Infection Prevention and Control for COVID-19 response in the Rohingya refugee camps: an Intra-Action Review

doi:10.21203/rs.3.rs-1947709/v1

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Research Article

Infection Prevention and Control for COVID-19 response in the Rohingya refugee camps: an Intra-Action Review

https://doi.org/10.21203/rs.3.rs-1947709/v1

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Journal Publication

published 06 Jun, 2023

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Introduction: Infection Prevention and Control (IPC) is key in the control of COVID-19 pandemic and one of the pillars considered in the WHO COVID-19 Strategic Preparedness and Response Plan 2020. We conducted an Intra-Action Review (IAR) of IPC response efforts to COVID-19 pandemic in Rohingya refugee camps in Cox’s Bazar, Bangladesh to identify best practices, challenges, and recommendations for improvement of the current and future responses.

Methods: Two meetings were conducted with a total of 54 participants purposively selected from different organizations and agencies that had been involved in frontline implementation of IPC in Cox’s Bazar district. We used the IPC trigger questions from the WHO country COVID-19 IAR: trigger question database to guide the discussions. Meetings notes and transcripts were analysed manually using content analysis and results presented in text and quotes.

Results: Best practices included: assessments, response plan, working group, trainings, early case identification and isolation, hand hygiene in HFs, monitoring and feedback, general masking in HFs, supportive supervision, design, infrastructure and environmental controls in Severe Acute Respiratory Infection Isolation and Treatment Centres (SARI ITCs) and HFs and waste management. Challenges included: frequent breakdown of incinerators, limited PPE supply, inconsistent adherence to IPC, lack of working uniforms and lack of culture- and gender adapted work uniforms and Personal Protective Equipment (PPE). Recommendations were: institutionalization of IPC, establishment of IPC monitoring mechanisms in all HCFs, strengthening IPC education and training and public health and social measures in communities.

Conclusion: IPC monitoring and continuous training provides critical support in promoting consistent and adaptive IPC implementation. Response to pandemic crisis combined with concurrent emergencies, like a protracted displacement with many, diverse actors, can only be successful with highly coordinated planning, leadership, resource mobilization and close supervision.

Infection Prevention and Control

COVID-19

Rohingya refugees

Bangladesh

intra-action review

The World Health Organization (WHO) declared COVID-19 a pandemic on the 11 March 2020 and called upon countries to scale up their COVID-19 response(1). On 8 March 2020, Bangladesh reported its first case of COVID-19 (2) , while Cox’s Bazar district reported the first case on the 15 April 2020. On 15 May 2020, the first case of COVID-19 was reported in the Rohingya refugee camps. As of 02 February 2021, when this Intra-Action Review (IAR) was completed, Cox’s bazar district had reported 5505 confirmed cases, and 73 deaths, while specifically for Rohingya, 381 confirmed cases and 10 deaths had been reported since the pandemic started (3). From June 2020 until 01 Feb 2021, a total of 166 health worker (HW) infections had been reported in the district including doctors, nurses, midwives, medical assistants, lab staff, Pharmacists, cleaners, guards, and volunteers.

Cox’s Bazar district in Bangladesh is located in the Southern region with an estimated population of 2.29 million people (4) , and 281 Health Facilities (HFs). In addition to the host population, the district has the world’s largest refugee camps with approximately 907,766 Rohingya refugees (5) served by 157 camp-level HFs (90 health posts, 41 Primary Healthcare centres, 23 special facilities and 03 field hospitals) run by approximately 80 health partners (6). In response to the COVID-19 pandemic, health partners established Severe Acute Respiratory Infection Isolation and Treatment Centre (SARI ITCs) and by Feb 2021 there were 13 SARI ITCs exclusively handling COVID-19 patients within the Rohingya camps and nearby host community (6). The IAR was conducted to cover all IPC response activities for both the host community and Rohingya refugee camps.

The fourth Emergency Committee Meeting of International Health Regulation (IHR) in July 2020 called upon countries to review their response to the COVID-19 pandemic for improvement (7). Following that meeting, WHO implored countries to conduct COVID-19 IAR to help identify the strengths, gaps, and ways forward to improve the response, and provided concept notes (8) and detailed guidance to countries (9).

