Primum non nocere is a Latin phrase attributed to the ancient Greek Hippocrates that means, “First, to do no harm.” Non-maleficence is one of the most important principles in medicine, and in its simplest translation expresses the expectation that medical practitioners and hospitals should not cause harm to patients.
Hospitals are supposed to be where people get better, yet, we have all heard of stories of people who have gone into the hospital with one ailment or infection and have come down with another infection altogether. Hospitals, by definition, will always have a good population of people with infections. Health workers are therefore tasked not only with helping ill people get well, but must also protect themselves from getting sick, and from passing along infections from one patient to another. The process of ensuring that infections are not passed from patient to health worker or vice versa is known in medical parlance as Infection Prevention and Control (IPC).
The recent outbreak of Ebola in Nigeria and the rest of West Africa highlighted the need for improved Infection Prevention and Control (IPC) systems and practices. This has been further highlighted by the recent Lassa fever outbreak in Nigeria, especially the death of some health care workers in Ebonyi. Poor IPC practice among healthcare workers leads to the spread of microorganisms in healthcare settings, and outbreaks of infectious diseases in Nigeria, such as that of Lassa, demonstrate that IPC culture is not well established in the country.
IPC is concerned primarily with preventing infections acquired in hospitals. It is a practical sub-discipline of epidemiology and has been under-recognised and under-supported in Nigeria. Nigeria currently has no cadre of healthcare workers specifically trained and certified for IPC. There is also no formal professional development program for any cadre of health workers in IPC meaning that health workers in Nigeria lack access to formal training opportunities in IPC. At no point in our health sector’s history has the need for proper IPC practice been higher than it is now.
Now an IPC Curriculum Development Team in Lagos is working to ensure that proper IPC practice becomes enshrined in Nigeria’s health sector. They have come together to create the first course curriculum to develop specialists in the prevention and control of infections, especially in hospital settings. This brand new Infection Prevention and Control Curriculum was unveiled at a closeout and award ceremony in Lagos on March 10th, 2018, in an admirable example of professionals coming together to solve a problem that needed solving.
Professor Folashade Ogunsola the Principal Investigator for the IPC Curriculum Development Project and her team were inspired by the deficits that they saw during the spread of the Ebola virus in Nigeria and the anxiety it caused among health care workers. At the closeout ceremony she asserted that, “Our vision was to make infection prevention and control routine practice and the quality standard in every hospital in Africa.” She noted that the Nigeria government’s hopes of reversing medical tourism cannot be realised “until we have safe hospitals. It is more than having infrastructure, we need safe hospitals. For instance, Lassa Fever is usually only indicated when a healthcare worker dies. The vertical nature of IPC training has been the problem. The only kind of training we have now is IPC for frontline healthcare workers. IPC should be embedded in our routine health system.”
Professor Ogunsola proudly pointed out that the training curriculum her team developed used the best evidence available to create a training and certification programme for healthcare professionals specifically in IPC and for the establishment of proper IPC programmes in health facilities across the country. The team worked for 18 long months on this project, with funds raised from Exxon Mobil through the CDC Foundation. Dr. Tochi Okwor, The Project’s Programme Manager, said that they did not want this to be another project that just ends with a report on a shelf but one that will be used for the training of infection prevention and control practitioners in Nigeria for many years to come.
The new IPC curriculum demands a substantial commitment. It involves 12 modules with over 30 sessions. In addition to the training curriculum itself, there is a logbook as the programme is designed as a skills-based and competency-based programme. Its actual development began in September 2016 with a baseline assessment, followed by a workshop in December 2016 to further structure the curriculum. The process continued with input from different faculty and teams for most of 2017, and in November 2017 the group hosted a roundtable to discuss components of the curriculum with a larger audience. In February 2018, the project held a two-week “Pilot Training” to test out the curriculum on a selection of health workers who were then tasked with observing their institutions for three days to note where there were IPC lapses with their new knowledge of proper IPC practice.
This new training program is intended to ensure that trainees are prepared to lead the provision of infection prevention and control services and are capable of developing and implementing infection prevention and control programs in different healthcare settings. It will also ensure that the graduates of the program are aware of emerging scientific literature and evidence-based guidelines and are capable of working as team members within the healthcare facilities as IPC practitioners.
Professor Oyin Oduyebo, Professor of Clinical Microbiology, College of Medicine, University of Lagos, was one of the course’s instructors during the two-week pilot training. She said she has taught infection prevention and control for many years. “Even at that I knew that we were inadequate in what we teach. Sometimes we do not get fulfilled in what we teach because we do not see what we teach come into practice.” Now, she and her colleagues are determined to change this and will work with partners to ensure that this effort is not in vain.
Having a curriculum in place has its advantages, she said. “First is the realization that infection prevention and control is an area of specialisation. It is not general nursing or general medicine! It is not simple hygiene, which is how some people describe it,” she said, adding, “I think it’s a very useful tool in our hand. We are bound to see a lot of development in Nigeria, especially in hospital practice, and I believe we are set to give the patients a better quality of care.”
The new IPC curriculum has already been received positively by both the Lagos State Ministry of Health and the Nigeria Centre for Disease Control (NCDC). Ogunsola promised that her team will continue to work on expanding the use of the curriculum. “We will seek more funding, we will be coming back in a year to see what has been put in place,” she said, adding, “We hope to see some major changes over time. We are not going to rest but we will keep pushing.”
This effort, with the right and continued support, may very well broker a new dawn for IPC in Nigeria, one that we hope will lead to the safer hospital environments we all desire. The efforts of the IPC Curriculum Development Team are commendable, and proof that sometimes, all it takes is a small group of determined people to change the world… for good.