Evaluation of the implementation of hospital hygiene components in 30 health-care facilities in the autonomous district of Abidjan (Cote d’Ivoire) with the WHO Infection Prevention and Control Assessment Framework (IPCAF)

This study analyzes hospital hygiene and WASH infrastructure according to the components of the WHO IPCAF framework in 30 health-care facilities in the autonomous district of Abidjan, particularly in the Health Region Abidjan-2 in Cote d’Ivoire. It represents the first application of the IPCAF tool in this country. It highlighted the level of performance of the implementation of the IPC program in the evaluated facilities and raises issues that deserve to be discussed.

This study showed an overall median IPCAF score of 256.7/800, which corresponded to a basic level of the IPC program in all the health-care facilities visited. Most facilities were at the basic and inadequate levels of IPC at the individual level. The organization of IPC activities (especially for components 1, 2, and 3) was not always in place in almost all the facilities assessed. This greatly hindered the achievement of higher performance scores across all institutions. These results reflect the fact that HH structures and activities were not yet formally established in all Ivorian health facilities in accordance with Decree No. 98–379 of June 30, 1998, which stipulates the establishment of a hospital hygiene service in urban public health facilities that do not have the status of a National Public Institution.

Our overall IPCAF score is similar to those of IPC programs implemented in low-income countries reported by Tomczyk S et al. [25]. This is similar to that found by Opollo MS et al. (2021) at Lira Teaching Hospital in Uganda, quantified as 225/800 in terms of overall score, which refers to a basic level of IPC compliance [13]. This result is also consistent with the result of Rayson D et al. (2021) (median overall HH score, basic, of 212.5) in an assessment of 18 health facilities in the Mwanza region of Tanzania [11].

Our results in terms of IPC components are not isolated and limited to Ivorian institutions; they have been highlighted in other countries. Jeong Y et al. (2022) reported an IPC training rate of less than 30% in all hospital groups in the Republic of Korea, while the prevention of healthcare associated infections was low in primary- and intermediate-level hospitals (25%) [21]. An Australian study found weak education and training on IPC practices and limited implementation of IPC interventions [26]. Training was rarely or never provided in Uganda, while monitoring and follow-up/audit of IPC activities existed [13]. Oppong TB et al. (2020) found inadequate provision of detergents, running water and personal protective equipment (gloves, masks, gowns, etc.) in 56 Ghanaian acute care hospitals [18]. IPC guideline components were low in 32 hospitals in the Indian healthcare associated infections Surveillance Network [27]. The individual score for the component “monitoring/auditing of practices and IPC feedback” was lowest in 11 health facilities in eastern China [17]. Three health facilities in the Ashanti region of Ghana had gaps in antimicrobial stewardship capacity and compliance with WHO guidelines on IPC [9]. The core component “education and training” was among the lowest scores, but low-income countries had the lowest scores in the core components “surveillance of hospital-acquired infections” and “monitoring, auditing of IPC practices and feedback.“ In addition, the study showed limited access to functional toilets and hand hygiene stations at the point of care in low-income countries [25].

In contrast, our result lags far behind those of European, American and Asian countries [17, 21, 26, 27]. In neighboring Ghana, a study involving 56 surveyed facilities found that 19 had an IPC program with clearly defined objectives. Overall, 8 facilities had an advanced level of IPC readiness, 18 an intermediate level, 23 a basic level, and 7 an inadequate level [18]. Another study conducted in three Ghanaian hospitals found that they had basic and intermediate IPC systems with scores of 385, 487.5 and 435.8 out of 800 [9].

Developed countries have implemented key aspects of the IPC program and have achieved good levels of implementation through mostly advanced practices [26, 27]. These results can be explained by the contribution of existing legislation [19], the strong involvement of policy makers, and the implementation of the IPC budget [21]. Indeed, in 2011, the German Infection Protection Act (“Infektionsschutzgesetz”) was revised, increasing the importance of IPC in hospitals [19]. In 2018, the National Health Commission of the People’s Republic of China issued the “Accreditation Regulations of Hospital Infection Control and Prevention,“ which specifies the basic principles, assessment content, and requirements of IPC. For example, annual surveys on the prevalence of hospital-acquired infections have become mandatory in mainland China [17].

Further analysis of the different core components of the IPC program in our study yielded diverse results. Mid-level facilities excelled in implementing an IPC program with a hygiene committee and more structured operational plans. Paradoxically, a peripheral-level facility achieved the highest IPC score ahead of the HGs because the latter had rigorous management of its funding. The guidelines were adapted to national standards and were not optimal. Staff education and training on IPC practices was a major weakness in this study, with implications for staff involvement and implementation of the guidelines. The hygiene staff were often coached by the manager or chief medical officer who was not trained on the issue (no formal IPC training was given or received by staff). This explains the lack of planning of their activities. The commitment of the head of the institution was not strongly felt and suggested that the responsibilities of the actors would not be clearly defined. In addition, IPC training, committee meetings, monitoring and auditing activities were not regular, well-structured, or documented. The few existing reports were not properly archived. These findings strongly contributed to the poor results of this evaluation, with a lack of skills and unacceptable performance in the monitoring and auditing of IPC practices.

Prevention of healthcare associated infections and antibiotic management were not practiced in the evaluated facilities. This result impacts the quality of health services provided and the hospital case fatality and morbidity rates as well as the overall mortality rate [20].

Aspects of WASH (environment, water, hygiene, and sanitation) and waste management were either deficient, nonexistent, or severely limited in almost all the health facilities assessed. This suggests that these facilities did not yet have appropriate structural arrangements for the successful implementation of the IPC program as recommended by the WHO [8, 16, 18]. This result highlights the thorny challenge of sustaining achievements in Africa in general. Indeed, substantial resources were mobilized to prepare the response to the Ebola epidemic, but not all of the achievements of this fight have been sustainable [20].

The IPC and hand hygiene programs were designed by the WHO to facilitate the achievement of Universal Health Coverage (UHC) because they have a direct impact on the quality of care and patient safety at all levels of health services [16]. Nevertheless, we note from the various results obtained that the implementation of IPC components remains problematic, regardless of the level of development of the countries, and raises challenges identical to those of any intervention. It involves contextual aspects, adequate human, material and financial resources, behavioral characteristics, involvement of all stakeholders, specific strategies and expertise in IPC [8].

The lessons learned from the very recent global COVID-19 pandemic should convince the governments of the world, especially those of resource-limited countries, to make a sustained investment in IPC and hand hygiene to ensure better national health.

At the conclusion of this work, we recommend the following: