The status of work-related coronavirus prevention measures and risk factors in hospitals

doi:10.21203/rs.3.rs-1950038/v1

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The status of work-related coronavirus prevention measures and risk factors in hospitals

https://doi.org/10.21203/rs.3.rs-1950038/v1

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Background: Hospitals around the world, counting in our nation, are confronting many problems and challenges within the battle against coronavirus infection. The aim of this study was to design a checklist and determining the status of preventive measures and risk factors that taken to combat coronavirus in the hospital.

Methods: This cross-sectional and descriptive-analytical study was performed in Tabriz hospitals in Iran. A literature search was carried out in scientific databases. Based on the results of reviewing the texts and guidelines, a checklist was designed and validated to assess the status of occupational risk factors and prevention measures against coronavirus in hospitals.

Results: Results of study confirmed validity of checklists for assessment of status of coronavirus prevention measures in hospitals. There was no significant difference in occupational risk factors of Covid-19 between governmental, non-governmental public, private and military hospitals. The risk of Total of preventive and control measures between governmental and military hospitals, Private and non-governmental public were not statistically significant.

Conclusions: Hospital staff are more and more directly exposed to patients with Covid-19, the importance of preventive measures is doubled. This study can serve as a guide for occupational health professionals and other policymakers to improve the prevention and control of Covid-19 and even other infectious diseases in the future.

Hospital

COVID-19

Occupational

Prevention

Risk factors

Coronavirus disease 2019 (COVID-19), as a startling respiratory danger, got to be an around the world emergency amid December 2019 and the primary quarter of 2020, which the World Health Organization (WHO) described as introduced a pandemic disease (1). In Iran, with the distinguishing proof of two cases in February 2020, the episode of COVID-19 was reported for the primary time (2).

In spite of the mortality rate of that of 2%, the COVID-19 infection contains a high transmission rate as well as a better mortality rate than that caused by both severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS)(3). In this respect, to decrease the rate of transmission, Iran’s government in March 2020 required all open individuals to remain at domestic, but for vital purposes(4).

Within the current circumstance, health care workers (HCWs) around the world, counting in our nation, are confronting many problems and challenges within the battle against Covid-19 infection. Restrictions on the admission capacity of medical centers and hospitals to supply administrations to patients, shortage of medical staff, loss of medical staff due to passing due to Covid-19 disease, and expanding exacerbation of depleting work conditions, counting these issues are considered (5).

It is worth mentioning that physicians, nurses and health care staff not only in the clinical management of patients, but also in ensuring the implementation of preventive measures against COVID-19 and controlling the spread of infection and managing the critical situation compared to other groups. Jobs play a very important role(6, 7).

Today, the spread of infectious diseases such as Covid-19 and the flu, in addition to being a serious concern for policymakers and officials, has also posed new challenges to the community of industrial health professionals (8).

In the midst of the widespread, frontline HCWs play a vital part in caring for COVID-19 patients and making a difference to counter the spread of the flare-up. In any case, a few reports appear to prove of the hazard that they are confronting, primarily due to the workload and the deficiency of personal protective equipment (PPE). Clearly, the lacking PPE supply is troubling, because it puts HCWs at hazard for contracting a COVID-19 disease (9–12).

Hospitals during the Covid-19 pandemic have accepted an increasing number of patients with coronavirus, some of whom have needed long-term vital care. Pressure on health care systems is exacerbated by multiple COVID-19 clusters in hospitals due to transmission of the virus to non-COVID-19 patients and staff(13). Ensuring effective infection control in hospitals protects patients and health care workers, and maintaining a healthy workforce is essential to responding to COVID-19 and providing other health care interventions(14). Employee safety should be prioritized by using appropriate PPE for HCWs during their duties and during the aerosol-producing steps to ensure that they are disease-free (15).

This highlights the role and responsibility of occupational health professionals in providing the necessary suggestions and advice. Providing suggestions and advice, especially in the field of preventive measures in the workplace, should be based on up-to-date and sufficient information and include a variety of management and engineering control methods (16).

