REPORT ON THE TONGA DENTAL HEALTH PROJECT JULY 1997

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1 1 REPORT ON THE TONGA DENTAL HEALTH PROJECT JULY 1997 A group of four F.A.I.M. Rotary volunteers from the Tonga Dental Health Project visited the Tongan islands of Tongatapu and Vava'u and spent two weeks from July 8th. - 22nd. in the hospitals there. The group consisted of ; Dr. David Goldsmith (dentist), Mr. Rod McLean, microbiologist and lecturer in infection control from R.M.I.T University, Mr. Peter Copp (dental equipment technician), Ms. Camille Lewis (dental nurse). They were part of the twinning programme between St. John of God Hospital in Ballarat, Australia, and the Viaola Hospital in Tonga, and the Ballarat West and Nuku'Alofa Rotary Clubs. This was the second visit by a dental work party following a previous needs assessment trip in October The 1996 visit compiled a report and identified the problem areas to be; 1. Infection Control and general cleanliness 2. Maintenance and supply of equipment, 3. Material shortages and availability, 4. Preventive services, and 5. Staff training and development. This trip aimed to make a start on the first three recommendations and set itself the following goals; 1. To install donated equipment that had been identified as appropriate for the Viaola Hospital and had previously been shipped over to Tonga by St. John's. 2. To do repairs and maintenance on any broken equipment and assess future equipment needs. 3. To deliver much needed dental supplies from a "wish list" provided by Viaola Hospital. 4. To improve infection control procedures within the dental clinic and give staff training in this area. 5. To meet with infection control staff within the main hospital and to assess the current status of infection control and to formulate guidelines for the future. 6. Visit the Prince Wellington Ngu hospital on Vava'u to assess their needs. 7. To liaise with staff to assess future directions for the twinning project.

2 2 1. EQUIPMENT. From our previous visit to Tonga we had identified the types of equipment that we felt were appropriate for Tongan conditions and had developed a "wish list" for donations. - Equipment that is simple, easy to maintain, self-contained, and inexpensive, and as far as possible, interchangeable between surgeries. Examples would be ; mobile operating carts (e.g. ADEC) on quick release couplings with self-contained water systems as the water quality can be poor, mobile aspirator units e.g. Cattani, W.Green or Clark which are portable, easily maintained and reliable and have very good suction, simple floor mounted operating lights. Chairs can be almost any type - the simpler the better, and handpieces should be interchangeable between surgeries. Through contacts in the dental trade, publicity in dental journals, talks etc. we have obtained many donations of such equipment, which our technician Peter Copp was able to check over and recondition where necessary before shipping to Tonga. On this trip we sent and installed ; one Belmont dental chair, one ADEC chair, two Pelton and Crane Operating lights, one ADEC mobile cart, one mobile suction unit, one cuspidor, an ultrasonic scaler, and a new portable ADEC Missionaire unit which could be run off a scuba tank and ideal for use on the islands or school dental service, two mobile instrument cabinets, an ultrasonic bath and an Aesculap autoclave. A conservative value of this equipment would be $17,000 but to replace it would cost over $50,000. This equipment was shipped out by St.John of God Hospital along with other medical equipment that they had sent to Viaola, and we are now putting aside further similar Old chair out. New donated chair in! equipment to take across with us next year. A schedule of the donated equipment is enclosed in the appendix. In addition Peter Copp was able to do repairs to equipment that we had identified needed attention and spare parts were taken with us, many having been donated free by the manufacturers. Also Peter has left a repair kit at the Viaola Hospital dental clinic containing tools, spare parts, equipment etc. that is likely to be useful in the interim, or on subsequent visits by this group or other service personnel.

