A tick
A Pakistani cattle herder, too sick to mind his livestock, went to a hospital in Balochistan, the country’s largest but least populated province located in the southwest, bordering Afghanistan. The medical staff initially suspected a snake bite; the herder was vomiting, had a high fever and an abnormal blood clotting profile. The health care provider tending to the herder didn’t wear goggles, a mask or gloves. Having been exposed to the patient’s bodily fluids, he rinsed his hands with just water and then sat down for dinner with his colleagues. Within days, that health care provider and others began suffering with shuddering chills and other severe symptoms of viral infection; one started bleeding from the nose and various mucous membranes.
Misdiagnoses and ineffective treatment complicated the situation. The cattle herder recovered but a week later, three health care workers died, including a doctor who had dined with colleagues and friends.
Now, two of the deceased doctor’s colleagues are sick. Although described as a disease of unknown origin at the start, there is new confirmation by the Provincial Public Health Laboratory of Crimean-Congo hemorrhagic fever (CCHF), an endemic viral illness transmitted to humans by ticks or by infected animals, such as livestock. Human-to-human transmission occurs through direct contact with the blood and other body fluids of infected persons.
This is where I come in. A Pakistani infection prevention and control (IPC) specialist working closely with the Ministry of Health on global health security issues, I was summoned to investigate and support the management of this outbreak. My charge is to help prevent the further spread of an illness that already has claimed the lives of three Pakistanis after it crossed the Pakistan-Afghanistan border and jumped from cattle to humans. A possible mutation in CCHF is rumored.
I am, of course, completely outfitted with personal protective equipment (PPE) when I enter the isolation room occupied by the two doctors infected with CCHF.
Tea
Inside are a half-dozen doctors. Some sit on a sofa sandwiched between the two hospital beds occupied by their sick colleagues. All had eaten and socialized with the doctor who died the previous day from massively severe bleeding.
They sip tea and share fruit.
I think I am in the wrong room,” I apologize.
Dr. Sobhan Qadir
“No, No,” they insist, welcoming me to enter. “This is the room of the doctors [who are now patients with CCHF] and we are here to have fruit with them.”
They offer me tea. No one wears gloves.
They smile. No one wears a mask.
“I’m OK,” I say. “I’m good.”
Actually, what I am is shocked. Even after losing their friend, a fellow doctor, basic transmission-based precautions are not being followed.
IPC
I realized then the core reason behind this outbreak: Even if there was adequate PPE for everyone to wear routinely, at all times, they wouldn’t be wearing it here and now. And they plan to leave this “isolation” room soon and head back to their patients and families. As a former member of the Young Doctor Association in Pakistan from this same region, I can assure you that neither ignorance nor arrogance nor denial are at issue. Rather, this scene I’m witnessing reveals a dire need for advocacy, refresher training and attention to a specific cultural context where health care providers’ roles are highly prescribed and kinship and hospitality are paramount.
It shows just how dangerous it is for all of us when IPC diligence wanes.
In a calm, measured voice, I ask the visitors to please leave this “isolation” room and sequester in another room nearby.
“It’s OK,” one doctor says, attempting to assuage my concerns. “We are using our own cups of tea.”
Lax attitudes about PPE can thwart even the most innovative policies and evidence-based strategies to safeguard global health security. Doctors and surgeons in traditional hierarchical health care roles risk mistaking the implementation of IPC as someone else’s concern; notably as the duty of nurses who provide direct patient care. Providers in health care facilities and communities too often lack an understanding of the importance of the basics of preventing and controlling infections.
More than Ebola, Zika and MERS (Middle East Respiratory Syndrome), COVID-19 showed us how failing to change a seemingly simple behavior can have alarming results. Not washing hands, not masking and not isolating caused preventable illness, suffering, death and economic havoc.
Certain diseases, like CCHF and COVID-19, require specific IPC responses that relate to the mode of transmission. There also are standard precautions that always apply, such as simple hand hygiene, protective equipment and waste management.
In this case, the Provincial Health Department took a systematic approach to control the outbreak with Jhpiego’s technical guidance and recommendations. Awareness, education, contact tracing, isolation measures and IPC precautions were instituted in the health care facility. But the lesson was clear: Be proactive in preventing infections and have at the ready a robust response by coordinating agencies, including those monitoring animal health. Don’t wait until a public health outbreak occurs.
Infection prevention and control is the cornerstone of global health security. Necessary as national documents and global guidelines are, all is for naught if proper implementation of IPC and related measures aren’t happening on the ground, not only in tertiary hospitals but also in provincial country hospitals and clinics.
I’ve seen firsthand how a tiny tick and a sip of tea stand to challenge our most sophisticated data-led measures to ensure global health security. That’s why we need enough equipment and enhanced education and training, cultural awareness and regulations and a commitment to use them. The goal is to have PPE in place and IPC practices operational before we discover that a disease variant is just waiting for someone—anyone—to offer a cup of tea, believing using one’s own cup is protection enough against the next pandemic.
Enhancing Global Health Security, implemented by Jhpiego in 21 countries, strengthens IPC, diagnostics, surveillance and responses to public health threats by supporting nations’ health care systems. Funded by the U.S. Centers for Disease Control and Prevention, the project addresses policy change at the national level and implementation of strategies in health care facilities and in communities.
Dr. Sobhan Qadir, a physician, IPC specialist and health care system management expert, is the Global Gealth Security Program Lead and IPC Technical Advisor with Jhpiego Pakistan. He supports the Ministry of Health in implementing the national IPC program and Enhancing Global Health Security.
Maryalice Yakutchik is a senior writer with Jhpiego.
Aleisha Rosario, Director of Jhpiego’s Enhancing Global Health Security project, provided technical review.
