On average, 15 out of every 100 patients in acute-care hospitals in low- and middle-income countries acquire at least one health-care-associated infection (HAI) during their stay in hospital. Infection prevention and control (IPC) interventions can reduce HAI by at least 30% for patients, health workers and visitors to health-care facilities.
IPC is also crucial for tackling the global crisis of antimicrobial resistance (AMR) that threatens to render antibiotics ineffective and limit our metabolic ability to treat common infections.
While countries in the Region have been making progress to strengthen IPC interventions, the COVID-19 pandemic brought into sharp focus the urgent need to scale up these measures. The Rohingya refugee camps in Cox’s Bazar, Bangladesh, which are among the most densely populated refugee camps in the world with 890 000 refugees, were especially vulnerable.
Congested living spaces, far-from-optimal water and sanitation facilities, and lack of awareness, among others, posed serious challenges to containing the spread of COVID-19 in the camps. According to February 2020 IPCAF (Infection Control and Assessment Framework) conducted by WHO team, only 20% of health facilities in the Rohingya camps had IPC committees.
To address vulnerabilities, plug the gaps and strengthen IPC interventions, Bangladesh launched a series of targeted measures with the support of WHO and partners that, among others, helped rapidly scale up IPC programmes from 4.4% of the health facilities in February 2020 to 100% of all health facilities by April 2022. The measures adopted also firmly institutionalized infection prevention and control protocols and actions within the health sector’s humanitarian response framework during the COVID-19 pandemic in Cox’s Bazar.
Scaling up training
In mid-February 2020 – just a fortnight after the COVID-19 outbreak was declared a public health emergency of international concern (PHEIC) on 30 January 2020 – WHO in collaboration with the Ministry of Health and Family Welfare and partners organized a general IPC training for health-care workers at all health facilities in the refugee camps. The training was integrated into the overall COVID-19 containment prevention and control strategy.
Participants were trained on a wide range of health and safety topics, including standard infection precautions, use of personal protective equipment (PPE); infection-limiting space requirements; environmental decontamination, health-care waste management,shifting of COVID-19 patients to the health facilities, and decontamination of equipment.
IPC training was provided in 100% of the health facilities, a huge leap from just 22% of such facilities that had received such training earlier. As a result, by July 2020, 3600 health and humanitarian workers had been trained in IPC. In March 2021, a refresher course for Master Trainers was also conducted.
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Training health-care workers on how to put on personal protective equipment (Photo credit: WHO/Bangladesh)
Master Trainers
To speed up the training of health workers in the district and establish a pool of experts on COVID-19 IPC, WHO in collaboration with MoHFW in April 2020 trained 43 participants (11 female, 32 male) as Master Trainers in Cox’s Bazar.
Master Trainers were also trained to run the severe acute respiratory infection isolation and treatment centres (SARI ITCs) in Cox’s Bazar.
A still from a video in Bengali produced by WHO detailing the proper usage of PPEs
Each trainee was also provided with a USB drive with relevant information on IPC Master Training Module and Training PPTs, such as Introduction to IPC; Introduction to COVID-19 and COVID-19 IPC; Setting-up the Healthcare Facility; Rational Use of PPE; Isolation of Suspected COVID-19 Patients, etc, IPC guidelines were also shared with all health facilities through an open-source digital platform. A video in Bengali was also made to outline the correct usage and handling of PPEs.
The WHO IPC team also adapted COVID-19 global guidance to the local context. IPC guidance was also prepared for travel, physical meetings, schools, health facilities, non-medical workplaces, etc. This guidance was made available on the health sector open platform for use by different partners and health-care workers.
IPC structures including IPC committees at the district, sub-district and health facility levels were also set up. The selection of IPC focal persons in all facilities was identified as a priority task. This was completed in three months.
Peer-to-peer support and knowledge exchange programme, wherein health-care providers gain technical knowledge and skills by learning from each other while performing their roles, were especially useful in enhancing skills and training. With guidance from WHO, the initiative served as a foundation for optimized clinical care to ensure the best possible chance of survival of patients in Cox’s Bazar and the adoption of best health-care practices incorporating IPC.
Setting up severe acute respiratory isolation and treatment centres
As part of the COVID-19 pandemic response, 14 severe acute respiratory infection isolation and treatment centres (SARI-ITC) were established in Cox’s Bazar between May 2020 to September 2020
To strengthen worker and patient safety at the SARI isolation and treatment centres, WHO worked closely with engineers and managers to integrate IPC into their design and construction. Transparent and protective screens and easy-to-clean surfaces to enable safe consultations between health-care workers and those visiting the health centres were among the several measures adopted.
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All SARI ITCs in Cox’s Bazar were set up according to WHO standards for isolation and treatment centres. This included design considerations to ensure staff and patient safety. (Photo credit: WHO/Bangladesh)
Adequate provision for proper seating and waiting spaces, directions of workflow, separation of different zones, and ventilation and lighting, was emphasized. WHO further encouraged partners to assign dedicated IPC professionals, define clear IPC objectives, and include IPC in their workplans.