Infection Prevention and Control (IPC) has been key in the control of the COVID-19 pandemic and is one of the pillars of the WHO COVID-19 strategic preparedness and response plan 2020 (10). The office of the Civil Surgeon, humanitarian partners organized under the Health Sector, and the WHO emergency sub office in Cox’s Bazar jointly conducted a COVID-19 IPC IAR. The review had four main objectives; firstly, to provide an opportunity for health partners to share IPC experiences and analyze the ongoing COVID-19 response in Cox’s Bazar by identifying challenges, best practices and recommendations for improvement. Secondly, to compile lessons learned by various stakeholders in IPC during the response to improve the current response by sustaining successful best practices and preventing recurrent errors. Thirdly, to document and apply the lessons learned in IPC from the response efforts to enable health system strengthening. Fourthly, to provide a basis to validate and update the COVID-19 IPC response plan for Cox’s Bazar and other response and strategic plans (e.g. Health Sector) accordingly. We believe that we have had a unique opportunity of responding to the COVID-19 crisis within Rohingya refugee crisis and our learning will not only benefit the ongoing response but also future responses in similar humanitarian settings. This paper therefore shares the learnings from the IAR of the COVID-19 IPC pillar preparedness and response in Rohingya refugee camps in Cox’s Bazar in form of best practices, challenges and recommendations.

IAR design and area

This was an IAR of IPC interventions in Cox’s Bazar district in Bangladesh during COVID-19 response adopted from WHO Guidance for Conducting a Country COVID-19 IAR (11). The review was conducted from 25 Jan to 02 February 2021. It was qualitative and cross sectional in nature, and conducted at district level looking at COVID-19 IPC response activities covering the response period January 2020 to January 2021.

IAR methods, selection of participants and data collection

The IAR discussions took place in two sessions with a total of 54 participants purposively selected from different organizations and agencies that had been involved in the frontline implementation of IPC in the HFs and SARI ITCs. Some participants were also professionals involved in oversight and management roles of the IPC interventions during the pandemic response in Cox’s Bazar district. The meetings were held using a hybrid format of both an online platform (Microsoft teams) and in person and all participants were invited through email. We used the IPC trigger questions adapted from the country COVID-19 IAR: trigger question database (12) as a discussion guide (See annex table 1 for trigger questions used). The trigger questions were used to elicit responses on best practices, challenges and recommendations for improvement of IPC in the COVID-19 response in Cox’s Bazar district. Prior to the IAR meetings, the IAR management team (see annex table 2 for list of management team) was assembled. The team consisted of facilitators, note takers, and report writers to aid information collection from participants. This team was oriented on the objectives, scope, and methodology of the IAR through video conferencing. The orientation also included; facilitation techniques, IPC IAR trigger questions, their roles in the IAR meetings and some examples of IAR.

We held two meetings with IAR participants each lasting about 2 hours and 30 minutes with the online meeting having 30 participants and the in-person meeting having 24 participants (see annex table 3 for participants list). During the meeting, the participants were given an overview of the response including Cox’s Bazar district COVID-19 IPC response plan; the capacities prior to the response, and those developed for and during the COVID-19 response; the actual response timeline in order to establish a baseline for the participants to conduct the review. The COVID-19 IAR IPC trigger questions were then used to guide participants in an open discussion to identify and analyze IPC response interventions in respect to: IPC best practices, IPC challenges, and recommendations for improvement.

Data management, analysis and ethical consideration

All meetings were recorded, and notes taken for different sessions. All notes were collected from different note takers and recordings transcribed verbatim. The data from the note takers and the transcripts from the recordings were then collated and manually analyzed using content analysis under the three main themes of best practices, challenges and recommendations for improvement. The results were mainly summarized using text; however, quotes from the meeting transcripts that elaborately illustrated meanings or emphasized key messages were also included.

The objectives, and benefits of the IAR were clearly explained to the participants and verbal informed consent obtained from all the participants before the meetings with all participants consenting to take part in the review and to be recorded. All data obtained was treated as confidential and anonymous identifiers were used during analysis. We restricted raw data access to only the IAR management team.

The two meetings conducted for the IAR discussions, collected information from the 54 participants identifying several best practices, challenges and recommendations for the improvement of COVID-19 IPC response, and the results are as per these three broad themes.

Best practices

IPC assessments for general HFs and SARI ITCs

Predesigned, easy to adapt WHO IPC assessment tools and technical expertise facilitated the Health Sector and WHO IPC assessments in HFs, conducted to assess the extent of IPC implementation in preparation for COVID-19 response. Additionally, before any SARI ITC opened, readiness assessments were conducted to identify gaps before patients were received.

