WHO REGIONAL OFFICE FOR AFRICA COVID-19 RAPID POLICY BRIEF SERIES SERIES 6: COVID-19 PREVENTION

(1)

WHO REGIONAL OFFICE FOR AFRICA COVID-19 RAPID POLICY BRIEF SERIES SERIES 6: COVID-19 PREVENTION

NUMBER 006-02: Effectiveness of different hygiene practices in nosocomial transmission of COVID-19

Based on information as at 01 December 2020

(2)

Rapid Policy Brief Number: 006-02 — Effectiveness of different hygiene practices in interrupting nosocomial transmission of COVID-19

WHO/AF/ARD/DAK/01/2021

© WHO Regional Office for Africa 2021

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.

Suggested citation. Rapid Policy Brief Number: 006-02 — Effectiveness of different hygiene practices in interrupting nosocomial transmission of COVID-19. Brazzaville: WHO Regional Office for Africa; 2020. Licence: CC BY-NC-SA 3.0 IGO.

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders . To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulti ng from infringement of any third-party-owned component in the work rests solely with the user.

General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

Designed and printed in the WHO Regional Office for Africa, Brazzaville, Congo

(3)

RAPID POLICY BRIEF 1

NUMBER: 006-02

RESEARCH DOMAIN: COVID-19 PREVENTION

TITLE: Effectiveness of different hygiene practices in interrupting household and community transmission of COVID-19 RAPID POLICY BRIEF NUMBER: 006-02

1 RAPID POLICY BRIEF NUMBER: 006-02

2 RESEARCH DOMAIN: COVID-19 PREVENTION

3 TITLE: Effectiveness of different hygiene practices in interrupting nosocomial transmission of COVID -19.

4 DATE OF PUBLICATION: 2 5 BACKGROUND

Coronavirus disease 2019 (COVID-19) continues to spread globally, overtaking health systems' capacity and resources worldwide. Due to its rapid spread, some hot spots of transmission have been identified, one of which is the hospital [1]. This has contributed to the disease's significant spread, resulting in the healthcare setting being under enormous pressure to prevent and control nosocomial infection [2].

Health care workers (HCW) are at high risk for contracting coronavirus disease 2019 (COVID-19) as it is the most infectious disease, and countries, including the developed ones who have advanced health care facilities, are facing it as their biggest challenge [3]. Most patient-centered care involves close doctor-patient contact, which places health care workers at risk of COVID-19 infection.

While some clinical specialties such as ophthalmologists and dentists and ear, nose, and throat specialists have recorded infection during routine visits [4, 5], it is essential to look at other specialties to stem transmission rates among health care workers and patients.

6 SEARCH STRATEGY / RESEARCH METHODS

A systematic search of the following databases was conducted to obtain peer review literature published between December 01, 2019, and December 01, 2020, PUBMED, WHO COVID-19, and Index Medicus. Using a combination of search terms - (COVID-19 or SARS-CoV-2) and (hygiene practices). Also, we searched the reference list of potentially eligible studies and related reviews obtained from the three databases. We included studies of any design and scoped Africa-related evidence published in English, which reported hygiene practices and clinical guidelines in any medical setting, clinical practices, or hospital management.

The search yielded 404 studies in PUBMED, 193 in the WHO COVID-19 databases, and nine from Index Medicus. After screening and removal of duplicates, 19 studies met the inclusion criteria.

Due to the results' heterogeneity, we present a descriptive analysis of the findings from different studies.

7 SUMMARY OF GLOBALLY PUBLISHED LITERATURE RELATED TO THE SUBJECT

Two studies were identified to contain empirical evidence, four as narrative review, and 14 were focused on clinical guidelines across the various clinical practice fields. We summarize th ese below in two categories.

The first category of studies contains the literature with empirical evidence and narrative review, while the second is a summary of all the guidelines in various clinical settings.

