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. 2021 Mar 9;16(3):e0248282. doi: 10.1371/journal.pone.0248282

Infection prevention and control compliance among exposed healthcare workers in COVID-19 treatment centers in Ghana: A descriptive cross-sectional study

Mary Eyram Ashinyo 1,*, Stephen Dajaan Dubik 2, Vida Duti 3, Kingsley Ebenezer Amegah 4, Anthony Ashinyo 5, Brian Adu Asare 6, Angela Ama Ackon 7, Samuel Kaba Akoriyea 1, Patrick Kuma-Aboagye 8
Editor: Wen-Jun Tu9
PMCID: PMC7943010  PMID: 33690699

Abstract

Compliance with infection prevention and control (IPC) protocols is critical in minimizing the risk of coronavirus disease (COVID-19) infection among healthcare workers. However, data on IPC compliance among healthcare workers in COVID-19 treatment centers are unknown in Ghana. This study aims to assess IPC compliance among healthcare workers in Ghana’s COVID-19 treatment centers. The study was a secondary analysis of data, which was initially collected to determine the level of risk of COVID-19 virus infection among healthcare workers in Ghana. Quantitative data were conveniently collected using the WHO COVID-19 risk assessment tool. We analyzed the data using descriptive statistics and logistic regression analyses. We observed that IPC compliance during healthcare interactions was 88.4% for hand hygiene and 90.6% for Personal Protective Equipment (PPE) usage; IPC compliance while performing aerosol-generating procedures (AGPs), was 97.5% for hand hygiene and 97.5% for PPE usage. For hand hygiene during healthcare interactions, lower compliance was seen among nonclinical staff [OR (odds ratio): 0.43; 95% CI (Confidence interval): 0.21–0.89], and healthcare workers with secondary level qualification (OR: 0.24; 95% CI: 0.08–0.71). Midwives (OR: 0.29; 95% CI: 0.09–0.93) and Pharmacists (OR: 0.15; 95% CI: 0.02–0.92) compliance with hand hygiene was significantly lower than registered nurses. For PPE usage during healthcare interactions, lower compliance was seen among healthcare workers who were separated/divorced/widowed (OR: 0.08; 95% CI: 0.01–0.43), those with secondary level qualifications (OR 0.08; 95% CI 0.01–0.43), non-clinical staff (OR 0.16 95% CI 0.07–0.35), cleaners (OR: 0.16; 95% CI: 0.05–0.52), pharmacists (OR: 0.07; 95% CI: 0.01–0.49) and among healthcare workers who reported of insufficiency of PPEs (OR: 0.33; 95% CI: 0.14–0.77). Generally, healthcare workers’ infection prevention and control compliance were high, but this compliance differs across the different groups of health professionals in the treatment centers. Ensuring an adequate supply of IPC logistics coupled with behavior change interventions and paying particular attention to nonclinical staff is critical in minimizing the risk of COVID-19 transmission in the treatment centers.

Introduction

The COVID-19 Pandemic, which emanated from Wuhan, China, has devastated the global community, disrupting all aspects of human lives [1, 2]. As of 8 February 2021, there were 105,805,951 reported COVID-19 cases with 2,312,278 deaths globally [1]. Currently (February 5 2021), there are 72,328 confirmed COVID-19 cases in Ghana, with 472 reported deaths and 6,707 active cases [3]. The disease is a highly infectious viral respiratory disease that is more severe in older people and people with underlying medical conditions [4, 5]. COVID-19 infection can either be asymptomatic or symptomatic with prominent ones being fever, cough, sore throat and shortness of breath [6, 7].

Healthcare workers play a critical role in fighting the COVID-19 pandemic and are at greater risk of COVID-19 virus infection in the line of duty [8]. For instance, data from recent studies showed healthcare workers are more likely to be exposed to SARS-COV-2 [9] and are, therefore, at higher risk of COVID-19 infection than the general community [10]. Hence, the impact of the COVID-19 pandemic on healthcare workers has been enormous [11]. However, prevention remains the best weapon for protecting healthcare workers against the COVID-19 pandemic [12]. Therefore, adherence to infection prevention and control protocols is critical at minimizing healthcare workers exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [8, 13]. Indeed, correct and consistent compliance with IPC protocols is effective in minimizing the risk of COVID-19 infection [8, 10]. Compliance with IPC protocols is facilitated by training of healthcare workers on IPC, provision of IPC materials and regular audit of IPC practices [14]. Generally, IPC strategies in response to highly infectious diseases, such as COVID-19, should include early recognition, physical distancing, source control, taking precautions and appropriate use of PPEs, restriction of movement, environmental cleaning and disinfection as well as support for healthcare workers [14, 15].

