As of October 29, 2021, more than 245 million confirmed cases of coronavirus disease 2019 (COVID-19) have been reported worldwide with 4.9 million deaths. 1 In Pakistan, the first case of COVID-19 was reported on February 26, 2020, and after that a substantial number of positive cases have been reported throughout the country in different phases of the COVID-19 outbreak. Reference Salman, Mustafa and Khan2–Reference Godman, Haque and Islam5 To date, more than 1.2 million laboratory confirmed cases of COVID-19 with 28,449 deaths have been reported in Pakistan. The COVID-19 recovery rate in Pakistan is more than 95%, and there are currently approximately 23,000 active cases in the country. 6 In the Province of Punjab, 440,139 laboratory-confirmed cases of COVID-19 have been reported, with more than 12,000 deaths. 6 While providing healthcare services, more than 115,000 HCWs have lost their lives around the globe after being infected with COVID-19 up until May 24, 2021. 7 Local media reports revealed that 14,627 HCWs were infected throughout Pakistan with 143 deaths as of March 22, 2021. 8
Healthcare workers (HCWs) are considered as highly vulnerable population to experiencing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to their clinical role, particularly in hospital settings. Reference Nguyen, Drew and Graham9–Reference Razu, Yasmin and Arif11 HCWs need to perform their duties in highly critical settings, including emergency units, isolation wards, intensive care units (ICUs), and critical care units (CCUs). Reference Deressa, Worku and Abebe12–Reference Yang, Parkins and Canakis15 Since the emergence of the COVID-19 pandemic, HCWs have shown remarkable resilience and professional dedication during the routine care processes despite fear of becoming infected and infecting others. Reference Liu, Luo and Haase16 However, HCWs possess an appreciably greater risk of being positive for SARS-CoV-2 compared with the population at large. Reference Muiry, Parsons and Madan17 Consequently, the protection of frontline warriors against COVID-19 is of great importance for a country’s preparedness against current and future pandemics. In addition, ensuring as far as possible available HCWs to deal with COVID-19 as well as other priority disease areas. Pakistan is currently under the sixth COVID-19 wave, where restrictions on the movement of citizens re-implemented in recent months. Reference Mirza18 The availability of effective vaccines against COVID-19 should help with reducing such activities in the future.
To prevent infection spread among HCWs, and to their patients, many standard precautions have been developed and practiced throughout the world, and HCWs have been advised to follow them strictly while attending to their patients. Reference Wong, Ho and Dong19 Many international organizations including the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have advised HCWs to follow standard infection prevention and control (IPC) principles while providing care to suspected or confirmed cases of COVID-19 in hospitalzed settings as well as in the community. 20,21 All these guidelines stress that HCWs exposed to actual or suspected COVID-19 patients in hospitals should adopt hand hygiene, respiratory hygiene, environmental cleaning, disinfection, and the use of personal protective equipment (PPE) while providing care to patients, in addition to vaccination. The government of Pakistan initiated vaccination campaigns for COVID-19 on February 2, 2021, and in the first phase of the vaccination drive, front-line HCWs received COVID-19 vaccines free of charge from the state. Reference Gul22
Country guidelines have also been issued to HCWs to follow standard operating procedures. In the case of Pakistan, these include guidelines by The Ministry of National Health Services, Regulation, and Coordination concerning the selection and recommended use of PPE by the HCWs against COVID-19, 23 with correct PPE seen as a physical barrier to prevent the spread of the virus from either a suspected or confirmed case of COVID-19. Reference Khalid and Ali24 Medical masks, gloves, gowns, and protective face shields/goggles are the recommended PPE that must be worn by HCWs while interacting with COVID-19 patients. 25 Hospital settings are considered as sites of infection spread particularly between COVID-19 patients and between patients and HCWs; consequently, effective water sanitation and hygiene (WASH) protocols are necessisateed to support IPC activities. However, we are currently unaware of any study that has been reported from Pakistan among exposed HCWs regarding their compliance with IPC in established treatment centers for COVID-19 patients. We are aware that certain health authorities in Pakistan as well as the WHO have advocated such practices, and similar studies have been undertaken in neighboring countries during the ongoing pandemic, 26–Reference Etafa, Gadisa and Jabessa29 however, we did not come across any study conducted in Pakistan. Consequently, the objectives of the current study are to evaluate IPC compliance among exposed HCWs in COVID-19 treatment centers in the Punjab Province, Pakistan. The findings can potentially be used to improve future compliance with IPCs and their directives in this province and wider in Pakistan if there are concerns. In addition, these findings can provide guidance to other low- and middle-income countries (LMICs) during these challenging times. This is important because the Pakistani healthcare system, similar to healthcare systems in other LMICs, has been under considerable strain since the emergence of this pandemic. Initially, this was due to the non-availability of sufficient medical and testing facilities, lack of trained HCWs to handle such disasters, and insufficient PPEs to treat COVID-19 patients. In addition, in Pakistan and elsewhere, the emergence of the COVID-19 pandemic has imposed an appreciable adverse psychological impact on HCWs. Reference Khalid and Ali24,Reference Shahbaz, Ashraf and Zakar30–Reference Salman, Mallhi and Khan32
Methods
Study Design
This cross-sectional study was conducted among HCWs working in different COVID-19 treatment centers in both public and private hospitals of the 4 divisions in the Punjab Province of Pakistan (Lahore, Sahiwal, Faisalabad, and Bahawalpur). The health department in the government of Punjab is partitioned into Specialized Healthcare and Medical Education Departments as the administrative body for tertiary/teaching hospitals, while the Primary & Secondary Health Care department controls primary and secondary hospitals established throughout the province of Punjab. Secondary and tertiary care hospitals in the Punjab were equipped with COVID-19 isolation wards for the treatment of hospitalized COVID-19 patients. Moreover, the private sector hospitals also established COVID-19 wards to accommodate suspected or positive COVID-19 patients. All these heath facilities were provided with the necessary health personnel and laboratory facilities to treat COVID-19 patients since the start of the pandemic in Pakistan.