This study has shown that in a surgical setting that the risk of contracting the disease from the hospital with standard precaution in place and with the surgical mask in use is very low, which can also be extrapolated to nonsurgical areas with the adoption of universal masking protocols in most institutions which include and not limited to hospital setting [6]. Besides, a review of the

(4)

RAPID POLICY BRIEF NUMBER: 006-02

management recommendation for surgical activity further proposed the precautions should be classified into the following categories [7]: 1. General aspects involve the use of personal protective equipment (PPE) such as surgical caps, protective masks (N95 or FFP2/FFP3), disposable overcoats, gloves, goggles or transparent barriers, and powered air-purifying respirators (PAPR).

The latter is recommended during aerosol-generating procedures (AGPs), such as intubation, extubation, or respiratory tract operations. These should be used for all surgical procedures regardless of the patient's COVID status.

2. Preoperative phase with recommendations about activating diverse pathways to separate suspect or confirmed COVID-19 patients from non-COVID-19 patients. Also, non-urgent outpatient clinical appointments should be canceled except when the doctor's physical examination is required; telemedicine, telephone clinics, and other remote patient management forms are preferred. 3. In the operative phase, it is mandatory to manage COVID-19 positive patients separately, establishing in-house protocol and well coded intra-hospital pathways. This implies that there must be dedicated operating rooms (ORs) for COVID-19 positive or suspect patients.

Healthcare staff in operating theatre must always use PPE regardless of the patient COVID-19 status. 4. The postoperative phase, with the recommendation that this phase is carried out carefully, is not underestimated. PPE used by health care personnel should be disposed off correctly, and the environment and equipment used during the operation, disinfected meticulously [7].

In a mental health center, a pre and post-intervention theoretical knowledge of nosocomial infection control, compliance and accuracy of hand hygiene, use of personal protective equipment (PPE), disinfection, and sterilization were compared and evaluated. An improvement in the implementation of the prevention and control measures provided strong evidence for the effectiveness of COVID-19 preventive strategies, which should be integrated into mental health centers (and, by extension, hospital infection control) during a significant epidemic [8].

Furthermore, because SARS-CoV-2 can be transmitted from patients aerosols, this places anesthesiologists at high risk for infection [9, 10]. A narrative review of the guideline and recommendation for the use of the anesthesia machine and the OR revealed that the environmental contamination is kept to a minimum as much as possible. In contrast, the surface of the anesthesia machine should be disinfected on a case-by-case basis [11]. The use of sodium hypochlorite or alcohol with 70-90% should be used for the surface disinfection. Also, disinf ection substances, including some surface surfactants and hypochlorous acid solutions, are effective at removing SARS-CoV-2 from surfaces. Emphasis on hand hygiene (HH) to be done at the appropriate time, this should be done at five moments (based on WHO guideline) – before putting on PPE and after removing it, when changing gloves, after any contact with patients, their waste, or the environment in the patients' immediate surroundings and after contact with any respiratory secretions. This HH should be done regardless of patient COVID-19 status.

In the practice of modern dentistry, COVID-19 is a new challenge. Therefore preventive measures against it are the use of telephone triaging, clinic questionnaires, body temperature measurement, usage of specific PPEs, oral rinses with 1% hydrogen peroxide, high-speed instruments equipped with an anti-retraction system [12]. In addition, surface disinfection with ethanol between 62%

and 71% and sodium hypochlorite between 0.1% and 0.5% is considered best among surf ace disinfectants, and a large volume of cannulas for aspiration proposed in another review [12]. A further narrative review of preventive measures for health care workers (HCW) revealed thorough

(5)

NUMBER: 006-02

hand hygiene, filtering facepiece (FFP) 2, high-quality standard surgical is critical in infection control measures [13].

