Optimizing the World Health Organization guidelines for health care workers' protection from COVID-19 in East Africa: an implementation research study

1. Background: In November 2019, Wuhan, China was the epicenter of an outbreak of cases of pneumonia of unknown origin (Zhou et al., 2020). Early in January 2020, Chinese scientists isolated the novel virus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) in patients with pneumonia (Kim et al., 2020). Later in February 2020, World Health Organization (WHO) designated the clinical syndrome as coronavirus disease 2019 (COVID 19) (WHO, 2020). COVID 19 is responsible for a wide spectrum of illnesses ranging from asymptomatic infection to severe pneumonia causing respiratory failure and fatal deaths. As of 18th April 2020, WHO reported 2,160,207 confirmed cases globally and 146,088 deaths attributed to COVID 19 (Practice, 2020). In one study of patients admitted with confirmed SARS-COV-2 infection, the overall in hospital mortality was 28% (Zhou et al., 2020). Notably, 48% of the deaths occurred in patients with co-morbidities such as hypertension, diabetes and coronary heart disease (Shi et al., 2020; Wu et al., 2020; Yang et al., 2020; Zhou et al., 2020). Some of the lessons learnt at this point in the pandemic include the value of taking extraordinary measures such as complete lock-down, tracing and testing contacts and major quarantine restrictions (Bong et al., 2020). However, the outbreak continues to escalate throughout the world causing unprecedented challenges in the healthcare systems. While millions worldwide are advised to stay at home to abate transmission, health care workers (HCWs) are preparing to do the opposite. Reports from China indicating 3,300 HCWs were infected in early March 2020 and of these, 18 died by the end of February 2020 (SU., 2020). The story is the same in Italy and the United States (US) (The Lancet, 2020; Weise, 2020), reinforcing apprehensions that the nation's frontline defense is now becoming especially vulnerable to the virus. Protecting HCWs is crucial. During the severe acute respiratory syndrome (SARS) outbreak in 2003, approximately 1,725 HCWs were infected (Dena and Darryl, 2004). Risk factors for SARS-CoV-2 infection in HCWs include involvement in procedures generating aerosols such as intubation, working longer hours >10 hours/day, and suboptimal hand hygiene (Ran et al., 2020). As the virus spreads into Africa, it is anticipated that facilities will be overwhelmed not only with patients suffering from COVID-19, but also from other known endemic diseases such as HIV, tuberculosis and malaria. Due to shortages in human resources for health, we expect that HCWs will be required to work long hours under considerable pressure. International guidelines that recommend N95 respirators and gowns may not be implemented due to resource limitations (WHO Global Infection Prevention and Control Network, 2020; World Health Organisation, 2020). As WHO has recommended, implementation research is urgently needed to identify the best strategy for preventing SARS-CoV-2 infection in HCWs in hospitals in Africa where resource limitations prevents adaptation of the international guidelines (WHO Global Infection Prevention and Control Network, 2020; World Health Organisation, 2020). We therefore aim to adapt the existing WHO COVID- 19 guidelines and develop an adopted guideline to protect HCWs from COVID 19 at Bugando Medical Center in Northwestern Tanzania. 2. Research question: What is the best strategy to protect health care workers from COVID-19 in North Western Tanzania? Objective: To develop and optimize guidelines to protect HCWs from COVID-19 at Bugando Medical Center using resources available in Tanzania. Hypothesis: The best strategy for preventing HCWs from developing COVID-19 will involve: 1. Careful hand washing with soap and water with monitoring and supervision at handwashing stations 2. Universal masking of healthcare workers from entry to the hospital campus until departure 3. Use of hospital scrubs with a dedicated changing area 4. Reducing out-patient clinic visits (each specialist seeing at least 5 patients) 5. Providing clothed masks for all patients prior to entering the hospital 6. Visiting hours reduced to once a day instead of twice a day 7. One relative per patient allowed during visiting hours 8. Preparing a designated room in all wards for a COVID suspect 9. Ensuring all in-patients are screened (with a questionnaire) prior to usual assessment. 10. All elective surgeries should be postponed 11. Weekly Continuous medical education for all HCWs to ensure adequate understanding of prevention guidelines 12. Limit work hours to <10 hours per shift 13. N95 masks reserved for HCWs performing intubations and other procedures generating aerosol. 3. Methodology Study design: Interrupted Time Series (Quasi-experimental Design). This study design is used to evaluate the impact of an intervention such as a policy change in real world settings. The outcomes are assessed repeatedly over time, both before and after the intervention is introduced (Shadish, Cook and Campbell, 2002). Study area: The study will be conducted in medical wards at Bugando Medical Centre (BMC). BMC is a tertiary teaching hospital that offers super specialized medical care to all specialties, in the city of Mwanza, Tanzania. It has a total bed capacity of 900, 154 of which are located in the medical ward. The medical department has 4 wards (both private and public patients) and 8 units. The medical staff compromises of 20 medical specialists who are allocated in different medical units within the department, 50 nurses and 40 medical ward attendants. Study population: All HCWs in the medical wards at BMC Study procedures: Using the WHO guidelines (WHO Global Infection Prevention and Control Network, 2020; World Health Organisation, 2020) for prevention of infection to HCWs from COVID 19, the first adapted in-hospital guideline to all medical HCWs at BMC will be deployed by a distinct medical committee after obtaining waivers from the BMC ethical board. Once approved, training will be done for all medical in-patient HCWs every day during the first week to ensure the protocol is well adopted and understood. Training will be conducted every morning from 730am in the usual departmental meetings before clinical routine work to 900am. Attendance and contact information for attendees will be captured. The training will also encompass knowledge on safety measures in handling a suspected or confirmed COVID 19 case. All in-patient medical HCWs will be assessed biweekly for infection with COVID 19 via phone interview (we will determine both suspected cases by verbal report and confirmed cases by PCR). Qualitative interviews will also be conducted either in-person or via phone, lasting ~15 minutes. This will be minimally structured, based on an interview guide, and implemented by the principal investigator to assess for knowledge, attitude and practices of HCWs to the adapted protocol. Interview guides will be composed in English, translated into Kiswahili, and back translated to ensure integrity of translation. Protocol adaptation: Following the assessment phase, we will decide whether the existing protocol can be applied to medical HCWs ("Decision") based on the outcomes. If we decide that the protocol will not be useful, we will revise and adopt another protocol. Next, we will conduct another round of training to HCWs using the revised protocol and assess for study outcomes. We will review the outcomes and a draft of the adapted protocol will be submitted to the hospital management for review ("Production"). Based on hospital feedback, we will produce a final adapted BMC guideline for protecting medical in-patient HCWs from COVID-19 in Tanzania. 4. Approach used to maximize the impact of research outputs, to improve health and the research community Findings from this implementation study will provide the most optimal strategies to help HCWs protect themselves from COVID 19 in Tanzania. The adapted protocol will be shared with other hospital institutions to help prevent infections in resource limited settings. 5. Expected outcomes 1. Number of HCWs infected 2. Knowledge, attitude and practices of HCWs to the adapted protocol 6. My role in the project As an internal medicine physician, my role will be to actively participate in developing and revising the various versions of the adapted protocols until the final draft, train the medical staff in the process of adopting the protocol, and follow up with the HCWs via interviews. This study will be conducted in collaboration and mentor-ship from other senior faculty members experienced in doing implementation studies: Prof. Robert Peck (Head of Research Department of Internal Medicine) and Dr. Fredrick Kalokola (Head of Department Internal Medicine).