Study Population
The study population included HCWs working in COVID-19 treatment centers in both public and private hospitals established in the 4 divisions of Punjab. All HCWs including medical doctors, nurses, pharmacists and laboratory personnel who were willing to participate in the study were included. Those who declined to participate were excluded. All HCWs currently serving in other departments of the hospitals besides COVID-19 wards and HCWs in COVID-19 wards unwilling to participate due to any reason, were excluded from this study. The sample size was calculated using the Raosoft sample size calculator using 50% response rate from the study participants, 95% confidence interval, and 5% margin of error. 33 The calculated sample was 377. A convenient sampling method was used to recruit the study participants.
Study Instrument
The questionnaire used in this study was adapted from the WHO risk assessment and management tool among HCWs specifically designed in the context of COVID-19. 25 A pilot study was conducted among 25 HCWs to enhance the utility of study instrument. During this study, all the participants were asked about the clarity, understandability, and relevance of all the questions and response options of the study tool. The final study sample did not include participants of this pilot study. Based on the finding of the pilot study, the content validity reached 1. Moreover, Cronbach’s alpha of the questionnaire was found to be 0.77, showing adequate internal consistency. The final version of questionnaire has 4 sections including section 1, which consists of 11 items covering demographic characteristics and the availability of IPC facilities at the hospital. Section 2 collected information on the activities performed by the HCWs on COVID-19 patients and has 4 items. Section 3 has 10 items and assessed the adherence to IPC measures among HCWs during their interactions with COVID-19 patients. Each item in section 3 has 4 different options, and HCWs were required to select 1 option according to their usual practices of wearing PPE and hand hygiene when they provide care to COVID-19 patients. The 4 options were “always, as recommended” (which means more than 95% of the time they follow this practice), “most of the time” (which means 50% or more but not 100%), “occasionally” (which means 20% to below 50%), and “rarely” (which means less than 20% following these practices). Section 4 comprised 10 items regarding IPC activities during aerosol-generating procedures. All the study participants were classified as either compliant or non-compliant. A compliant category assigned to those HWCs who were following IPS measure “always, as recommended” and “most of the time,” while non-compliant were those HCWs who were adopting IPC measures “occasionally” or “rarely.”
Data Collection Procedure
Due to COVID-19 restrictions, online versions of the data collection tool were developed using Google Forms®. The hyperlink of the questionnaire was sent to all the participants through social media channels, including WhatsApp, Facebook, and Gmail, with the request to provide their responses. All the participants were recruited using convenient sampling technique to complete the questionnaire voluntarily according to their routine practices while providing care to COVID-19 patients. The principal investigator (ZUM) sought the help of medical doctors and pharmacists to provide assistance to the ward servants and cleaners, laboratory personnel, and those who had difficulty filling out the e-questionnaire at their respective centers.
Statistical Analysis
The statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22.0 for Microsoft Windows. The categorical data were presented as frequencies and percentages. Kruskal-Wallis (3 or more groups) and Mann-Whitney (2 groups) tests were used to assess the difference based on demographic characteristics. A P < 0.05 was considered statistically significant during the analysis.
