Research Article: WASH activities at two Ebola treatment units in Sierra Leone

Date Published: May 24, 2018

Publisher: Public Library of Science

Author(s): Michaela Mallow, Lee Gary, Timmy Jeng, Bob Bongomin, Miriam Tamar Aschkenasy, Peter Wallis, Hilarie H. Cranmer, Estifanos Debasu, Adam C. Levine, Tetsuro Ikegami.


The 2014 outbreak of Ebola virus disease (EVD) in West Africa was the largest in history. Starting in September 2014, International Medical Corps (IMC) operated five Ebola treatment units (ETUs) in Sierra Leone and Liberia. This paper explores how future infectious disease outbreak facilities in resource-limited settings can be planned, organized, and managed by analyzing data collected on water, sanitation, and hygiene (WASH) and infection prevention control (IPC) protocols.

We conducted a retrospective cohort study by analyzing WASH/IPC activity data routinely recorded on paper forms or white boards at ETUs during the outbreak and later merged into a database from two IMC-run ETUs in Sierra Leone between December 2014 and December 2015.

The IMC WASH/IPC database contains data from over 369 days. Our results highlight parameters key to designing and maintaining an ETU. High concentration chlorine solution usage was highly correlated with both daily patient occupancy and high-risk zone staff entries; low concentration chlorine usage was less well explained by these measures. There is high demand for laundering and disinfecting of personal protective equipment (PPE) on a daily basis and approximately 1 (0–4) piece of PPE is damaged each day.

Lack of standardization in the type and format of data collected at ETUs made constructing the WASH/IPC database difficult. However, the data presented here may help inform humanitarian response operations in future epidemics.

Partial Text

The outbreak of Ebola virus disease (EVD) outbreak in West Africa that began in 2014 is the largest and most devastating since the Ebola virus was first discovered in 1976.[1, 2] The World Health Organization (WHO) estimates there were over 28,000 suspected and confirmed cases and more than 11,000 deaths.[1–3] The epidemic affected countries around the world, but the hardest hit were three countries in West Africa: Guinea, Liberia and Sierra Leone.[2, 4, 5] The outbreak placed a significant strain on the region, which was already lacking a robust public health infrastructure, including appropriate Infection Prevention and Control (IPC) measures, critical water, sanitation and hygiene (WASH) supplies, accessible health care facilities and well trained health and infection control professionals.[3, 6, 7]

The full International Medical Corps WASH/IPC activities database consisted of information collected from two ETUs in Sierra Leone over the course of 369 days. Approximately one-third of the data were from the Makeni ETU in Bombali District, covering the period of December 2014 to April 2015, while the rest of the data were from the Kambia ETU in Kambia District, covering the period of April 2015 to December 2015.

Like other infectious disease interventions, EVD outbreak interventions require efficiently designed and operated treatment facilities in order to ensure a low risk of nosocomial infection and easy to maintain monitoring WASH/IPC practices. [11] Our study highlights parameters that are key in designing and managing a treatment facility for future infectious disease outbreaks in resource-limited settings.

Even for organizations and individuals with significant humanitarian logistics and supply chain experience, the unique factors involved in managing an ETU during an EVD outbreak require special consideration. The key findings from this study, as well as lessons learned with regards to data collection, will inform the planning, organizing, and managing of ETUs in future Ebola or other infectious disease outbreak. In particular, this research provides estimates on the amount of chlorine and personal protective equipment required to manage an ETU during a future Ebola epidemic, based on the anticipated size and staffing of the ETU. The manuscript also provides recommendations for improving operational data collection in future similar humanitarian emergencies, in order to contribute to continuous learning and improvement.




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