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Year : 2022  |  Volume : 27  |  Issue : 3  |  Page : 306-312

Emergency preparedness for management of suspected cases of viral haemorrhagic fever among healthcare workers in a tertiary referral center

1 Paediatrics Department, Nnamdi Azikiwe University, Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State, Nigeria
2 Chemical Pathology Department, NAUTH, Nnewi, Nigeria
3 Medical microbiology Department, Nnamdi Azikiwe University, Awka, Nigeria
4 Obstetrics and Gynaecology Department, NAUTH, Nnewi, Nigeria
5 Surgery Department, Nnamdi Azikiwe University, Awka, Nigeria
6 Family Medicine Department, NAUTH, Nnewi, Nigeria
7 Radiology Department, Nnamdi Azikiwe University, Awka, Nigeria
8 Community Medicine Department, Nnamdi Azikiwe University, Awka, Nigeria

Date of Submission14-Dec-2021
Date of Decision01-Mar-2022
Date of Acceptance14-Mar-2022
Date of Web Publication2-Jun-2022

Correspondence Address:
Chinyere U Onubogu
Paediatrics Department, Nnamdi Azikiwe University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_14_22

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Background: Effective viral haemorrhagic fevers (VHFs) control demand adequate emergency preparedness among healthcare workers (HCWs). Objective: This study assessed the emergency preparedness for VHF control among HCWs at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra state, Nigeria. Materials and Methods: It was a cross-sectional study conducted among 345 HCW at the NAUTH, Nnewi, Nigeria. Data was analysed using statistical package for social sciences (SPSS, IBM, Chicago IL, USA) software version 21. Chi square and student’s t-test were used to test associations between categorical and continuous variables, respectively. A p-value of <0.05 was considered statistically significant. Results: Their mean age and length of service were 33.9 ± 8.88 and 6.6 ± 7.08 years, respectively. Two-third were doctors, nurses and lab scientists. A major proportion of the HCWs were aware of VHF (88.4%), and knew it could be acquired at workplace (83.8%) and at least 2 correct features (74.2%) or one preventive measure (79.1%). Only 53.0% and 47.2% knew that the hospital had a VHF control policy and standard operating procedure (SOP), respectively. Different category of HCWs varied significantly in awareness of VHF; and knowledge about the risk of acquiring it at workplace, features or preventive measures, and VHF control policy or SOP. Doctors, nurses and lab scientists performed better than other HCWs in VHF knowledge. Previous training on VHF or encounter with suspected case was highest among the doctors (P < 0.001) while adequate supply (P < 0.001) or regular use (P = 0.008) of PPE was highest among lab scientists. Suspected VHF case was encountered by 21.2% of the HCWs out of which 26% (19/73) notified relevant unit. Only 29.3% of the HCWs agreed that VHF control was adequate in their unit. Commonest reasons cited for disagreeing were lack of training (79.2%), standard precaution materials (63.6%), SOPs (59.7%) and inadequate support by hospital management (58.4%). Conclusion: Emergency preparedness for VHF control was poor among studied HCWs. Innovative surveillance/notification system, and best practices for infection control should be enforced. HCWs should be adequately trained on VHF control.

Keywords: Awareness, knowledge and practice, lassa fever, Nigeria

How to cite this article:
Onubogu CU, Njoku JG, Ushie SN, Egeonu RO, Obasikene G, Anyaoku CS, Nwosu C, Emelumadu OF. Emergency preparedness for management of suspected cases of viral haemorrhagic fever among healthcare workers in a tertiary referral center. Int J Med Health Dev 2022;27:306-12

How to cite this URL:
Onubogu CU, Njoku JG, Ushie SN, Egeonu RO, Obasikene G, Anyaoku CS, Nwosu C, Emelumadu OF. Emergency preparedness for management of suspected cases of viral haemorrhagic fever among healthcare workers in a tertiary referral center. Int J Med Health Dev [serial online] 2022 [cited 2022 Aug 12];27:306-12. Available from: https://www.ijmhdev.com/text.asp?2022/27/3/306/346426

  Introduction Top

Viral hemorrhagic fevers (VHFs) constitutes a great challenge to public health due to their high infectivity, recurrent outbreaks and associated mortality.[1] The VHFs encompass an array of infectious diseases caused by a group of ribonucleic acid (RNA) viruses whose symptoms include but are not restricted to haemorrhage, as the name implies. They are classically zoonotic infections caused by four families of viruses: Arenaviridae (Lassa fever virus), Filoviridae (Ebola virus), Flaviviridae (Yellow fever virus) and Bunyaviridae (Congo Crèmean haemorrhagic fever virus).[1],[2] The viruses have lipid envelop that makes them susceptible to destruction by chemical (detergents, bleach, solvents) or physical (low PH, heat, sunlight, gamma rays) methods. However, they remain stable in blood and cold storage, and this promotes their survival, infectivity and spread.[2] The VHF Lassa fever is a highly infectious and potentially lethal disease that is endemic in Nigeria and parts of West African region, has recorded several outbreaks which claimed the lives of many healthcare workers (HCWs).[3] In 2014, the Ebola outbreak had a devastating effect on HCWs, claiming the lives of at least half of about 600 affected HCWs in 3 West African Countries (Guinea, Liberia, and Sierra Leone).[4]

The VHF viruses naturally occur in animal hosts and are often restricted to the geographical locations where the hosts live. Transmission to humans is through contact with infected host(s), consumption of food and water soiled with excrements of infected hosts, or through inhalation of the host’s aerosolized fecal materials.[1] Once an initial person is infected, some VHF viruses such as Ebola, Marburg, Lassa and Crimean-Congo can spread directly from person to person through close contact with infected persons or their body fluids, or indirectly, through contact with objects contaminated with infected person’s body fluids. This has a potential to result in epidemic outbreaks such as occurred during the Ebola scourge of 2014 and the recurrent Lassa fever virus outbreaks in the West African sub-region.[4],[5]

VHFs generally cause a severe life-threatening multisystem disease characterized by damage of the vascular system and body’s ability to regulate itself although some illnesses could be mild.[1] Features of VHF include sudden sustained high temperature >380C unresponsive to treatment, severe headache, myalgia, fatigue, vomiting and diarrhoea, abdominal pain. A distinct and important symptom of VHF is unexplained bleeding from orifices which may appear 2–21 days after exposure.[5],[6]

Unfortunately, outbreaks in humans are often sporadic and difficult to predict. In addition, VHFs do not have effective vaccine or a cure. Therefore, the mainstay of control remains health education with strong risk communication emphasizing the avoidance of exposure to potential hosts such as rodents and insects.[1],[6] Person to person spread can be prevented by avoidance of close physical contact with infected people or their body fluids, isolation of infected individuals, wearing appropriate personal protective equipments (PPEs), and proper disinfection and disposal of instruments/equipment used in treating suspected VHF cases. However, transmission often occurs before cases are identified. Therefore, having a high index of suspicion and strict adherence to standard precautions (SP) are critical to controlling VHF spread within communities and health facilities.[5] Unfortunately, adherence to SP is often poor among HCWs.[7],[8],[9],[10] Therefore, hospitals serve as dangerous places for intensification of transmission of the viruses among staff, patients and communities rather than disease control during VHF outbreaks.[11]

The rise in death of HCWs from VHFs has heightened the concern to contain this deadly occupational healthcare risk. Therefore, it pertinent to study the emergency preparedness of HCWs in handling VHF cases in order to forestall spread within hospitals. The findings will provide scientific data to drive development of evidence-based practice guidelines for effective infection control in our teaching hospitals.

  Materials and Methods Top

A cross sectional study was conducted among HCWs at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State in 2018. NAUTH provides full complement of specialist inpatient and outpatient services in all clinical department and is a referral center for Lassa fever. Any suspected case of Lassa fever is first isolated in a holding area at the point of identification, then the Rapid Response Team is quickly notified to transfer the patient to Lassa fever isolation center, and collect blood sample using standard recommendations and procedures. The blood sample is sent to Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Edo state for diagnosis using RNA polymerase chain reaction (PCR). Confirmed positive cases are treated in the center according to national recommendations. During the study period, NAUTH had about 1600 HCWs which included 421 doctors, 416 nurses, 174 medical laboratory scientists, 119 pharmacists, 58 medical record officers, 47 radiographers, 46 physiotherapist, 43 ward attendants and 39 cleaners.

Participants were various cadres of HCWs who had worked in NAUTH for six months or more, come in direct contact with patients or by-products of patient’s care in the course of their work and gave a written informed consent. This consisted of doctors, pharmacists, nurses, medical laboratory scientists, radiographers, physiotherapists, dieticians, and non-clinical staff such as health records officers and cleaners. The minimum sample size of 320 was calculated based on sample size formula for a finite population (n = N/1+N (e)[2] [Where n = required sample size, N = the finite population, e = level of significance, 1 is a unit constant]). Participants were proportionately recruited from the various categories of HCWs using stratified random sampling technique. This was based on the relative proportion of each group of HCWs as reflected in the data obtained from NAUTH Information Communication Technology department. The number of participants from each category was calculated by multiplying the population of that category with the sampling fraction (sample size ÷ total population). Doctors, nurses and laboratory scientists were further stratified to ensure proportionate inclusion of all departments. Participants were recruited by convenient sampling until the number allotted to their category/department was attained.

Study tool was a semi-structured questionnaire which was developed by the researchers based on findings from literature review, interview of relevant staff and personal experience. This was tested during a pilot study done among 20 randomly selected participants (2 from each group) who were not part of the main study. Eligible participants interviewed to obtain relevant socio-demographic data and assess the knowledge, attitude and practice of health workers regarding the management of VHF.

Data was analysed using SPSS (IBM, Chicago IL, USA) software version 21. Chi square and student’s t-test was used to test associations between categorical and continuous variables, respectively. Level of significance was set at 0.05 and p-values (P < 0.05) was considered statistically significant. The research was carried out in accordance with Declaration of Helsinki.

  Results Top

A total of 345 healthcare workers with mean age and length of service of 33.9 ± 8.88 and 6.6 ± 7.08 years, respectively, were studied. The male: female ratio was 1:1.5. About 2/3rd of the study population were medical doctors, nurses and medical lab scientists and 54.2% of respondents were married as shown in [Table 1].
Table 1: Socio-demographic characteristics of respondents

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Majority (88.4%) of the respondents were aware of VHF and profession was significantly associated with having heard about it as shown in [Table 2]. Doctors (96.2%), nurses (94.6%), lab scientists (90.7%) and radiographers (85.7%) had the highest proportion of healthcare workers who had heard about VHFs in descending order while dieticians had the lowest proportion (71.4%).
Table 2: Awareness of the term “VHF” among the respondents

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As shown in [Table 3], 83.8% of respondents knew that VHF could be acquired in the workplace, 74.2% knew at least 2 correct symptoms, 79.1% knew at least one preventive measure, 53.0% knew that the hospital had a policy on VHF control while 47.2% knew that the hospital had SOP for case detection, notification and management.
Table 3: Knowledge of VHF features and control among respondents

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The different categories of HCWs varied in their knowledge regarding VHF and its control. Proportion of HCWs who had correct knowledge about VHF was highest among doctors, nurses and lab scientists in descending order. However, a higher proportion of lab scientist knew that the hospital had a policy on VHF control compared to nurses, and had the highest proportion of those who knew that that the hospital had SOP for case detection, notification and management.

