Infection control practices and challenges in Pakistan during the COVID-19 pandemic: a multicentre cross-sectional study

Abstract

Background:

Patient and staff safety at healthcare facilities during outbreaks hinges on a prompt infection prevention and control response. Physicians leading these programmes have encountered numerous obstacles during the pandemic.

Aim/objective:

The aim of this study was to evaluate infection prevention and control practices and explore the challenges in Pakistan during the coronavirus disease 2019 pandemic.

Methods:

We conducted a cross-sectional study and administered a survey to physicians leading infection prevention and control programmes at 18 hospitals in Pakistan.

Results:

All participants implemented universal masking, limited the intake of patients and designated separate triage areas, wards and intensive care units for coronavirus disease 2019 patients at their hospitals. Eleven (61%) physicians reported personal protective equipment shortages. Staff at three (17%) hospitals worked without the appropriate personal protective equipment due to limited supplies. All participants felt overworked and 17 (94%) reported stress. Physicians identified the lack of negative pressure rooms, fear and anxiety among hospital staff, rapidly evolving guidelines, personal protective equipment shortages and opposition from hospital staff regarding the choice of recommended personal protective equipment as major challenges during the pandemic.

Discussion:

The results of this study highlight the challenges faced by physicians leading infection prevention and control programmes in Pakistan. It is essential to support infection prevention and control personnel and bridge the identified gaps to ensure patient and staff safety at healthcare facilities.

Background

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) (World Health Organization, 2020a). The first case of COVID-19 was reported in Wuhan, China, in December 2019 (World Health Organization, 2020a). This highly contagious infection quickly travelled to other parts of the world and the outbreak was declared a pandemic in March 2020 (World Health Organization, 2020a). The course of the pandemic has varied across the globe. While some countries effectively contained the infection at the outset by imposing strict measures, others have struggled with mitigation and containment efforts (Semaan et al, 2020). Months later, the virus continues to perplex scientists and clinicians alike. Uncertainty regarding the treatment and prevention of COVID-19 and varying clinical outcomes among infected patients have created a wave of fear among the general public as well as healthcare personnel (HCP) (Apisarnthanark et al, 2020; Semaan et al, 2020; Todd, 2020; Zhang et al, 2020). Poor coordination of COVID-19 response activities in some countries has compromised the image of healthcare authorities and adversely impacted public engagement (Cénat, 2020). Dealing with a novel virus has overwhelmed healthcare systems worldwide and posed major challenges (World Health Organization, 2020a).

Healthcare facilities struggled to balance infection prevention and patient care as they navigated an unchartered territory in the midst of rapidly evolving guidelines, uncertainty regarding the clinical management of COVID-19 and shortages of beds, ventilators, negative pressure rooms, personal protective equipment (PPE) and testing supplies (Centers for Disease Control and Prevention, 2020a; Nyashanu et al, 2020; Semaan et al, 2020; World Health Organization, 2020b). Hospitals were forced to transform non-clinical areas into wards and even intensive care units (ICUs) to accommodate patients (New York Times, 2020). While installation of heating, ventilation and air conditioning (HVAC) systems is recommended to create additional negative pressure rooms, temporary solutions such as high-efficiency particulate air (HEPA) filters were used as alternatives where resources permitted (Shadpour F and Johnson S, 2020). HCP resorted to PPE reuse and extended use as PPE, particularly N-95 masks, became a precious commodity (Todd, 2020). Disinfection methods using vaporised hydrogen peroxide, ultraviolet light and ethanol were adopted to allow for safe reuse and extended use of N-95 masks (Fischer et al, 2020). Stress and physical exhaustion adversely impacted the mental health of HCP (Chersich et al, 2020). Infections among HCP fuelled COVID-centred fears, facilitated the chain of infection within healthcare facilities and aggravated staff shortages (Bellizzi et al, 2020). The impacts of COVID-19 have been worse in low and middle-income countries (LMICs), where health care is poorly structured and access to resources is limited (Semaan et al, 2020).