Results
Demographic Characteristics of Study Population and Availability of the IPC Facilities
A total of 610 HCWs were invited to participate, with 414 subsequently responding, giving a response rate of 67.8%. The majority of the study participants were male (56.3%) and aged 25-36 years (60.9%). More than two-thirds resided in urban areas (76.8%). Most of the participants (62.4%) had less than 6 years of working experience. More than one-third of the participants were nurses (39.6%), followed by medical doctors (27.3%) and laboratory personnel (13.3%). The majority of the participants (90.3%) were working in public hospitals. Most of the HCWs (52.9%) reported that they did not have sufficient PPE. Fifty-nine percent indicated that their hospitals had functional IPC teams, while 41.8% had attended IPC training. Table 1 summarizes the demographic characteristics of the respondents.
Table 1. Demographics characteristics and availability of IPC facilities
Health-Care Workers Activities Performed on COVID-19 Patients
The different activities performed by HCWs on COVID-19 patients are shown in Table 2. More than two-thirds (67.1%) were providing direct care to COVID-19 patients, while 64.5% indicated that they had face-to-face contact (within 1 meter) with COVID-19 patients. Approximately 50% of the study participants indicated that they were present around the patients when aerosol-generating procedures were performed.
Table 2. Healthcare worker activities performed on COVID-19 patient in a health care facility
Adherences to IPC Measures During Health-Care Interactions
The majority of the participants used disposable gloves (89.4%) and N95 masks (90.3%) when they had health interactions with COVID-19 patients. However, less than half of the study participants used protective face shield/goggles (45.1%) and disposable gowns (44.9%) when they had health interactions with COVID-19 patients. Most of the HCWs (70.6%) removed their PPE according to the predefined protocols. More than two-thirds practiced hand hygiene practices before and after touching a patient (70.5%) and before and after performing any aseptic procedure (74.1%). Table 3 shows the adherence to IPC guidance among HCWs during healthcare interactions with COVID-19 patients.
Table 3. Adherence to IPC procedures during health care interactions
Adherences to IPC Measures During Aerosol-Generating Procedures
During aerosol-generating procedures including tracheal intubation, open airway suctioning, sputum collection, nebulizer treatment, tracheostomy, bronchoscopy, and cardiopulmonary resuscitation, the most compliant IPC measures among HCWs were hand hygiene before and after any clean or aseptic procedure (89.6%), hand hygiene before and after touching a COVID-19 patient regardless of whether HCWs were wearing gloves (88.9%), wearing single-use gloves (82.1%), and wearing an N95 mask (or equivalent respirator) (79.3%). The least compliant IPC measures were wearing a face shield or goggles/protective glasses (54.8%) and wearing a disposable gown (56.2%). Table 4 describes the adherence to IPC measures when participants were performing aerosol-generating procedures.
Table 4. Adherence to IPC measures when performing aerosol-generating procedures
Aerosol-generating procedures include tracheal intubation, nebulizer treatment, open airway suctioning, sputum collection, tracheotomy, bronchoscopy, cardiopulmonary resuscitation (CPR), etc.)
Association Between Demographics and IPC Facilities Variables With IPC Adherence
The association between demographic variables including gender, age, marital status, residence, working experience, level of education, medical staff, hospital ownership, hospital type, study areas, and availability of different IPC facilities with IPC adherence is shown in Table 5. Significant (P < 0.05) association was observed with the medical staff category, with IPC adherence indicating that the highest adherence manifested by HCWs.
Table 5. Association of demographic variables with IPC adherence
Discussion
To the best of our knowledge, this is the first study undertaken in Pakistan that has assessed adherence to IPC measures among HCWs providing care for COVID-19 patients. In addition, one of the first exploratory studies from a LMIC determining adherence levels to IPC measures among HCWs working in COVID-19 treatment centers providing guidance for others. The current study revealed that more than half of the HCWs indicated that the availability of PPE was insufficient in their health facilities. However, these findings are higher than the results reported in a multinational study conducted in South America, which reported that only 13% of HCWs had enough PPEs. Reference Martin-Delgado, Viteri and Mula34 Sarfraz et al. (2020) reported similar findings from LMICs, where there were appreciable differences in the availability of PPE among HCWs across LMICs. Reference Sarfraz, Sarfraz and Anwer35 This is a concern because, as mentioned, the availability and correct use of PPE is essential to help prevent HCWs from getting COVID-19, Reference Ashinyo, Dubik and Duti36 and could be one of the major obstacles to implementing effective IPC measures in many LMICs. Our survey also reported that around one-quarter of the participants experienced an interruption in water supply in the previous week, which is concerning given the necessity of WASH protocols to support IPC activities. This is in contrast with the results of a recent study conducted in Ghana, where the majority of hospitals did not experience any interruption in fresh water supply in their COVID-19 treatment centers. This is a reflection generally of the proactive approach in Ghana during the pandemic. Reference Ashinyo, Dubik and Duti36,Reference Afriyie, Asare and Amponsah37 Consequently, interventions to ensure an uninterrupted water supply at COVID-19 treatment facilities are essential to enhance IPC adherence.
