The status of work-related COVID-19 prevention measures and risk factors in hospitals

1 Introduction

Coronavirus disease 2019 (COVID-19), a startling respiratory danger, which the World Health Organization (WHO) described as introducing a pandemic disease [1]. In Iran, with the distinguishing proof of two cases, COVID-19 was reported for the first time in February 2020 [2].

Despite the low mortality rate, COVID-19 infection contains a high transmission rate as well as a higher mortality rate than that caused by both severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome (MERS) [3]. In this respect, to decrease the transmission rate, Iran’s government in March 2020 required all individuals to remain domestic for vital purposes [4].

The number of deaths induced by the COVID-19 pandemic is increasing all over the world and this alarming statistic has many negative effects on the personal and professional life of people, especially the personnel of health care centers. Also the increase in confirmed daily deaths of patients has caused stress, anxiety and depression in hospital personnel [5, 6]. High working hours, disruption and irregularity in the schedule of work shifts, irregular sleep and a decrease in nighttime sleep hours, lack of provision of appropriate personal protective equipment (PPE), and working in high-risk work areas are risk factors of infection with COVID-19 [7]. In order to manage all of these existing challenges, prevention measures such as training the employees regarding the transfer of patients in the hospital, how to use PPE, managing COVID-19 patients, limiting non-urgent clinical activities, preparing a response plan in response to pandemic conditions, and forming emergency service teams to support the number of HCWs are necessary [8]. The researchers concluded that laboratories should consider organizing staff into smaller shift teams and reducing the number of consecutive work days [9].

It is necessary to implement engineering and management measures to control infection with COVID-19 high-risk workplaces [10]. Health care systems should ensure adequate availability of PPE and develop additional strategies to protect health care workers from COVID-19 infection [11]. Since COVID-19 is spreading rapidly in the world, the guidelines should be adapted based on available resources and local conditions [12].

The lack of PPE supply puts HCWs at risk of infection with COVID-19 [13–16]. Multiple COVID-19 clusters exacerbate pressure on health care systems in hospitals due to transmission of the virus to non-COVID-19 patients and staffs [17]. HCWs safety should be maintained by using appropriate PPE during their duties specially in aerosol generating processes [18]. Providing recommendations and guidelines, 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 [19].

Studies have examined prevention measures in industry workplaces [20], but there are limited studies on prevention measures for COVID-19 in hospitals. This study aimed to determine the status of occupational risk factors of COVID-19 infection and prevention measures in hospitals.

2 Methods

This cross-sectional and descriptive-analytical study was performed from October 21, 2021 to February 24, 2022 to determine the status of preventive measures taken to combat COVID-19 in Tabriz hospital, Tabriz located in northwest of Iran.

3 Results

To assess the validity of the checklist, first, questions with a CVI of less than 79 percent and a CVR of less than 61 percent were removed. Then, 142 questions remained on the checklist, which had a CVI of at least 85 percent and mean of 96 percent, with scale-level CVI: universal agreement of 0.68 and scale-level CVI of0.96 and also a mean CVR of 79 percent. The mean impact score was 4.56. These values indicated favorable validity for this checklist.

As shown in Table 1, PPE was supplied and available to staff in all studied hospitals (100%). The correct use of PPE was 100% in public and non-governmental public hospitals and 50% in military hospitals. The highest percentage of the 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 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 were 80%, 69.2%, and 33.3%, respectively. Avoiding unnecessary meetings and observing health protocols in meeting were fully observed in private, and public non-governmental hospitals and not observed in only one public hospital. Social distancing was fully observed in private hospitals (100%), followed by public hospitals (84.6%), non-governmental public hospitals (60%), and military hospitals (50%), respectively. Training on prevention and control of COVID-19 and proper disposal of infectious 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 infection prevention and control (IPC) principles were related to non-governmental public hospitals (100%), followed by private hospitals (83.3%), government hospitals (76.9%), and military hospitals (50%).

As shown in Table 2, a higher score indicates a higher risk for COVID-19 infection. The provision and use of PPE has a significant relationship with the type of hospital (P-value<0.05). On the other hand, the status of management preventive and control measures and engineering preventive and control measures have no significant relationship with the type of hospital (P-value > 0.05). Among the studied hospitals, the highest mean 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 mean risk factors. However, there was no significant difference in occupational risk factors of COVID-19 infection between governmental, non-governmental public, private, and military hospitals (P-value > 0.05).

