Supporting Vulnerable Health Systems Improve Infection Prevention and Control to Fight the COVID-19 Pandemic

1 Development Impact Evaluation Department (DIME), World Bank. We thank Jishnu Das, Arianna Legovini, Yoon Sun Hur and Ju Young Lee for their comments and inputs. The findings, interpretations, and conclusions expressed here are those of the authors and do not necessarily represent the views of the World Bank, its executive directors, or the governments they represent. Funding is provided by UK aid from the UK government and from the Korea World Bank Partnership Facility (KWPF); however the views expressed do not necessarily reflect the Korean or UK government’s official policies. All remaining errors are our own. 2 Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, et. al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. Imperial College COVID-19 Response Team. 2020. https://www.imperial.ac.uk/media/imperial-college/ medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf. [cited 20 March 2020]. L eading epidemiological models show that, even with draconian suppression measures, COVID-19 rapidly overwhelms healthcare systems.2 As more patients are hospitalized, healthcare workers at the frontline of delivering care are at the greatest risk of contagion. Worse, if infection prevention and control (IPC) systems are Protecting healthcare workers and patients is critical to reduce the spread of the disease. In this brief we highlight three urgent actions:

1 Development Impact Evaluation Department (DIME), World Bank. We thank Jishnu Das, Arianna Legovini, Yoon Sun Hur and Ju Young Lee for their comments and inputs. The findings, interpretations, and conclusions expressed here are those of the authors and do not necessarily represent the views of the World Bank, its executive directors, or the governments they represent. Funding is provided by UK aid from the UK government and from the Korea World Bank Partnership Facility (KWPF); however the views expressed do not necessarily reflect the Korean or UK government's official policies. All remaining errors are our own. the lowest healthcare worker densities worldwide at 2 and 5 per 1000 people, or 14% and 33%, respectively, of those available in Europe. 9 The source of vulnerabilities in low-and middleincome countries are not well studied, but a study by Bedoya et al. (2017) contributes to our understanding of such vulnerabilities through the largest data collection effort on IPC practices and patient safety in primary care settings in any low-and middleincome country. 10 To understand their results, it is helpful to think of a patient journey through a primary care visit. They will first see a nurse, who must wash his/her hands before the examination. The nurse will then go through the examination, and will have to disinfect the thermometer with an alcohol-based solution. To conduct an invasive procedure, for instance, attending to an open wound, the nurse must wear personal protective equipment (PPE) such as gloves, and segregate infectious waste into appropriate containers. If the patient requires an injection or a blood draw, additional practices will be required. In IPC terminology, every action by a healthcare worker that should trigger an IPC action (washing hands, wearing gloves, segregating waste appropriately) is called an "indication. " If the healthcare worker does not complete this action, it is recorded as a "violation. " Building on In China's Wuhan city, where COVID-19 was first reported, an overwhelmed healthcare system contributed to a fatality rate of 5.8% versus 0.7% in the rest of the country, in spite of considerable centralized support to increase the city's healthcare capacity. 5 Italy's healthcare workers are facing high rates of infection at 5 times that of the general population. Similar levels were reported for Hubei's province, where Wuhan city is located. 6 In short, healthcare workers are disproportionately affected.
Those are the grim statistics for high-income and high-capacity countries. In low-and middle-income countries, the problem might be worse. In Africa, only a few countries have put in place national policies on safe healthcare practices and monitoring systems. 7 By the end of the last Ebola epidemic, the rate of infection among healthcare workers was 21 to 32 times that of the general population in the most affected countries.
These were low-income countries in West Africa, with systems unprepared to face such an outbreak. 8 In the current pandemic, this could further overwhelm health care systems in regions such as Africa or the Eastern Mediterranean, reporting among 3 IPC is "a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers. It is grounded in infectious diseases, epidemiology, social science and health system strengthening, which have been designed to reduce the spread of infections in healthcare settings. " World Health Organization. Infection Prevention and Control. https://www.who.int/gpsc/ipc/en/.
[cited 20 March 2020]. 4 As Peter Piot, co-discoverer of Ebola, stated: "Clinics that failed to observe this [safe injection practices] and other rules of hygiene functioned as catalysts in all additional Ebola outbreaks. " Their mistakes, "drastically sped up the spread of the virus, or made the spread possible in the first place. " 5 WHO's estimated crude mortality rate as of February 20, 2020. China's efforts to support their healthcare system in Wuhan included 40,000 additional healthcare workers sent from other areas of the country to assist the city, the construction of two dedicated hospitals in a few days, and the rapid establishment of fever clinics that separated potential infected people from other patients. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). World Health Organization, 2020. https://www.who.int/publications-detail/report-of-the-whochina-joint-mission-on-coronavirus-disease-2019-(covid -19). [cited 20 March 2020]. 6 The rate of infection is estimated as the proportion of confirmed cases relative to the relevant population. Own estimates based on data from John Hopkins COVID-19 Situation Reports as of March 19, 2020 for Italy and WHO-China Joint Mission Report as of February 20, 2020 for Hubei, China. Healthcare worker infections are more likely to be confirmed than for the general population due to higher access to testing. Healthcare workers includes health service providers, health management staff and support workers in healthcare institutions. John Hopkins COVID- 19

