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Article

Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study

by
Senesie Margao
1,*,†,
Bobson Derrick Fofanah
2,*,†,
Pruthu Thekkur
3,
Christiana Kallon
1,
Ramatu Elizabeth Ngauja
1,
Ibrahim Franklyn Kamara
2,
Rugiatu Zainab Kamara
4,
Sia Morenike Tengbe
5,
Matilda Moiwo
6,
Robert Musoke
2,
Mary Fullah
5,
Joseph Sam Kanu
5,7,
Sulaiman Lakoh
5,7,
Satta Sylvia T. K. Kpagoi
5,
Kadijatu Nabie Kamara
5,
Fawzi Thomas
7,8,
Margaret Titty Mannah
5,
Victoria Katawera
2 and
Rony Zachariah
9
1
National Infection Prevention and Control Coordinating Unit, Ministry of Health and Sanitation, Freetown 00232, Sierra Leone
2
World Health Organization Country Office, Freetown 00232, Sierra Leone
3
Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, 75001 Paris, France
4
US Centre for Disease Control and Prevention Country Office, Freetown 00232, Sierra Leone
5
Ministry of Health and Sanitation, Freetown 00232, Sierra Leone
6
Republic of Sierra Leone Armed Forces, HIV/AIDS/TB Control Program Coordinator, 34th Military Hospital, Wilberforce, Western Area Urban 00232, Sierra Leone
7
College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown 00232, Sierra Leone
8
National Pharmacovigilance Center, Pharmacy Board of Sierra Leone, Freetown 047235, Sierra Leone
9
UNICEF, UNDP, World Bank, WHO Special Programme for Research and Training in Tropical Diseases (TDR), 1211 Geneva, Switzerland
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Trop. Med. Infect. Dis. 2023, 8(7), 376; https://doi.org/10.3390/tropicalmed8070376
Submission received: 28 June 2023 / Revised: 19 July 2023 / Accepted: 21 July 2023 / Published: 23 July 2023
(This article belongs to the Special Issue Impact of Operational Research in Tackling Antimicrobial Resistance through the Structured Operational Research Training Initiative in Ghana, Nepal and Sierra Leone)
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Abstract

:
Introduction: Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in 2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement. Methods: This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0–25%), basic (25.1–50%), intermediate (50.1–75%), and advanced (75.1–100%). Results: The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023. Conclusions: The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.

1. Introduction

Infection prevention and control (IPC) measures at health facilities are a central pillar for protecting patients, visitors, and health workers from acquiring healthcare-associated infections (HAIs) [1]. The World Health Organization (WHO)’s Global Report on IPC (2022) revealed that good IPC programs could reduce 70% of HAIs [2]. Also, IPC is a strategic pillar of the Global Action Plan to tackle antimicrobial resistance (AMR), the logic being that “one prevented infection is one antibiotic treatment avoided” [3].
An effective IPC program is essential to ensure the quality of universal health coverage and health system resilience, especially in low- and middle-income countries with high rates of HAIs [4,5,6,7]. However, a global assessment of the IPC program (2020-21) showed that about 11% of countries did not have a national IPC program, and in 54% of countries, the IPC program was only implemented in a few health facilities [2,8]. This prompted a resolution during the 75th World Health Assembly in May 2022 requesting that WHO develop a global strategy for IPC, in consultation with member states and regional economic integration organizations [9].
The WHO guideline on “Core Components of Infection Prevention and Control at the National and Acute Health Care Facility Levels” recommends the optimal establishment of six IPC core components at the national level and eight at the health facility level [10]. In addition, the WHO developed standardized checklists with a percentage scoring system (0% to 100%) to assess the IPC performance and facilitate improvements [11,12]. A recent (2022) global survey using the WHO checklists reported that IPC performance scores were low in low-income countries and public health facilities [13]. Even individual studies from low-income countries like Tanzania, Liberia, Uganda, Pakistan, and Bangladesh have reported low IPC performance scores [14,15,16,17,18].
In countries like Sierra Leone, with a high risk of infectious diseases, establishing a good IPC program is paramount to prevent the transmission of infections of global concern such as pandemic influenza, Ebola virus disease (EVD) and other viral hemorrhagic fevers, and of recent concern, COVID-19. During the 2014–2015 EVD outbreak in West Africa, Sierra Leone alone reported about 14,000 cases and 3955 EVD deaths, including those of 221 health workers [19,20]. The rapid transmission of EVD among healthcare workers during the 2014–2015 EVD outbreak could be attributed to inadequate IPC practices. In 2015, the national IPC unit was established within the Ministry of Health and Sanitation (MoHS), and the IPC program was implemented in health facilities [20]. The strategic plan to combat AMR in Sierra Leone emphasized the need to improve IPC measures as a means to stop the accelerating rate of antimicrobial resistance [21].
In 2021, Fofanah et al. conducted operational research study using the WHO standardized checklists to assess the IPC performance and gaps in the national IPC unit and district-level secondary public hospitals of Sierra Leone [22]. This study was designed and conducted as part of the Structured Operational Research Training Initiative (SORT IT) to tackle antimicrobial resistance led by TDR, the Special Program for Research and Training in Tropical Diseases [23,24]. The operational research was used to generate knowledge on interventions, strategies, or tools that can enhance the quality, effectiveness, or coverage of IPC program studies [25]. Operational research is shown to be effective in helping policy makers to make evidence-based changes to policy or practice to improve program performance in different contexts [26,27,28,29].
The study by Fofanah et al. found that IPC performance was low, with an ‘intermediate’ level (58%) of performance in the national IPC unit and a ‘basic’ level (50%) in the district-level secondary public hospitals [22]. The priority gaps for low IPC performance at national and district-level hospitals were identified, and specific recommendations were made to address the identified gaps. In addition, through SORT IT, the capacity of the principal investigator (PI) was developed to prepare and use elevator pitches, plain language handouts, Lightning PowerPoints, and technical presentations for effective dissemination of study findings and recommendations to decision makers [23,30,31].
The TDR conducts post-SORT IT evaluation after 12 months of course completion as part of routine monitoring and evaluation. The PI of the previous study reported that the study findings were disseminated to decision makers. Some recommendations were translated into actions to improve IPC performance in national IPC units and hospitals (details provided in the methods section). Thus, we aimed to assess whether there was any improvement in the IPC performance scores across core components in April 2023 compared to those reported by Fofanah et al. [22] in June 2021 for the national IPC unit and the 12 district-level secondary public hospitals. We also assessed whether the gaps identified in 2021 were bridged by 2023.

2. Materials and Methods

2.1. Study Design

This was a before (June 2021) and after (April 2023) comparison of the data from the cross-sectional IPC assessments conducted routinely by the IPC program of Sierra Leone.

