necessary to advocate for financial and human resources for IPC.
The district IPC committee reviewed progress at PHUs and government hospitals, worked to resolve challenges with facility-level implementation of national standards and provided budget input to support the district medical officer. The district IPC committee also supported district logistic officers to strengthen supply procurement and distribution.
At government hospitals, the IPC committee reviewed hospital assessments and other data provided by the IPC focal person and addressed facility IPC issues that required coordination across wards. The hospital committee also provided input to support the hospital medical superintendent in formulating the IPC component of the hospital budget. International partners supported the development of fit for purpose, effective and action-focused hospital IPC committees, including training on functions of an IPC committee and involvement in initial meetings to provide mentorship. Stakeholder involvement was crucial to getting the committees established and functioning.
Monitoring of IPC implementation
Various methods and tools were used to track IPC implementation at the facility level. A quality assurance checklist was deployed for routine supervision visits in conjunction with the national Ebola IPC training at PHUs.16 This standards-based checklist for screening, isolation and referral identified areas for immediate action during supervision visits. As the national IPC programme was scaling up, 24 government hospitals performed an assessment of IPC infrastructure, systems and practices in early-to-middle 2015. The assessment highlighted that while many IPC activities were implemented, there was still much to be done (table 3). The MoHS and partners also developed a ward monitoring tool for IPC focal persons to use as a ‘quick check’ on wards. This scored tool collected data on IPC supplies, waste management and environmental cleanliness, hand hygiene, personal protective equipment use, sharps management, screening and monitoring for Ebola. The tool provided opportunities for direct coaching from the IPC focal person. Some IPC focal persons also used the ward monitoring tool to promote competitive improvement among wards, with the ward scoring the highest monthly total receiving a certificate from the IPC focal person.