COVID-19 infection among frontline healthcare workers put patients, other healthcare workers and the general community at risk of infection. Minimizing exposure of healthcare workers to the SARS-CoV-2 is the best option for protecting frontline healthcare workers from COVID-19 infection, and this is best done through healthcare worker adherence with IPC protocols as well as inoculating against the SARS-COV-2 [16]. Therefore, an understanding of IPC compliance among healthcare workers managing COVID-19 patients is essential for preventing the spread of COVID-19 infections among healthcare workers, reducing secondary transmission in the treatment centers and updating IPC policies in Ghana.

Materials and methods

The study was a descriptive cross-sectional survey that was conducted from May to August 2020 in four COVID-19 treatment centers located in Greater Accra (Pentecost Convention Center, Ga East Municipal Hospital) and Ashanti regions (Barekese and Kumasi South Hospital). The Greater Accra and Ashanti regions were purposively selected, being epicenters, and having the greatest burden of cases, with 50% and 24% of all cases in Ghana, respectively.

Study participants, sample size and sampling

The study participants included clinical and nonclinical healthcare workers working in COVID-19 treatment centers. The sample size was calculated using the Cochran formula [17]; N = z2×p(1-p)d2 at 95% confidence interval (1.96), exposure level of 50% (0.5), and a 5% margin of error (0.05). After adding a contingency of 10%, the estimated sample size was 424. Using convenience sampling, healthcare workers were invited to participate in the study. Those who consented to participate were given the questionnaire with clear instruction on how to complete the questionnaire. Completed questionnaire was collected immediately. Out of 424 questionnaires distributed, 408 were completed and retrieved. Up to 328 out of the 408 respondents were exposed to a COVID-19 patient and were, therefore, qualified to answer questions on adherence to IPC measures during healthcare interactions with COVID-19 patients. Of the 328, eighty of them performed AGP. Compliance with IPC measures when performing AGP was therefore assessed for only 80 of the study participants. The details of the methodology have been explained elsewhere [18].

Ethical consideration

The study was part of a large study titled “Exposure risk Assessment: A survey among frontline healthcare workers in designated COVID-19 treatment centers”, which was approved by the Ghana Health Service Ethics Review Committee. Written informed consent was obtained from all study participants.

Study variables

We adopted the study tool from the WHO risk assessment tool for healthcare workers in the context of COVID-19 [19], attached as S1 File. This tool was used to assess the healthcare workers reported compliance with IPC measures during healthcare interactions and when performing AGPs on COVID-19 patient. Ten (10) items each, were assessed for compliance to IPC measures during healthcare interactions and while performing AGPs, (Tables 1 and 2) with Likert responses: “always, as recommended”, “most of the time”, “occasionally” and “rarely”. Healthcare workers were scored one (compliant) if the healthcare worker responded either “always, as recommended” or “most of the time”, otherwise the healthcare worker was scored zero (noncompliant) (Tables 1 and 2).

Table 1. Measure of infection prevention and control compliance during healthcare interactions.

PPE usage domain Measure of compliance
Single-use gloves Healthcare worker responds either “always as recommended” or “most of the time.”
Medical mask As seen above
Face shield or goggles/protective glass As seen above
Disposal gown As seen above
Remove and replace PPE according to protocol As seen above
Hand hygiene domain Measure of compliance
Perform hand hygiene before and after touching COVID-19 patient Healthcare worker responds either “always as recommended” or “most of the time.”
Perform hand hygiene before and after any clean or aseptic procedure As seen above
Perform hand hygiene after exposure to body fluids As seen above
Perform hand hygiene after touching patient surroundings As seen above
Frequent decontamination of high touch surfaces As seen above
Compliance with IPC during healthcare interactions with COVID-19 patients Healthcare worker responds either “always as recommended” or “most of the time.” to all variables on PPE use and hand hygiene domains
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Table 2. Measure of infection prevention and control compliance when performing AGPs on COVID-19 patients.

PPE use domain Measure of compliance
Single-use gloves Healthcare worker responds either “always as recommended” or “most of the time.”
N95 mask or respirator equivalent As seen above
Face shield or goggles/protective glass As seen above
Disposal gown As seen above
Remove and replace PPE according to protocol As seen above
Hand hygiene domain Measure of compliance
Perform hand hygiene before and after touching COVID-19 patient Healthcare worker responds either “always as recommended” or “most of the time.”
Perform hand hygiene before and after any clean or aseptic procedure As seen above
Perform hand hygiene after exposure to body fluids As seen above
Perform hand hygiene after touching patient surroundings As seen above
Frequent decontamination of high touch surfaces (at least three times) As seen above
Compliance with IPC measures when performing AGP on COVID-19 patients Healthcare worker responds either “always as recommended” or “most of the time.” to all variables on PPE use and hand hygiene domains
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Statistical analysis

We analyzed the data using STATA 14.2. First, descriptive statistics were used to present the study participant characteristics, compliance with hand hygiene and PPE usage in text, figures and tables. Overall compliance during healthcare interactions with COVID-19 patients and when performing AGPs were also summarized using text and figures. Logistic regression analyses were performed to ascertain the association between healthcare workers’ sociodemographic information, availability of IPC facilities and IPC compliance during healthcare interactions with COVID-19 patients. All variables were significant at p-values less than 0.05 at 95% confidence intervals.