A prompt infection control response is essential for the containment and mitigation of COVID-19 and healthcare facilities are heavily reliant on infection prevention and control (IPC) programmes (Cheng et al, 2020). These programmes are traditionally led by infectious diseases physicians, supported by infection preventionist nurses (IPNs), physicians from other specialties, microbiologists, pharmacists and administrative staff (World Health Organization, 2016). From keeping up with the emerging evidence to devising and implementing policies tailored to their respective settings, IPC personnel, where present, are likely to have been at the forefront of the COVID-19 response (Wang et al, 2020). It is conceivable that individuals leading these programmes have faced major challenges across the globe, especially in LMICs where resources are scarce (Chersich et al, 2020; Semaan et al, 2020; Wang et al, 2020).

Data on IPC programmes in LMICs are limited (Alp et al, 2018; World Health Organization, 2016). While the presence of such programmes is the norm for healthcare facilities in developed countries, IPC programmes are not consistently incorporated into hospitals in LMICs (Alp et al, 2018). Moreover, the function of these programmes may be undermined by the lack of expertise and resources. This is evidenced by the several-fold higher rates of healthcare-associated infections (HAIs) in LMICs compared to high-income countries (World Health Organization, 2016). The structure of IPC programmes in LMICs and the challenges faced by physicians leading these programmes during the COVID-19 pandemic have not been explored previously. Pakistan is an LMIC with a population of 220,900,000 (United Nations Population Fund, 2020). Health care in Pakistan devolved from the federal to the provincial level in the year 2010 (Khan, 2019). The average doctor to patient ratio is 1:1300 and the doctor to nurse ratio is 1:2.7 (Khan, 2019). Infection prevention programmes, when present, are led by infectious diseases or microbiology physicians, supported by IPNs. Physicians oversee the programmes and devise the infection prevention strategies, while IPNs are tasked with carrying out activities such as hand hygiene audits, HAI surveillance and staff education. There is no reporting or monitoring of these data at the national level and institutions are responsible for creating their own IPC programmes using international benchmarks for reference. The first case of COVID-19 in Pakistan was reported on 26 February 2020 and, as of 19 August 2020, the total number of confirmed cases stands at 290,443 (Government of Pakistan, 2020). The National Institute of Health (NIH), Pakistan, a public health organisation and a World Health Organization (WHO) collaborating centre, published the first national IPC guidelines in 2020, directing healthcare facilities to establish IPC programmes led by infectious diseases physicians or microbiologists (National Institute of Health, 2020a). The same group compiled national PPE and IPC guidelines specific to COVID-19 (National Institute of Health, 2020b). Health care in Pakistan has been faced with multiple challenges during the COVID-19 pandemic, such as a lack of healthcare capacity and quarantine facilities, limited number of trained ICU physicians and constrained PPE and testing supplies (Ahmed et al, 2020). We conducted this study to determine IPC practices and explore the challenges faced by physicians leading IPC programmes in Pakistan during the COVID-19 pandemic. The results will highlight gaps in practices and identify areas of focus as we navigate the COVID-19 pandemic.

Methods

We conducted this cross-sectional study in Pakistan between 1 July 2020 and 23 July 2020. Our study population comprised infectious diseases physicians or microbiologists leading IPC programmes at their hospitals. A national database to track and regulate IPC programmes does not exist. We referred to the Medical Microbiology and Infectious Diseases Society of Pakistan (MMIDSP) members’ directory and a WhatsApp group of Pakistani infectious diseases physicians and microbiologists to identify potential participants. The MMIDSP members’ list, last updated in 2019, includes 61 infectious diseases specialists and 124 microbiologists, mostly based in larger cities such as Islamabad, Lahore and Karachi, and clustered at a few major hospitals within these cities. We performed a literature search on PubMed to review the existing literature on IPC practices in LMICs and challenges during the COVID-19 pandemic. We defined universal masking as implementing the use of masks for all HCP throughout healthcare facilities. We adopted the Centers for Disease Control and Prevention (CDC) and WHO definitions for airborne precautions, droplet precautions, aerosol generating procedures, PPE use and PPE reuse (Centers for Disease Control and Prevention, 2020a; World Health Organization, 2020b). We developed a survey tool (Supplementary Appendix A) reflecting our literature search findings and local observations. The questionnaire included a section on demographics followed by 24 questions covering IPC programme structure and staffing, IPC practices during the pandemic, challenges faced by physicians leading these programmes and opportunities for improvement. The survey questions were phrased in open-ended and close-ended formats. The study was approved by the institutional review board at Shaukat Khanum Memorial Cancer Hospital and Research Center.

We invited physicians leading IPC programmes to participate in our study by text messages. Those who expressed interest in participation were contacted over the phone. We informed the participants that they would not be able to withdraw their consent or responses once the survey had been completed. We obtained verbal consent and administered the questionnaire to physicians who opted to participate. Data were anonymously entered into password protected electronic files with access limited to a single team member. Frequencies and proportions were calculated for all survey responses.

Results

We identified a total of 20 physicians leading IPC programmes at their hospitals and, of these, 18 opted to participate in the study. Survey respondents comprised a higher number of women (n=11, 61%), with equal representation from government and private hospitals. Only three (17%) physicians reported having received formal IPC training. Except for six (33%) participants, all had been involved in IPC for more than 5 years (Table 1). The average number of beds at government hospitals was 754 (median 500, range 192–1700) and at private hospitals was 278 (median 220, range 150–700). All survey respondents from private hospitals reported a minimum of one IPN to 100 hospital beds. Government hospitals had a lower IPN to hospital bed ratio with one programme being run without an IPN (Figure 1).

Table 1.

Characteristics of survey respondents (N=18).

Demographic variables	N (%)
Gender
Men	7 (39)
Women	11 (61)
Work experience
<5 years	6 (33)
5–10 years	7 (39)
10–15 years	1 (6)
15–20 years	4 (22)
IPC training
Received formal training	3 (17)
Learnt on the job	15 (83)
Practice setting
Government hospital	9 (50)
Private hospital	9 (50)

Figure 1.

The ratio of infection preventionist nurses (IPs) to hospital beds at government and private hospitals.

Infection control programmes did not exist at two (11%) government hospitals previously and had been established during the COVID-19 pandemic. Seventeen (94%) participants were familiar with the national PPE and IPC guidelines. Most physicians referred to the WHO (n=16; 89%), the CDC (n=15; 83%) and NIH (n=13; 72%) for guidance on IPC practices and PPE. Sixteen (89%) participants had limited the intake of patients at their hospitals (Table 2).

Table 2.

Infection prevention and control (IPC) practices during the COVID-19 pandemic (N=18).

IPC Practices	N (%)
Limited or suspended the intake of patients overall	16 (89)
Limited or suspended the intake of patients in the following areas:
Inpatient	2 (11)
Outpatient	15 (83)
Surgery	14 (78)
Bronchoscopy	9 (50)
Endoscopy	11 (61)
Radiology	3 (17)
Established separate screening counters	18 (100)
Designated the following for COVID-19 patients:
Separate ward	17 (94)
Separate ICU	17 (94)
Separate OR	11 (61)
Implemented universal masking	18 (100)
Instituted N-95 reuse or extended use	13 (72)
Measures to cope with the shortage of negative pressure rooms
Installation of exhaust fans	13 (72)
HVAC re-engineering	7 (39)
Installation of HEPA filters	4 (22)
Precautions in inpatient departments
DP + CP + EP for all patients	1 (6)
DP + CP + EP for suspected or confirmed COVID-19 patients	7 (39)
AP + CP + EP for all patients	1 (6)
AP + CP + EP for suspected or confirmed COVID-19 patients	9 (50)
Precautions in outpatient departments a
DP + CP + EP for all patients	3 (17)
DP + CP for all patients	6 (33)
AP + CP + EP for all patients	2 (11)
DP for all patients	3 (17)
Precautions for aerosol generating procedures
AP + CP + EP	18 (100)

ICU: intensive care unit; OR: operating room; HVAC: heating, ventilation and air conditioning; HEPA: high-efficiency particulate air; DP: droplet precautions; CP: contact precautions; EP: eye protection; AP: airborne precautions.

^aOutpatient visits were suspended at four hospitals.

Survey respondents unanimously identified the lack of negative pressure rooms at their hospitals as a major challenge during the pandemic (n=18; 100%). Most physicians (n=13; 72%) recommended installing exhaust fans in patients’ rooms to create negative pressure. All participants implemented universal masking at their hospitals. Infection control practices in the outpatient departments varied from the use of surgical masks alone to the use of N-95 respirators along with contact precautions and eye protection (Table 2). For inpatient units, most participants favoured droplet or airborne precautions in addition to contact precautions and eye protection (Table 2). Infection prevention programmes uniformly instituted airborne precautions in combination with contact precautions and eye protection for aerosol generating procedures across institutions (Table 2).