The second category of studies focused majorly on guidelines, infection preventive precautions, safety protocols, and recommendations. The guidance given to orthopedic outpatient emphasizes hygiene at all levels for both patients and orthopedic surgeons [14]. Telephone triaging was positively encouraged, duties of help desk and OPD hall supervisor were given. Patients and health staff do’s and don’ts were proposed as well as optimum and saf e utilization of human and material resources. Re-emphasized in this guideline is the need to set up a contact, containment, cough, aarogya setu app, temperature, travel, and trouble (CCCATTT). Urologists' recommendation is full PPE, including at least FFP-2 masks and safety goggles should be in use, scrupulous hygiene and disinfection of surfaces must be carried out [15]. Pneumoperitoneum should be evacuated with suction devices to prevent aerosolization during laparoscopic interventions, while non-emergency urological interventions should be postponed until negative COVID-19 tests become available. For routine anesthesia care, the guidance of universal masking (respirator masks for th e surgical team during anesthetic care, ordinary surgical masks in the public area of the health care facility and OR complex), hand gel close to a health care worker or personal, wearable gel dispenser, eye protection at all times during anesthetic care, avoiding entering anesthesia cart without HH first, double glove for airway management, enclosing cell phones and other personal communication devices in a plastic bag [16]. Similar to the review of management recommendations for surgical activity [7], the guideline recommendation optimizes the healthcare services provision (which involves the use of PPE and infection control measures) and should reduce the risk of occupational transmission to other patients and health care professionals [17]. Like every other clinical practice already highlighted the speech-language pathology, chest radiographs and CTs, head and neck and otolaryngology, ophthalmic and plastic reconstructive surgery, oral health, dentistry, and periodontology have overlapping guidance which requires PPE, PAPR, N95 mask, goggles, blood repelling gloves, and gown are required [3, 18-25]. More so, comprehensive training sessions and N95 fit tests should be undertaken by all health care staff before working in areas requiring PPE was strongly emphasized in all the guidelines reviewed [3, 18-25].

8 SUMMARY OF AFRICA-SPECIFIC LITERATURE ON THE SUBJECT No study was specific to Africa.

9 POLICY FINDINGS

Preventing measures from the transmission is the best practice to flatten the pandemic curve and contain the viral spread. Some effective measures are

 Active disease surveillance

 Constant, consistent, and correct use of PPE and HH

 Universal masking should be adopted in all clinical settings.

An urgent and necessary rearrangement of the standard health care setting to maximize patient and health care providers' safety is highly recommended.

Current evidence of deferring all elective activity and assistance provision for only acute and chronic sight or life-threatening conditions should be adopted.

Further clinical and surgical activity should be reorganized into varying levels of dedicated precautions based on the severity of conditions and risk assessments.

(6)

10 ONGOING RESEARCH IN THE AFRICAN REGION None was identified

11 AFRO RECOMMENDATIONS FOR FURTHER RESEARCH

There is huge evidence paucity in the region which includes but not limited to

 Researchers are encouraged to scientifically explore the effectiveness of these guidelines and protocols in the African setting, as the limited evidence available may not be generalizable. For instance, an adapted acute stroke unit (ASU) pathway was designed by Silva et al. to be simple, requiring little training and cover critical elements of ASU care and can be adopted by other hospitals and centers facing challenges of maintaining ASU care during the COVID-19 crisis the generalizability of this study in a setting in Africa may require a varying pathway [26].

 Development of recommendation and safety precautions contextualized to the African region, which can be further adapted by countries, should be highly considered.

 Research focusing on the various guideline and safety protocols in the African context is greatly encouraged.

(7)

NUMBER: 006-02

12 REFERENCES

1. Cascella, M., et al., Features, evaluation and treatment coronavirus (COVID-19), in Statpearls [internet]. 2020, StatPearls Publishing.

2. Control, 1. Wang, D., et al., Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama, 2020. 323(11): p. 1061-1069.

2. Wu, A., et al., Novel coronavirus (2019-nCov) pneumonia in medical institutions: problems in prevention and control. Chin J Infect Control, 2020. 19: p. 1-6.

3. Lam, D.S.C., et al., COVID-19: special precautions in ophthalmic practice and FAQs on personal protection and mask selection. Asia-Pacific Journal of Ophthalmology (Philadelphia, Pa.), 2020.

4. Xia, J., et al., Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS‐

CoV‐2 infection. Journal of medical virology, 2020. 92(6): p. 589-594.