2.2. Study Setting

2.2.1. General Setting

Sierra Leone is a West African country on the Atlantic coast bordering Guinea and Liberia. The Figure 1 below shows the geographic map of Sierra Leone which is made up of sixteen districts and five regions, and its population is around 8 million [32]. Tertiary hospitals (6), district-level secondary hospitals (4 regional hospitals and 8 district hospitals), other secondary hospitals (11), and peripheral health units (PHUs) provide services under the public healthcare system of the country [33]. From 1991 to 2002, Sierra Leone struggled through a civil conflict that disrupted the healthcare infrastructure. The resource-limited health system was also challenged by several infectious disease outbreaks of pandemic influenza, COVID-19, EVD, Lassa fever, and other high-risk infectious diseases [20].
Like Sierra Leone, the neighboring countries of Guinea and Liberia were also equally affected by multiple infectious disease outbreaks and the West African Ebola outbreak in 2013 to 2016. It is also true that these three countries share similar health system organizations and performances, including a shortage of healthcare workforce, information and surveillance research, medical products and technologies, health financing, and leadership. Following the EVD outbreak, WHO developed Infection Prevention and Control Recovery Plans for the three countries. It was reported that all the three countries made progress in terms of IPC and Water, Sanitation, and Hygiene (WASH) during the emergency response phase. Thus, the international agencies called for consolidating those gains in IPC by shifting from a vertical IPC Ebola response approach to an integrated and sustainable IPC program. This led to the establishment of IPC national and sub-national structures in these countries.

2.2.2. The IPC Program in Sierra Leone

The outbreak of EVD in 2014–2015 exposed the deficiencies in IPC at health facilities, leading to the establishment of a national IPC unit by MoHS, with technical and funding support from WHO and other public health partners [20]. This unit is mandated to provide leadership, coordinate activities, provide training, and supervise the optimal implementation of IPC programs in health facilities. The unit consists of a national IPC coordinator and seven supporting IPC officers, with assigned tasks for supporting IPC implementation in health facilities.
At the hospital level, IPC programs are established, and designated IPC personnel/focal points coordinate IPC activities. The IPC committee in each health facility is responsible for implementing the national IPC policy and guidelines in their facilities. The national IPC program provides responsible personnel, accountable for action points, who also support health facilities in the optimal implementation of IPC.

2.2.3. The IPC Performance Assessments

The standardized WHO checklists are used for routine IPC performance assessments of the national IPC unit and hospitals. IPC performance is assessed by the personnel from the national IPC unit and WHO, in consultation with the IPC focal points using checklists in paper form.
The National Infection Prevention and Control Assessment Tool (IPCAT) is used for the performance assessment of the national IPC unit (Supplementary File S1) [11]. The IPCAT has 112 items, with ‘yes’ or ‘no’ responses for each item. The items are divided into six core components: (i) IPC program, (ii) IPC guidelines, (iii) IPC education and training, (iv) HAI surveillance, (v) IPC multimodal strategies for implementation, and (vi) IPC monitoring/audit of IPC practices. The total number of ‘yes’ responses from all the listed items under the core component is used to calculate a percentage score for each component. The scores can also be deduced for the subcomponents within each of the core components. The overall percentage score is derived using the total number of items with a ‘yes’ response out of the 112 items in the checklist [11].
The Infection Prevention and Control Assessment Framework (IPCAF) is used to assess the performance at the health facility level (Supplementary File S2) [12]. The IPCAF checklist consists of 81 items, split across eight core components. The first six core components of the IPCAF are the same as those of the IPCAT; the additional two are ‘Workload, staffing and bed occupancy’ and ‘Built environment, materials and equipment for IPC at facility level’. In addition, the IPCAF percentage scoring system is the same as that of IPCAT.

2.2.4. Dissemination of Findings of the Operational Research Study

As mentioned earlier, Fofanah et al. [22] conducted a study to assess the IPC performance of the national IPC unit and district-level secondary public hospitals. The PI and the co-investigators disseminated the study findings and the recommendations to the decision makers and key stakeholders involved in implementing the IPC program in the country. The published article and the dissemination materials developed during module 4 (module on communicating research findings) of the SORT IT course were used for dissemination. The dissemination details reported by the PI are provided in Table 1.

2.2.5. Recommendations Made and Actions Taken

Following the effective dissemination of information, some of the recommendations by Fofanah et al. [22] were translated into actions. In Table 2, we have mapped the recommendations made and actions taken, as reported by the PI of the previous study.

2.3. Study Inclusion and Period

We included data from the routine IPC performance assessment of the national IPC unit and all the twelve district-level secondary public hospitals of Sierra Leone, conducted in April 2023. In addition, to compare the IPC performance with that in June 2021, we included the data from the IPC assessments of the same facilities reported in the previous study [22].

2.4. Data Variables and Sources

In April 2023, the IPC team conducted an IPC performance assessment using the paper-based WHO checklists, as was accomplished in 2021. In 2022, the national IPC unit made minor modifications to the WHO IPCAF checklist to adapt it to the country context and started using an adapted checklist for assessment. However, during the IPC performance assessment conducted in April 2023, the IPC team used the WHO IPCAF.
The IPC team entered the data from the paper-based checklist into a customized Microsoft Excel (Microsoft Corporation, Redmond, WA, USA, 2018) database developed by the WHO for calculating scores for each component of the IPCAT and IPCAF checklists. The calculated scores from the assessment of the national IPC unit and twelve district-level secondary public hospitals were merged into one Excel database for analysis.
We included the IPCAT scores in each of the six core components and sub-components for assessing whether there was any improvement in the IPC performance at the national IPC unit between 2021 and 2023. Similarly, the name of the assessed facility and the scores for the eight core components and sub-components of the IPCAF tool were included for assessing improvement in the IPC performance at district-level secondary public hospitals.

2.5. Data Analysis

Microsoft Excel (Microsoft Corporation, 2018) was used for data analysis. Each of the six core components of the IPCAT and eight core components of the IPCAF boast a maximum score of 100. The overall IPC performance score for the assessed unit or hospital was obtained by adding the scores in each of the core components. The maximum IPC performance score for the national IPC unit using IPCAT was 600 (six core components), and for hospitals using IPCAF, it was 800 (eight core components). The median scores were calculated to summarize the IPC performance in the twelve district-level secondary public hospitals.
A percentage IPC performance score was calculated (score obtained divided by maximum score multiplied by 100) for the overall score and scores for each core component and subcomponent. The percentage scores ranged from 0% to 100%. The IPC performance was graded based on the obtained percentage score: (i) inadequate (0–25%), (ii) basic (25.1–50%), (iii) intermediate (50.1–75%), and (iv) advanced (75.1–100%) level.
The change in the percentage IPC scores was calculated for each core component by subtracting the percentage score from 2021 from that of 2023. The radar charts were used to depict the percentage scores in the core components at the national IPC unit and district-level secondary hospitals during 2021 and 2023. The IPCAT and IPCAF sub-components with inadequate scores (≤25%) were considered as gaps, and these were compared between the scores from the 2021 and 2023 assessments.

3. Results

3.1. Assessment of IPC Performance at the National IPC Unit

3.1.1. Change in IPC Performance Score between 2021 and 2023

The overall IPC performance improved from the intermediate (58%) to the advanced level (78%), with a 20% absolute improvement in the percentage score (Table 3).
There was an increase in the IPC percentage scores in each of the six core components. Four out of six core components achieved the advanced level in 2023, in contrast to only “IPC Guidelines” which had already achieved this status in 2021. Three additional core components which achieved the advanced level in 2023 were “IPC program” (88%), “Multimodal strategies” (83%), and “Monitoring/audits and feedback” (83%). In spite of more than 20% absolute improvement in “HAI surveillance” (27% to 53%), the component only reached the intermediate level (Figure 2).