Fit testing for N-95 masks was not routinely performed due to time and resource constraints. All participants reported checking for a tight seal by deeply inhaling and exhaling after wearing an N-95 mask. Physicians from 11 (61%) hospitals reported limited PPE supplies; this included N-95 shortages at 11 (61%), face shields at two (11%) and gowns and surgical masks at one (6%) hospital. Staff at three (17%) hospitals worked without the required PPE during the pandemic. Thirteen (72%) physicians adopted N-95 reuse or extended use guidelines. Of these, one (6%) participant implemented the reuse of N-95 masks following vaporised hydrogen peroxide disinfection, three (17%) opted for N-95 mask rotation or alternating between two N-95 masks every 3 days, one (6%) switched to reusable respirators, while the rest recommended extended use of N-95 masks at their hospitals.

Participants identified fear and anxiety among hospital staff (n=17; 94%), rapidly evolving IPC guidelines (n=14; 78%), PPE shortages (n=11; 61%) and opposition from hospital staff regarding the recommended PPE (n=9; 50%) as other key issues faced during the pandemic (Table 3). Six (33.3%) study participants did not receive adequate human resource support from hospital leadership. All participants reported feeling stressed and overworked during the pandemic. Physicians acknowledged that support from hospital leadership (n=9, 50%), support from hospital staff (n=11; 61%), ready availability of PPE (n=6; 33%), access to resources (n=10; 56%), early engagement of the general public (n=1; 6%), timely IPC training of hospital staff (n=3; 17%) and well integrated patient referral systems within the healthcare sector (n=1; 6%) could have improved their overall experience during the pandemic.

Table 3.

Challenges faced by physicians leading infection prevention and control (IPC) programmes during the COVID-19 pandemic (N=18).

IPC challenges	N (%)
Lack of negative pressure rooms	18 (100)
Fear and anxiety among hospital staff	17 (94)
Rapidly evolving guidelines	14 (78)
PPE shortages	11 (61)
Opposition from hospital staff regarding PPE choice	9 (50)
Lack of resources	8 (44)
Poor compliance with recommended PPE	7 (39)
Lack of testing supplies	7 (39)
Lack of support from hospital leadership in terms of the following:
(a) Human resources	6 (33)
(b) PPE provision	2 (11)
(c) Implementation of infection control policies	2 (11)
Lack of clear, timely guidelines on infection control and PPE guidance	5 (28)
Staff shortages due to COVID-19 HCP infections	2 (11)
Shortages of hand sanitisers	2 (11)
Shortages of surface disinfectants	1 (6)

PPE: personal protective equipment; HCP: healthcare personnel.

Discussion

This is among the first studies evaluating the structure of IPC programmes in LMICs and exploring the challenges faced by physicians leading these programmes during the COVID-19 pandemic. The results revealed discrepancies in resources and staffing between government and private hospitals in Pakistan. The WHO recommends a minimum of one IPN per 250 hospitals beds and strongly favours one IPN per 100 hospital beds to optimise the outcomes of IPC programmes (World Health Organization, 2016). Five (28%) government hospitals fell short of this standard with one IPN per 200–500 beds. Two (11%) hospitals established IPC programmes during the pandemic. Only three (17%) participants reported having received formal IPC training. This underscores the urgency to train professionals in IPC and allocate human resources to these programmes, especially at government facilities. Female physicians leading IPC programmes outnumbered the male participants in our study. Leadership positions in medicine are typically skewed towards men and this observation may herald a positive shift in the trend (Carr et al, 2017). The lack of negative pressure rooms, fear and anxiety among hospital staff, rapidly evolving guidelines, PPE shortages and opposition from hospital staff regarding the recommended PPE emerged as the key challenges encountered.