3 3 2. DENTAL SUPPLIES. A "wish list" of much needed items was obtained from Viaola prior to our departure and local Australian dental supply companies were generous in their support. A schedule is enclosed with the appendix. One donation particularly worthy of mention is Dentsply Australia's donation of 200 boxes of local anaesthetic valued at almost $8,000. The total value of donated supplies would be over $12,000. Some anaesthetic was taken over in July with the work party and some still remains to be shipped, as our generous weight allowance from Polynesian Airlines was more than filled! This remaining anaesthetic (3 x 16kg cartons.) will now be air-freighted to Tonga in September thanks to another sponsor. Also many useful hand instruments and forceps were donated by dentists who had heard of the Tongan Dental Project. Shortages of supplies is still a problem and during our stay in Tonga no denture work was being done by the two technicians due to the lab. having run out of plaster and stone. 3. INFECTION CONTROL - DENTAL CLINIC, VIAOLA. Previously the dental clinic relied on cold disinfection using Savlon solution and one large water boiler. However no proper facilities existed to properly sterilise instruments using steam autoclaves. This was a real worry in an area which has so much blood contamination. Whilst we were at Viaola the dental clinic was seeing in excess of 100 patients a day, and World Health Organisation surveys of blood donors in Tonga show the carrier rate for Hepatitis B to be 15% of the population.

4 4 We found a new, unused, but nonfunctioning autoclave at Viaola, which we managed to repair, and this together with the autoclave and ultrasonic bath we brought with us allowed us to set up a proper sterilising program in a pre-existing sterilising room which was only being partially utilised. This room was thoroughly cleaned, then it was set up with a proper instrument flow, so that dirty instruments arrived at one end, were scrubbed in the sink, put in the ultrasonic bath, rinsed, put in the autoclave, and then on to the clean area for storage, before exiting via the door at the other end of the room to go back into the surgeries. This was set up in the first two days that we arrived and the sterilising program using autoclaves for all dental instruments was still operating satisfactorily when we left two weeks later. We would like to see a total of four autoclaves operating simultaneously in the clinic to speed up instrument flow and to have a reserve in case of future malfunctions of the equipment, and we have several offers of donations of suitable autoclaves (at least three have been offered by the United Dental Hospital in Sydney.) which just now need transporting to Tonga. We would also like to see the dental clinic having its own de-ioniser/distiller to provide distilled water for its own autoclaves as the need for distilled water is stretching the supplies of the main hospital. An in-service lecture on Hepatitis B and other blood-borne pathogens was given by Rod McLean to all the dental staff, using appropriate slides and videos from the R.M.I.T. Health Sciences new audio-visual library, and this was enthusiastically received. Recommendations. 1. A Dental nurse be appointed to have responsibility for overseeing infection control procedures in the Dental clinic. 2. A distiller be purchased for the Dental clinic to produce its own supply of distilled water for the autoclaves. A suitable type would be such as a Tuttnauer or an Ecowater --- which retails in Australia for approximately $ A minimum of two more autoclaves be made available for the dental sterilising room - suitable models are in store at Sydney United Hospital at no cost and could be shipped with the next consignment of materials to Tonga from St. Johns. 4. All current staff should be immunised against Hepatitis B, and all new staff employed at the dental clinic also should be similarly immunised before starting work there as a matter of policy. 5. The project be ongoing with another work party to visit in INFECTION CONTROL - MAIN HOSPITAL, VIAOLA. Inspection of Hospital Facilities On 18/7/97 Mr. Rod McLean, Dr. David Goldsmith and Dr. Siale 'Akau'ola made a tour of the hospital facilities with regard to identifying problem areas for cross infection within the hospital and a report with their findings and recommendations is reproduced in the attached appendix.