As shown in Table 3, a score higher as 5.5 indicates favorable status for PPE, and a score lower than that indicates unfavorable status. The highest score was related to military hospitals (10.50±0.70), then governmental (9.84±1.40), non-governmental public)9.20±1.48) and private)8.66±2.87). All hospitals were in favorable status in the field of PPE use, but there was no statistically significant difference among type of hospitals (P-value > 0.05). In management control measures section, a score higher than 51.5 indicates favorable status for management control measures, and a score lower than that indicates the unfavorable status. 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 favorable status in field of management control measures, but among governmental, military, private and non-governmental public hospitals was not significant difference (P-value > 0.05). In engineering control measures section, a score higher than 7 indicates favorable status for engineering control measures, and a score lower than indicates unfavorable status. The highest score was related to military hospitals (11±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 favorable status in terms of engineering controls. The mean of engineering controls among hospital was not statistically significant difference (P-value > 0.05). In the total of preventive measures, a score higher than 64 indicates favorable status for a total of preventive measures and a score lower than indicates the unfavorable status. 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). Prevention measures in all hospitals were in favorable status, and among hospitals were not statistically significant (P-value > 0.05). The percentage of preventive and control measures is shown in detail in Table 1.

Results of present study indicated that a higher rate of mean risk factors was in non-governmental public hospitals, and the military hospitals studied had the lowest mean of occupational COVID-19 risk factors. Considering that this study was conducted from the end of the fifth peak of the spread of COVID-19 and continued until the end of the sixth peak of the spread of COVID-19 in Iran, the problems related to the preparation and supply of PPE had been resolved. The results of this study also showed that PPE were fully available to employees in all hospitals. The correct use of PPE was different in hospitals, in public and non-governmental hospitals, and the proper use of PPE was fully observed. Arantes et al. indicated that the spread of the COVID-19 result in an increase in awareness about the use of PPE [21].

However, a significant difference was observed between the type of hospital and the provision and use of PPE. Thus, the highest risk associated with the provision and use of PPE was observed in non-governmental public hospitals. On the other hand, the answers to PPE questions in the checklist of preventive and control measures was not show any significant difference among the types of hospitals. Of course, it should be noted that the questions of PPE in the two checklists of occupational risk factors and preventive and control measures were different from each other. The supply and availability of PPE alone are not enough, and PPE should be used correctly and appropriately. Studies showed that proper use of PPE by HCWs decreases the risk of COVID-19 infection [22, 23], and inadequate PPE use [24] increases the risk of a positive COVID-19 polymerase chain reaction (PCR) test. In present study, the correct use the face mask was taught and approximately PPE correctly used in hospitals. 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 PPE [25]. This may be due to a lack of appropriate training and justification for staff to use PPE properly. Staff training is essential for the proper use of PPE. In line with results of current study, many studies have reported that close contact with a COVID-19 patient [23, 26, 27] and working in COVID-19 wards [28] as a risk factors that can cause COVID-19 infection. In the present study, high work pressure in the studied hospitals was more than 50%, except in military hospitals. Work overload dramatically affected an incremental spread of seropositivity among HCWs [29, 30]. The use of public transportation in non-governmental, public, and private-public hospitals was 80%. Because of using public transport systems or standard vehicles facilitated by hospital workers, some studies have believed that crowded and confined spaces can cause a greater risk for COVID-19 transmission among HCWs [31–34].

The Ministry of Health of Iran obliges hospitals to implement the prevention guidelines for dealing with controlling COVID-19. The WHO and the Ministry of Health of Iran have suggested that management controls, including employee training, IPC measures in the workplace, and laboratory screening tests to control COVID-19 [35, 36], with good planning and implementation of guidelines, can limit the spread of COVID-19 [37]. All hospitals were in favorable status in terms of COVID-19 preventive measures. A study in Ethiopia found that preventive measures against COVID-19 provided by HCWs were poor. In this study, lack of resources, less commitment and insufficient training were declared as the main factors of poor preventive measures [38]. A study conducted in China on HCWs, showed that comprehensively during the time of increased risk of COVID-19, most HCWS improved IPC performance [39]. In a study on IPC measures in ophthalmology centers, Veritti et al. showed that in order to reduce the risk of transmission and control the spread of COVID-19 in the hospital, IPC measures should be identified and implemented [40]. Another study in India found that suboptimal compliance with preventive measures is common among young HCWs, especially resident physicians and paramedical staff, and compliance with preventive measures is high [41].

