The UK Public Health Rapid Support Team (UK-PHRST), funded by UK aid from the Department of Health and Social Care, supports low- and middle-income countries in investigating and responding to disease outbreaks and conducts research to improve our response to future epidemics.

Our expertise in infection and prevention and control, which includes the use of Personal Protective Equipment (PPE), is used to protect people from infection in disease outbreaks. PPE can diminish transmission when used as part of an integrated package of measures, and crucially helps protect medical staff from disease, but there is variation in the need for, and use of PPE for different diseases, across countries, and differing views on its necessity.

This project investigated the use of PPE to protect people from Lassa Fever, in specific Lassa Fever Treatment Centres (LTCs) across Nigeria.

Lassa fever is often confused with Ebola or other viral haemorrhagic fevers, but it differs - it is less fatal, and its transmission is very different. Ebola is transmitted between people, whereas Lassa fever is spread to most people (~80%) through exposure to food or household items contaminated by rats. Less commonly, transmission can occur in laboratories, or between people, particularly in health care settings with inadequate infection prevention and control measures.

Why are the UK-PHRST involved?

Lassa Fever is an important cause of outbreaks of infectious disease. It is one of the pathogens in the World Health Organizations’ list of epidemic threats needing urgent research. The disease is endemic in rodent populations in parts of West Africa including Benin, Ghana, Guinea, Liberia, Mali, Sierra Leone, Togo, and Nigeria, and most likely exists in other West African countries as well. Cases are increasing in Nigeria.

The nuances between viruses causing haemorrhagic fevers, such as Ebola and Lassa Fever, are not translated into official guidance, and policies end up addressing them in the same manner. In addition, much of the research and guidance for PPE are developed in high-income settings, where there are few cases of disease, therefore the guidance is built on data, rather than lived experience. 

Recognising limitations in existing guidance, The Nigerian Centre for Disease Control (NCDC) invited the UK-PHRST work with them to investigate whether their infection, prevention and control (IPC) policies devised in 2017 were effectively disseminated and how, in the case of Lassa Fever, they were operationalised.

The nuances between viruses causing haemorrhagic fevers, such as Ebola and Lassa Fever, are not translated into official guidance, and policies end up addressing them in the same manner. In addition, much of the research and guidance for PPE are developed in high-income settings, where there are few cases of disease, therefore the guidance is built on data, rather than lived experience. 

Recognising limitations in existing guidance, The Nigerian Centre for Disease Control (NCDC) invited the UK-PHRST work with them to investigate whether their infection, prevention and control (IPC) policies devised in 2017 were effectively disseminated and how, in the case of Lassa Fever, they were operationalised.

What did they discover? 

The team found that health care workers in Lassa treatment centres (LTCs) were frequently not using PPE in line with government guidelines. Limited availability of PPE in some centres led to health care workers using personal risk assessments to drive decision-making about its use, and there is a gap in understanding of staff perceptions, and how they protect themselves, in the absence of adequate PPE.

During interviews, researchers noticed that much importance was placed on the language, behaviour and understanding of PPE by the health workers. For example, some staff were basing their decision-making on what they perceived as ‘careful’ best practice, but this is not reflected in guidance. Staff also consistently expressed challenges with using PPE,  for example in the environment they were using it in (high temperatures), with poor quality materials (gloves breaking or tearing), and limited function (reduced visibility when using eye protection).

To mitigate some of these issues, some health workers adapted PPE to suit their local context; for example, choosing to wear a surgical gown in replacement of gowns provided, saying they were cooler to wear and simpler to remove.

The study team observed that judgements made by health workers were based on their experience and understanding of the situation, and this was very different to PPE guidance from international and national bodies.

In low- and middle-income countries (LMICs), funds assigned for PPE procurement and supplies can be limited. Where there are competing demands, funds are often redirected to more immediate requirements, such as emergency operations, or treatments.  

Alongside this, there were worries that the PPE provided was substandard. Much of the PPE in use had been donated, for example from non-governmental organisations, and there was no formal process in place to ensure it was fit for purpose.

Capacity strengthening: Preventing future fires

As a result of the collaborative work carried out in the LTCs, The Nigeria Centre for Disease Control (NCDC) has revised national guidance on infection prevention control for viral haemorrhagic fevers.

Together with this success, emphasis on the quality of PPE facilitated prompted dialogue at a national level about developing assurance systems so that donation of equipment is fit for purpose in the future. These results have informed national advocacy work for improvements to supplies to Lassa Treatment Centres – with the ultimate aim of reducing countrywide infection.

How can this work be translated into other contexts?

There has also been ongoing professional collaboration between the NCDC as part of the COVID-19 response with Africa Centre for Disease Control and as part of the African Union Taskforce for COVID-19.

Thinking through novel and more nuanced approaches to PPE is useful when considering PPE for COVID-19. It is also helpful in the face of supply chain issues, with many countries unable to source PPE during the pandemic. Rational use of PPE has been suggested to mitigate insufficient PPE supplies.

While COVID-19 has brought worldwide disruptions to PPE supplies, and its availability, the experience of clinicians in LMICs has much to teach us all about the realities of working with limited resources; developing adaptations and creating innovative local solutions. However, it is important that guidelines are rooted in evidence-based best practise, as well as reflecting the reality of those who are required to implement them.

Read the updated guidelines and vital role the NCDC plays in keeping hospitals, clinics, and health facilities safe and free from disease.