5 5 5. PRINCE WELLINGTON NGU HOSPITAL, NEIAFU, VAVA'U. The work party spent four days on Vava'u during which time they had discussions with the Chief Medical Officer in Charge, Dr. Seini Kupu, and the Senior Dental Officer, Dr. Sililo Tomiki, visited all areas of the hospital under their direction, visited two regional health clinics on the island, and did repairs and maintenance to the equipment in the Dental department. The main problems encountered by the staff at the hospital relate primarily to severe infrastructure deficiencies and broken lines of communication with the main hospital at Viaola resulting in shortages of supplies and equipment. For instance Peter Copp was restricted in his ability to get the dental equipment functioning optimally, even though he had brought along the correct spare parts, because there was no water supply to the dental unit. One area that needs urgent attention is sterilisation - the main hospital autoclave has failed and been removed and the only sterilisation facilities in the CSSD are a hot air oven and a small hot water bath. A brand new steam powered autoclave is in the CSSD waiting to be installed, but as there is no steam generating plant at the hospital this new autoclave cannot be connected. If it were to be moved to the Viaola Hospital in Nuku'Alofa it would be a very useful back-up for the existing old and overworked one and there is room and steam power available for it there. The Prince Wellington Ngu Hospital now needs a new electrically operated autoclave urgently. On the positive side we found the hospital to be clean, the staff morale and attitude to be very good, and the prestige of the hospital and its staff with the community to be in high regard. Before a comprehensive infection control program could be introduced at this hospital, however, we felt that some of the major infrastructure problems need to be addressed. There are many areas here that a volunteer Rotary F.A.I.M. Work Party could make a worthwhile contribution. The dental equipment on Vava'u is coming towards the end of its useful life but we feel that we could help to progressively reequip the surgery here if we can obtain transport from Australia. In conclusion we feel that Prince Wellington Ngu Hospital is badly in need of help and should be included in the twinning program with St. John of God and Viaola Hospitals.

6 6 RECOMMENDATIONS; 1. The next F.A.I.M. work party to Tonga should visit the Prince Wellington Ngu Hospital in Neiafu to do a needs assessment there, especially with regard to infrastructure needs. We have photos and slides of the hospital and are available to brief the team. 2. A new electric autoclave be obtained for the CSSD. 3. The existing new steam operated autoclave be shipped to Nuku'Alofa and installed at Viaola Hospital. 4. Running water, hot and cold, be connected to the units in the dental surgery. CONCLUSIONS As before, the main recommendation is to keep the Tongan Dental Project an ongoing one, with a work party of differing personnel returning annually.. A good start was made to address the problems identified in the October 1996 visit and there has been real progress in the areas of infection control and equipment in the dental clinic at Viaola. However, more still needs to be done in both areas. Now that all dental instruments are being scrubbed, ultrasonically cleaned and autoclaved, the clinic is a much safer workplace for both staff and patients. However we would prefer to see two more autoclaves operating (to total four) and for the dental clinic to have its own distiller to ensure a constant supply of pure water. If this does not happen then breakdowns will inevitably occur, and, with no back-up available, the potential for cross infection will again be great. Likewise, there have been improvements in equipment and maintenance. Handpieces are now being cleaned and oiled, so this will save on running costs, and the new chairs, carts, and operating lights will help improve health delivery in the fillings department. However, much of the old equipment being used is antiquated and needs replacing with more modern equipment and we have some suitable dental chairs, stools and lights here awaiting transportation. In the future we would like to offer help with staff training and development, preventive dentistry (particularly fissure sealants in children's teeth), and material shortages and availability. By judicious shopping there are cost savings to be made in both materials and equipment and we hope to provide information on this before the next visit. Finally we would like to say again how much we enjoyed our time in Tonga. The

7 7 friendliness and co-operation shown to us without exception by the whole of the hard working dental staff both on Tongatapu and Vava'u made our visit a memorable one. APPENDIX Infectious disease control recommendations for Viaola Hospital List of equipment donated List of materials donated.