Results and discussion

Results

Sociodemographic information of the study participants and the availability of IPC facilities

The sociodemographic characteristics of the healthcare workers are presented in Table 3. The average age of the healthcare workers in this study was 33 years, with most (62.2%) of them between the age brackets 30–49. More (70.7%) healthcare workers from the Greater Accra region participated in the study compared to the Ashanti region. Most (56.4%) of the study participants were females, 50.6% of the healthcare workers were married, and the majority (32.6%) of the healthcare workers had certificate as their highest qualification. Clinical staff formed the majority (78.0%) of the healthcare workers. Participating health professionals were registered nurses (43.6%), assistant nurses (13.7%), cleaners (11.3%), medical doctors (7.9%), midwives (7.3%), laboratory personnel (3.0%), pharmacists (1.8%) and other health professionals (11.3%). The majority of the HCWs indicated that they have never experienced an interruption in water supply in the treatment centers (87.2%), that PPEs were sufficient (86.6%) and a significant proportion (97.9%) of the healthcare workers have received training on IPC (Table 3).

Table 3. Sociodemographic information of the study participants.
VARIABLES Frequency Percent (%)
Healthcare worker characteristics (n = 328)
Region
 Ashanti 96 29.3
 Greater Accra 232 70.7
Mean age (SD), Min–Max 32.6 (6.14), 20–49
Age (In years)
 < 30 124 37.8
 30–49 204 62.2
Gender
 Female 185 56.4
 Male 143 43.6
Marital Status
 Single 156 47.6
 Married 166 50.6
 Separated/Divorced/Widowed 6 1.8
Highest Qualification
 Secondary level qualification 35 10.7
 Certificate* 107 32.6
 Diploma 81 24.7
 Bachelor 82 25.0
 Masters 23 7.0
Staff Category
 Nonclinical 72 22.0
 Clinical 256 78.0
Type of health professional
 Assistant nurse or equivalent 45 13.7
 Cleaner 37 11.3
 Laboratory personnel 10 3.0
 Medical doctor 26 7.9
 Midwife 24 7.3
 Registered nurse 143 43.6
 Pharmacist 6 1.8
 Other staff** 37 11.3
Work Experience
 < 5 167 50.9
 5–10 104 31.7
 11+ 57 17.4
Availability of IPC facilities
Experienced an interruption in water supply
 No 286 87.2
 Yes 42 12.8
Sufficiency of PPEs
 No 44 13.4
 Yes 284 86.6
Training on IPC
 No 7 2.1
 Yes 321 97.9
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*Healthcare workers who pursued certificate program as their highest qualification;

**Other staff included Physical and respiratory therapist, catering staff, Admission/reception clerks, administrative and IT manager, Clinical engineers;

*** Nonclinical staff included cleaners, catering staff, administrative and IT managers,

Infection prevention and control reported compliance during healthcare interactions with COVID-19 patients

Compliance with hand hygiene during healthcare interactions with COVID-19 patients was high (88.4%). Similarly, compliance with PPEs usage during healthcare interactions with COVID-19 patients was high (90.6%) (Fig 1). Detailed analysis showed that adherence with frequent decontamination of high touch surfaces and hand hygiene before and after touching COVID-19 patients was high (97.3%). The healthcare workers also reported performing hand hygiene after touching patient surroundings (96.3%), after exposure to body fluids (95.1%), before and after any clean or aseptic procedure (93.9%) (Fig 1).

Fig 1. Infection prevention and control reported compliance during healthcare interactions with COVID-19 patients.

Fig 1

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Compliance with medical mask use was nearly universal (98.8%). Disposable gown use was the lowest (93.9%) complied in PPE usage domain. Compliance with single-use gloves was 96.7%, and 98.2% of the healthcare workers reported compliance with removing and replacing PPE according to protocol (Fig 1). Details analysis on IPC compliance during healthcare interactions is attached as S1 Table.