There are studies of status of prevention measures in industry workplaces(17). Studies on status of occupational risk factors and preventive measures for coronavirus in hospitals are limited and no study has been conducted in this field in Iran. Also, checklists have been designed in great detail to review all aspects of preventive and control measures and in accordance with the standards of the Ministry of Health of Iran and other international authorities So, the aim of this study was to determine the status of occupational risk factors and prevention and control measures of Covid-19 in Tabriz hospitals.

This cross-sectional and descriptive-analytical study was performed to determine the status of preventive measures taken to combat Covid-19 in the hospital. The present study was performed by census in Tabriz hospitals.

In order to review the texts of studies conducted at home and abroad in the field of measures to prevent Covid-19 in hospitals in a recent year, a systematic review of texts was performed. Iranian databases such as SID, Magiran, etc. were searched using the keywords Corona virus, Covid-19, prevention measures, hospital, workplace. External databases such as Pubmed, Science direct, Scopos, Google schoolar, etc. were searched using keywords, coronavirous, Covid-19, prevention measures, health care worker, hospitals, and workplaces. The proposed guidelines for the prevention of Covid-19 in hospitals were also used by various organizations such as WHO, NIOSH, and OSHA

Based on the results of reviewing the texts and instructions, a checklist was designed to assess the status of occupational risk factors and prevention measures against Covid-19. The data collection tools will be a checklist designed to prevent Covid-19 infection and a checklist of occupational risk factors for Covid-19 infection.

This study conducted among hospitals located in Tabriz, Iran. The studied hospitals included 13 government hospitals, 5 non-government public hospitals, 6 private hospitals and 3 military hospitals (27 hospitals in total), one of which was removed from the study population due to lack of cooperation and a total of 26 hospitals were studied. In each hospital, checklists for risk factors for Covid-19 infection and preventive measures for Covid-19 were completed with the help of the occupational health expert of the hospital. The occupational risk factors checklist consisted of 13 questions. The questions of the Covid-19 prevention measures checklist were divided into three parts: personal protective equipment, management control measures, engineering control measures. The Covid-19 preventive measures checklist included 11 questions in the field of personal protective equipment, 103 questions on management control measures, 14 questions on engineering control measures (128 questions in total).

The questions in the coronavirus risk factors checklist have two answers yes and no, the answer yes means absence of risk, in all questions except for questions 3, 6, 9 and 10 (in these questions answer "Yes" means presence of risk). A score of 1 is given for a "No" answers and a score of zero is given for a "Yes" answers. So, higher scores indicate a higher risk of Covid-19. The questions in the coronavirus prevention measures checklist have two answers yes and no, the answer "Yes" means good condition of coronavirus prevention measures, in all questions and "No" means poor conditions of coronavirus prevention measures. A score of 1 is given for a "Yes" answers and a score of zero is given for a "No" answers. So, higher scores indicate a good condition of coronavirus prevention measures of Covid-19.

Conditions of coronavirus prevention measures of Covid-19 were good if the scores in the fields of "use of PPE", " management measures", " engineering measures" and” total preventive measures" are higher than 5.5, 51.5, 7 and 64, respectively.

In order to check the content validity of the checklist, the opinions of experts in the fields related to the subject of study including occupational health, public health, environmental health, epidemiology, etc. were used. To determine the validity of the CVR content, experts were asked to review each question based on a three-part spectrum: necessary, unnecessary, but relevant and unnecessary. In determining the CVI validity index, three criteria of simplicity, relevance and clarity were reviewed and rated separately by experts based on a range of four for each item. Lawshe criterion was used to evaluate the CVR score. Also, some items were modified according to the comments received from experts by replacing them with simpler words or phrases. To check the face validity of the checklist, an occupational health specialist, general, epidemiologist and hospital expert were consulted

Statistical analysis

Statistical analysis was performed with SPSS Version 22.0 statistic software package. Data were expressed as means ± standard deviation (SD). Comparisons between hospitals were performed with analysis of non-parametric test (Kruskal Wallis Test). A value of P < 0.05 was considered statistically significant.

