Knowledge regarding Infection Prevention and Control guidelines during COVID 19 pandemic among health care workers in tertiary care hospital.

Introduction:

The global outbreak of coronavirus disease (COVID-19) is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During the last 20 years, 2 other coronavirus epidemics, SARS-CoV and Middle East respiratory syndrome (MERS)- CoV, have resulted in a considerable burden of cases across multiple countries.^1,2 During the outbreaks of both SARS-CoV and MERSCoV, patient-to-patient and patient-to-HCP transmission occurred in healthcare settings^3,4. Although the level of risk of transmission across hospital occupants (to HCPs and others) falls on a spectrum, all of these groups pose unique challenges when it comes to reducing transmission. In hospital settings, performing aerosolgenerating procedures (AGPs, eg intubation, suction, bronchoscopy, cardiopulmonary resuscitation) or using a nebulizer on a SARS patient facilitated patient-to-HCP transmission.^5,6 Overcrowding in emergency rooms, poor compliance with IPC measures, and contamination of the environment also contribute to viral spread.⁷ There are salient evidences shown that proper IPC measures during outbreak management could remarkably change the course of the outbreak. Actually, policy rule is not the only determinant of IPC behaviours of HCWs, as optimal IPC behaviours are influenced by many factors.⁸ Outbreak, contact with confirmed and suspected patients, key clinical departments (such as intensive care unit and emergency department) are critical risk factors in the pandemic outbreak and always cited as important causes of high healthcare-associated prevalence worldwide.⁹

Safety guidelines have been developed by the Ministry of health and family welfare in line with recommendations from the World Health Organization (WHO) regarding the coronavirus. Existing evidence suggests that COVID-19 is a viral infection transmitted by droplets and contact, rather than by air. This explains the existence of precautions on social and physical distancing, environmental hygiene, as well as infection prevention and control (IPC) practices.¹⁰

Similarly, standard IPC precautions have existed regarding hospital-acquired infection (HAI). HCWs exist as vectors in the patientto-patient transmission of HAI. Available evidence demonstrates the effectiveness of safety guidelines including the use of PPE, disinfection of equipment and environment and waste management. However, compliance to IPC measures remain poor.¹¹

The aim of this study is to assess knowledge about Infection prevention and Control [IPC] guidelines during COVID-19 pandemic among Health care workers (HCW).

Materials and method:

The present hospital based study was a cross sectional study was carried out in a tertiary care hospital attached to Bangalore Medical College and Research Institute, Bengaluru from October 2020 to December 2020. After getting clearance from institutional ethical committee.

A list of HCWs in Victoria hospital Bengaluru was listed. Using simple random sampling technique 100 HCWs were contacted via telephonic call by the investigator. They were explained the purpose of the study over the call and their verbal consent was taken to be included in the study.

Out of 100 healthcare workers who were contacted, 98 gave consent to be included in the study. Two refused to give consent because of their busy time schedule. 98 healthcare workers were sent the questionnaire via email and via Whatsapp messaging app. Out of these 98 subjects, 90 responded and answered the questionnaire. Hence, final analysis comprised of these 90 respondents.

Questionnaire was developed based on WHO Infection Prevention and Control(IPC) guidelines, it was pilot tested and validated. P-value of less than 0.05 was considered statistically significant and all the statistical analysis was performed using Statistical Packages for Social Sciences (SSPS) version 20.0. Data analysis and management We extracted information related to COVID-19 transmission dynamics, clinical presentations, and exposures that may facilitate the transmission while reviewing the literature. For guidelines, we extracted title, country or organization, department, target audience, and the different control measures recommended to control COVID-19.

The lead author extracted the information from the guidelines, and all co-authors reviewed and validated it. We performed a content analysis of all data and summarized it under certain themes, and we then compared and contrasted our findings as they related to COVID-19 IPC measures.¹²

Results

In this study,out of 90 subjects, 62 were Doctors and rest 28 were Nurses (Fig-1). Among doctors 36 (58.04%) were females and 26 (41.94%) were males. Among nurses 21 (75%) were males and 7 (25%) were females (Fig-2). Regarding socio-demographic characteristics, Age group of all participants is between 18-39yrs. The mean age of the study population was 29.7yrs and 33.8yrs among doctors and nurses respectively.WHO based IPC questionnaire was asked. Chi-square test is applied. Table -1 showing P-value of various right responses given to the mentioned topic questions. P-Value < 0.05 is statistically significant. P value taken based on percentage of right response given by doctors and nurses.

Conclusion :

This study shows Many of the healthcare professionals had fair knowledge regarding IPC guidelines, but they still more need to be updated regarding this, which is very much needed as IPC guidelines are very important aspect of pandemic mitigation and control.

