Feedback from Western Ukraine

Results of M&E Missions in Western Ukraine 27 08 2020

Dr Yurii Zhyhariev, National Consultant on Clinical Management, WHO COVID Response Incident Management Team Overview of the situation

WHO conducted Monitoring and Evaluation Mission with regard to COVID-19 pandemics response in Lviv, Zakarpattya and Chernivtsi Oblasts, 27-31 July 2020 The western regions of Ukraine (Lviv, Zakarpattya and Chernivtsi) are among the worst affected by the COVID-19 epidemic. These three regions accounting for up to 30% of the total number of confirmed COVID-19 cases in Ukraine. Mission purpose: • Assess the situation in selected hospitals and check the level of hospital bed occupancy and admission to care; Determine if there are other hospitals that do not prescribe COVID-19 but accept patients with COVID-19; • Visit major hospitals and identify the root causes of high levels of infection among healthcare professionals; • Assess the hospital's ability to manage the situation and its readiness to respond in case of oversaturation of the number of new methods, biomedical equipment, trained health care professions, PPE, etc.; • Liaise with regional health authorities and hospital administration and provide regular information, arrange meetings with regional health authorities and discuss urgent needs, especially in technical support.

2 Ivano-Frankivsk city and oblast (7-10 July 2020)

Exceptionally heavy rainfalls during the last week of June reported to have caused severe damage in five regions of western Ukraine (Ivano-Frankivsk, Chernivtsi, Zakarpattia, Ternopil and Lviv oblasts). Among the five affected oblasts, Ivano Frankivsk was identified as the most affected due to two reasons – one was its highest number of populations and the other was its geographical features, with Dnister river running through the northern part and the Carpathian Mountains in the south.

• A multi-sectoral assessment mission was initiated and coordinated by OCHA. The mission comprised of six team members representing five UN agencies, namely FAO representing Food Security and Livelihood (FSL) Cluster, UNICEF representing Water, Sanitation and Hygiene (WASH) Cluster, WHO representing Health Cluster and United Nations Development Programme (UNDP). • The mission was conducted in collaboration with the Ukrainian Red Cross Society, Caritas Ukraine and other key partners currently operational on the affected areas. • Ivano-Frankivsk oblast was selected as a site for the mission to visit. • During the mission we had the opportunity to visit several healthcare facilities, including in the affected regions.

3 Ivano-Frankivsk city and oblast (7-10 July 2020)

1.The mission found that the flooding has not disrupted health services’ provision. The locations that were cut off remained accessible with support of the State Emergency Service, and access to the 17 paramedic points (FAP) and 1 hospital which were flooded was shortly resumed. 2.While small pockets of needs remained to be addressed, particularly among those whose houses were completely destroyed and those who have been cut-off from services due to infrastructure damage in the mountainous areas, at the time of the mission the situation had improved considerably and stabilized. 3.The mission, therefore concluded that there was no need for a large-scale international emergency humanitarian response, assuming that the government would continue its effort in addressing the immediate and long-term needs. 4.Observational data from visits to designated COVID-19 hospitals are included in the overall conclusions.

4 Ivano-Frankivsk city and oblast

➢17 health facilities affected. ➢200 km of roads completely destroyed and 500 km of roads partially damaged. ➢Some 12,000 water wells polluted. ➢In the mountainous areas, 93 bridges destroyed and 249 partially damaged. ➢80,000 km of the embankment damaged. ➢Limited damage on the transport connections.

5 Chernivci, Lviv, Uzhgorod city and Zakarpatska !oblast

• In each oblast, meetings with representatives of health departments were held and hospitals designated for COVID-19 were visited. • In each region, hospitals of regional, city and district subordination, as well as some specialized centers were visited. This made it possible to assess the situation and determine the needs of hospitals at different levels. • In each hospital, I tried to talk not only with representatives of the administration, but also with ordinary doctors and medical personnel. • Also, when communicating with the health authorities, I always took contacts and received prior consent to receive information in the future.

6 Ivano-Frankivsk city and oblast

Paramedic point (FAP) during and after the flood. Ivano-Frankivsk region 7 Correct use of available opportunities

The doors were locked with safes to prevent unauthorized access to the red zone.

City Hospital No. 1, Chernivtsi

8 Inappropriate use or not using existing medical equipment

The disinfection tunnel was installed with the help of volunteers but very quickly stopped working for unknown reasons.

Chernivtsi Regional Clinical Hospital Disinfection tunnel at the entrance to the hospital (does not work) 9 Inappropriate use or not using existing medical equipment

The Aveo Care Fusion high-class ventilator can only work with a compressor. The compressor is old and creates an unacceptable noise level. There is no other compressor, so the device is not used (explanation of the head of the ICU department)

Chernivtsi Regional Clinical Hospital. Intensive care unit.

High-class ventilator Aveo Care Fusion 10 Old and non-functional equipment

On the device the inscription "When using, hold the monitor" (the monitor comes and falls off).

Chernivtsi Regional Clinical Hospital.

Intensive care unit. Ultrasound machine. 11 ! Infection prevention and control (IPC)

IPC measures (social distance, wearing a mask) in public places are relatively respected, but this is a big problem in public transport.