5. Peng, X., et al., Transmission routes of 2019-nCoV and controls in dental practice. International Journal of Oral Science, 2020. 12(1): p. 1-6.

6. Parkulo, M.A., et al. Risk of SARS-CoV-2 transmission among coworkers in a surgical environment.

in Mayo Clinic Proceedings. 2020. Elsevier.

7. Bresadola, V., et al., General surgery and COVID-19: review of practical recommendations in the first pandemic phase. Surgery today, 2020: p. 1-9.

8. Yang, M., et al., Prevention and control of COVID-19 infection in a Chinese mental health center.

Frontiers in medicine, 2020. 7.

9. Guo, Z., Z. Wang, and S. Zhang, Aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards, wuhan. 2020, China.

10. Dexter, F., et al., Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic. Journal of Clinical Anesthesia, 2020: p. 109854.

11. Obara, S., Anesthesiologist behavior and anesthesia machine use in the operating room during the COVID-19 pandemic: awareness and changes to cope with the risk of infection transmission.

Journal of anesthesia, 2020: p. 1-5.

12. Villani, F.A., et al., COVID-19 and dentistry: prevention in dental practice, a literature review.

International journal of environmental research and public health, 2020. 17(12): p. 4609.

13. Sommerstein, R., et al., Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19. Antimicrobial Resistance & Infection Control, 2020. 9(1): p. 1-8.

14. Lal, H., et al., Out Patient Department practices in orthopaedics amidst COVID-19: The evolving model. Journal of Clinical Orthopaedics and Trauma, 2020.

15. Kunz, Y., W. Horninger, and G.M. Pinggera, Are urologists in trouble with SARS‐CoV‐2? Reflections and recommendations for specific interventions. Bju International, 2020.

16. Bowdle, A., et al., Infection prevention precautions for routine anesthesia care during the SARS- CoV-2 pandemic. Anesthesia & Analgesia, 2020. 131(5): p. 1342-1354.

17. Awad, M.E., et al., Perioperative Considerations in Urgent Surgical Care of Suspected and Confirmed COVID-19 Orthopaedic Patients: Operating Room Protocols and Recommendations in the Current COVID-19 Pandemic. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 2020. 28(11): p. 451-463.

18. Zaga, C.J., et al., Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective. American Journal of Speech-Language Pathology, 2020: p. 1-15.

19. Chia, A.Q.X., et al., Chest radiographs and CTs in the era of COVID-19: indications, operational safety considerations and alternative imaging practices. Academic Radiology, 2020. 27(9): p.

1193-1203.

(8)

20. Boccalatte, L., et al., Brief guideline for the prevention of COVID-19 infection in head and neck and otolaryngology surgeons. American Journal of Otolaryngology, 2020: p. 102484.

21. Nguyen, A.X., K.A. Gervasio, and A.Y. Wu, COVID-19 recommendations from ophthalmic and plastic reconstructive surgery societies worldwide. Ophthalmic plastic and reconstructive surgery, 2020. 36(4): p. 334.

22. Romano, M.R., et al., Facing COVID-19 in Ophthalmology department. Current Eye Research, 2020. 45(6): p. 653-658.

23. Ch, T., et al., Changing Trends in Dentistry: Corona Effect. Journal of Advanced Medical and Dental Sciences Research, 2020. 8(4): p. 70-72.

24. Diegritz, C., et al., A detailed report on the measures taken in the Department of Conservative Dentistry and Periodontology in Munich at the beginning of the COVID-19 outbreak. Clinical oral investigations, 2020. 24(8): p. 2931-2941.

25. Zachary, B.D. and J.A. Weintraub, Oral Health and COVID-19: Increasing the Need for Prevention and Access. Preventing Chronic Disease, 2020. 17.

26. De Silva, D.A., et al., A protocol for acute stroke unit care during the COVID-19 pandemic: Acute stroke unit care during COVID-19. Journal of Stroke and Cerebrovascular Diseases, 2020: p.

105009.

BRIEF PRODUCED BY: Information Management Cell, of the WHO Regional Office IMST and the Cochrane Africa Network