If we had told you a year ago that the United States has roughly 160,000 ventilators compared to Mali, which has 20, you might not have given that statistic much thought. Just one of many numbers that loses its significance in the blur of statistics describing global inequality. Enter the pandemic. Suddenly otherwise obscure health statistics have a lot more meaning.
People around the world now have a global collective understanding for what some of these numbers really mean. Italy’s health system has been overwhelmed, and the spread of the virus suggests that many, if not most, other countries will experience a similar onslaught. Italy has 100 doctors and nurses per 10,000 people. Kenya has 17. How can places like Kenya even begin thinking about launching a pandemic counterattack with such limited resources?
One thing is clear: health systems will be stressed everywhere in the world, but frontline health care workers in Sub-Saharan Africa are going to be particularly stretched. Global statistics on basic health provisions – e.g. number of health care workers and hospital beds per country – highlight the stark contrasts. But since a rapid expansion of a skilled health workforce is not a viable option in the timeframe that the pandemic has imposed on us, we need to work out how to make best use of existing resources. As a start, we need to do whatever we can to keep our health care workers safe. Italy’s health care workers face COVID-19 infection rates 5 times higher than the general population. In countries with less effective health systems, this could be much higher, reducing even further the pool of health care workers who are available. Infection prevention and control (IPC) guidelines provide the playbook for what health facilities should be doing to minimize the risk of patient and worker infections. Unfortunately, there’s very little data on what IPC practices are in place in developing country health facilities, which makes it difficult to work out where to focus attention.
A recent paper, Observations of infection prevention and control practices in primary health care, Kenya and policy brief, Supporting Vulnerable Health Systems Improve Infection Prevention and Control to Fight the COVID-19 Pandemic, provide valuable insight. The study fills in some important data points that provide guidance on how to begin breaking down the daunting task ahead. The work is a culmination of a massive effort tracking the journeys of 14,328 patients through 935 health facilities in Kenya. The methods used to trace IPC practices deserves its own blog, but in a nutshell, they study patient visits to a health facility, tracking each time possible infections could occur and whether health care workers took appropriate action to keep themselves and their patients safe. Each juncture where potential contamination could occur is referred to as an “indication.” In all, 106,464 such indications were recorded, representing the single largest data collection effort on IPC practices and patient safety in primary care settings in any low- or middle-income country.
The authors help illustrate the process:
“…it is helpful to think of a patient journey through a primary care visit. They will first see a nurse, who must wash his/her hands before the examination. The nurse will then go through the examination, and will have to disinfect the thermometer with an alcohol-based solution. To conduct an invasive procedure, for instance, attending to an open wound, the nurse must wear personal protective equipment (PPE) such as gloves, and segregate infectious waste into appropriate containers.”
The results from the exercise are sobering. Out of an average of 7.5 indications per visit, there were 5.1 “violations,” where the IPC guidelines were not followed. With more complex consultations requiring more IPC practices, the number of violations steadily increased (Figure 1).
Rather than observing poor IPC practices across the spectrum, the main source of violations centered on a handful of common practices. While the vast majority of injections and blood draws were administered safely (87%), appropriate hand hygiene–hand washing with water and soap or hand rubbing with an alcohol-based solution–was practiced in only 2.3% of relevant indications. Figure 2 shows the variation in compliance across practices.
The good news is that the data provide more clarity on where early interventions could help to significantly improve the safety of patients and health care workers compared to the status quo. Three targeted quick wins can help increase the defenses of Kenya’s frontline health care efforts:
- Immediately distribute IPC policies to health facilities: These already exist. But only 2% of the health facilities had a hygiene protocol and only 5% had any IPC guidelines.
- Provide critical IPC supplies to health facilities: 15% of facilities had face masks and 47% had any disinfectant available in outpatient areas. While global supply shortages make this task more challenging, redirecting local manufacturing capacity to this is important, but low-cost personal protective equipment can ensure health care workers have what they need to implement IPC guidelines.
- Ramp up hand hygiene campaigns: Improving hand hygiene practices is the single most important challenge for limiting the spread of COVID-19 in health facilities, and among the general public. But the status quo knowledge sharing approaches are unlikely to yield results. Even with knowledge of best practices and necessary supplies, Kenyan health care workers only practiced appropriate hand hygiene practices in 4.2% of observed indications. While changing hand hygiene behavior has proven notoriously difficult in the past, novel mass media edutainment has proven successful for behavior change in other domains and could be directed to this purpose.
In the short run, ramping up the number of health care workers, ICU beds and respirators may be difficult for most developing countries, underscoring the importance of making the best use of existing resources. The sheer magnitude of the challenge that lies ahead could immobilize us. Or we can use insightful and timely data to help find solutions: there are low cost, viable actions that all developing country governments can take right now to help protect their health care workers and save lives.