The WHO IPC guideline also recommends training and education of HCWs at the health facility level to optimize IPC measures. 38 In the current study, the majority of the HCWs were not trained in IPC measures. This observation contrasts with the findings of a Ghanaian study, in which almost all HCWs received training on IPC measures at the health facility level. Reference Ashinyo, Dubik and Duti36 However, other studies conducted among LMICs have shown poor compliance among HCWs with IPC measures. Reference Etafa, Gadisa and Jabessa29,Reference Bekele, Ashenaf and Ermias39,Reference Ilesanmi, Afolabi and Akande40
Most of the HCWs in our survey used disposable gloves and masks during their interaction with COVID-19 patients, similar to the findings in Saudi Arabia. Reference Almohammed, Aldwihi and Alragas13,Reference Albeladi, Alluli and Daghriri41 Encouragingly, this is higher than a study in Ethiopia, where only a small proportion of HCWs used facemasks in the correct way; however, a higher proportion was wearing PPE correctly before entering the patient area. Reference Tekalegn, Sahiledengle and Bekele42 Of concern is that approximately half of the HCWs in our study were not using protective face shields/goggles and gowns before interacting with COVID-19 patients and during aerosol-generating procedures, which needs to be addressed going forward. These results are in contrast to a study conducted in Saudi Arabia, where appreciably greater adherence was reported among HCWs relating to their usage of protective face shield/goggles and gowns. Reference Albeladi, Alluli and Daghriri41 and a study conducted by El-Sokkary et al. (2021) in Egypt with a similar high adherence to correct PPE among HCWs. Reference El-Sokkary, El-Kholy and Mohy Eldin43
Encouragingly again, most of the HCWs in our study were practicing the doffing of PPE according to the recommendations during interactions with COVID-19 patients or during aerosol-generating procedures. These findings are similar to the findings of a study conducted in India, which reported that the majority of HCWs practice donning and doffing PPE according to the guidelines. Reference Alao, Durodola and Ibrahim44 Our findings showed a higher proportion of HCWs adhering to PPE than a study from Nigeria, where only 6-12% of HCWs perform doffing of PPEs as per recommended protocols. Reference Garg, Grewal and Mahajan45
Hand hygiene is another recommended strategy to prevent the spread of infection. Consequently, it is highly recommended that HCWs practice hand hygiene while providing care to COVID-19 patients, especially in LMICs where there can be concerns with the cleanliness of wards. In the current study, encouragingly more than three-quarters of HCWs practiced recommended hand hygiene techniques before and after touching COVID-19 patients, after exposure to patient’s body fluid, and when carrying out any aerosol-generating procedures. This contrasts with a study in Sri Lanka, where only one-third of medical students surveyed were performing recommended hand hygiene during care provision for COVID-19 patients. Reference Liyanage, Dewasurendra and Athapathu46
We are aware that this study has several limitations. These include the inclusion of only 4 divisions of the Punjab Province, which will impact the generalizability of the findings. In addition, a convenience sampling technique was used, which is associated with the risk of biases. The responses were self-reported, making the results vulnerable to social desirability bias. Despite these limitations, this study has described adherence to IPC measures among HCWs in Pakistan and other low-resource settings, giving direction for the future research and policy implementation.
Conclusions
Adherence to IPC strategies among Pakistani HCWs is encouraging. However, key areas were identified for improvement to enhance future protection. Institutional IPC teams comprising all stakeholders need to be established to effectively execute all infection prevention activities. Moreover, the provision of necessary PPE, training on proper donning and doffing, and the development and implementation of effective IPC guidelines at the hospital level are critical going forward for the maximum protection of HCWs. We will be monitoring this in the future in Pakistan.
Data availability statement
The data set for this study are available on appropriate request from corresponding author.
Acknowledgments
We thank the administration of the concerned hospitals for their cooperation and support in the completion of this study. Moreover, we acknowledge the services of pharmacy technicians of the participated while completing data collection procedures.
Funding
No funding available for this study.
Conflict of interest
All the authors declared that no conflict of interest is associated with this project.
Ethical considerations
The study protocol was approved by the Research Ethics Committee, Department of Pharmacy Practice, University of Lahore, Lahore (reference no. REC/DPP/FOP/42). Approval was also obtained from the various hospital administrators before data collection. All participants provided an electronic informed consent before their participation in the study. Participation was voluntary and all the participants were assured about the confidentiality of their data.
