Infection prevention and control in the COVID-19 pandemic: what have we learnt?

Infection prevention and control (IPC) services play a central role in assuring patient and healthcare worker safety and are focussed on applying scientific, behavioural, environmental and organisational strategies to prevent healthcare-associated infections and limit the spread of infectious diseases. In the United Kingdon (UK), the Civil Contingencies Act 2004 requires that all National Health Service (NHS) organisations prepare for emergencies, including having a specific plan for pandemic influenza (NHS England 2017). However, existing influenza/pandemic plans pay little, if any, attention to issues that have emerged as critical in this pandemic, such as the segregation of patients suspected or known to have the infection, discharging patients to high-risk settings or systems for surveillance of healthcare-associated transmission. In addition, these pandemic plans do not consider the critical role that IPC play in their management and control and the consequent demands on limited IPC resources associated with supporting Incident Command Systems, responding to policy and training demands and managing in-hospital outbreaks of infection.

In the UK, the Health and Social Care Committee and Science and Technology Committee has announced recently that they will be holding a joint inquiry into lessons to be learned from the response to the coronavirus pandemic so far (UK Parliament 2020). The Infection Prevention Society (IPS) has gathered opinion from its members in order to make a submission to this inquiry. The skills of specialist IPC practitioners have been fundamental to supporting the effective management of COVID-19 across the whole healthcare economy and our members therefore have a unique insight into the challenges and lessons. Our findings clearly identify some important problems encountered in responding to the pandemic and demonstrate key lessons that need to be addressed to enable a more effective response to future pandemics.

Probably the most important challenge early in the pandemic was personal protective equipment (PPE), both in relation to managing inadequate supplies but also Government-generated equipment being of poor quality or not fit for purpose. The difficulties were often exacerbated by conflicting guidance being issued by professional bodies and inappropriate demands for high-level PPE depleting stocks. Pandemic plans do not consider the implications for IPC service of training large sections of the workforce in the use of PPE or the need for fit-testing respirators to ensure that they provide effective protection. In many Trusts, fit-testing became an IPC team responsibility despite using a considerable amount of their scarce resource. Instead, there needs to be a planned rolling programme for fit testing conducted by “competent fit testers” as mandated by the Health and Safety Executive (HSE 2013).

Many of the risks that contributed to hospital-related transmission of COVID-19 during the course of the pandemic would have been recognised by IPC specialists familiar with the frontline delivery of care. However, such expertise was not adequately represented on national decision-making committees and, given that IPC is fundamental to managing the pandemic, this is a significant oversight. It is not enough to assume that relevant expert advice can be provided by a generalist with a background in nursing or microbiology. IPC is a highly scientific and technical area of practice that requires a detailed understanding of the delivery of care across all professional groups and healthcare settings.

Similarly, some national guidance did not recognise practical implications in clinical settings. The emphasis on the use of gloves, when hand hygiene is perfectly effective in many situations, generated conflicting messages about the risk of acquiring virus via the skin and was likely to increase virus transmission as staff will touch many surfaces with the same pair of gloves. The recommendations for high-risk areas overlooked the key principle of PPE that it should be for single patient use only (Public Health England 2020). The widespread and continuous use of gloves and gowns enables the transfer of pathogens between patients and to all surfaces touched by staff with gloved hands. This practice contributed to the widespread transmission of antibiotic-resistant pathogens that occurred in many ICUs caring for COVID-19 patients and this guidance needs to be changed.

The pandemic exposed the scant resources to support IPC in the care home sector, with a lack of clarity about responsibilities for training and oversight and very few IPC practitioners available to support education and training. The national training that was made available was not appropriate for the care home environment, where the priorities and challenges are very different to acute care. Thus, care homes were expected to be able to prevent and manage outbreaks of a respiratory virus successfully with little or no training and support. We urgently need to develop robust systems for advising and training staff in care homes in IPC to avoid similar problems occurring in the future.

Finally, the lack of compassionate care implemented in the name of IPC has caused immense pain and suffering to many patients and their loved ones. Whilst controls on visiting are clearly required, essential visiting with appropriate IPC precautions could, and should, be managed (Infection Prevention Society 2020). In care homes, fear of being blamed for outbreaks and lack of staff to facilitate the visit or additional cleaning has resulted in many residents being totally isolated from their loved ones for months. More guidance on facilitating safe visiting with appropriate IPC input is urgently required.

A key warning from this pandemic is that the IPC programmes, both in the UK and worldwide, which are focused predominantly on the prevention of common healthcare associated infection, such as norovirus and Clostridium difficile, and reducing the risk of antimicrobial resistance, are not prepared for the challenges of dealing with a major global pandemic. Indeed, in many countries, the structure and activity of IPC services are underpinned and driven by guidance and inspection frameworks (Department of Health 2015; World Health Organisation 2016). This pandemic has shown us that the capacity and capability of IPC services need to be examined in order to develop more effective systems and structures for the management of future pandemics.

We must not be complacent about the likelihood of future pandemics. While 100 years has elapsed since the influenza pandemic of 1918 and the emergence of SARS-CoV-2, in the last 20 years, a range of novel pathogens (severe acute respiratory syndrome (SARS) in 2003, Middle East respiratory syndrome (MERS) in 2012) and other known pathogens (influenza H1N1 2009, Zika 2013–2015, Ebola 2014–2016) with the capacity to cause severe infection in humans and spread rapidly have caused major epidemics worldwide. There is growing evidence that decline in biodiversity as forests are cut down and the species they contained are replaced by animals more likely to host pathogens that can jump to humans, has contributed to the rapid increase in emerging infectious diseases (Tollefson 2020). The interface between humans, wildlife and livestock as people move into previously undeveloped areas facilitates the emergence of novel routes of transmission, and pathogens take advantage of this. The COVID-19 pandemic may be the worst we have experienced but it surely is not going to be the last and we need to act on what we have learnt if we are to be prepared for the next one.