For assess validity of checklist, first, questions with a CVI of less than 79 percent and a CVR of less than 61 percent were removed. After this, 142 questions remained in the checklist, which had a CVI with at least 85 percent and an average of 96 percent with Scale-level CVI: Universal Agreement = 0.68 and Scale-level CVI: Average = 0.96 and also an average CVR of 79 percent. The mean impact score = 4.56. These values indicated good validity for this checklist.

As shown in Table 1, PPE was supplied and available to staff in all surveyed hospitals (100%). The correct use of PPE was 100% in public and non-governmental public hospitals and 50% in military hospitals. The largest difference in the incidence of Covid-19 in occupations that have direct exposure with Covid-19 patients in non-governmental public hospitals (80%), military hospitals (50%), public hospitals (15.4%) and private hospitals (0%), respectively. The highest percentage of optimal ventilation system was related to private hospitals (66.7%), followed by non-governmental public hospitals (60%), military hospitals (50%) and government hospitals (38.5%), respectively. The use of PPE during aerosol production processes in military and public non-governmental hospitals was fully observed (100%) and the percentage of PPE use during aerosol production procedures in public (84.6%) and private hospitals (66.7%). The use of public transportation to attend work was not observed in military hospitals (0%). The use of public transportation in non-governmental, public and private public hospitals was 80%, 69.2% and 33.3%, respectively. Avoiding unnecessary meetings and observing health protocols if held in military, private and public non-governmental hospitals were fully observed (100%) and not observed in only one public hospital (7.7%). Social distancing is fully observed in private hospitals (100%), followed by public hospitals (84.6%), non-governmental public hospitals (60%) and military hospitals (50%), respectively. The highest workload was observed in non-governmental public hospitals (100%) and then in private hospitals (66.7%), government hospitals (53.8%) and military hospitals (50%), respectively. Shift work was observed in all military, private and public non-governmental hospitals (100%) and only 2 public hospitals (15.4%) did not work in shifts. Training on prevention and control of Covid-19 and proper disposal of infectious waste and waste was conducted in all military, government and public non-governmental hospitals and was not provided in only one private hospital (16.7%). The highest percentages of IPC principles are related to non-governmental public hospitals (100%), followed by private hospitals (83.3%), government hospitals (76.9%) and military hospitals (50%).

Table 1

Occupational risk factors for infection with Covid-19 (percent)
Occupational Risk Factors		Type of hospitals
		Governmental		Public non-governmental		Private		Military
		N	Percent	N	Percent	N	Percent	N	Percent
Availability of PPE	Yes	13	100.0%	5	100.0%	6	100.0%	2	100.0%
Availability of PPE	No	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Proper use of PPE	Yes	13	100.0%	5	100.0%	6	100.0%	1	50.0%
Proper use of PPE	No	0	0.0%	0	0.0%	0	0.0%	1	50.0%
Differences in Covid-19 infection in occupations that have direct exposure with Covid-19 patients	No	11	84.6%	1	20.0%	6	100.0%	1	50.0%
	Yes	2	15.4%	4	80.0%	0	0.0%	1	50.0%
Optimal ventilation system	Yes	5	38.5%	3	60.0%	4	66.7%	1	50.0%
Optimal ventilation system	No	8	61.5%	2	40.0%	2	33.3%	1	50.0%
Use of PPE during aerosol production procedures	Yes	11	84.6%	5	100.0%	4	66.7%	2	100.0%
Use of PPE during aerosol production procedures	No	2	15.4%	0	0.0%	2	33.3%	0	0.0%
Use of public transport	No	4	30.8%	1	20.0%	4	66.7%	2	100.0%
Use of public transport	Yes	9	69.2%	4	80.0%	2	33.3%	0	0.0%
Avoid holding unnecessary meetings and observing health protocols if held	Yes	12	92.3%	5	100.0%	6	100.0%	2	100.0%
	No	1	7.7%	0	0.0%	0	0.0%	0	0.0%
Social distancing	Yes	11	84.6%	3	60.0%	6	100.0%	1	50.0%
Social distancing	No	2	15.4%	2	40.0%	0	0.0%	1	50.0%
High working pressure	No	6	46.2%	0	0.0%	2	33.3%	1	50.0%
High working pressure	Yes	7	53.8%	5	100.0%	4	66.7%	1	50.0%
Shift work	Yes	11	84.6%	5	100.0%	6	100.0%	2	100.0%
Shift work	No	2	15.4%	0	0.0%	0	0.0%	0	0.0%
Training	Yes	13	100.0%	5	100.0%	5	83.3%	2	100.0%
Training	No	0	0.0%	0	0.0%	1	16.7%	0	0.0%
Proper disposal of waste and infectious waste	Yes	13	100.0%	5	100.0%	5	83.3%	2	100.0%
Proper disposal of waste and infectious waste	No	0	0.0%	0	0.0%	1	16.7%	0	0.0%
Observance of IPC principles	Yes	10	76.9%	5	100.0%	5	83.3%	1	50.0%
Observance of IPC principles	No	3	23.1%	0	0.0%	1	16.7%	1	50.0%