As shown in [Table 4], only 44.9% of respondents had been trained on standard precaution for infection control with 32.5% trained specifically on VHF control. Less than 1/5th of the respondents had steady and sufficient supply of PPE in their unit while about half of them always wore PPE while attending to suspected case of VHF. A significantly higher proportion of doctors were trained on VHF control, and encountered cases suspected to be VHFs in the course of their work during the 3 months preceding the study, while a higher proportion of lab scientists had adequate supply of PPE and used PPE while attending to patients suspected to have VHF or their specimen.
Table 4: Training, perception and practice of respondents on VHF control

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Less than a 3rd (29.3%) of participants agreed while 22.3% disagreed that control measures for VHF control were adequate in their units. The reasons most cited by the 77 respondents who disagreed that control measures were adequate in their units were lack of training and retraining of staff on VHF control (79.2%) and lack of materials for standard precaution (63.6%), lack of SOPs on VHF management (59.7%), inadequate support by hospital management (58.4%), poor water (18.2%) or electricity (18.2%) supplies and lack of incentives (11.7)%)

About 21.2% of respondents encountered a suspected case of VHF in the 3 months preceding the study. However, only 26.0% (19/73) of those who did so notified appropriate authorities

  Discussion Top

Our findings indicate substantial knowledge and practice gaps in VHF control among HCWs and agree with previous reports.[12],[13] Although majority (88.4%) of HCWs were aware of VHF, this fell below expectation for HCWs who work in a major Lassa fever referral center, and come in direct contact with patients as well as patients’ environment, specimen, care instruments and waste. The fact that almost a quarter of the HCWs could not cite at least 2 correct features of VHF or one control measure imply that many HCWs may not be able to recognize a VHF case or know the right thing to do when they encounter one. Worse still, almost half of the respondents did not know that the hospital has a policy for VHF control and that there were SOPs for case detection, notification and management, despite the fact that the hospital is a Lassa fever referral center. Effective control of VHF outbreaks require preparedness and planning as they can be encountered at any time. According to the Nigeria Center for Disease Control (NCDC), the first strategy for VHF preparedness and response involves enhanced surveillance, rapid verification and response at points of entry (PoEs).[6] Therefore, the above findings are unacceptable, indicate poor preparedness for outbreaks and agree with previous report that surveillance, diagnostic capacity, infection control and the overall preparedness level for VHF outbreaks are are limited in most facilities in endemic countries.[13]

VHF outbreaks are often heralded by death of the HCW. Therefore, early recognition and implementation of measures to protect HCWs is a major objective of early outbreak management.[6],[14],[15] But how HCWs and their patients be protected if some of them cannot recognize and initiate actions to prevent further spread? Therefore, it is pertinent that all HCWs understand the clinical features of VHF and adhere SP at all times whether there is an outbreak or not. To appreciate the real risks, it is critical that all HCWs clearly understand the means of VHF transmission in healthcare settings. In addition, hospital managements should ensure that hospital’s policy on VHF are communicated to all staff irrespective of their profession, and SOPs on VHF case detection, notification and management should be displayed in prominent places in every unit. The later strategy has been previously reported to improve adherence to SP.[9]

The variation in knowledge between different groups of HCWs was not surprising and could be explained by difference in exposure to trainings as demonstrated in this study. In view of the high infectivity of VHFs, efforts should be intensified at ensuring that all HCWs are trained on recognition and prevention of these deadly occupational hazards. This could be achieved by incorporating the topic in school curriculums as well as trainings by hospital managements and relevant bodies. Training gaps were highlighted by our study as only 44.9% and 32.5% of the respondents had been trained on SP and VHF control, respectively. Therefore, efforts should be intensified at ensuring that all HCWs are trained irrespective of their profession. In addition, drills should be organized at regular intervals using pseudo-patients in order to improve the proficiency of HCWs on identification and handling suspected VHF cases.