“The assessments were kind of needs assessments to prepare us for proper planning for interventions we needed for the response. It helped us to design activities for COVID-19 IPC in the camps informed by evidence on the ground, otherwise we could have just blindly implemented activities which would not yield good results” Participant 33

COVID-19 IPC response plan

The Health Sector with support from WHO developed an IPC response plan for COVID-19 for Cox’s Bazar, which was shared with Health Sector partners. The IPC response plan was informed by the Health Sector response plan and it continues to guide the different interventions in IPC as emphasized in the subsequent voice.

“For us as the IPC technical working group, having a well laid out COVID-19 IPC response plan was a key to success because it guided our response systematically and we followed our plan well. On a monthly basis we reviewed our plan to make sure we were on track and to see if any adjustments needed to be made for better response” Participant 10

IPC Technical Working Group (TWG), leadership and coordination

The Strategic Advisory Group (SAG) of the Health Sector approved an Ad hoc IPC TWG for COVID-19 response on 20 May 2020. The group provided leadership and coordination in IPC, promoted sharing of IPC knowledge across partners, facilitated practical drills and trainings across HFs and drafting of IPC materials for training, monitoring and guiding IPC interventions in the response. The IPC TWG is journeying towards institutionalization of IPC in HFs beyond COVID-19 and is an advocacy platform for IPC in the district.

“The IPC Technical Working Group has been a strong forum for mobilizing all health partners to improve IPC in all facilities in the camp and has led the IPC interventions. The monthly IPC technical working group meetings have always given us chance to share experiences and next course of action during this response.” participant 30

The IPC TWG through the Health Sector provided leadership and a coordinated approach to resource mobilization and implementation of IPC interventions that helped all partners systematically and similarly support the response efforts.

Existence of adapted guidance documents

As a preparedness strategy, the WHO Cox’s Bazar Emergency Sub Office disseminated the WHO guidance documents on IPC for COVID-19 to all Health Sector partners. Different guidance documents were also adapted and contextualized to Cox’s Bazar and Rohingya camps HFs’ setting and provided to humanitarian workers through the health sector Google drive document storage platform, accessible to all partners. The documents included but were not limited to; hand hygiene, respiratory hygiene, and rational use of PPE, decontamination, travel and physical meetings among others.

“We got a lot of guidance documents on COVID-19 IPC from WHO and we followed them very strictly in our SARI ITC and because of this COVID-19 infection among our health workers is almost zero and COVID-19 patients on the ward did not get infected with other diseases due to strict IPC followed by staff.” Participant 3

“Initially we had shortage of PPE due to overuse of PPE, so we planned to minimize unnecessary use of PPE through following rational use of PPE for example according to severity of patient and proper risk assessment and that reduced PPE shortage in our SARI ITC” Participant 1

COVID-19 IPC trainings

WHO and the Health Sector conducted a five-days master trainers’ course, which created a pool of 43 trainers (see annex table 4 for training modules covered). The master trainers then trained all other HWs in the SARI ITCs and all other HFs in the Rohingya refugee camps, entire district and humanitarian workers within 3 months. Their trainings took various forms including lectures, practical sessions, simulations and practical drills before starting patient admission. The following quotes illustrate the role played by the trainings

“The IPC master training really helped us a lot…me and my colleagues have each trained at least 500 health care workers in different aspects of IPC in our health facilities throughout the camp.” (Participant 1)

“The five days IPC master trainers course was a very practical and effective strategy to develop human resource to fight the new disease…. we were confused and scared, we didn’t know what to do but after the training everything became clear…. we were able to set up and run big SARI ITCs like the 150 bedded SARI ITC we have here.” (Participant 6)

“The dry runs gave us the confidence to handle patients with less fear, as you know it was the first time for us to manage such patients, so the dry runs helped us not to make unnecessary mistakes once we received the real patients and to reduce our chances of exposure to infections from patients” Participant 38

Screening, early identification and isolation of suspected COVID-19 patients

The HFs in Cox’s Bazar introduced screening for COVID-19 signs and symptoms for all persons entering the HFs including HWs. This was supported by availability of human resources, screening tools and materials. Screening at HF entrances helped rapidly identify and separate suspected COVID-19 patients from other patients to reduce transmission. Early identification of suspected cases for immediate isolation and or referral gave patients confidence to continue to utilize non-COVID related essential health services.