As shown in Table 2a higher score indicates existence of higher risk for infection with Covid-19. Among the studied hospitals, the highest average risk factors were related to non-governmental public hospitals (4.40 ± 1.140), followed by governmental (3.76 ± 1.09), private (3.16 ± 2.04) and military (3.00 ± 1.41), respectively. In other words, the military hospitals studied had the lowest average risk factors. However, there was no significant difference in occupational risk factors of infection with Covid-19 between governmental, non-governmental public, private, and military hospitals. (P-value > 0.05).

Table 2

Mean ± SD of occupational risk factors of infection with Covid-19 in different hospitals
Type of hospitals/ Checklists	Governmental (Mean ± SD) (N = 13)	Non-governmental Public (Mean ± SD) (N = 5)	Private (Mean ± SD) (N = 6)	Military (Mean ± SD) (N = 2)	P-value
Occupational risk factors	3.76 ± 1.09	4.40 ± 1.140	3.16 ± 2.04	3.00 ± 1.41	0.47

As shown in Table 3 in the field of PPE, score higher than 5.5 indicates good conditions for PPE and a score lower than that indicates poor conditions. the highest score was related to military hospitals )10.50 ± .70(, then governmental )9.84 ± 1.40(, non-governmental public )9.20 ± 1.48(and private )8.66 ± 2.87(, but the conditions for PPE from the supply and use of personal protective equipment between governmental, military, private and non-governmental public hospitals. All hospitals were in good condition in field of PPE conditions but there was no statistically significant difference. (P-value > 0.05).

Table 3

Mean ± SD of status of preventive measures of Covid-19 in different hospitals
Type of hospitals/ Checklists	Governmental (Mean ± SD) (N = 13)	Non-governmental Public (Mean ± SD) (N = 5)	Private (Mean ± SD) (N = 6)	Military (Mean ± SD) (N = 2)	P-value
PPE	9.84 ± 1.40	9.20 ± 1.48	8.66 ± 2.87	10.50 ± .70	0.49
Management preventive and control measures	87.15 ± 10.40	82.60 ± 9.28	87.00 ± 12.86	89.00 ± 7.07	0.67
Engineering preventive and control measures	9.84 ± 2.99	8.60 ± 4.33	10.83 ± 3.37	11.00 ± 4.24	0.65
Total preventive and control measures	106.84 ± 12.52	100.40 ± 13.68	106.50 ± 17.21	110.50 ± 12.02	0.69

In the field of management preventive and control measures, score higher than 51.5 indicates good conditions for management preventive and control measures and a score lower than that indicates poor condition. the highest score is related to military hospitals )89.00 ± 7.07(, then governmental )87.15 ± 10.40(, private )87.00 ± 12.86( and non-governmental public )82.60 ± 9.28( respectively, All hospitals were in good condition in field of management preventive and control measures conditions but the conditions of management preventive and control measures was not statistically significant between governmental, military, private and non-governmental public hospitals. (P-value > 0.05).