3.1.2. Gaps in IPCAT Sub-Components in 2021 and 2023

Table 4 shows the percentage scores for the 20 IPC sub-components in 2021 and 2023. In 2023, 13 of 20 sub-components had reached the advanced level, in contrast to only six in 2021. None of the sub-component’s scores showed a decline between the two assessments. Of the four sub-components which had inadequate scores (≤25%) and were considered as gaps in 2021, only one (“Monitoring of training and education”) remained as a gap in 2023.

3.2. Assessment of IPC Performance at District-Level Secondary Public Hospitals

3.2.1. Change in IPC Performance Score between 2021 and 2023

The median overall IPC performance improved from basic (50%) to intermediate level (59%), with a 9% absolute improvement in percentage score (Table 5). Out of 12 hospitals, only one remained at the basic level (all others were at the intermediate level) in 2023, compared to seven during 2021 (Supplementary Table S1).
In district-level secondary public hospitals, there was an increase in the median IPC percentage scores in six of the eight core components between 2021 and 2023. Only the “IPC Program” component moved from the basic to the intermediate level, and the “IPC Guidelines” moved to the advanced from the intermediate level.
Although the “Workload, staffing, and bed occupancy” remained at the basic level, there was a 15% increase in the score (30% to 45%). Similarly, the “Built environment, materials, and equipment for IPC” remained at the basic level, even with an increase of 7% in the percentage score (Figure 3). There was a slight decline in median percentage scores for “IPC education and training” (2%).

3.2.2. Gaps in IPCAF Sub-Components in 2021 and 2023

Table 6 shows the percentage scores of the selected 25 IPC sub-components in 2021 and 2023. In 2023, 9 of the 25 sub-components reached the advanced level, in contrast to only 5 in 2021. Among the sub-components, only the “Frequency of IPC training” showed a decline in the score between 2021 and 2023. Out of the seven sub-components considered as gaps (scores ≤ 25%) in 2021, three remained as a gap, even in 2023. The sub-components that remained as gaps were: lack of senior facility leadership commitment and support with a budget allocated specifically for IPC activities; not being able to establish a multidisciplinary team for implementing IPC multimodal strategies at hospitals; and no need-based assessment for hospital staffing.

4. Discussion

This before-and-after study showed an improvement in IPC performance scores at the national IPC unit and district-level secondary public hospitals following operational research on IPC by Fofanah et al. [22]. There was a substantial improvement in IPC performance at the national IPC unit, which moved from the intermediate (58%) to the advanced (78%) level. On the other hand, although there was an improvement in the IPC performance score (50% to 59%) at the hospitals, none of the hospitals reached the desired advanced level. Except for the “IPC program” and “IPC guidelines”, there was little improvement in other IPC core components at the hospitals.
This study is important as it shows the role of operational research in informing decisions and actions for improving the IPC implementation in line with recommendations of the WHO global report regarding IPC [2]. Also, this study justifies the 75th World Health Assembly resolution that recommends operationalizing research to produce science-based evidence on IPC [9]. The study findings are primarily important to the Western Sub-Saharan African countries such as Sierra Leone, Guinea, and Liberia, which are vulnerable to outbreaks and have a high risk of death due to antimicrobial resistance [19,20,34].
This study has several strengths. First, as the national IPC unit and all the district-level public hospitals were simultaneously assessed, the findings are generalizable and likely to reflect operational realities of IPC implementation in Sierra Leone. Second, the use of the same standardized WHO checklists reduced the risk of social desirability bias. Third, implementation of IPC checklists by the same IPC officers in both assessments (2021 and 2023) improved the internal validity by limiting observer bias. Finally, we adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for conducting and reporting the study [35].
The study has three limitations. First, we could not quantify the contribution of the operational research by Fofanah et al. on the decisions made and actions taken to improve the IPC performance. In-depth qualitative interviews with the decision makers would have provided a better insight into the utilization of operational research in decision making and the root causes for the improvements in IPC performance. This merits further research. Second, as all the district-level hospitals were included in the study by Fofanah et al., we did not have a concurrent counterfactual (comparison group) to establish the independent effect of operational research on improving IPC performance. Third, as the IPC performance was reassessed in a relatively short time after the dissemination of the findings of Fofanah et al., some actions are still ongoing, and the full effect is yet to be manifested.
The study has six important implications for stakeholders involved in implementing an IPC program in low- and middle-income countries. First, the IPC performance scores improved at the national IPC unit and district-level secondary public hospitals following operational research. We believe that operational research contributed to this improvement in IPC performance, as six decision makers of IPC implementation (co-investigators of this study) acknowledged that the findings of operational research by Fofanah et al. galvanized them to make decisions and take actions.
The enabling factors for such research uptake included: (1) the relevance of the research topic; (2) the early engagement of six decision makers of IPC implementation in the conduct and reporting of research findings, thereby creating ownership of these research findings and the responsibility to act on the recommendations; (3) training of the PI of the previous study in research communication [30] and effective dissemination of study findings to the national IPC committee and other key stakeholders; and (4) the PI of the previous study being the WHO IPC focal point; as a result, he worked closely with the national IPC committee and was able to encourage research uptake and provide technical support for implementing recommendations. This experience highlights the importance of “local research, with local ownership, for local solutions”, as well as the importance the early engagement of decision maker in conceptualizing and conducting the study [36,37].
Second, there was a remarkable improvement in IPC performance at the national IPC unit. Sierra Leone now has a national IPC unit functioning at an advanced level, in contrast to most other low-income countries with non-functional national IPC programs [2,8,38]. This progress in the national IPC unit has a positive trickle-down effect on the IPC implementation in health facilities, as effective leadership, policies, action plans, and a framework for implementation exist. However, despite active advocacy in line with a recommendation from Fofanah et al., the national IPC program has yet to receive a dedicated budget. Globally, about three-fourths of the countries with national IPC programs do not have a dedicated budget [38]. A five-year funded national IPC action plan currently being developed with support from the WHO and other partners is a step forward for the creation of a dedicated budget. However, there is a need for continued efforts to present a funded national IPC action plan to the MoHS and acquire a dedicated budget for IPC programs across all levels.
Third, acknowledging the basic performance in the “Multimodal Strategy” and “HAI Surveillance”, the National IPC unit has concentrated on improving the performance of these core components. To improve the “Multimodal Strategy”, the national IPC unit facilitated the sub-national implementation of IPC improvement interventions and made effective linkages with other units of MoHS, including AMR, WASH, and Quality of Care. This is laudable, as studies have shown that an effective “Multimodal Strategy” can increase compliance with IPC interventions and reduce HAIs [39,40,41]. The national HAI surveillance strategy is being formulated with clear objectives and an implementation plan. Along with a national HAI surveillance strategy, the prospects of renovating laboratories under the AMR Fleming Fund grant to Sierra Leone is reassuring [42]. As a priority, the national IPC unit should finalize the HAI surveillance strategy and start implementing HAI surveillance.
Fourth, even though there was progress in IPC performance at district-level secondary public hospitals, none of the hospitals reached the desired advanced level. However, the progress from the basic to the intermediate level is satisfactory, as the WHO Global survey showed that the average IPC performance in the health facilities of low-income countries is at the basic level [13]. This progress is encouraging, as public hospitals of Sierra Leone still face infancy challenges, such as poor infrastructure and staffing, lack of IPC expertise, and weak financial resource allocation [13]. The improvement in IPC performance at district-level hospitals was mainly due to the implementation of recommendations such as: (1) ‘terms of reference’ for full-time IPC focal points; (2) distribution of updated national IPC guidelines and standard operating procedures across all hospitals; and (3) adopting and implementing IPC guidelines, including a well-defined monitoring plan with clear goals, targets, and activities.
Fifth, though recommended by Fofanah et al., no efforts were made to increase the number of hospital healthcare workers in line with the needs assessment. The country has no standards or guidelines for staff needs assessment for district-level secondary hospitals. Thus, the national IPC unit needs to follow up with MoHS to formulate and conduct staff needs assessments to improve the hospital health workforce. Similarly, the progress in “Built environment, materials, and equipment for IPC at the facility level” is suboptimal. However, WASH-FIT in-depth assessment to investigate and quantify the needs for effective WASH implementation in hospitals has been conducted. As WASH-FIT needs assessment helps hospitals to identify specific requirements to improve WASH practices [43,44], IPC focal points and hospital managers should leverage information from this assessment and actively advocate for fund allocation to fix these deficiencies.
Finally, given the utility of operational research in improving IPC performance through actionable recommendations, there is a need for embedding operational research in the routine monitoring of the IPC program. In line with the agenda of the national IPC action plan to prioritize operational research capacity-building activities, the IPC focal points in the hospitals can be trained through operational research programs like SORT IT. This would enable the IPC focal points to systematically identify and tackle local challenges in implementing IPC at hospitals and contribute to the global agenda of the 75th World Health Assembly to improve IPC [9].