“We have separate entrances for staff and patients, and we screen everyone coming to the facility if we find that a health worker has signs and symptoms of COVID-19, we put them in isolation and a sample is taken. We don’t allow such health worker to go in to work as they could infect other health workers and patients too” participant 1

Hand hygiene at strategic points in the HFs

Almost all HFs in Cox’s Bazar installed hand hygiene points at gates, waiting, consultation and inpatient care areas. This increased hand hygiene practice among staff, patients and visitors as echoed here:

“We have placed hand washing points at the gate, waiting areas and all points of care which has increased hand washing among the patients and health workers and hand washing as you know helps control spread of many infections not just COVID-19” Participant 16

Increased hand hygiene points were reported by IAR participants to have increased the trust of the community in HFs for seeking essential health services knowing that HFs were keeping them safe. This intervention was facilitated by the availability of adequate hand hygiene supplies and Information Education and Communication (IEC) materials from different partners.

“When beneficiaries saw that we were strict about hand washing in our facility, the fear reduced they now trust our system to protect them from COVID-19 so they freely come to the facility for all services” Participant 7

IPC monitoring, audit and feedback in SARI ITCs

WHO supported partners to design a contextualized user-friendly daily IPC checklist and a monthly score card that were used for monitoring and facilitating feedback on IPC activities in SARI ITCs. The daily checklist consisted of fourteen main areas of observation vital for IPC in SARI ITCs, which the IPC team in the SARI ITC checked daily and gave immediate feedback to concerned HWs (see annex table 5 for checklist). The average scores of the daily checklist for all areas of observation were calculated by the IPC team at the end of the month to obtain a monthly score for the monthly score card. The monthly scores were represented on HF notice boards using colors; green=good performance (80% and above), yellow= fair performance (50-79%) and red= poor performance (0-49%) (See annex table 6 for score card). The daily checklist improved IPC practice through the daily monitoring and corrections facilitated by the IPC team as they gave feedback to HWs while the scorecard triggered continuous monthly improvement in IPC practices for better scores (see Annex table 7 for an example of observed changes in scores for one SARI ITC).

“Having the daily IPC checklist helped us a lot in the health facilities, whenever we found a breach, we gave immediate feedback to the health workers to correct it and that helped us a lot in maintaining high standards of IPC in our facilities” Participant 27

“The monthly score card encouraged us to work harder to improve IPC practices, whenever you see an indicator that has not turned green for example it is red or yellow, you work harder at it in the coming month to turn green because green is more desirable, and all staff are more motivated when they see green on the score card” Participant 11

General masking for all patients

All patients who visited any HF to seek for any sort of care were given a mask before entering the HF to reduce chances of spread of COVID-19. Patients with respiratory symptoms were given medical masks while other patients without respiratory symptoms received cloth masks. An adequate supply of masks from different agencies, IEC material on how to use masks and HWs’ commitment to show patients how to use the masks, all contributed to adherence to mask wearing in HFs as expressed below

“At our health facility, we provide free masks to all patients coming to seek care, it helps not to spread infections of COVID-19 and other respiratory infections within our facility.” Participant 26

Additionally, the Food Security Sector in Cox’s Bazar coordinated community-wide distribution of cloth masks and all persons were encouraged to use them in public places, including HFs through communication campaigns.

Health education of patients

Patients admitted to SARI ITCs received briefings on IPC (including respiratory hygiene, hand hygiene, keeping physical distance, personal hygiene and waste management) on admission and in the ward during daily IPC rounds, which was reinforced through distribution IEC materials. The availability of adequate IPC staff in HFs and the IEC materials facilitated the sensitization sessions in the SARI ITCs.

“We have put up IEC materials in all visible areas in our SARI ITC and this has helped the staff and patients to be reminded of what to do to control spread of COVID-19 in the facility and community.” Participant 34

“Every morning our IPC team goes to the ward to conduct IPC sensitization for patients. It has helped eliminate open spitting, littering, and poor hygiene in the wards, we also emphasize hygienic use of washrooms and proper waste segregation” Participant 25

IPC supportive supervision to SARI ITCs and HFs

The WHO and IPC TWG conducted quarterly and bi-annual COVID-19 IPC supportive supervision for all SARI ITCs and all HFs respectively using contextualized detailed checklists (see annex table 8 and 9 for supportive supervision checklists). The visits were for quality control, but also led to continuous improvement of IPC practices like environmental cleaning, hand hygiene and waste management among others in all HFs.

“Every time we receive colleagues who come for supportive supervision, they guide us on things that are not doing well in the facility and we immediately improve on them, this helped us a lot.” Participant 39

Tracking of PPE and IPC supplies utilization in SARI ITCs

Different SARI ITCs used different innovations to track the consumption of IPC supplies and PPE in their HFs for example using Cloud based spreadsheets and other software. All the SARI ITCs had supportive IT systems with various tracking, forecast and estimation methods for PPE and supplies. Tracking consumption ensured regular supply of PPE and supplies due to timely ordering.