In the field of engineering preventive and control measures, score higher than 7 indicates good conditions for Engineering preventive and control measures and a score lower than that indicates poor conditions. the highest score was related to military hospitals )11.00 ± 4.24(, then private )10.83 ± 3.37(, governmental 9.84 ± 2.99 and non-governmental public )8.60 ± 4.33(, All hospitals were in good condition in terms of engineering preventive and control measures conditions but the conditions but the conditions of engineering preventive and control measures between governmental, military, private and non-governmental public hospitals There was no statistically significant difference. (P-value > 0.05)

In the total of preventive and control measures, score higher than 64 indicates good conditions for total of preventive and control measures and a score lower than that indicates poor condition. The highest score was related to military hospitals )110.50 ± 12.02(, then governmental )106.84 ± 12.52(, private )106.50 ± 17.21 (and non-governmental public )100.40 ± 13.68(,All hospitals were in good condition in field of management preventive and control measures conditions but the conditions of total of preventive and control measures between governmental and military hospitals, private and non-governmental public were not statistically significant (P-value > 0.05). The percent of preventive and control measures in details was shown in Table S1 of Supplementary.

The aim of this study was to investigate the status of occupational risk factors and preventive and control measures of Covid-19 took place in Tabriz hospitals.

Results of our study indicated that higher rate of average risk factors were in non-governmental public hospitals (4.40 ± 1.140) and the military hospitals studied had the lowest average risk factors (3.00 ± 1.41). Considering that this study was conducted during the fourth peak of Covid-19 in Iran, the problems related to the preparation and supply of PPEs had been resolved. The results of our study also showed that PPEs was fully available to employees in all hospitals. The rate of correct use of PPE was different in hospitals, in public and non-governmental hospitals, the correct use of PPE was fully observed and in military hospitals this amount was reduced by half (50%). The study of Arantes et al. indicated that outbreak of covid-19 caused an increase in awareness about the use of PPE (17) The supply and availability of PPEs alone is not enough, and PPEs should be used correctly and appropriately. Studies showed that proper use of PPE by HCWs decreases the risk of COVID-19(18, 19) and inadequate PPE use(20) increased the risk of a positive COVID-19 PCR test. An observational study by Phan et al. found that 90% of HCWs did not use the correct PPE sequence or technique or did not use the proper PPEs (19). This may be due to a lack of proper training and justification for staff to use PPEs properly. Staff training is essential for the proper use of PPE. Studies have shown that reusing PPEs can increase the risk of a positive Covid-19 test (20, 21). In present study, the highest score in the PPE use section of the preventive measure’s checklist is related to military hospitals, which had a better condition than other hospitals.

Many studies have reported that close contact with a COVID-19 patient (19, 21, 22) and working in Covid-19 wards (23), as the type of risk factor that can cause infection. In our study the prevalence of covid-19 among occupations that have direct exposure with Covid-19 patients are indirectly in non-governmental public hospitals is 80% higher than other occupations.

In present study, high work pressure in the studied hospitals was more than 50%, except military hospitals. Work overload dramatically affected an incremental spread of seropositivity among HCWs (24, 25). The use of public transportation in non-governmental, public and private public hospitals was 80%. Because of using of public transport systems or common vehicles facilitated by hospital workers, some studies have believed that crowded and confined spaces can cause the greater risk for COVID-19 transmission among HCWs (26–29).