Manufacturing and Provision of Critical IPC Supplies
to Health Facilities: The WHO recommends essential IPC supplies for safe practices, such as hand hygiene, disinfection and sterilization, and PPE for healthcare workers, including standard (gloves, gowns, masks) and specialized PPE like N95 masks and eye protection (e.g., goggles or face shields) for certain procedures. In Kenya, minimum supplies for hand hygiene were available in 70% of facilities-either running water and soap or alcohol-based hand-rub-but only 5% reported the stricter complete set including single-use towels, which is recommended to maximize the effectiveness of hand hygiene. 15 For outpatient services, 72% of facilities had gowns, 84% had gloves, 47% had disinfectant available, and only 15% of facilities had face masks. 16,17 The number of facilities without important supplies in key departments, such as admission and outpatient services, point to suboptimal capacity to protect healthcare workers and patients in the absence of a crisis. This is severely exacerbated during the pandemic-when potential infected patients must also wear a mask-and contributes to the spread of the disease, as well as to increased infection and potential death of health 15 According to Kenya National IPC Guidelines supplies include running water (in a sink or from a bucket with a tap or a bucket with a pitcher), soap (either bar or liquid soap), and availability of single-use towels. The standards set by the WHO and CDC are soap, water, and single-use towel or alcohol-based handrub. The study uses the more lenient indicator without single towels based on the main tools from the WHO  workers. 18 Based on the shortages reported in high-capacity countries such as the US and Italy, countries must redirect manufacturing capacity towards the production and delivery of needed supplies. Supplies are critical to protect healthcare workers and patients, and reduce the spread of the disease. This requires tracking the number of healthcare workers and patient loads, infection rates, stocks and demand, as well as planning for the production and provision of timely, efficient access to the supplies required to fight the spread of the disease.

Mass Media Hand Hygiene Behavior Change Campaigns:
There is real progress in some domains in IPC practice in Kenya, particularly in injections and blood draw safety with compliance reaching 100% for the action of "using new needles and syringes for injections and blood sampling. " However, as Figure 3 shows, some basic practices like hand hygiene compliance remain extremely low even with availability of required supplies (3.2%) and supplies and knowledge (4.2%). Gaps are reported across several domains. This problem is common to many countries.
Appropriate hand hygiene was performed in less than 1% of birth deliveries in a study in India. 19 In Australia 44% of healthcare workers performed hand hygiene before a national intervention. 20  surveillance and infection control response includes early patient detection with rapid expansion of screening clinics and testing Nigeria, 22 to increase awareness of vaccination in Indonesia, 23 and to improve school investments in Ethiopia. 24 Mass media campaigns are cost-effective and can have massive outreach potential with multiplier effects across news and social media.
The systems for prevention and control of infections that are critical for a well-functioning health system are indispensable during a pandemic of a highly infectious disease such as COVID-19. In the past, unprepared health systems across the world, even in high-income countries, contributed to disease transmission during the epidemics of Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). 25 These episodes led some to improve their infection  They also recommend the designation of an infection control staff member at each healthcare institution to ensure infection prevention measures are reinforced and monitored. 29 Singapore and Hong Kong, which faced SARS outbreaks in the past have also had success in controlling the initial spread of the virus. 30 Their basic tactics at health facilities rely on wearing regular PPE for each patient (surgical masks and gloves), performing appropriate hand hygiene and disinfecting surfaces after each patient. They only use more specialized PPE (N95 masks, face protectors, goggles and gowns) for potential infected cases when procedures that could aerosolize respiratory secretions.
They also rely on appropriate triage of suspected cases and social distancing in health facilities to limit exposure of healthcare workers. 31 Learning from countries that have invested in IPC and surveillance systems such as South Korea, Singapore and Hong Kong is essential to protect healthcare workers and patients, reduce risk at health facilities, and help slow down community spread. Providing significant support to low-capacity countries to strengthen their vulnerable systems is of primary importance to reduce the potentially devastating consequences they may face and as a protective action to limit the spread of COVID-19 worldwide.