Infection prevention and control reported compliance when performing aerosol-generating procedures on a COVID-19 patient

Compared to hand hygiene and PPE usage compliance during healthcare interactions, healthcare workers reported the same compliance with hand hygiene (97.5%) and PPE usage (97.5%) when performing AGPs (Fig 2). Compliance with hand hygiene after touching the patient surroundings, before and after any clean or aseptic procedure was universal (100%). Healthcare workers’ compliance with N95 respirator use, disposable gown, face shield or goggles/protective glass and glove use were also universal when performing AGPs (Fig 2). Details analysis on IPC compliance during AGPs is attached as S2 Table.

Fig 2. Infection prevention and control reported compliance when performing aerosol-generating procedures on COVID-19 patients.

Fig 2

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Total compliance during healthcare interactions and when performing AGPs

Compliance with IPC during healthcare interactions was high (80.8%). However, the highest (95%) compliance with IPC was when performing AGPs (Fig 3).

Fig 3. Total compliance during healthcare interactions and when performing AGPs.

Fig 3

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Association between healthcare workers’ sociodemographic information, availability of IPC facilities and IPC compliance during healthcare interaction with a COVID-19 patient

Table 4 shows an association between healthcare workers’ sociodemographic information, availability of IPC facilities and IPC compliance during healthcare interaction with a COVID-19 patient. Region of residence, age, gender, work experience, interruption in water supply and IPC training was not associated with compliance in either PPE use or hand hygiene. Risk factors for lower compliance with PPE use were being separated/divorced/widowed (OR 0.08; 95% CI 0.01–0.43), having secondary level qualifications (OR 0.08; 95% CI 0.01–0.43) and being a non-clinical staff (OR 0.16 95% CI 0.07–0.35). We also observed lower odds of compliance with PPEs usage among cleaners (OR 0.16; 95% CI 0.05–0.52) and pharmacists (OR 0.07; 95% CI 0.01–0.49). Insufficiency of PPEs was also associated with lower odds of compliance with PPE usage (OR: 0.33; 95% CI: 0.14–0.77).

Table 4. Association between healthcare workers’ sociodemographic information, availability of IPC facilities and IPC compliance during healthcare interaction with a COVID-19 patient.
Healthcare worker characteristics (n = 328) PPE Use (297/328) Hand hygiene (n = 290/328)
Compliance OR [95% CI] P-value Compliance OR [95% CI] P-value
n/N (%) n/N (%)
Region
 Ashanti 19/96 (20.0) 2.30 [0.85–6.17] 0.099 89/96 (92.7) 1.96 [0.83–4.62] 0.124
 Greater Accra 57/232 (24.6) Ref 201/232 (86.6) Ref
Age (In years)
 < 30 23/124 (18.6) 0.97 [0.44–2.13] 0.934 109/124 (87.9) 0.92 [0.46–1.85] 0.822
 30–49 53/204 (26.0) Ref 181/204 (88.7) Ref
Gender
 Female 42/185 (22.7) Ref 166/185 (89.7)
 Male 34/143 (23.8) 0.61 [0.29–1.28] 0.819 124/143 (86.7) 0.75 [0.38–1.47] 0.398
Marital Status
 Single 33/156 (21.2) 0.68 [0.31–1.49] 0.379 136/156 (87.2) 0.83 [0.42–1.63] 0.583
 Married 42/166 (25.3) Ref 148/166 (89.2) Ref
 Separated/Divorced/Widowed 1/6 (16.7) 0.08 [0.01–0.43] 0.003 6/6 (100.0) - -
Highest Qualification
 Secondary level qualification 2/35 (5.7) 0.24 [0.08–0.71] 0.010 27/35 (77.1) 0.24 [0.08–0.71] 0.010
 Certificate 33/107 (30.8) Ref 100/107 (93.5) Ref
 Diploma 16/81 (19.8) 0.56 [0.20–1.57] 0.271 71/81 (87.7) 0.50 [0.18–1.37] 0.176
 Bachelor 20/82 (24.4) 1.08 [0.33–3.53] 0.901 72/82 (87.8) 0.50 [0.18–1.39] 0.185
 Masters 5/23 (21.7) 0.74 [0.14–3.79] 0.713 20/23 (87.0) 0.57 [0.11–1.96] 0.298
Staff Category
 Non-Clinical 6/72 (8.3) 0.16 [0.07–0.35] <0.001 58/72 (80.6) 0.43 [0.21–0.89] 0.021
 Clinical 70/256 (27.3) Ref 232/256 (90.6) Ref
Type of health professional
 Assistant nurse or equivalent 11/45 (24.4) 0.78 [0.15–4.16] 0.770 41/45 (91.1) 0.78 [0.23–2.59] 0.673
 Cleaner 4/37 (10.8) 0.16 [0.05–0.52] 0.003 29/37 (78.4) 0.27 [0.10–0.75] 0.012
 Laboratory personnel 6/10 (60.0) - - 10/10 (100.0) - -
 Medical doctor 6/26 (23.1) 0.91 [0.10–8.08] 0.929 23/26 (88.5) 0.58 [0.15–2.25] 0.429
 Midwife 7/24 (29.2) 0.40 [0.07–2.18] 0.289 19/24 (79.2) 0.29 [0.09–0.93] 0.037
 Registered nurse or equivalent 38/143 (26.6) Ref 133/143 (93.0) Ref
 Pharmacist 1/6 (16.7) 0.07 [0.01–0.49] 0.007 4/6 (66.7) 0.15 [0.02–0.92] 0.041
 Other staff 3/37 (8.1) 0.08 [0.02–0.23] <0.001 31/37 (83.8) 0.39 [0.13–1.15] 0.088
Work Experience
 < 5 33/167 (19.8) Ref 145/167 (86.8) Ref
 5–10 25/104 (24.0) 0.93 [0.40–2.15] 0.861 92/104 (88.5) 1.16 [0.55–2.46] 0.693
 11+ 18/57 (31.6) 0.84 [0.31–2.28] 0.730 53/57 (93.0) 2.01 [0.66–6.12] 0.218
Availability of Infection prevention and control facilities
Experienced interruption in water supply
 No 66/286 (23.1) Ref 256/286 (89.5) Ref
 Yes 10/42 (23.8) 2.26 [0.52–9.83] 0.278 34/42 (81.0) 0.50 [0.21–1.17] 0.111
PPE available in sufficient quantity in the health care facility
 No 13/44 (29.6) 0.33 [0.14–0.77] 0.010 37/44 (84.1) 0.65 [0.27–1.58] 0.339
 Yes 63/284 (22.2) Ref 253/284 (89.1) Ref
Received training on IPC
 No 1/7 (14.3) 0.25 [0.05–1.34] 0.105 6/7 (85.7) 0.78 [0.09–6.67] 0.822
 Yes 75/321 (23.4) Ref 284/321 (88.5) Ref
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Compliance with hand hygiene was significantly lower for healthcare workers with secondary level qualifications (OR 0.24; 95% CI 0.08–0.71) and nonclinical staff (OR 0.43; 95% CI 0.21–0.89) than healthcare workers with certificate qualifications and clinical staff. Cleaners (OR 0.27; 95% CI 0.10–0.75), midwives (OR 0.29; 95% CI 0.09–0.93), and pharmacists (OR 0.15; 95% CI 0.02–0.92) compliance with hand hygiene was significantly lower than that of registered nurses (Table 4).