“We have an excel Google sheet we use to track PPE and IPC supplies daily utilization for our health facilities. This helps us to monitor stock and procure on time to avoid stock out of PPE and IPC supplies which are essential in controlling spread of infection.” Participant 40

Design, infrastructure and use of Environmental controls in SARI and HFs

The SARI ITCs had separate entrances and exits for patients and staff; clear marking of red zones (patient care area) and green zones (areas without patients). All SARI ITCs had adequate human resources, signposts marking direction of movement and physical barriers (like doors that open to only one direction) between different zones. This controlled cross contamination from zones with patients and ultimately reduced HF associated COVID-19 infection among health workers as echoed below.

“We have worked with our security staff to maintain strict use of single entrance and exists and movement of patients in the right direction and making sure patients don’t cross from SARI ITC to field hospital to avoid transferring infections between the two facilities.” Participant 23.

All HFs practiced the 1-meter distance between persons in waiting and triage areas, consultation rooms, wards and all other HF spaces using several innovations like marking seats with paint, using physical barriers made from bamboo, or volunteers to instruct people on sitting and queuing arrangements.

“We maintain physical distancing in all our facilities right from waiting, screening areas, wards and other areas which I believe has contributed to reducing spread of COVID-19 in our facilities and community” Participant 26

The IPC teams worked closely with engineers to make sure that the construction of SARI ITCs had appropriate designs with IPC considerations including; spaces, directions of workflow, separation of different zones, ventilation and lighting. This made the general operations easy and safe when patient care started as all IPC protocols had been considered.

“Our management allowed us as master trainers to work with the engineers during the construction of our SARI ITC and they were flexible to follow our advice on the necessary spaces needed in infectious diseases hospital for proper management of patients.” participant 20

Health Care Waste management

Participants attested to the fact that most of the HFs practiced waste minimization, segregation and disposal as the pandemic continued. This helped in reduction of quantity of waste and enhanced waste handler safety. The SARI ITCs also innovated ways of reducing wastes so that the burden of waste management was low; as echoed by HWs below.

“All fresh food and fruits ere cleaned or peeled, preprocessed from the market and only ready to cook food and ready to eat fruits brought into the SARI ITC which reduced the load of waste ending up in our waste management zone.” Participant 24

“We also use reusable PPE where applicable to reduce the burden of waste generated by unnecessarily using disposable PPE for which an alternative reusable PPE is available and is equally safe” Participant 19

2. Challenges

Frequent break down of incinerators

SARI ITCs reported incinerator breakdowns due to high quantities of waste generated compared to the capacity of the incinerators, improper waste segregation and low-quality construction materials as echoed below.

“Our incinerators had been designed for low capacity of waste but with too much use of PPE came a lot of waste which was beyond the capacity of the incinerators, so they broke down often. Also, the incinerators had been built without heat resistant materials, so they cracked and broke down quickly” Participant 50

Limited PPE supply and irrational use

The global demand on PPE resulted in PPE scarcity in the market and difficulty in procurement of PPE from international sources due to travel restrictions. As a result, the initial stages of the response suffered from limited supplies, which led to reusing of single-use PPE and slowing down activities in the HFs as emphasized by participant below.

“In the beginning, we had a problem of limited stock of PPE, so it led to reusing one time use PPE like the face shield which actually hampered our activities in the beginning.” Participant 5

There was irrational use of PPE in the early phase of the pandemic mainly driven by fear of infection, and low knowledge on risk assessment for proper use of PPE. This exacerbated shortage of PPE and caused unnecessary panic in patients, visitors and communities.

“We faced challenges in the beginning where health workers wanted us to give them three or four masks to put on during donning. Others wanted respirators to attend to mild patients where no aerosol generating procedures were done while others wanted to put on both coverall and gown at the same time which led to a lot of PPE going to waste” participant 25

Inconsistent adherence to IPC practices by HWs

Some HWs did not consistently follow IPC practices as received in trainings especially in the absence of refresher training and follow-up on actual practices. The participants highlighted that this could have possibly resulted in healthcare associated COVID-19 infections among some HWs especially in HFs (health posts, primary healthcare centres and field hospitals) where there was no dedicated IPC supervisor to check staff adherence to IPC practices.