5. Conclusions

This before-and-after study using standardized WHO checklists showed that the IPC performance improved in 2023 following the implementation of recommendations stemming from an operational research study in 2021. The active dissemination of relevant operational research findings and subsequent actions moved the IPC performance substantially from the intermediate to the advanced level at the national IPC unit and from the basic to the intermediate level at the district-level hospitals. This study highlights the importance of embedding operational research as part of routine IPC monitoring and its contribution to informed decision making. Further research is needed to explore the efficiency and the cost-effectiveness of improving the performance of the IPC program in the control and prevention of HAI and AMR.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/tropicalmed8070376/s1, Supplementary Table S1: Percentage scores of the core components of IPCAF in twelve district-level secondary public hospitals of Sierra Leone during 2021 and 2023; Supplementary File S1: The details from the IPCAF tool, with associated scale and scorings; Supplementary File S2: The details of the IPCAT tool, with associated scale and scorings.

Author Contributions

Conceptualization, S.M., B.D.F., P.T., C.K., M.F., R.E.N. and R.Z.; methodology, S.M., B.D.F., P.T., J.S.K. and R.Z.; validation, S.M., P.T., B.D.F., I.F.K., C.K., M.T.M. and R.Z.; formal analysis, S.M., B.D.F., P.T., S.L. and R.Z.; investigation, S.M., B.D.F., C.K., M.F. and I.F.K.; resources, S.M., P.T., B.D.F., R.Z., C.K., R.E.N., R.Z.K., S.M.T., R.M., M.M., F.T., K.N.K. and S.L.; data curation, S.M., B.D.F., P.T., C.K., S.S.T.K.K., M.F. and V.K.; writing—original draft preparation, S.M., B.D.F., R.Z., P.T., I.F.K. and V.K.; writing—review and editing, J.S.K., S.L., C.K., M.F., M.T.M., R.E.N., R.M., R.Z.K., S.S.T.K.K., S.M.T., F.T., K.N.K. and M.M.; visualization, S.M., B.D.F., P.T., R.Z., I.F.K., J.S.K., M.F., S.L., M.T.M., S.S.T.K.K., K.N.K. and V.K.; supervision, S.M., P.T., R.Z., B.D.F. and C.K.; project administration, S.M. and R.Z.; funding acquisition, R.Z. All authors have read and agreed to the published version of the manuscript.

Funding

The Government of the United Kingdom of Great Britain and Northern Ireland, represented by its department of health and social care (DHSC), has contributed designated funding for this SORT IT-AMR initiative, which is branded as the NIHR-TDR partnership, grant number AMR HQTDR 2220608. The APC was funded by DHSC. TDR is able to conduct its work thanks to the commitment and support from a variety of funders. A full list of TDR donors is available at: https://tdr.who.int/about-us/our-donors, accessed on 8 June 2023.

Institutional Review Board Statement

Permission to use the IPC national data was obtained from the Chief Medical Officer of the MOHS, Sierra Leone. Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Committee (SLESRC, 9 March 2023) and the ethics advisory group of the International Union Against Tuberculosis and Lung Disease, Paris, France (EAG 11/2023, 28 March 2023).

Informed Consent Statement

As we used secondary anonymized data, the issue of informed consent did not apply.

Data Availability Statement

The metadata record of the data used in this paper is available at DOI 10.6084/m9.figshare.23574771 (accessed on 7–8 June 2023) under a CC BY 4.0 license. Requests to access these data should be sent to the corresponding author.

Acknowledgments

This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership coordinated by TDR, the Special Program for Research and Training in Tropical Diseases at the World Health Organization. The specific SORT IT program that led to this publication included a partnership of TDR with the WHO country offices and ministries of health of Ghana, Nepal, and Sierra Leone. It was implemented along with the Tuberculosis Research and Prevention Center Non-Governmental Organization, Armenia; the International Union Against Tuberculosis and Lung Diseases, Paris, France; and the Southeast Asia offices, Delhi, India; Medecins Sans Frontières—Luxembourg, Luxembourg; the ICMR–National Institute of Epidemiology, Chennai, India; the Institute of Tropical Medicine, Antwerp, Belgium; the Damien Foundation, Kathmandu, Nepal, and Brussels, Belgium; the CSIR water institute, Accra, Ghana; the Kitampo Health Research Center, Accra, Ghana; the Environmental Protection Agency, Accra, Ghana; the University of Ghana, Accra, Ghana, the National Training and Research Center in Rural Health, Maferinyah, Guinea, and the national IPC unit, and hospital IPC focal points from the twelve districts public hospitals included in this study.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