Discussion

Healthcare workers in Ghana’s COVID-19 treatment centers are actively involved in managing COVID-19 cases. This put them in constant exposure to SARS-CoV-2, which can translate into COVID-19 virus infection if recommended IPC measures are not adhered to. We did a secondary analysis of healthcare workers responses on compliance with IPC measures at the COVID-19 treatment centers in Ghana. Findings from this study suggest that infection prevention and control compliance during healthcare interactions and when performing AGP was high. A high rate of IPC compliance, which is consistent with this study, has been reported in a similar study among healthcare workers [20]. However, a study among healthcare workers in Tanzanian outpatient facilities concluded that IPC compliance was inadequate [21]. The vast differences in IPC compliance may be due to the time the studies were conducted and whether compliance was observed or reported. The study in Tanzania [21] measured compliance by observation, while we measured compliance by healthcare worker self-reporting. Besides, a study in China reported improvement in IPC behaviors of healthcare workers during the COVID-19 outbreak [22]. This may be a possible explanation for high compliance with IPC protocols in this study. Infection prevention and control compliance plays a critical role in reducing healthcare workers’ exposure to the COVID-19 virus. In contrast, non-compliance with IPC measures is an important factor for COVID-19 infection among healthcare workers [23]. WHO in their interim guidance on IPC recommends strict adherence to IPC protocols in managing COVID-19 patients [14].

Evidence from this study also suggests a high rate of compliance with hand hygiene protocols during healthcare interactions with COVID-19 patients. There are also reports of high hand hygiene compliance among intensive care unit healthcare workers in India [24]. However, an observational study in Turkey revealed low compliance with hand hygiene during healthcare interactions with patients [25]. Improving sustained hand hygiene compliance in healthcare settings will require continuous training of healthcare workers on IPC [24]. Additionally, the vast majority of the healthcare workers admitted that they have received training on IPC measures. This might be the reason for the high compliance reported in this study. We also found high compliance with PPE usage during healthcare interactions with COVID-19 patients by healthcare workers. This varies from a previous study conducted in Tanzania [21]. A network of factors comes into play in facilitating healthcare workers’ compliance with IPC protocols. Clear IPC guidelines, effective communication, support from managers, training, access and trust in PPEs are critical in promoting healthcare compliance with IPC protocols [26]. Consistent with studies elsewhere [21, 27], there was nearly universal compliance with medical mask use during healthcare interaction with COVID-19 patients. Appropriately adhering to PPEs use is effective in reducing the risk of infection among healthcare workers [8]. Indeed, personal protective equipment use is efficacious in preventing nosocomial transmission of SARS-CoV-2 [28].

