One of a new generation of soluble disinfectants, SoChlor has been at the forefront of the fight against Ebola in West Africa. SoChlor has been supplied in bulk to all West African government health organisations and to major charities including UNICEF and MSF. It was also exclusively used by the British Army Ebola task force in Sierra Leone.
Over 11,100 people are now known to have died of Ebola Virus Disease (EVD) during the 2014-15 West African Ebola outbreak. At the time of writing, the outbreak has been contained with the rate of new reported cases significantly down. A number of countries including Nigeria and Mali have been declared free of the disease. How has this been achieved and what lessons can be learned?
NO MAGIC BULLET FIX
The first point to note is that no breakthrough treatment or vaccination has been developed. Medical researchers are little nearer to finding a ‘cure’ than at the start of the outbreak and Ebola remains as deadly as ever.
Success has come instead from the implementation of a range of measures which include:
- high vigilance for new cases
- early reporting
- rapid cultural changes particularly with regard to funerary practices and corps disposal
- strict cross border and in-country movement controls
- rigorous infection control
Rigorous infection control underpins the entire process and other measures mentioned above are all directly aimed at isolating the disease to prevent the infection spreading. World Health Organisation (WHO) Director General Margaret Chan, speaking in May 2015, said “Sierra Leone is where Liberia was in January of this year. Guinea is still further behind. Even when all three countries get to early recovery, it must be grounded in a strong culture of infection control, and high vigilance for new cases”.
INFECTION CONTROL IS KEY
The importance of soluble chlorine disinfectants in the Ebola infection control process cannot be overstated. Their role has been vital in bringing the outbreak under control and they have been used extensively, both in public health settings and during the care and treatment process to protect medical, nursing and care staff as well as patients, whether infected or not.
Good public health and patient safety practices are essential both for preventing the spread of EVD, and during the management and treatment of patients infected with it. It is widely understood that those treating and caring for victims are themselves at very great risk. But until recently it was not as widely known that that this includes those involved in the removal and disposal of the bodies of deceased victims.
There are still huge challenges remaining for public health officials and medical practitioners in containing the outbreak as well as providing protection for the population in areas where the outbreak is occurring. Secondary infections also pose a very high risk.
TACKLING DEEP-SEATED CULTURAL NORMS
The Ebola outbreak is mainly concentrated in areas where there are often very limited existing medical facilities, and where those that do exist are of a poor standard. Public health services and the general levels of hygiene in many affected areas are often rudimentary, and governments lack both the resources and sufficiently trained staff to address the challenges.
Amongst some communities affected by EDV, knowledge and understanding of hygiene and the ways in which infectious diseases are spread is limited. Moreover, as the outbreak unfolded it rapidly became clear that deep-rooted social and cultural practices, in particular those relating to death and burial, were significantly increasing the spread of Ebola.
Morbid as it may be, the corpses of those who have succumbed to EVD remain highly infectious and require complete isolation, extremely careful handing and must be fully disinfected during the disposal process. WHO guidelines state that the bodies of Ebola victims must be cremated not buried, which is contrary to the centuries old practices followed in many West African communities. It is much to the credit of governments and public health education services in these areas that they have succeeded in overturning these traditions in such a short period of time.
The remoteness of many communities also presents challenges. These areas are more difficult to reach for public health officials and medical practitioners. Delivering equipment and disinfectants can itself be challenging in remote and inhospitable terrain.
EVD greatly lowers the resistance of sufferers to other infectious diseases. Particularly in more remote areas of West Africa, infections such as TB and c-difficile are prevalent among the population. As a result, a high proportion of those who succumb to Ebola in the current crisis are also carrying a secondary infection. This leads to complications and increased risk for both patients and healthcare practitioners.
THE USE OF CHLORINE DISINFECTANTS
Against this challenging background, public health officials and medical practitioners fighting the Ebola outbreak have been turning to chlorine-based disinfectants as a key tool to improve hygiene in healthcare facilities as well as public health and hygiene. They are also key to protecting those living in affected areas and all those directly involved in the treatment and care of EVD sufferers.
In the early days of the outbreak, liquid chlorine was the principal type of disinfectant used. There are even reported cases of diluted household bleach being used in Ebola clinics. However, as the outbreak has progressed, soluble chlorine has become the principal form of disinfectant. It is now used both by government health teams and by all major charities working in the field wherever possible.
ADVANTAGES OF SOLUBLE CHLORINE
Soluble chlorine disinfectants offer a number of advantages over liquid chlorine. Key among these are ease of portability and storage, coupled with much lower risk of spillage and injury to those involved in transporting, handling and storing the disinfectant. Moreover, soluble chlorine does not degrade, retaining its full effectiveness over much longer time periods and in a much wider range of environments compared to liquid forms of chlorine.
These advantages also translate into lower costs when compared to liquid disinfectants. This has proven vital during the 2014-15 Ebola outbreak where resources are limited. In many developed countries, soluble chlorine tablets and granules have almost completely taken over from liquid forms of chlorine disinfectant for public health and healthcare uses.
Soluble chlorine disinfectants are available from a number of suppliers. However, there are major differences between the formulations and presentations. Factors such as the range of different tablet weights, available NaDCC and granular structure affect their ease of use. This has now been recognised as a major factor in locations where skills and training are limited.
From a medical perspective the exact formulation affects the range of pathogens that a disinfectant is effective against, the speed of virus kill, the effective temperature range, and the dilution rate which determines the area that can be effectively disinfected with a given quantity.
NEW GENERATION SOLUBLE CHLORINE
Only the latest generation of soluble chlorine disinfectants, developed within the past 2-3 years, offer healthcare workers and public health officials with the full range of benefits needed for the fight against Ebola:
- Temperature tolerance: remains fully effective across a very wide temperature range which is vitally important in tropical settings
- Effective against major secondary risk pathogens such as c-difficile and TB: these are both frequently encountered due to the high levels of bloody diarrhoea and coughing encountered in EVD
- Remains effective in the presence of high organic matter: prevalent in remote locations where facilities are limited
When selecting a supplier it is important to ensure that their products are fully tested to the appropriate European or US EPA standards. The European Standards for the evaluation of virucidal activity of chemical disinfectants and antiseptics used in human medicine (EN14476) require that disinfectants should inactivate all viruses in one minute at a dose of 500 ppm (clean conditions) or 1000 ppm (dirty conditions).
The 2014-15 Ebola outbreak is not yet over and EVD remains a serious threat to life. Bruce Aylward, Assistant Director-General of the WHO, speaking at a WHO meeting in May 2015 said “This week 35 cases of Ebola were reported from 2 countries. That is 4 times the number of cases from the week before. The job is not done and, if we do not finish [it], the virus will exploit the opportunity it is given.”
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