8 8 ACKNOWLEDGEMENTS There are many people we would like to thank for their support of the Tonga Dental Health Project. Firstly, Viaola Hospital Chief Dental Officer, Dr.Moi Tapealava and Dr.Villiami Latu for their support and co-operation in the Tongan Dental Project from its inception. Also the whole of the staff at the dental clinic who have made both work parties feel so welcome, both professionally and socially. More than anybody else they have made our visits to Tonga so pleasurable and worthwhile. On the island of Vava u Dr. Sililo Tomiki gave up his weekend to transport us around this beautiful island, its hospital and health clinics, and gave us an insight into the way of life of these northern islands. To the St. John of God Hospital in Ballarat, and its CEO Daniel Slattery for their vision in initiating and continuing on with the twinning program with Viaola. Also for their help with sponsoring Rod McLean s airfare(along with RMIT), and accommodation on Vava u, and the transportation of all the dental equipment to Tonga from Ballarat. Rotary s role has been crucial both in Tonga and Australia. The Nuku Alofa Rotary Club sponsored our very comfortable accommodation on Togatapu at he Captain Cook Apartments,and a special thank you goes to Emily Moala for picking us up from the airport on our arrival (at 3.00.a.m.!!) and for looking after us generally. In Australia we had invaluable support and advice from several Rotarians who have long experience with the twinning project, particularly John Oswald from Ballarat West Rotary Club. Many members of the Australian Dental Association generously donated useful equipment which we were able to take with us and install at Viaola and we would like to particularly thank the following; Drs., Andrew Langton-Joy, Graeme Kilpatrick, Manju Palam, McLean, Albert Cherk and Kevin Willing amongst others. Their equipment will now give many more years of useful service to the people of Tonga. The Australian Dental Trade have also been very supportive, and, in difficult trading conditions have donated useful new equipment and materials to the project, particularly Dentsply (anaesthetic), ADEC (new unit), supplies from Southern Dental Industries, Halas, Commonwealth, Rudolf Gunz, Voco, and Bourke Dental supply, and W.Green and Cattani for spare parts. The array of materials and equipment we arrived with was quite impressive and attracted full media attention in Tonga. They were all enthusiastically received and immediately put to good use. For further details on the Tonga Dental health Project please contact; Dr. David Goldsmith 11, Lyons Street North, Ballarat, Victoria 3350, Australia Tel , FAX , dgold@netconnect.com.au

9 9 1. INFECTIOUS DISEASE CONTROL RECOMMENDATIONS FOR VAIOLA HOSPITAL, NUKU'ALOFA, TONGA. INTRODUCTION An infection control committee for the Viaola Hospital was in existence but had not yet met so Dr.David Goldsmith and Mr. Rod McLean were able to convene this first meeting on 11/7/97 which was also attended by the Chairman, specialist anaesthetist Dr. Bernard Tu'inukuafe, medical officer Dr. Frank Gutman, head of Pathology Dr. Siale 'Akau'ola, senior dental officer Dr.Tevita Vao, senior microbiologist Mrs. Ane Ika, Assistant Matron Sr. Valoa Fifita, senior nursing sister Sr.L.Pele and senior pharmacist Mrs. Melenaite Mahe. This was a productive meeting with free and open discussion of the problems. It was resolved to begin with simple easily achievable goals and to meet again in one week by which time guidelines would have been drawn up for the future direction of the infection control committee. A second meeting of the Infection Control Committee (I.C.C.) was held on 17/7/97. A suggested plan for the working of the I.C.C. drawn up by Rod McLean and David Goldsmith was tabled at this meeting. This involved; the appointment of an Infection Control Officer, the staffing of an Infection Control Committee and an Infection Control Work Party, and the Duties and Responsibilities of; the Infection Control Officer, the Infection Control Committee and the Work Party, and the development of Protocols. It was felt that the infection control protocols should be specific for the medical and dental services of TONGA, with input from all members of staff through the Work Party and the Infection Control Officer. This would enable a set of protocols to be developed which would be followed and understood by all staff, to achieve an infection control policy that is appropriate and enforceable within the hospital. All staff need to understand, accept, and be trained in an infection control program and all staff should feel part of the policy direction throughout the hospital. This will not only assist in the standing of the hospital in the community, but it will also improve staff morale and the level of patient confidence in the medical and dental services. The meeting was very productive and involved much open discussion from all involved. Copies of infection control protocols from Australian hospitals were left with the Infection Control Officer, Dr. Siale 'Akau'ola.