Guidance on IPC rapidly evolved during the COVID-19 pandemic as leading public health organisations struggled to reach a consensus. The most recent version of the CDC guidelines favours the use of N-95 masks over surgical masks when available, while caring for patients with suspected or confirmed COVID-19 (Centers for Disease Control and Prevention, 2020a). The WHO recommends the use of surgical masks along with contact precautions and eye protection for suspected or confirmed COVID-19 cases, except during aerosol generating procedures where N-95 masks must be used (World Health Organization, 2020b). Moreover, recommendations vary by geographical locations (Centers for Disease Control and Prevention, 2020b). Discrepancies in guidelines endorsed by leading international organisations bred confusion and created a divide in IPC practices during the pandemic. As is evident in our study findings, IPC practices varied across institutions. These inconsistencies undoubtedly compromised the credibility of IPC programmes and public health authorities (Cénat, 2020). This may explain the resistance encountered by our study participants regarding the choice of recommended PPE. In two surveys administered to healthcare workers, respondents either reported a lack of confidence in their institutional IPC policies or perceived the provided PPE as inadequate (Apisarnthanark et al, 2020; Jin et al, 2020). This highlights the need for public health organisations to collaborate, further investigate the modes of transmission of SARS-CoV-2 and disseminate information once a clear consensus has been attained.

Our survey respondents observed fear and anxiety among HCP at their hospitals. This mirrors the findings of multiple studies (Apisarnthanark et al, 2020; Semaan et al, 2020; Todd, 2020; Zhang et al, 2020). Similarly, several studies identified shortages of PPE, particularly N-95 masks and testing supplies and the lack of negative pressure rooms as major challenges during the pandemic (Bressan et al, 2020; Elhadi et al, 2020; Jin et al, 2020; Nyashanu et al, 2020). As in our study, healthcare facilities worldwide instituted PPE reuse and extended use guidelines when faced with PPE constraints (Ahmed et al, 2020; Elhadi et al, 2020). Moreover, reports of HCP purchasing and using their own PPE exist in the literature (Ahmed et al, 2020). The results of our study indicate that hospitals in Pakistan are not well equipped to absorb a surge in airborne infections. Our study participants opted for the installation of exhaust fans as one of the strategies to cope with the scarcity of negative pressure rooms. This appears to be an innovative approach, albeit one that is not evidence based and warrants further investigation. Fit testing for N-95 masks is highly recommended for protection against airborne infections (Occupational Safety and Health Administration, 2012). Our results corroborate the findings of a recent study highlighting that most hospitals in Pakistan forego fit testing for N-95 masks, compromising the protection afforded (Ahmed et al, 2020).

Stress among HCP in the context of COVID-19 has been extensively investigated. Several studies have linked stress and exhaustion among healthcare workers to poor mental health outcomes (Chersich et al, 2020; Semaan et al, 2020). In contrast to other specialties, IPC professionals shouldered additional responsibilities during the pandemic that could account for the high levels of stress among our study participants. These included rigorous evaluation of emerging literature to implement best IPC practices, conducting preparedness drills and training hospital staff while juggling routine IPC activities, enduring institutional pressures and navigating power dynamics (Wang et al, 2020). For some, this meant working without adequately trained support staff or building a team from scratch in the wake of the pandemic. Leadership support is a prerequisite to propel these programmes to success. Our study participants reported feeling overworked and recognised inadequate support from hospital administration as a challenge during the pandemic.

This study is limited by its cross-sectional design. This exposes our results to potential reporting bias. As no database exists for IPC programmes in Pakistan, we were able to identify a total of 20 physicians leading IPC programmes and may have missed infectious diseases physicians and clinical microbiologists who are not MMIDSP members or are not part of the infectious diseases and microbiology WhatsApp group. Finally, the results of this study may not represent practices across Pakistan, especially at hospitals without formally structured IPC programmes.

We have added to the existing body of literature on IPC practices and core issues encountered during the COVID-19 pandemic. Resource allocation to IPC programmes often pales in comparison with other essential services such as medicine and nursing worldwide, particularly in LMICs. This is well illustrated in our study, in which barring a few healthcare facilities, IPC programmes are in their infancy. The obstacles highlighted in our study are a solemn reminder that much needs to be accomplished in the realm of infection control. We must consider the opportunity to reflect on and better our healthcare system, a silver lining in this otherwise trying time. The lessons learnt must pave the way to strengthen IPC practices globally. Relevant health departments must collaborate and share data with national and international public health organisations, assess healthcare surge capacity, provide guidance on recommended measures during outbreaks, allocate resources to produce and equitably distribute PPE, mandate the establishment of IPC programmes at all healthcare facilities and introduce IPC training and ensure regular refreshers for HCP. It is essential to support IPC personnel and bridge the identified gaps to ensure patient and staff safety at healthcare facilities and prepare for future waves of the COVID-19 pandemic or other outbreaks.