References

  1. World Health Organization. Minimum Requirements for Infection Prevention and Control Programmes; World Health Organization: Geneva, Switzerland, 2019. [Google Scholar]
  2. World Health Organization. Global Report on Infection Prevention and Control: Executive Summary; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
  3. World Health Organization. Global Action Plan on Antimicrobial Resistance; World Health Organization: Geneva, Switzerland, 2015. [Google Scholar]
  4. Pittet, D.; Donaldson, L. Clean Care Is Safer Care: The First Global Challenge of the WHO World Alliance for Patient Safety. Infect. Control Hosp. Epidemiol. 2005, 26, 891–894. [Google Scholar] [CrossRef] [Green Version]
  5. Allegranzi, B.; Donaldson, L.J.; Kilpatrick, C.; Syed, S.; Twyman, A.; Kelley, E.; Pittet, D. Infection Prevention: Laying an Essential Foundation for Quality Universal Health Coverage. Lancet Glob. Health 2019, 7, e698–e700. [Google Scholar] [CrossRef] [Green Version]
  6. World Health Organization. Patient Safety: Health Care-Associated Infections. Available online: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf (accessed on 28 January 2022).
  7. Allegranzi, B.; Nejad, S.B.; Combescure, C.; Graafmans, W.; Attar, H.; Donaldson, L.; Pittet, D. Burden of Endemic Health-Care-Associated Infection in Developing Countries: Systematic Review and Meta-Analysis. Lancet 2011, 377, 228–241. [Google Scholar] [CrossRef]
  8. FAO; OIE; World Health Organization. Global Database for the Tripartite Antimicrobial Resistance (AMR) Country Self-Assessment Survey (TrACSS). Available online: https://amrcountryprogress.org/#/map-view (accessed on 21 May 2022).
  9. World Health Assembly. Global Strategy on Infection Prevention and Control; World Health Organization: Geneva, Switzerland, 2022; Volume 18. [Google Scholar]
  10. World Health Organization. Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level; World Health Organization: Geneva, Switzerland, 2016. [Google Scholar]
  11. World Health Organization. Instructions for the National Infection Prevention and Control Assessment Tool 2 (IPCAT2); World Health Organization: Geneva, Switzerland, 2017. [Google Scholar]
  12. World Health Organization. Infection Prevention and Control Assessment Framework at the Facility Level; World Health Organization: Geneva, Switzerland, 2018. [Google Scholar]
  13. Tomczyk, S.; Twyman, A.; de Kraker, M.E.A.; Coutinho Rehse, A.P.; Tartari, E.; Toledo, J.P.; Cassini, A.; Pittet, D.; Allegranzi, B. The First WHO Global Survey on Infection Prevention and Control in Health-Care Facilities. Lancet Infect. Dis. 2022, 22, 845–856. [Google Scholar] [CrossRef]
  14. Powell-Jackson, T.; King, J.J.C.; Makungu, C.; Spieker, N.; Woodd, S.; Risha, P.; Goodman, C. Infection Prevention and Control Compliance in Tanzanian Outpatient Facilities: A Cross-Sectional Study with Implications for the Control of COVID-19. Lancet Glob. Health 2020, 8, e780–e789. [Google Scholar] [CrossRef]
  15. Tremblay, N.; Musa, E.; Cooper, C.; Van den Bergh, R.; Owiti, P.; Baller, A.; Siafa, T.; Woldeyohannes, D.; Shringarpure, K.; Gasasira, A. Infection Prevention and Control in Health Facilities in Post-Ebola Liberia: Don’t Forget the Private Sector! Public Health Action 2017, 7, 94–99. [Google Scholar] [CrossRef] [Green Version]
  16. Opollo, M.S.; Otim, T.C.; Kizito, W.; Thekkur, P.; Kumar, A.M.V.; Kitutu, F.E.; Kisame, R.; Zolfo, M. Infection Prevention and Control at Lira University Hospital, Uganda: More Needs to Be Done. Trop. Med. Infect. Dis. 2021, 6, 69. [Google Scholar] [CrossRef]
  17. Tahir, M.A.; Khan, M.A.; Ikram, A.; Chaudhry, T.H.; Jabeen, A.; Quddous, A.; Haq, I.U. Assessment of Infection Prevention and Control (IPC) Implementation and Strategies Used for IPC Preparedness at Facility Level in Underdeveloped Areas of Pakistan. Infect. Drug Resist. 2023, 16, 1997–2006. [Google Scholar] [CrossRef]
  18. Harun, M.G.D.; Anwar, M.M.U.; Sumon, S.A.; Hassan, M.Z.; Haque, T.; Mah-E-Muneer, S.; Rahman, A.; Abdullah, S.A.H.M.; Islam, M.S.; Styczynski, A.R.; et al. Infection Prevention and Control in Tertiary Care Hospitals of Bangladesh: Results from WHO Infection Prevention and Control Assessment Framework (IPCAF). Antimicrob. Resist. Infect. Control 2022, 11, 125. [Google Scholar] [CrossRef]
  19. Ministry of Health and Sanitation; Government of Sierra Leone Ebola Viral Disease Situation Report. Available online: https://reliefweb.int/sites/reliefweb.int/files/resources/Ebola-Situation-Report_Vol-260.pdf (accessed on 28 January 2022).
  20. Ministry of Health and Sanitation. National Infection Prevention and Control Guidelines; Ministry of Health and Sanitation: Freetown, Sierra Leone, 2015.
  21. Ministry of Health and Sanitation, Government of Sierra Leone. National Strategic Plan for Combating Antimicrobial Resistance; Ministry of Health and Sanitation, Government of Sierra Leone: Freetown, Sierra Leone, 2018.
  22. Derrick Fofanah, B.; Abrahamyan, A.; Maruta, A.; Kallon, C.; Thekkur, P.; Franklyn Kamara, I.; Kuria Njuguna, C.; Sylvester Squire, J.; Sam Kanu, J.; Jawo Bah, A.; et al. Achieving Minimum Standards for Infection Prevention and Control in Sierra Leone: Urgent Need for a Quantum Leap in Progress in the COVID-19 Era! Int. J. Environ. Res. Public Health 2022, 19, 5642. [Google Scholar] [CrossRef]
  23. TDR. SORT IT Operational Research and Training. Available online: https://tdr.who.int/activities/sort-it-operational-research-and-training (accessed on 27 January 2023).
  24. Zachariah, R.; Stewart, A.G.; Chakaya, J.M.; Teck, R.; Khogali, M.A.; Harries, A.D.; Seeley-Musgrave, C.; Samba, T.; Reeder, J.C. The Structured Operational Research and Training Initiative for Strengthening Health Systems to Tackle Antimicrobial Resistance and Improve Public Health in Low-and-Middle Income Countries. Int. J. Environ. Res. Public Health 2022, 19, 4582. [Google Scholar] [CrossRef]
  25. Zachariah, R.; Harries, A.D.; Ishikawa, N.; Rieder, H.L.; Bissell, K.; Laserson, K.; Massaquoi, M.; Van Herp, M.; Reid, T. Operational Research in Low-Income Countries: What, Why, and How? Lancet Infect. Dis. 2009, 9, 711–717. [Google Scholar] [CrossRef] [Green Version]
  26. Harries, A.D.; Kumar, A.M.V.; Satyanarayana, S.; Thekkur, P.; Lin, Y.; Dlodlo, R.A.; Zachariah, R. How Can Operational Research Help to Eliminate Tuberculosis in the Asia Pacific Region? Trop. Med. Infect. Dis. 2019, 4, 47. [Google Scholar] [CrossRef] [Green Version]
  27. Thekkur, P.; Takarinda, K.C.; Timire, C.; Sandy, C.; Apollo, T.; Kumar, A.M.; Satyanarayana, S.; Shewade, H.D.; Khogali, M.; Zachariah, R.; et al. Operational Research to Assess the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Health Facilities in Harare, Zimbabwe. Trop. Med. Infect. Dis. 2021, 6, 94. [Google Scholar] [CrossRef]