“When health workers are in health facilities, they follow the IPC guidance very strictly for example wearing masks, hand washing, physical distance but when they leave the health facility and go to public places like malls, markets, public transport, they don’t even put on a mask. It made it hard to actually trace where health workers got the infections” Participant 10

“In the beginning it was hard to get health workers to use the masks properly. Instead of covering the nose and mouth, the mask would be below the chin, yet we had trained on the right way to put on the masks” participant 6

Limited investigation of HW infections and Healthcare-associated Infections (HAI) of COVID-19

We were not able to investigate all COVID-19 HW infections in the district due to inadequate human resources to administer the WHO IPC investigation tools for HW COVID-19 infections. Additionally, healthcare associated COVID-19 infections surveillance in HFs was not conducted; yet tools like daily screening registers were availed.

“WHO has tools for investigating health worker infections however these have not been used by different facilities...also we have screening registers to use in the in-patient wards to follow up on signs and symptoms of COVID-19 so that if we get any suspect, a sample is taken for testing however no HF has used these registers for inpatients” Participant 10

Lack of working uniform in many HFs

In many HCFs, HWs use clothes from home at work, which could potentially carry infections from the HF to their communities. This was mainly driven by unfamiliarity with the need for HF working uniforms, limited budget to afford uniforms for staff, as well as inadequate logistics for decontamination and storage.

“We don’t have working clothes for our staff, so they use their own clothes for work and return to their homes with the same clothes. We know that could lead to spread of infections from our SARI ITC to the community, but we don’t have enough money to buy scrubs for our staff” Participant 13

Lack of culture- and gender adapted work uniforms and PPE in SARI ITCs

Almost all the SARI ITCs in Cox’s Bazar had working uniforms for staff however; in some cases the uniforms were not adapted for gender and culture. For example, lack of provision for head covering for female Muslim staff and low neck and upper chest for all female staff. Some PPE like surgical masks only had provisions for ear bands yet some female health workers put on head and neck covering which makes putting on and off such masks difficult and can lead to poor adherence to PPE.

“The scrubs did not have head and neck covering like hijab yet we need to cover ourselves and the design of the shirts was not comfortable for us the ladies, it was too open so we could not use those scrubs” Participant 20

Low implementation of IPC practices in the community

IPC interventions for COVID-19 such as hand washing, respiratory hygiene, and physical distancing were not widely practiced in the community, as was the case in HFs. The identified drivers of lack of IPC implementation in the communities were: ineffective communication of IPC interventions to the community and the cultural beliefs and ways of life of people. Additionally, the comparatively low numbers of COVID-19 cases did not create a sufficient sense of urgency in the different communities to drive behavioral changes, and compliance with IPC practices such as hand washing, respiratory hygiene and physical distancing.

3. Recommendations

Establishment of an institutionalized IPC program for Cox’s Bazar district

The participants recommended that IPC should be integrated throughout the health system through reflection in the budgets, staffing and leadership structures from the district to the lowest level of care within the health system.

Establishment of IPC monitoring, audit and feedback mechanisms in all HFs

Introduction of daily IPC checklists and monthly score card in the HFs coupled with training of IPC focal points on implementation would be a good initiative for sustained and continuous improvement of IPC performance in the HFs beyond the COVID-19 pandemic.

“We should roll out the IPC score card to other facilities in the camp as well, it has worked so well for the SARI ITCs… it is such a good innovation” participants 48

IPC education and training

There is need to train all HWs on aspects of IPC on the job, through structured training (including refresher trainings) and in the medical colleges. This requires stakeholders to develop a contextualized curriculum for IPC for HWs as short courses to be taught in HFs using in-services for HWs and as part of health care education curriculum.

“WHO should work with Cox’s Bazar Medical College to develop a module for teaching IPC to medical students and other health workers to build IPC capacity at wider scale and more sustainably ” participant 47

Strengthening public health and social measures in the communities

The review recommended innovation of more robust community engagement approaches to promote IPC beyond the HF settings. There is a need for the IPC team to work closely with risk communication and community engagement experts, sociologists, psychologists, and other stakeholders to design approaches that can trigger community behavior change towards practicing recommended public health and social measures for the control of COVID-19. Recognition of message fatigue is critical in designing alternative and more creative methods to deliver common IPC messages. Close engagement with community representatives in design of community engagement approaches is very important, with due consideration of age, gender and diversity factors.