Intercity train. Chernivtsi oblast

12 Infection prevention and control (IPC)

The quality of PPE is not always sufficient. When you try to put on this mask, the attachments on it immediately come off (Ivano-Frankivsk Regional Infectious Diseases Hospital)

Poor quality mask.

13 Infection prevention and control (IPC)

Some healthcare facilities are located in rooms that are absolutely not suitable for this, which makes it very difficult for IPC measures.

Ivano-Frankivsk Regional Phthisiopulmonology Center. Parquet floor in COVID-19 department 14 Infection prevention and control (IPC)

These "boxes" are more like a stable or prison cells. This impression is not far from the truth: one of the infectious diseases rooms there used to be a stable more than 150 years ago. This building is completely unsuitable for the treatment of any patients, especially with infectious diseases.

Illusion of isolation does not prevent the risk of infection: for all needs patients are forced to go into the common space. The toilet in the department is only one and there is only one water tap.

Patients are often in this department for more than 2 weeks and are forced to use wet wipes for personal hygiene because there is no shower or bathroom.

It is almost impossible to create an effective IPC system in the existing conditions. There is no clear division into red and green zones, etc. Therefore, this «infectious disease department» has created ideal conditions for nosocomial infections of patients and medical staff. Chernivtsi Regional Clinical Hospital. Infectious Diseases Department. The so-called "boxes" 15 Key Findings and Recommendations

1.The situation in the Western Ukraine regions is tense, but stable and represent a complex of systemic problems. Lviv, Zakarpattya and Chernivtsi oblast are among the worst affected by the COVID-19 epidemic. These three regions accounting for up to 30% of the total number of confirmed COVID-19 cases in Ukraine. 2.The flood impact in some regions of Ivano-Frankivsk and Lviv oblast has been exacerbated by COVID-19 outbreak. But the flooding has not disrupted health services’ provision. The locations that were cut off remained accessible with support of the State Emergency Service, and access to the 17 paramedic points (FAP) and 1 hospital which were flooded was shortly resumed. 3.The provision of hospitals with medicines and medical equipment is generally satisfactory. There is a small shortage of PPE and some medical equipment in some hospitals (patient ventilators, OC, etc.). This problem is being solved both with the help of state and hospital purchases, and with the help of volunteers. At the same time, there is a big problem with old and non-functional equipment and with the rational use of new equipment. 4.Most cases of COVID-19 infections in health care workers have occurred outside the workplace. Very often, these are familial foci of infection that can be identified. But in some departments there are big problems with IPC measures, which may explain the high incidence of healthcare workers in these facilities.

16 Key Findings and Recommendations

5. The testing capacity for COVID-19 has considerably improved. However, there are still problems with access to tests, long waiting times for results and the possibility of incorrect results (especially in small laboratories in some hospitals). 6. Infection prevention and control (IPC) measures in healthcare facilities continue to be limited and require improvement. Most critical gaps include: lack of systematic trainings, inadequate Healthcare- Associated Infections (HAI) survailance, lack of alighnment of IPC plans with WASH requirements, excessive and ineffective use of disinfectants, poor natural ventilation (windows need repair, poor supervision), outdated and run down tools for cleaning, lack or absence of Standard Operating Procedures (SOPs). IPC measures (social distance, wearing a mask) in public places are relatively respected, but this is a big problem in public transport. 7. A lot of misconceptions among healthcare workers regarding IPC measures and clinical management of patients with COVID-19. The most popular misconceptions include the effectiveness of antibiotics and some other medicines in treating COVID-19. 8. The mental health of medical personnel is of concern. Mental Health and Psychosocial support very important for both healthcare workers and the entire population. 9. Limited financial resources for COVID-19 response remains a serious problem. Many of healthcare authorities noted the inadequate level of funding that most hospitals receive from the NHS (НСЗУ) for the treatment of patients with COVID-19. This could lead to limited availability of medical services in the near future if the situation does not improve. 17 Needs

1.Short-term needs •Needs of PPE for medical staff, including at non-designated hospitals, SES labs, EMS and EECPs. •IPC support to hospitals, including training and donation of IPC equipment (autoclaves, disinfection stations, etc.). •Biomedical equipment such as patient ventilators, monitors, oxygen equipment in some COVID-19 designated hospitals.

2.Medium-term needs •Need for Mental Health and Psychosocial support for both healthcare workers and the entire population. •The testing capacity for COVID-19 and testing availability needs to be improved.

3.Long term needs •Case management and IPC support including onsite training and webinars. •Improving financing and attracting additional sources to improve the equipment of hospitals and cover current needs. •The pharmacy network does not cover all the location (especially remote mountainous areas). Establishment of the mobile pharmacy would be recommended.

18 Sources

• Clinical care for severe acute respiratory infection: toolkit: COVID-19 adaptation – EN, RU, UA • COVID-19 Response Dashboard as of 18 August 2020 • Epidemiologic situation in all regions of Ukraine as of 31 July, Public Health Center – UA • Strengthening the health systems response to COVID-19 - Technical guidance #5, 17 June 2020 – EN, RU • UKRAINE: Humanitarian Impact of COVID-19 Situation Report No.4 - 3 June 2020 • Updated Health Cluster page on Humanitarian Info

19 Thank you!

Dr Yurii Zhyhariev WHO COVID Response Incident National Consultant on Clinical Management Team Management