In the present study, management controls such as training programs to prevent COVID-19 were implemented. A study conducted by Marya et al. in different countries to investigated the risk of COVID-19 and preventive measures showed that dentists have sufficient knowledge of the methods of transmission of COVID-19 and the principles of IPC [42]. The study of Ilesanmi et al. conducted on HCWs in Nigeria showed that inadequate knowledge about IPC measures is one of the main reasons for the increase in COVID-19 infection among HCWs [43].Other Studies indicated that the inability to provide training programs could results in infection risk management failure [44, 45].

The study by Colaneri et al. showed that asymptomatic or mild COVID-19 infection in HCWs should be considered severe, and screening should be done more strictly [28]. A study at a specialized infectious disease center in Italy showed the importance of periodic screening for COVID-19 for health care workers [46]. Screening for asymptomatic people, developing a protocol for screening employees before entering the workplace, compliance of screening protocols with other labor laws, distribution of screening checklists, developing screening guidelines and preliminary screening, pre-examination and patient management in hospitals were investigated. Military hospitals had a more unfavorable situation in screening processes compared to other hospitals. In a study conducted by Lahiri et al. in India, results showed that in addition to social distancing measures, other related measures should be taken, such as increasing screening tests and increasing the capacity to accept patients [47].

The Astiena et al. study on a military hospital in Indonesia showed that emergency services did not follow the technical guidelines of hospital services. Some influential factors are staff, room and equipment, budget, patient behavior, and the screening process [48]. In a study conducted at three private hospitals in Hong Kong, results showed preventive measures at these hospitals successfully prevented the transfer of COVID-19 [49]. Periodic screening of HCWs reduced the prevalence of COVID-19 in HCWs by 37% [50] and routine rapid testing of COVID-19 on patients and HCWs is one way to reduce the risks of COVID-19 [51]. A study by Lala et al. showed that contact tracing of COVID-19 patients and increasing the capacity to accept mild COVID-19 patients were the most important factors in controlling the spread of COVID-19 in China and Singapore, which had a greater effect on reducing the spread of COVID-19 in these countries [52]. Another study conducted in Italy also showed the importance of timely screening and isolation of cases with Covid-19 and correct use of PPE by HCWS [53].

Despite the fact that personnel vaccination in military and private hospitals has been done completely, in a governmental hospital and a non-governmental public hospital, not all personnel has been vaccinated. A study by Pratibha Taneja et al. showed that in order to increase the acceptance of the COVID-19 vaccine, awareness campaigns should be formed and extensive information should be provided in this field [54].

Engineering controls, including isolated rooms with proper ventilation to keep susceptible or suspected of COVID-19 patients and people have been suggested by the WHO to control COVID-19 in hospitals [36]. All hospitals were in favorable condition regarding engineering controls. In present study, hospitals had a higher risk than other risk factors in the term of optimal ventilation. To reduce the risk of infections, it is necessary to maintain the air quality in the operating room and use a proper ventilation system [55]. Other studies also confirm that despite the expansion of WHO recommendations regarding improving ventilation systems, many centers and institutions still do not follow patient triage policies [56, 57]. Improving the status of preventive measures in hospitals requires the support of governments, governmental organizations, and non-governmental organizations through increasing attention to health care workers and valuing them [58].

5 Conclusion

The provided checklists could be a suitable tool for monitoring the status of occupational risk factors of COVID-19 infection and prevention measures in hospitals. This study indicated that status of prevention measures against COVID-19 in Iranian hospitals were in favorable condition. The risk of preparing and using PPE is related to the type of hospital. Improving engineering controls such as of ventilation systems is necessary in most of hospitals.