Mental distress among Liberian medical staff working at the China Ebola Treatment Unit: a cross sectional study

With significant support from the international community, the fight against the recent Ebola outbreak in West Africa primarily focused on promptly bringing the underestimated epidemic under control. Despite said efforts, the Ebola epidemic reached crisis levels with toll mounting by April 2015 according to WHO [16] to 25,178 cumulative case counts and 10,445 case deaths.

Prominent among the reasons cited for the Ebola virus spread across West Africa and into other continents was insufficient medical staff not only stemming from impoverished health systems in affected African countries but also fueled by severe mental stress during the epidemic [17]. Previous Ebola outbreaks in Africa had attested to the great sacrifices endured by medical staff [18‐21]. The frontline staff facing infected patients has been not only at great peril of becoming themselves infected because of inadequate availability of protective gear, but also subjected to intense stigmatization by family, coworkers, and the community [22]. Effective intervention unfortunately remains elusive despite recognition of these problems and formulation of pertinent recommendations by the World Health Organization and Médecins Sans Frontières et al. [17]. The present cross-sectional study therefore was conducted among local medical staff in an attempt to gain further insight into this unmet medical need.

Data from the present study showed that mental distress among local medical staff in an ETU was not very serious. Possible reasons include: 1. At assessment time, local medical staff had worked at the ETU from 3 to 10 months, and some had even worked at an Island Clinic Centre for a while before being employed by our ETU, which made them be very familiar with Ebola virus and decreased fear about it; 2. the study was implemented from March 1 to 10, when vigilance already had been implemented without any newly lab-confirmed Ebola cases in Liberia after March 1 [16], which might significantly relieve their distress; and 3. close cooperation and early psychosocial support by our medical team and other organizations also might have contributed to mitigation of emotional distress consequences among Liberian medics. Nonetheless, subgroup analyses revealed that scores for psychological dimensions such as obsessive-compulsive, anxiety, phobic anxiety, interpersonal sensitivity, paranoid ideation and Positive Symptom Total significantly increased among male medical staff and those responsible for cleaning and disinfection. At our ETU, the cleaning and disinfection section was responsible for disinfection of recycled protective gear, garbage collection out of isolated wards, and incineration. Although personnel was not directly in contact with suspected or confirmed Ebola patients as were those at observation and treatment wards, the garbage handled was hazardous and high risk even under the protection of personal protective equipment (PPE). Furthermore, heat and smoke during incineration was not without hazards related to heat stress and dehydration, as evinced by fainting occurrences during work.

As for the male medical staff, abnormal levels of interpersonal sensitivity, paranoid ideation and PST relative to females might be derived from relative differences in workload which was physically more demanding for males, who were mainly in charge of garbage collection and cleaning within the wards. The possibility of greater negative influence by communal stigmatization against male medical staff could not be excluded.

No significant difference was apparent in mental distress despite the difference in education level between nurses and hygienists (100 % vs. nearly 50 % had higher education, respectively) possibly because: 1. Both nurses and hygienists had been intensively trained for 2 weeks at our ETU on donning, doffing, use and disposal of PPE and dealing with infected patients according to WHO recommendations, which might have changed their attitudes toward Ebola overall; and 2. As shown by studies of intensive care units [23], the abundant information exchange during dinners and night duties among staff might have fostered prompt identification and correction of potential flaws, and possibly effectively alleviated tense attitudes towards working in isolated wards with many infected patients.

Attention should be paid to increased levels of obsessive-compulsive, anxiety, phobic anxiety, interpersonal sensitivity, and paranoid ideation among local medical staff seen in the present study because of the very prevailing social stigma in Ebola affected areas. Stigmatization against medical staff working against Ebola had already fueled viral spread and hampered efficient infection control during the alert management phase not only in Africa but also in other affected countries [24‐27]. To offset such stigma, Ebola infection survivors were encouraged to engage in the fight against Ebola as burial team members, contact tracers, and community educators, which benefitted affected communities [26, 28, 29]. However, despite several plans proposed by WHO and its partners aimed at resolving the problem [30], stigma against local medical staff has not received adequate attention, which might further undermine the already fragile public health system infrastructure against further possible infectious outbreaks in Africa.

The present study was limited by its observational design; the lack of a suitable reference for SCL-90R psychological dimension norms for the Liberian population; and the small study sample size which might have precluded finding significant associations among variables. Further research with normal controls and larger sample sizes is warranted.