  28. Kumar, A.M.; Harries, A.D.; Satyanarayana, S.; Thekkur, P.; Shewade, H.D.; Zachariah, R. What Is Operational Research and How Can National Tuberculosis Programmes in Low- and Middle-Income Countries Use It to End TB? Indian J. Tuberc. 2020, 67, S23–S32. [Google Scholar] [CrossRef]
  29. Pereira, R.C.A.; Moreira, M.Â.L.; Costa, I.P.d.A.; Tenório, F.M.; Barud, N.A.; Fávero, L.P.; Al-Qudah, A.A.; Gomes, C.F.S.; dos Santos, M. Feasibility of a Hospital Information System for a Military Public Organization in the Light of the Multi-Criteria Analysis. Healthcare 2022, 10, 2147. [Google Scholar] [CrossRef]
  30. TDR. Communicating Research Findings with a KISS. Available online: https://tdr.who.int/newsroom/news/item/21-06-2021-communicating-research-findings-with-a-kiss (accessed on 6 June 2023).
  31. Structured Operational Research Training IniTiative Summary Brief: Infection Prevention and Control in Sierra Leone: Need for a Quantum Leap Forwards. Available online: https://tdr.who.int/docs/librariesprovider10/sort-it/2.-bobson_fofanah_ipc.pdf?sfvrsn=e9dadab4_5 (accessed on 27 January 2023).
  32. Institute for Health Metrics and Evaluation Sierra Leone Population and Housing Census 2015 | GHDx. Available online: http://ghdx.healthdata.org/record/sierra-leone-population-and-housing-census-2015 (accessed on 28 January 2022).
  33. Ministry of Health and Sanitation. Sierra Leone Basic Package of Essential Health Services; Ministry of Health and Sanitation: Freetown, Sierra Leone, 2015.
  34. Murray, C.J.; Ikuta, K.S.; Sharara, F.; Swetschinski, L.; Robles Aguilar, G.; Gray, A.; Han, C.; Bisignano, C.; Rao, P.; Wool, E.; et al. Global Burden of Bacterial Antimicrobial Resistance in 2019: A Systematic Analysis. Lancet 2022, 399, 629–655. [Google Scholar] [CrossRef]
  35. von Elm, E.; Altman, D.G.; Egger, M.; Pocock, S.J.; Gøtzsche, P.C.; Vandenbroucke, J.P. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. Lancet 2007, 370, 1453–1457. [Google Scholar] [CrossRef] [Green Version]
  36. Zachariah, R.; Reid, T.; Ford, N.; Van den Bergh, R.; Dahmane, A.; Khogali, M.; Delaunois, P.; Harries, A.D. The 2012 World Health Report “No Health without Research”: The Endpoint Needs to Go beyond Publication Outputs. Trop. Med. Int. Health 2012, 17, 1409–1411. [Google Scholar] [CrossRef]
  37. Zachariah, R.; Reid, T.; Van den Bergh, R.; Dahmane, A.; Kosgei, R.J.; Hinderaker, S.G.; Tayler-Smith, K.; Manzi, M.; Kizito, W.; Khogali, M.; et al. Applying the ICMJE Authorship Criteria to Operational Research in Low-Income Countries: The Need to Engage Programme Managers and Policy Makers. Trop. Med. Int. Health 2013, 18, 1025–1028. [Google Scholar] [CrossRef] [Green Version]
  38. Tartari, E.; Tomczyk, S.; Pires, D.; Zayed, B.; Coutinho Rehse, A.P.; Kariyo, P.; Stempliuk, V.; Zingg, W.; Pittet, D.; Allegranzi, B. Implementation of the Infection Prevention and Control Core Components at the National Level: A Global Situational Analysis. J. Hosp. Infect. 2021, 108, 94–103. [Google Scholar] [CrossRef]
  39. Allen, G.B.; Miller, V.; Nicholas, C.; Hess, S.; Cordes, M.K.; Fortune, J.B.; Blondin, J.; Ashikaga, T.; Ricci, M. A Multitiered Strategy of Simulation Training, Kit Consolidation, and Electronic Documentation Is Associated with a Reduction in Central Line-Associated Bloodstream Infections. Am. J. Infect. Control 2014, 42, 643–648. [Google Scholar] [CrossRef]
  40. Peredo, R.; Sabatier, C.; Villagrá, A.; González, J.; Hernández, C.; Pérez, F.; Suárez, D.; Vallés, J. Reduction in Catheter-Related Bloodstream Infections in Critically Ill Patients through a Multiple System Intervention. Eur. J. Clin. Microbiol. Infect. Dis. 2010, 29, 1173–1177. [Google Scholar] [CrossRef]
  41. Marra, A.R.; Guastelli, L.R.; de Araújo, C.M.P.; dos Santos, J.L.S.; Lamblet, L.C.R.; Silva, M.; de Lima, G.; Cal, R.G.R.; Paes, Â.T.; Neto, M.C.; et al. Positive Deviance: A New Strategy for Improving Hand Hygiene Compliance. Infect. Control Hosp. Epidemiol. 2010, 31, 12–20. [Google Scholar] [CrossRef]
  42. The Fleming Fund Sierra Leone | AMR Action Plan. Available online: https://www.flemingfund.org/countries/sierra-leone/ (accessed on 31 January 2022).
  43. Hirai, M.; Nyamandi, V.; Siachema, C.; Shirihuru, N.; Dhoba, L.; Baggen, A.; Kanyowa, T.; Mwenda, J.; Dodzo, L.; Manangazira, P.; et al. Using the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) in Zimbabwe: A Cross-Sectional Study of Water, Sanitation and Hygiene Services in 50 COVID-19 Isolation Facilities. Int. J. Environ. Res. Public Health 2021, 18, 5641. [Google Scholar] [CrossRef]
  44. Weber, N.; Martinsen, A.L.; Sani, A.; Assigbley, E.K.E.; Azzouz, C.; Hayter, A.; Ayite, K.; Baba, A.A.B.; Davi, K.M.; Gelting, R. Strengthening Healthcare Facilities Through Water, Sanitation, and Hygiene (WASH) Improvements: A Pilot Evaluation of “WASH FIT” in Togo. Health Secur. 2018, 16, S24–S45. [Google Scholar] [CrossRef] [Green Version]
Tropicalmed 08 00376 g001 550
Figure 1. Map of Sierra Leone showing the 16 districts and the boundaries with Guinea and Liberia.
Figure 1. Map of Sierra Leone showing the 16 districts and the boundaries with Guinea and Liberia.
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Tropicalmed 08 00376 g002 550
Figure 2. IPC percentage scores for National IPC unit assessment in June 2021 [22] and April 2023 in Sierra Leone. Note: the radar chart shows IPC components emanating from the center (0%) connected by lines expanding outwards (100%). The 2023 scores (green line) lie outside the 2021 scores (red line), indicating an overall improvement in all the components of IPC. The maximum score for each component is 100, and percentages are calculated relative to the maximum score for the component. Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection.
Figure 2. IPC percentage scores for National IPC unit assessment in June 2021 [22] and April 2023 in Sierra Leone. Note: the radar chart shows IPC components emanating from the center (0%) connected by lines expanding outwards (100%). The 2023 scores (green line) lie outside the 2021 scores (red line), indicating an overall improvement in all the components of IPC. The maximum score for each component is 100, and percentages are calculated relative to the maximum score for the component. Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection.
Tropicalmed 08 00376 g002
Tropicalmed 08 00376 g003 550
Figure 3. Median IPC scores in the twelve district-level secondary public hospitals during June 2021 [22] and April 2023 in Sierra Leone. Note: the radar chart shows IPC components emanating from the center (0%) connected by lines expanding outwards (100%). The 2023 scores (green line) lie outside the 2021 scores (red line) in six out of eight core components, indicating improvement in median IPC scores between the two assessments. Percentages are calculated relative to the maximum score for the component for each hospital. Later, the median percentage score for the twelve district hospitals was obtained. Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection.