Compliance with hand hygiene and PPE usage was significantly lower among nonclinical staff than among clinical staff. This is in line with a previous study, where they found low compliance with PPEs usage among ancillary staff [29]. The risk of COVID-19 infection is not limited to only frontline healthcare workers, but other nonclinical staff, such as cleaners, drivers and security officers, also face a substantial risk of being infected with SARS-CoV-2 [30]. Perhaps, our findings may be an indication of over prioritization of IPC logistics and training of the clinical staff to the neglect of the nonclinical staff. Infection prevention and control efforts to combat the spread of COVID-19 in hospitals should include ancillary staff [30]. This is crucial in achieving zero healthcare-associated transmission of COVID-19 in healthcare settings [29].

We found the majority of the healthcare workers indicating the availability of sufficient quantities of PPEs in the treatment centers. This is in line with a previous study in Ethiopia, where most healthcare workers indicate the adequacy of infection prevention supplies in a referral hospital [31]. However, during the COVID-19 outbreak, frequent stock out and inadequate supply of PPEs have been a major challenge for healthcare workers [32] and health systems performance worldwide [33]. Ensuring the continuous availability of PPEs for healthcare workers managing COVID-19 patients is essential for maintaining healthcare workers infection rates below 10% and mortality below 1% [34]. Additionally, wide-scale procurement and distribution of PPEs for low-and-middle-income countries is cost-effective and yields a large downstream return on investment [34]. In this study, insufficiency of PPEs was associated with lower odds of compliance with PPEs usage. The role of infection prevention and control facilities in facilitating adherence with IPC measures have been reported in previous studies [31, 33, 35].

We also found lower odds of compliance with PPEs use among pharmacists compared to registered nurses. In a previous study, nurses and midwives had better compliance with glove use than other medical staffs [21]. The possible explanation for lower compliance among pharmacists may be that they do not constantly interact with patients. This could affect their compliance with PPEs usage in the treatment centers.

There was overwhelmingly high compliance with IPC protocols during AGPs by healthcare workers. Aerosol-generating procedures are high-risk procedures that are associated with an increased risk of SARS-CoV-2 transmission to healthcare workers [36]. This might be the reason for high IPC adherence among healthcare workers who performed AGPs in this study. Some AGPs generate aerosols that can facilitate the transmission of SARS-CoV-2 to healthcare workers managing COVID-19 patients. The WHO recommends the use of special respirators, gloves, aprons and eye protection during AGPs [19].

In this study, compliance with IPC protocols was self-reported by the healthcare workers, which could lead to recall bias. We could not establish how adherence to IPC protocols translates to zero COVID-19 infection in the treatment centers.

Conclusions

Healthcare workers’ compliance with IPC protocols in the treatment centers was high. The study showed wide gaps in IPC compliance across different health professional groups with nonclinical staff, cleaners, pharmacists, those with secondary level qualification and healthcare workers who report of insufficient PPEs at risk of non-compliance with IPC protocols. Ensuring an adequate supply of IPC logistics coupled with behavior change interventions and paying special attention to nonclinical staff is critical for minimizing the risk of COVID-19 transmission in the treatment centers.

Supporting information

S1 Table. Adherence to infection prevention and control procedures during health care interactions.

(DOCX)

Click here for additional data file. (20.9KB, docx)
S2 Table. Adherence to infection prevention and control measures when performing aerosol-generating procedures.

(DOCX)

Click here for additional data file. (13.5KB, docx)
S1 File. English questionnaire.

Questionnaire used for data collection.