“We need to come up with a better strategy to change the behavior of the community…. The IPC team should work with other working groups like communicating with communities, risk communication and community engagement to craft new strategies” participant 54

Best practices

IPC assessments were helpful in informing the response on the gaps in HFs and what interventions to design for the success of the response. The needs assessments provide the evidence for targeted responses while continuous assessments help in adjusting plans to further improve the response, which is also the aim of the IAR.

Just as it was necessary for governments to have COVID-19 response plans as a call from WHO (10), it was equally important to have a detailed step by step living plan for COVID-19 IPC response activities. The IPC TWG played a major role in steering the IPC related activities and implementing the IPC response plan, which was the guiding document. Additionally, in contexts where there are many actors as is the case with refugee settings, a coordinating platform such as the IPC TWG in Cox’s Bazar helped to better organize and structure the IPC responses, as well as maintain uniformity and standards.

Implementation of IPC is not possible without contextualized guidance documents for feasibility. In Cox’s Bazar the guidance documents were adapted from global WHO materials by a dedicated team of IPC focal persons who worked in the refugee camps and understood the context well. WHO encourages governments and HFs to adapt IPC guidance to different contexts (13) however, sometimes the capacities are limited and external experts may need to be recruited to facilitate the adaptation.

Training of the 43 master trainers helped in swiftly building capacity and putting in place a work force where IPC human resource was limited yet the task at hand was huge. The trainers reached all HWs of all cadres in the district within minimal time by cascading the training using materials centrally availed by the WHO Cox’s Bazar Emergency Sub-Office. This approach proved very fast, effective and efficient for the Cox’s Bazar emergency response reaching at least 3600 trained people within 3 months (14). Such trainings should consider trainers who have a certain level of authority or leadership among their peers and can cascade the training to their respective jurisdictions. Training of trainers with limited authority and support from the organization to cascade the training will not achieve the desired result of passing on knowledge to others.

Hand hygiene, use of masks, physical distancing and screening are some of the IPC measures recommended by WHO for control of COVID-19 transmission in health care facilities (9). These were comprehensively implemented in Cox’s Bazar and we believe they contributed to reduction of infections in general, not only COVID-19, because similar interventions have registered reduction of infections in HFs elsewhere (15)(16)(17). The interventions were possible due to adequate funding from different partners and donors, however this may be difficult to implement in settings where there is not a similar level of available resources. Although the main aim of increased hand hygiene, provision of masks and screening before entering HFs was to control COVID-19 transmission, these interventions resulted in unintended positive effects including increased trust and sustained essential healthcare seeking by refugees. While utilization of essential health services reduced briefly at the early phases of the pandemic in the Rohingya camps (18), it was not as much and not for prolonged period as observed globally (19–22). These interventions build the confidence and trust amongst the community that HFs were trying their best to control spread of COVID-19 hence reducing fear among patients of getting infected from HFs as they seek care.

IPC monitoring, audit and feedback is a back bone in IPC and is one of the core components of IPC programs (13). It helps in timely identification and correction of any IPC gaps in HFs. Consistent monitoring, audits and feedback using different tools and methods including the daily IPC checklists and monthly scorecards such as the ones used in Cox’s Bazar context requires dedicated IPC staff, training and supportive leadership.

Challenges

The global demand on PPE resulted in PPE scarcity in the market and difficulty in procurement of PPE from international sources due to travel restrictions. In addition, there was also irrational use of PPE by HW in the early phase of the pandemic. It is important to continuously build the capacity of HWs with IPC knowledge right from school training to on the job and refresher trainings thus enabling them to use the appropriate PPE according to the context and situation. Most importantly risk communication and community engagement experts play an integral role in helping people understand the disease transmission to avoid unnecessary use of PPE and reduce fear as also recommended by other studies (22)

Risk assessment and management of exposure of HWs in the context of COVID-19 using WHO tools helps the IPC focal points and HF management to determine IPC gaps that may increase HW exposure to COVID-19 within the HF and work towards finding solutions (23). In Cox’s Bazar however, due to lack of human resource training on the tool and absence of a system in place, investigation of risk of exposure of HWs in the HFs and SARI ITCs was not done comprehensively.

Although budgets are limited, appropriate work uniforms and PPE should be prioritized for HWs in all health care settings and these should be adapted to culture and gender. Work uniforms and PPE that are not culture and gender sensitive will not be used properly leading to potential breaches of IPC. For example; female Muslim staff whose uniforms lacked neck and head covering used their own head coverings while attending to patients then took the same cloth home hence potentially transferring infections to the home. It is therefore important for health systems to study the culture then adapt working uniforms and procure PPE to suit the particular contexts.