Limitations:

This study was carried out with limited number of HCWs, a bigger study involving more HCWs would have helped in generalizing the results of the study.

Recommendations:

Frequent orientation regarding IPC measures and updates need to be given to all groups of HCWs. It helps in tackling the pandemic in hospital settings. Thus it prevents spread of disease to HCWs and to the public.

Discussion

The SARS-CoV-2 is a zoonotic virus, and bats are assumed to be the reservoir.¹³ The suspected mode of COVID-19 transmission in Wuhan is from bats to humans; this animal served as an intermediate host that facilitated the transfer of this virus to humans. Transmission may occur pre symptomatically, during the incubation period, or even after recovery.^14,15 The CDC team reasoned that when an infected person coughs or sneezes, the large respiratory droplets expressed from the patients’ mouth and nose are likely to transmit the virus from the infected patient to a healthy person.16These droplets may travel up to ~4 mand may increase the risk of infection to HCPs.

AGPs, such as bronchoscopy, bronchial suction, tracheal intubation, and sputum induction, may generate aerosols containing the virus and increase the risk of transmission.¹⁷ These modes of transmission may contribute to spreading the virus in healthcare settings, including superspreading eventsand they inform guidance for IPC in healthcare settings.

As of April 8, 2020, >22,000 HCPs have been infected with COVID-19 in 55 countries.18 One of the largest known outbreaks of hospitalacquired COVID-19 was reported in China among 17 (12.3%) of 138 patients and 40 (29%) of 138 HCPs in 1 hospital. Currently, the following IPC measures are in practice: suspected source control, use of personal protective equipment, rapid diagnosis, physical distancing, isolation, investigation, and follow-up of close contacts.¹⁹ All guidelines recommend early diagnosis and isolation of COVID-19 patients in a single room, if available. In settings where single room isolation facilities are limited, all of the guidelines recommend cohorting or group zoning of suspected COVID-19 patients in a well-ventilated room. The guidelines prioritize source control and recommend providing face masks to patients. The guidelines also recommend training for all HCPs regarding IPC measures. However, there are discrepancies in the guidelines regarding IPC measures. For example, the WHO recommends at least 1 meter distance between patients or between patients and HCPs when patients are cohorted in a large room All of the guidelines highlight visitor controls in the hospitals. However, only China and the WHO discuss family members giving care in healthcare settings; they recommend that family caregivers use contact and droplet precautions while attending family members in the hospital. In addition, the ECDC guidelines recommend PPE for social workers when they provide care in healthcare settings.

Due to the global supply shortages of PPE, almost all of the guidelines revised their initial recommendations related to PPE use. Of the 6 guidelines, 5 now recommend reuse of PPE following the manufacturers’ instructions. Considering the global scarcity of PPE supplies, the WHO, CDC, ECDC, Australian, and UK updated guidelines recommend surgical masks as an acceptable alternative to N95 respirators for HCPs during routine care, and N95 or equivalent respirators have been prioritized during AGPs. However, the recommendations around the type of face mask vary; for example, some guidelines recommend fluid repellent surgical face masks, whereas others recommend general surgical masks.²⁰

Physical separation is efficient in reducing transmission of respiratory virus in hospital settings. The CDC, and WHO guidelines emphasize engineering control as an IPC measure. These guidelines recommend the following engineering control measures: spatial barriers or partitions to manage patients in triage areas, curtains around each bed in inpatient wards closed. suctioning systems for airway suctioning in intubated patients, and airflow management. The CDC guidelines also recommend installing physical barriers using glass or plastic windows in the hospital reception area.

The increasing numbers of COVID-19 cases among HCPs along with evidence of ongoing transmission in some hospitals suggest some that gaps in IPC measures should be revisited in the guidelines. Low- and middle-income countries often adopt international IPC guidelines as they stand or with modifications for the local context. Therefore, we recommend international guidelines consider the global context while recommending IPC measures. In conclusion, SARS-CoV-2 may spread faster than the previous SARS-CoV. IPC measures should consider SARS-CoV-2 to spread as a droplet, an aerosol, and through the oral–fecal route. All of the guidelines should target these modes of transmission while recommending control measures. Because no drug or vaccine is publicly available for SARS-CoV-2, HCPs and other frontline outbreak responders must rely on IPC measures for safety. In addition, gaps always occur between the development of IPC guidelines, their introduction to target audience, and their implementation. During a public health emergency, international agencies may use an online platform to introduce IPC guidelines to HCPs in a shorter time. National authorities should provide training on the IPC guidelines to people at risk of infection.