The Ministry of Health of Iran communicates and obliges hospitals to implement the guidelines for dealing with and controlling the Covid-19(30). Management control measures including employee training, IPC measures in the workplace and laboratory screening tests to control the coronavirus have been suggested by WHO and the Ministry of Health of Iran (30, 31). All hospitals were in good condition in terms of coronavirus preventive measures. In the risk factor checklist, training on prevention measures of Covid-19 was conducted in all military, government and public non-governmental hospitals and was not provided in only one private hospital (16.7%). Studies indicated that inability to provide training result in infection risk management failure (32, 33). The study of Colaneri et al. showed that asymptomatic or mild covid-19 infection in HCWs should be considered serious and screening should be done more strictly (23). Screening for asymptomatic people, develop a protocol for screening employees before entering the workplace, compliance of screening protocols with other labor laws, distribution of screening checklists, develop screening guidelines and preliminary screening, pre-examination and patient management in hospitals were investigated. Compared to other hospitals, military hospitals had a more unfavorable situation in screening processes. The results of the Astiena et al. study on a military hospital in Indonesia showed that emergency services do not follow the technical guidelines of hospital services. Some influential factors are: staff, room and equipment, budget, patient behavior as well as the screening process(34). A study conducted at three private hospitals in Hong Kong, result showed preventive measures at these three hospitals successfully prevented the transfer of Covid-19 (35). Periodic screening of HCWs reduced the prevalence of covid-19 in HCWs by 37%(36).

Engineering control measures, including isolated rooms with proper ventilation to keep patients and people susceptible or suspected of covid-19, have been suggested by WHO to control the covid-19 virus in hospitals (31). All hospitals were in good condition in terms of engineering preventive and control measures. But in the risk factor checklist, in the aspect of optimal ventilation, the hospitals had a higher risk than other risk factors that investigated. In order to reduce the risk of infections, it is necessary to maintain the air quality in the operating room and use a proper ventilation system (37). Other studies also confirm that despite the expansion of WHO recommendations regarding the improvement of ventilation systems, many centers and institutions still do not follow patient triage policies (38, 39).

In general, there was no significant difference in all total preventive measures between the studied hospitals. In other words, the studied hospitals paid equal attention to the implementation of preventive measures in the hospital. However, disease control strategies can be tailored or adjusted to fit the unique circumstances of each hospital (40) and control measures to be well known by healthcare experts and instantly connected in arrange to moderate the chance of nosocomial transmission and flare-up (41). Anyway, a prompt reaction and usage of disease control measures is basic to spare lives amid an scourge both interior and exterior the healing center (40). Improving the situation of preventive measures in hospitals requires the support of governments, governmental organizations, non-governmental organizations through increasing attention to health care workers and valuing them (42) .We can use the encounters of other countries that had similar experiences (for example Taiwan particularly through the involvement of 2003 SARS) (43).

Results of study confirmed validity of checklists for assessment of status of coronavirus prevention measures in hospitals. Results showed that the status of risk factors of infection with coronavirus and prevention measures in all hospital were in favorable condition. Due to the fact that hospital staff are more and more directly exposed to patients with Covid-19, the importance of preventive measures is doubled. This study can serve as a guide for occupational health professionals and other policymakers to improve the prevention and control of Covid-19 and even other infectious diseases in the future.

Ethics approval and consent to participate

This study was confirmed by the Ethics Committee of Tabriz University of Medical Sciences (Ref. No: IR.TBZMED.REC.1400.458). All methods were carried out in accordance with principles outlined in the Helsinki declaration. All participants signed informed consent before filling out the checklist.

Consent for publication

Availability of data and materials

All preventive and control measures data are available in Table S1 of Supplementary

Competing interests

All authors in this manuscript only work in the field of research and education. Also, none of the authors are representative of the government.

Acknowledgements

The authors are grateful for the financial support of this study by the Department of Health, Rescue and Treatment of I. R. Iran Police Force, Applied Research Center.

Funding

The authors are grateful for the financial support of this study by the Department of Health, Rescue and Treatment of I. R. Iran Police Force, Applied Research Center.

Authors' contributions

All authors of this research paper have directly participated in the planning, execution, or analysis this study

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The status of work-related coronavirus prevention measures and risk factors in hospitals

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