Observations of infection prevention and control practices in primary health care, Kenya.

Introduction The prevention and control of infections is critical for a well-functioning health system. However, worldwide an estimated 21 million cases of hepatitis B virus infection and 200 000 cases of human immunodeficiency virus (HIV) infection result from unsafe injection practices each year. (1) In the United States of America, an estimated 40 000 to 80 000 deaths are due to nosocomial infections annually, which may cost as much as 4.5 billion United States dollars (US$). (2) Moreover, the rapid spread of multidrug-resistant organisms and outbreaks of Ebola virus disease, yellow fever and Zika virus infections has further increased the human and financial cost. Fortunately, proven and cost-effective, infection prevention and control practices can reduce the risk. (3-6) However, ensuring compliance with these practices depends on understanding the extent of the problem and there has been little research on infection prevention and control practices in low- and middle-income countries, particularly in primary health care. (7-10) Previous studies have several limitations. First, many involved small samples--one review found that only 10 of 41 studies on hand hygiene interventions were conducted in more than one hospital. (10,11) Second, they were often based on self-reported data from health-care providers, which tend to overestimate compliance. (12) Third, they frequently focused on single domains, such as injection safety, rather than on the range of possible exposures encountered by patients during outpatient visits. (1,13-17) Consequently, given that infections are transmitted by multiple pathways, these data are of limited use for modelling the spread of different pathogens. (10,18) To address these limitations, we designed a novel observational tool. We based the tool on existing World Health Organization (WHO) tools that can track patients throughout the course of an outpatient visit, which may include examinations, laboratory tests and injections. Our tool can be used to assess compliance with infection prevention and control practices throughout primary health care and can help identify associations between compliance and individual characteristics of health-care facilities and workers. We used the observational tool to investigate compliance with infection prevention and control practices in a pilot sample of 23 health-care facilities in Nairobi, Kenya and, subsequently, in 935 facilities in three Kenyan counties. Methods The design of the observational tool took into account the possibility that an outpatient may experience a violation of infection prevention and control practices in several different locations: the consulting room, the laboratory and the injection room. In this study, trained assessors spent three consecutive hours in each of 958 health-care facilities. The observational tool was used to record all interactions between patients and at least one health-care worker at each location. In collaboration with the Kenyan Ministry of Health and local experts, we identified three key procedures for observation: (i) physical examination; (ii) injection; and (iii) blood sampling. Five infection prevention and control domains were observed across these procedures: (i) hand hygiene; (ii) use of protective gloves; (iii) injection and blood sampling safety; (iv) disinfection of reusable equipment; and (v) waste segregation. These domains have been identified as critical for outpatient safety by WHO, (19) the United States Centers for Disease Control and Prevention, (20) the WHO Regional Committee for Africa (21) and the Kenyan Ministry of Health. (22) In accordance with the broad consensus that safety of care is a characteristic of the system and not just of individual health-care providers, (23) for each of these domains, we assessed: (i) compliance with infection prevention and control practices by health-care workers; (ii) knowledge of these practices among health-care workers; and (iii) the availability of the equipment and supplies needed for implementing these practices. …