Figure 3. Median IPC scores in the twelve district-level secondary public hospitals during June 2021 [22] and April 2023 in Sierra Leone. Note: the radar chart shows IPC components emanating from the center (0%) connected by lines expanding outwards (100%). The 2023 scores (green line) lie outside the 2021 scores (red line) in six out of eight core components, indicating improvement in median IPC scores between the two assessments. Percentages are calculated relative to the maximum score for the component for each hospital. Later, the median percentage score for the twelve district hospitals was obtained. Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection.
Tropicalmed 08 00376 g003
Table
Table 1. Dissemination of findings and recommendations for improving IPC performance from the operational research study conducted by Fofanah et al. [22] in 2021 (Censored on 30 April 2023).
Table 1. Dissemination of findings and recommendations for improving IPC performance from the operational research study conducted by Fofanah et al. [22] in 2021 (Censored on 30 April 2023).
Mode of Delivery *To Whom (Numbers $)WhereWhen
Three-min Lightning PowerPoint presentation National IPC program (7)National IPC unitMarch 2022
MoHS stakeholders (32)National SORT IT module 4 April 2022
MoHS stakeholders (16)MoHS stakeholders meeting July 2022
Published article [22]Global and national IPC professional groupsSocial media platforms—Whatsapp, Facebook, and LinkedInMay 2022
Hospital IPC focal points (16) and WHO AFRO IPC Team (2)WhatsApp, email exchange, and during a consultative meeting to develop the national IPC action plan February 2023
Ten-min technical PowerPoint presentationHospital IPC focal point (12)IPC training June 2022
Hospital managers and IPC focal points (24)National SORT IT dissemination meetingNovember 2022
Plain language handouts [31]Global and national IPC professional groupsSocial media platforms—Whatsapp, Facebook, and LinkedIn April 2022
Researchers, AMR advocates, and communityWHO Sierra Leone websiteMarch 2023
* Dissemination materials included a published article, a plain language handout, a three-minute Lightning PowerPoint presentation, a ten-minute technical presentation, and any other material; $ The number of individuals attending the meeting. Abbreviations: SORT IT—Structured Operational Research Training IniTiative; IPC—infection prevention and control; MoHS—Ministry of Health and Sanitation; WHO AFRO: World Health Organization, Africa Region.
Table
Table 2. List of recommendations from the operational research study conducted in 2021 for improving IPC performance at national and facility levels and the status of these actions as of April 2023.
Table 2. List of recommendations from the operational research study conducted in 2021 for improving IPC performance at national and facility levels and the status of these actions as of April 2023.
RecommendationAction Status *Details of Action (When)
Advocate for dedicated budget for IPC activities Fully implementedActivation of national IPC advisory committee headed by the deputy chief medical officer (public health), which advocated for a dedicated budget for an IPC program in October 2022.Funding secured for the national IPC unit to develop the national IPC action plan in March 2023.
Distribution of national IPC guidelines to health facilitiesFully implementedThe WHO printed 1200 copies of the updated national IPC guidelines, which were shared with all the health facilities in September 2022.
Dedicated time allocated to IPC staff at health facilities to adapt and implement IPC guidelinesFully implementedThe WHO and National IPC unit shared ‘terms of reference’ for full-time IPC focal points in August 2022.
Clear goals, targets, and activities introduced in the monitoring framework for health facilitiesFully implementedNational IPC unit and WHO disseminated the updated monitoring frameworks in July 2022.IPC focal points of hospitals were trained on the monitoring frameworks in August 2022.
Increase the healthcare workforceNot implemented
Safe and sufficient water suppliesNot implementedThis recommendation was not directly implemented. However, in December 2022, the WASH manager (co-investigator in the previous study), with support from the WHO and national WASH and IPC unit, implemented the WASH-FIT in-depth assessment to investigate and quantify the needs for effective WASH implementation in hospitals. Based on WASH-FIT assessment, the specific actions at facility level were recommended.
Adequate numbers of functional toilet facilities
Facilities for sterilization and disinfection
Waste disposal
Supply of consumables such as soap, alcohol-based hand rub, and personal protective equipmentPartially implementedMOHS has continued its efforts to increase the local production and uninterrupted supply of soaps and alcohol-based hand rub to health facilities.
Formulating HAI surveillance strategy Partially implementedThe WHO acquired funds from US CDC to develop the first HAI surveillance strategy for Sierra Leone, which is ongoing.
Access to microbiological laboratoriesNot implemented
* Fully implemented—actions taken and no further work required in line with the recommendation; partially implemented—some actions taken, but there is need for further work in line with the recommendation; not implemented—no action taken. Abbreviations: IPC—infection prevention and control; WHO—World Health Organization; WASH-FIT—Water and Sanitation for Health Facility Improvement Tool; US CDC—United States Center for Disease Control and Prevention.
Table
Table 3. Change in the IPC performance score at the national IPC unit between June 2021 [22] and April 2023 in Sierra Leone.
Table 3. Change in the IPC performance score at the national IPC unit between June 2021 [22] and April 2023 in Sierra Leone.
IPC Components a 20212023% Change d
Grade b % Score cGrade b% Score c
IPC program Intermediate61Advanced8827
IPC guidelinesAdvanced83Advanced929
IPC education and trainingIntermediate67Intermediate714
HAI surveillanceBasic27Intermediate5326
Multimodal strategies Basic40Advanced8343
Monitoring/audits of IPC practices and feedbackIntermediate69Advanced8314
Overall score (%)Intermediate58Advanced7820
Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection. a Maximum score for each component is 100, and for the cumulative, it is 600. b Grade: IPC performance in each component was graded based on the obtained percentage: (i) inadequate (0–25%), (ii) basic (25.1–50%), (iii) intermediate (50.1–75%), and (iv) advanced (75.1–100%) level. c Percentages are calculated relative to the maximum score for the component. d Percentage in 2023—percentage in 2021.
Table
Table 4. The percentage scores of the sub-components of IPCAT at the national IPC unit in Sierra Leone during June 2021 [22] and April 2023.