Although outbreaks start in the community, patients eventually present to health facilities for treatment. Initially, patient may present with symptoms that may mimic common ailments such as malaria, typhoid, bacterial sepsis and acute gastroenteritis. This puts HCWs at great risk of acquiring the infections if SP is not strictly adhered to in all patients care, and if high index of suspicion for VHF is not entertained while making differential diagnosis. SP requires that HCWs assume that blood and body fluids of all patients are potential sources of infection, regardless of the diagnosis, or presumed infectious status. To ensure safety of patients, staff and visitors in the healthcare environment, SP are to be used by all staff, in all care settings, at all times, and for all patients regardless of the suspected or confirmed presence of an infectious agent. Unfortunately, majority of respondents do not have adequate supply of PPE in their units and almost half do not always adhere to PPE use while attending to suspected cases of VHF. Shortage of basic PPE such as eye shields, facemasks, gloves, gowns and shoe covers has been reported as a major barriers to SP in several countries.[7] Therefore, there is need for greater commitment on the part of healthcare managers to ensure adequate supply of PPE materials, running water, and regular electricity which are critical for VHF control.[16],[17]

This pivotal role of hospital managements in creating an enabling environment that promotes VHF control practices was demonstrated by about a 3rd of the respondents who strongly disagreed that VHF control practices were adequate in their units. Commonest reasons cited were lack of training, shortage of materials for SP, lack of SOPs and management support. These areas should be critically looked and gaps addressed to ensure best practices in VHF control.

Key principles for containment of VHF outbreak screening of cases involve isolation of suspected, probable and confirmed cases to mitigate further spread of the disease. However, only 26% of HCWs who saw a case suspected to be VHFs over the 3 months preceding the study actually notified the relevant authorities. Innovative surveillance approaches should be adopted to ensure that cases are properly identified and notified to forestall spread within the hospitals. This may entail strong messages on attitudinal change; effective monitoring, patient audit and tracking system; and incentives where applicable.

  Conclusion/Recommendations Top

Emergency preparedness for VHF control was poor among studied HCWs. There were knowledge and practice gaps on VHF identification, notification and management among HCWs and this varied significantly with profession. Major reasons cited for poor VHF control practices in various units include lack of training, materials for SP, SOPs and management support. To curb the menace of VHF among HCWs and the general population, these factors should be addressed. In addition, an innovative VHF surveillance/notification system, and best practices in infection prevention control should be adopted in healthcare settings.

  Post Research intervention Top

The Infectious Disease Group of NAUTH Research Society in collaboration with the Quality Improvement Committee of the hospital conducted interventions through advocacy to the hospital management, conference organized by NAUTH management. The hospital management also sponsored lectures/workshop involving all cadres of HCWs in the hospital. Major thrust of interventions were increased awareness, attitudinal change and advocacy for regular provision of necessary materials, and display of relevant SOPs in prominent places in the facility. Post-intervention assessments will be undertaken in due course.

Financial support and sponsorship


Conflicts of interest

The authors declare no conflict of interestAcknowledgement

The research team is grateful to the NAUTH management for their support during the research and post-research interventions, as well as all the members of the Infectious Disease subunit of NAUTH Research Society.

Author statement

Conception and study design: CUO, NJGC, OG, EOF

Data collection: CUO, NJGC, OG, USN, ERO, ACS, NC,

Data analysis and result interpretation: CUO, EOF

Drafting initial manuscript: CUO

Revising manuscript critically for important intellectual content: CUO, NJGC, OG, USN, ERO, ACS, NC, EOF

All authors approved the version of the manuscript

  References Top

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National Centre for Disease Control (NCDC). An update of Lassa fever outbreak in Nigeria 2018. Abuja: NCDC; 2018.  Back to cited text no. 3
Green A Remembering health workers who died from ebola in 2014. Lancet 2014;384:2201-6.  Back to cited text no. 4
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UK Department of Health: Advisory Committee on Dangerous Pathogens. Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence 2015. London: ACDP; 2015. Accessed 2021 August 24. Available from: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947382005  Back to cited text no. 15
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  [Table 1], [Table 2], [Table 3], [Table 4]


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