(DOCX)

Click here for additional data file. (21.6KB, docx)

Acknowledgments

We extend our gratitude to the healthcare workers and managers of the COVID-19 treatment centers.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

We confirm receipt of funding from IRC-Ghana. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. MEA, IRC-Ghana https://www.ircwash.org/ghana

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Decision Letter 0

Wen-Jun Tu

1 Feb 2021

PONE-D-20-29930

Infection Prevention and Control Compliance among Healthcare Workers in COVID-19 Treatment Centers in Ghana: A Descriptive Cross-sectional Study

PLOS ONE

Dear Dr. Ashinyo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating in the text of your manuscript "The study was part of a large study titled “Exposure risk Assessment: A survey among frontline healthcare workers in designated COVID-19 treatment centers”, which was approved by the Ghana Health Service Ethics Review Committee. Written informed consent was obtained from all study participants.". Please also add this information to your ethics statement in the online submission form.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

4. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. ("Yes, It does not constitute a dual publication because the pending manuscripts exposure level of healthcare workers to the COVID-19 virus while the current manuscripts went ahead to measured  IPC compliance among healthcare workers who were exposed to a COVID-19 patients.) Please clarify whether this conference proceeding or publication was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

5. Please ensure that you refer to Figure 3 in your text as, if accepted, production will need this reference to link the reader to the figure.

6. We note you have included tables to which you do not refer in the text of your manuscript. Please ensure that you refer to Tables 3 and 4 in your text; if accepted, production will need this reference to link the reader to the Table.

7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript contains interesting and useful data about Covid-19 infection prevention and control compliance among healthcare workers in Ghana.

Minor Revision is required:

- Lines 96-98: you wrote "The sample size was calculated using the Cochran formula at a 95% confidence interval, an assumed exposure level of 50%, and a 5% margin of error."

Please quote the source, and include it in the References.

If the Cochran formula is not too long,include it as well.

- Line 117: "occasionally"

You forgot to close the quotation marks.

- Lines 306-307: "Maliszewska M, Mattoo A, Van Der Mensbrugghe D. The potential impact of COVID-19 on GDP and trade: A preliminary assessment"

Please include the year of the publication

Thank you.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Giovanni Vinti

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Mar 9;16(3):e0248282. doi: 10.1371/journal.pone.0248282.r002

Author response to Decision Letter 0

10 Feb 2021

To PLOS ONE Academic Editor (Wen-Jun Tu)

From the corresponding author (Dr. Mary Eyram Ashinyo)

First of all, We would like to express my sincere gratitude to you for devoting part of your schedules for our manuscript and for the valuable comments. We also express our profound gratitude to the reviewers for devoting their golden time to review this manuscript.

Below are our point by point responses to the comments raised during the review process.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response 1: we accept this comment and we have made changes to reflect PLOS ONE style requirements

2. Thank you for stating in the text of your manuscript "The study was part of a large study titled “Exposure risk Assessment: A survey among frontline healthcare workers in designated COVID-19 treatment centers”, which was approved by the Ghana Health Service Ethics Review Committee. Written informed consent was obtained from all study participants.". Please also add this information to your ethics statement in the online submission form.

Response 2: We accept this comment and we have incorporated in the online submission form

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response 3: We accept this comment and we have incorporated the survey questionnaire as additional file “S1 File”

4. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. ("Yes, It does not constitute a dual publication because the pending manuscripts exposure level of healthcare workers to the COVID-19 virus while the current manuscripts went ahead to measured IPC compliance among healthcare workers who were exposed to a COVID-19 patients.) Please clarify whether this conference proceeding or publication was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

Response 4: We have provided the reasons for which this manuscript should not be considered as a dual publication in the cover letter. We have also included the related manuscript in this current manuscript.

5. Please ensure that you refer to Figure 3 in your text as, if accepted, production will need this reference to link the reader to the figure.

Response 5: We accept this comment and figure 3 have been cited appropriately in the text

6. We note you have included tables to which you do not refer in the text of your manuscript. Please ensure that you refer to Tables 3 and 4 in your text; if accepted, production will need this reference to link the reader to the Table.

Response 6: We accept this comment and Table 3 and 4 have been cited accordingly in the text.

7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response 7: We accept this comment. Captions for supporting files have been updated and cited accordingly

Lines 96-98: you wrote "The sample size was calculated using the Cochran formula at a 95% confidence interval, an assumed exposure level of 50%, and a 5% margin of error."

Please quote the source, and include it in the References.

If the Cochran formula is not too long, include it as well.

Response 8 : We accept this comment and we have reference it appropriately. We have also included the Cochran formula.

- Line 117: "occasionally"

You forgot to close the quotation marks.

Response 9: We accept this comment and quotation mark have been added accordingly

- Lines 306-307: "Maliszewska M, Mattoo A, Van Der Mensbrugghe D. The potential impact of COVID-19 on GDP and trade: A preliminary assessment"

Please include the year of the publication

Response 10: The year of publication have been incorporated appropriately.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (15.7KB, docx)

Decision Letter 1

Wen-Jun Tu

16 Feb 2021

PONE-D-20-29930R1

Infection prevention and control compliance among exposed healthcare workers in COVID-19 treatment centers in Ghana: a descriptive cross-sectional study

PLOS ONE

Dear Dr. Ashinyo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 02 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

1. In order to provide a more complete information to our readers on the topic, we would like to emphasize the importance to cross referencing very recent material on the same topic published in "PLoS ONE ". Therefore, it would be highly appreciated if you would check the contents published in the last two years of "PLoS ONE" (https://journals.plos.org/plosone/) and add all material relevant to your article to the reference list.