Table 4. The percentage scores of the sub-components of IPCAT at the national IPC unit in Sierra Leone during June 2021 [22] and April 2023.
IPC Core ComponentsSub-Components2021 *2023 *
i. IPC ProgramOrganization and leadership of the program63%75%
Defined scope of responsibilities71%100%
Linkages with other programs and professional organizations50%88%
ii. IPC GuidelineDevelopment, dissemination, and implementation of national technical guidelines100%100%
Education and training of relevant healthcare workers on IPC guidelines67%67%
Monitoring of guideline adherence100%100%
iii. IPC Education and TrainingSupporting and facilitating IPC education and training at the facility level100%100%
National curricula and IPC training and education100%100%
Monitoring of training and education0%0%
Implementation of training and education67%83%
iv. HAI SurveillanceCoordination of surveillance at the national level43%43%
National objectives of surveillance20%80%
Prioritized HAIs for surveillance17%50%
Methods of surveillance67%100%
v. Multimodal StrategiesNational and sub-national coordination in support of local implementation of IPC improvement interventions100%100%
National and sub-national facilitation in support of local implementation of IPC improvement interventions60%80%
Program and accreditation linkages0%50%
vi. Monitoring/Audits of IPC Practices and FeedbackMonitoring/audit and feedback framework for IPC50%67%
Monitoring/audit indicators75%100%
Monitoring/audit and feedback process and reporting83%83%
Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection. * The % score for each component in the facility was calculated using IPCAF scores. The median of this score for the national IPC program is presented. Tropicalmed 08 00376 i001 Inadequate; Tropicalmed 08 00376 i002 Basic; Tropicalmed 08 00376 i003 Intermediate; Tropicalmed 08 00376 i004 Advanced.
Table
Table 5. Change in the median IPC percentage score in the twelve district-level secondary public hospitals between June 2021 [22] and April 2023 in Sierra Leone.
Table 5. Change in the median IPC percentage score in the twelve district-level secondary public hospitals between June 2021 [22] and April 2023 in Sierra Leone.
IPC Components a20212023% Change d
Grade b Median % Score cGrade b Median % Score c
IPC program Basic43Intermediate6522
IPC guidelinesIntermediate68Advanced7911
IPC education and trainingAdvanced80Advanced78-2
HAI surveillanceBasic45Basic483
Multimodal strategies Basic45Basic450
Monitoring/audits of IPC practices and feedbackIntermediate53Intermediate585
Workload, staffing, and bed occupancyBasic30Basic4515
Built environment, materials, and equipment for IPCIntermediate51Intermediate587
Overall score (%)Basic50Intermediate599
Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection. a The maximum score for each component is 100, and for the overall score, it is 800. b Grade: IPC performance in each component was graded based on the obtained percentage: (i) inadequate (0–25%), (ii) basic (25.1–50%), (iii) intermediate (50.1–75%), and (iv) advanced (75.1–100%) level. c Percentages are calculated relative to the maximum score for the component for each hospital. Later, the median percentage score for the twelve district hospitals was obtained. d Percentage in 2023—percentage in 2021.
Table
Table 6. The median percentage scores of the sub-components of IPCAF in the twelve district-level secondary public hospitals in Sierra Leone during June 2021 [22] and April 2023.
Table 6. The median percentage scores of the sub-components of IPCAF in the twelve district-level secondary public hospitals in Sierra Leone during June 2021 [22] and April 2023.
IPC Core ComponentsSub-ComponentsMedian Percentage Score *
20212023
i. IPC ProgramIPC program at facility50%75%
Functional IPC committee100%100%
Senior facility leadership commitment and support, with a budget allocated specifically for the IPC activities0%0%
ii. IPC GuidelineExpertise in IPC to develop or adapt guidelines0%100%
Availability of IPC guidelines57%93%
Consistent with national/international guidelines100%100%
iii. IPC Education and TrainingAvailability of personnel with the IPC expertise to lead IPC training100%100%
Frequency of IPC training67%33%
IPC training integrated in the clinical practice and training of other specialties0%50%
iv. HAI SurveillanceSurveillance as a defined component of IPC program100%100%
HAI surveillance performed14%29%
Methods of surveillance40%40%
v. Multimodal StrategiesUse of multimodal strategies to implement IPC interventions100%100%
Multimodal strategy elements implemented in an integrated way40%40%
A multidisciplinary team for implementing IPC multimodal strategies0%0%
vi. Monitoring/Audits of IPC Practices and FeedbackA well-defined monitoring plan, with clear goals, targets and activities0%100%
Monitoring of IPC processes and indicators44%44%
Feedback of auditing reports on the state of the IPC activities/performance60%80%
vii. Workload, Staffing, and Bed OccupancyAssessment of hospital staffing needs0%0%
Hospital bed occupancy43%54%
viii. Built Environment, Materials, and Equipment for IPC at the Facility LevelWater availability and access42%50%
Functioning hand hygiene and sanitation facilities67%58%
Patient placement and personal protective equipment (PPE) in health care settings67%67%
Medical waste management, and sewage50%53%
Decontamination and sterilization50%67%
Abbreviation: IPC = infection prevention and control; HAI = healthcare associated infection. * Percentages are calculated relative to the maximum score for the sub-component for each hospital. Later, the median percentage score for the twelve district hospitals was obtained. Tropicalmed 08 00376 i001 Inadequate; Tropicalmed 08 00376 i002 Basic; Tropicalmed 08 00376 i003 Intermediate; Tropicalmed 08 00376 i004 Adequate.
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Margao, S.; Fofanah, B.D.; Thekkur, P.; Kallon, C.; Ngauja, R.E.; Kamara, I.F.; Kamara, R.Z.; Tengbe, S.M.; Moiwo, M.; Musoke, R.; et al. Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study. Trop. Med. Infect. Dis. 2023, 8, 376. https://doi.org/10.3390/tropicalmed8070376

AMA Style

Margao S, Fofanah BD, Thekkur P, Kallon C, Ngauja RE, Kamara IF, Kamara RZ, Tengbe SM, Moiwo M, Musoke R, et al. Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study. Tropical Medicine and Infectious Disease. 2023; 8(7):376. https://doi.org/10.3390/tropicalmed8070376

Chicago/Turabian Style

Margao, Senesie, Bobson Derrick Fofanah, Pruthu Thekkur, Christiana Kallon, Ramatu Elizabeth Ngauja, Ibrahim Franklyn Kamara, Rugiatu Zainab Kamara, Sia Morenike Tengbe, Matilda Moiwo, Robert Musoke, and et al. 2023. "Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study" Tropical Medicine and Infectious Disease 8, no. 7: 376. https://doi.org/10.3390/tropicalmed8070376

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