According to IAR participants the limited implementation of IPC practices, for example use of masks and physical distancing in the community could have been driven by culture and beliefs. For example, the women have a culture of wearing a face veil which they believed was sufficient covering and therefore reduced their perceived need to wear a facemask to prevent COVID-19 transmission. Also, the comparatively limited number of detected COVID-19 cases in the different communities did not create sufficient perceived susceptibility to drive people towards new behavior as one of the variables in the health belief model suggests (24).

The Intra Action Review for IPC in the COVID-19 response was instrumental in identifying gaps in the operational response to trigger rapid adjustments in the Cox’s Bazar refugee camps and lessons that could be used elsewhere, in similar settings.

IPC monitoring tools and continuous training adapted to the local context provide critical support in promoting consistent IPC implementation.

Proper coordination and leadership at all levels is key in IPC response efforts for the ongoing response to COVID-19. IPC for COVID-19 and other infectious diseases in emergency situations like refugee settings with a multitude of actors, can only be successful with highly coordinated leadership, efficient resource mobilization and close supervision throughout the entire response.

Purposeful and consistent engagement with HWs and the community, including appreciating cultural practice, is critical to the success of implementation and adaption of IPC measures.

BDRCS: Bangladesh Red Crescent Society

CME: Continuous Medical Education

FH: Food for Hungry

HFs: Health Facilities

HWs: Health Workers

HCWM: Healthcare Waste Management

IAR: Intra-Action Review

ICDDR, B: International Centre for Diarrheal Diseases Research, Bangladesh

IEC: Information Education and Communication

IFRC: International Federation of the Red Cross and the Red Crescent

IOM: International Organization of Migration

IPC: Infection Prevention and Control

ITC: Isolation and Treatment Centre

MHPSS WG: Mental health and psychosocial support Working Group

MoHFW: Ministry of Health and Family Welfare

MoHFWCC: Ministry of Health and Family Welfare Coordination Cell

MSF: Médecins Sans Frontières

MTI: Medical Teams International

PPE: Personal Protective Equipment

RI: Relief International

RRRC: Refugee Relief and Repatriation Commissioner

SARI Severe Acute Respiratory Infection

SCI: Save the children International

TWG: Technical Working Group

UNFPA: United Nations Population Fund

UNHCR: United Nations High Commissioner for Refugees

UNICEF: United Nations International Children’s Emergency Fund

WHO: World Health Organization

Ethics approval and consent to participate

Ethical approval for this IAR was not needed since the health sector partners conducted it as a part of COVID-19 outbreak response activities. However, consent to be recorded and participate in the IAR was obtained verbally from all participants before the online and the in-person meetings.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests. The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

Funding

No funding

Authors' contributions

RRA led IPC IAR conceptualization, tools adaption, data collection, analysis and manuscript writing. SSK, ESE, KVH, NM, PD, AS and AD contributed to IAR conceptualization, data collection, analysis and write up of the manuscript. ATNRHB, MR, AB, AGKM, MS MN and VW contributed to writing of the manuscript. All authors reviewed the transcripts and contributed to data analysis. All authors read and approved the final manuscript.

Acknowledgements

We acknowledge all the participants of this IAR and the following organizations and agencies for contributing participants; Bangladesh Red Crescent Society (BDRCS), Bangladesh Rural Advancement Committee (BRAC), Care Bangladesh, Cox’s Bazar Sadar District Hospital, Food for Hungry/Medical Teams International (FH/MTI), Government of Bangladesh, Ministry of Health and Family Welfare coordination Cell (MoHFW-CC), Government of Bangladesh, Office of Refugee Relief and Repatriation Commissioner (RRRC), Health sector coordination -Cox's Bazar, Bangladesh, International Centre for Diarrheal Diseases Research, Bangladesh (ICDDR, B), International Federation of the Red Cross and the Red Crescent (IFRC), International Organization of Migration (IOM), Médecins Sans Frontières (MSF), Prantic/Obat helpers, Relief International (RI)- Bangladesh, Save the children International (SCI), United Nations High Commissioner for Refugees (UNHCR), Cox's Bazar – Bangladesh, United Nations International Children’s Emergency Fund (UNICEF), United Nations Population Fund (UNFPA) and World Health Organization (WHO), Cox's Bazar Emergency Sub office, Bangladesh.

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No competing interests reported.

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Infection Prevention and Control for COVID-19 response in the Rohingya refugee camps: an Intra-Action Review

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