2. Add “Clinical Features and Short-term Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan, China. Clinical Infectious Diseases, 71(15):748-755” in the revision text。

3. The grammar needs to be edited throughout.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Lines 78-80:

Please, mention Covid-19 vaccines as well. For example, here you can find some clues:

- Matrajt et al., 2021. Vaccine optimization for COVID-19: Who to vaccinate first? Science Advances Vol. 7, no. 6, eabf1374. DOI: 10.1126/sciadv.abf1374

Line 93: “formula [12];” and “with the following parameters;”

You should use “:” instead of “;”.

Lines 258-169: I did not understand how you obtained 23.2% for “PPE use total”. Could you please recheck it and clarify it in the text? Because it seems very low, compared to the other individual values you showed, and even checking Supporting information – S1 file and S1 table, it is not clear to me how you got that value. Therefore, a better explanation would be needed.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Giovanni Vinti

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Mar 9;16(3):e0248282. doi: 10.1371/journal.pone.0248282.r004

Author response to Decision Letter 1

19 Feb 2021

1. In order to provide a more complete information to our readers on the topic, we would like to emphasize the importance to cross referencing very recent material on the same topic published in "PLoS ONE ". Therefore, it would be highly appreciated if you would check the contents published in the last two years of "PLoS ONE" (https://journals.plos.org/plosone/) and add all material relevant to your article to the reference list.

We accept this recommendation, but we are unable to add references that cannot be cited in the text. We have however, added articles published in PLOS ONE which are citable in our work. References 9, 11, 13, 32, 34 and 36

2. Add “Clinical Features and Short-term Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan, China. Clinical Infectious Diseases, 71(15):748-755” in the revision text。

We accept this recommendation and we have cited it in the manuscript, reference 6

3. The grammar needs to be edited throughout.

The manuscript have undergone grammar editing

Reviewer #1: Lines 78-80:

Please, mention Covid-19 vaccines as well. For example, here you can find some clues:

- Matrajt et al., 2021. Vaccine optimization for COVID-19: Who to vaccinate first? Science Advances Vol. 7, no. 6, eabf1374. DOI: 10.1126/sciadv.abf1374

We accept this comment and we have incorporated it accordingly. Reference 16; lines 83-84

Line 93: “formula [12];” and “with the following parameters;”

You should use “:” instead of “;”.

we have modified it to suit this comment, but we rather used “at” 95% confidence interval (1.96)

Lines 258-169: I did not understand how you obtained 23.2% for “PPE use total”. Could you please recheck it and clarify it in the text? Because it seems very low, compared to the other individual values you showed, and even checking Supporting information – S1 file and S1 table, it is not clear to me how you got that value. Therefore, a better explanation would be needed.

Thank you very much for this important comment. We realized that there was a mistake in recoding some of the variables into compliant and non-compliant. This has been rectify accordingly. How compliant and non-compliant was measure have been explained in Table 1 and 2.

Attachment

Submitted filename: Response to reviewers.docx.docx

Click here for additional data file. (13.9KB, docx)

Decision Letter 2

Wen-Jun Tu

24 Feb 2021

Infection prevention and control compliance among exposed healthcare workers in COVID-19 treatment centers in Ghana: a descriptive cross-sectional study

PONE-D-20-29930R2

Dear Dr. Ashinyo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Acceptance letter

Wen-Jun Tu

26 Feb 2021

PONE-D-20-29930R2

Infection prevention and control compliance among exposed healthcare workers in COVID-19 treatment centers in Ghana: a descriptive cross-sectional study

Dear Dr. Ashinyo:

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on behalf of

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PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Adherence to infection prevention and control procedures during health care interactions.

    (DOCX)

    Click here for additional data file. (20.9KB, docx)
    S2 Table. Adherence to infection prevention and control measures when performing aerosol-generating procedures.

    (DOCX)

    Click here for additional data file. (13.5KB, docx)
    S1 File. English questionnaire.

    Questionnaire used for data collection.

    (DOCX)

    Click here for additional data file. (21.6KB, docx)
    Attachment

    Submitted filename: Response to reviewers.docx

    Click here for additional data file. (15.7KB, docx)
    Attachment

    Submitted filename: Response to reviewers.docx.docx

    Click here for additional data file. (13.9KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

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