10 10 Inspection of Hospital Facilities On 18/7/97 Mr. Rod McLean, Dr. David Goldsmith and Dr. Siale Akau'ola made a tour of the hospital facilities with regard to identifying problem areas for cross infection within the hospital and a report with their findings and recommendations is reproduced below. GENERAL WARDS (SURGICAL / MEDICAL) 1. Absence of running water in wards (staff unable to wash their hands between examinations) 2. Toilets and showers not cleaned adequately. 3. Lack of soap and hand towels. 4. Inadequate supplies of linen. INFECTIOUS DISEASE WARD. 1. No protective boots (overshoes) 2. Lack of visitor control. 3. Patient's own linen brought in by relatives usually not washed in the hospital before taking home. 4. No adequate segregation of patients with different infectious conditions. 5. Poor ventilation. 6. Lack of appropriate infectious disease control markings. 7. The poor perception of this ward by the general population. 8. Toilets and showers dirty and a definite health hazard. 9. Disinfection procedures inadequate. 10.No protective surgical masks. KITCHEN. 1. Inadequate drainage under cookers. 2. Animals (cats and dogs) allowed to live in the kitchen. 3. Food coolers and freezers not maintained at correct temperature, decomposing meat on floor of freezer. 4. Poor hand washing facilities. 5. Open food containers near filthy hand washing sink. OBSTETRICS WARD 1. Inadequate supply of disinfectants. 2. Acute shortage of soap and handtowels. 3. No disinfectant hand washing bottles available at sinks. 4. Shortage of linen supplies.

11 11 RECOMMENDATIONS The following recommendations are made as a matter of urgency. The kitchen and infectious disease ward have the potential to seed the rest of the hospital. The general wards (surgical and medical ) are potential reservoirs of infection for inpatients and their visitors. The obstetrics ward needs to address the basic infectious disease shortfalls to protect the most vulnerable members of the community, the babies. 1. The infectious disease control committee to develop appropriate and effective guidelines for all sections of the hospital. 2. The cleaning staff must be made aware of the hygiene requirements in a hospital environment and these appropriate standards must be maintained and regularly monitored by the cleaning supervisor. 3. The kitchen including general food preparation area, freezers, staff hand washing facility and cooking area must be thoroughly cleaned and maintained at appropriate standards. The kitchen staff should be trained in basic food preparation hygiene skills. (This area to be closely monitored by the hospital infectious control officer.) 4. All personal linen to be thoroughly cleaned and aired at the hospital before returning to patient on discharge. The ideal situation is to supply all patients with hospital linen on admission. 5. Supply adequate soap and paper handtowels for staff in wards to prevent potential cross infection. 6. The disinfectants to be correct (not Savlon) and the correct strength. These guidelines to be clearly outlined by the infection control committee. 7. Antiseptic hand washing liquid to be placed in dispenser, bottles over all sinks used by staff in all wards. 8. Sodium hypochlorites to be used as disinfectant in the infectious disease control ward. 9. Appropriate barrier nursing techniques and visitor control for all infectious ward patients. 10. Segregation of patients with different infection disease states (tuberculosis patients not in contact with leprosy patients) 11. Supply of surgical masks to staff, visitors and some patients in infectious disease ward, particularly TB patients and visitors. 12. The training of all staff in basic hygiene procedures to control cross infection hazards. This training must be on-going and include all staffing levels, and be closely monitored by the infectious control officer. Unless the above recommendations are implemented as a matter of urgency the potential exists for an increase in communicable diseases throughout the community with the hospital being the focus of infection. This potential has been recognised by the general population, however not fully understood. It has however resulted in a lack of confidence by the people in their hospital which will only increase in the future unless the simple recommendations outlined above are implemented.