All these measures enabled people in the camps to visit health facilities safely, and recover and return to their community without acquiring associated infections.
‘COVID-19 is a highly infectious disease, and we are committed to creating the safest environment possible before caring for patients, while doing so, and even after. Our top priority is patient safety and that means ensuring health workers stay safe too,’ said Dr Nazia Sultana, medical in-charge at UNHCR/Relief International SARI-ITC.
Daily checklist and monthly scorecards
To effectively monitor the implementation of IPC measures, WHO and health sector partners introduced a user-friendly daily IPC checklist along with a monthly scorecard. IPC focal persons from all the health facilities were also trained on how to use the daily checklist and scorecard for IPC monitoring.
The checklist helped bolster IPC practices through daily monitoring and course corrections. The regular feedback on IPC measures also resulted in better performance on the scorecard. These tools were adopted by all SARI-ITCs in September 2020 and then followed by general health facilities in November 2021.
In addition, WHO supported the development of a quarterly supportive supervision checklist for SARI-ITCs as well as a six-monthly upportive supervision checklist for district general health facilities.
While only 17% of the health facilities had reported monitoring of any IPC activity till February 2020, 70% of the facilities reported using daily IPC checklists for monitoring all IPC activities by April 2022.
The supportive supervision checklists are also useful for WHO and the ad hoc IPC Technical Working Group, which consists of the Government, the UN and international NGOs, and a few other agencies, in carrying out quarterly and six-monthly technical support to partners.
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A monthly scorecard displayed at primary health care in a Rohingya camp. These became a useful monitoring and quality assurance tool for regular supportive supervision visits made by WHO (Photo credit: WHO/Bangladesh)
Stakeholder involvement is key to success
In order to strengthen the implementation of IPC interventions not only in the refugee camps but also in the district overall, WHO facilitated several consultative meetings and a workshop for stakeholders including the WHO Country Office, the Office of the Civil Surgeon of Cox’s Bazar district, the Office of the Refugee Relief and Repatriation Commissioner, the Ministry of Health and Family Welfare’s Coordination Cell and health sector partners.
WHO also supported the formation of eight sub-district hospital IPC committees and a district hospital IPC committee, along with an overarching district IPC committee. None of these committees existed before the IPC programme started in Cox’s Bazar. All committees of over 300 health workers received training to enable them to perform their responsibilities for IPC sustainability with the goal of reduction of HAIs and ensuring patient and health worker safety in the district.
At the divisional level, the WHO Country Office supported the Directorate-General of Health Services (DGHS) in training 65 physicians and nurses from medical colleges and district hospitals in eight divisions on infection prevention and control in March 2021.
‘It is essential that all staff are aware of IPC measures. They must learn and be committed and devoted to the work they do. There is no alternative to IPC practices in all clinical settings, and all health-care workers must be vigilant about this. We highly appreciate WHO’s support in building the national capacity on IPC. This is an essential matter, especially during emergencies like this,’ said Professor Dr Khursid Alam, Director-General of DGHS
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Prof. Dr. Khursid Alam, Director General of DGHS Bangladesh addressing physicians and nurses at a workshop in Dhaka in March 2021 on Infection Prevention and Control (Photo credit: WHO/ Bangladesh)
Challenges and the road ahead
Since 2020, the rapid scale-up of IPC measures in Cox’s Bazar following the COVID-19 pandemic has provided the impetus to strengthening such measures in the district. To date, all 137 health facilities in the Rohingya camps have IPC committees and focal persons, comprising health workers. The committees include the lead of PHCC/field hospital, leads of all major clinical departments, the lead nurse, lead pharmacists, lead of laboratories, head of maintenance and cleaning departments, and IPC focal persons.
Although there are efforts at institutionalization made by IPC personnel recruited by organizations, as well as allocated budgets, workplans with clear objectives and monitoring, there is still no microbiology laboratory support.
Although there are institutionalization efforts taken through IPC personnel recruited by organizations, budgets, workplans with clear objectives and monitoring, there is still no microbiology laboratory support. Health care-associated infections and studies of antimicrobial resistance and surveillance need the laboratory to culture, identify and test the microorganisms. Additionally, sustainability of the programs can be challenging especially if funding is not continuously channeled towards this cause.”
To reduce cost and time in reporting on IPC feedback, WHO is currently advocating for embedding IPC activities into existing systems. Integrating IPC feedback as part of the routine quarterly review meetings at the district or health-facility level instead of having a separate quarterly IPC feedback meeting will help achieve this objective.
For other stories, check out WHO SEARO publication - Sustain Accelerate Innovate - South-East Asia: flagship priority programmes driving impact in countries for the health of billions: https://www.who.int/southeastasia/publications-detail/9789290209867