Implementing evidence-based biosecurity protocols in Veterinary Teaching Hospitals: a critical review and guide for best practices.

Supplement: STRIVE1 October 2019The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care–Associated Infections at the Local LevelFREEKyle J. Popovich, MD, MS, David P. Calfee, MD, Payal K. Patel, MD, MPH, Shelby Lassiter, BSN, RN, CPHQ, Andrew J. Rolle, MPH, Louella Hung, MPH, Sanjay Saint, MD, MPH, and Vineet Chopra, MD, MScKyle J. Popovich, MD, MSRush University Medical Center, Chicago, Illinois (K.J.P.), David P. Calfee, MDWeill Cornell Medicine, New York, New York (D.P.C.), Payal K. Patel, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), Shelby Lassiter, BSN, RN, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Andrew J. Rolle, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Louella Hung, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Sanjay Saint, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), and Vineet Chopra, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3529 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Health care–associated infection (HAI) remains an important problem in the United States (1, 2). Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are among the most common device-associated infections, whereas Clostridioides difficile and methicillin-resistant Staphylococcus aureus (MRSA) are among the most prevalent pathogens causing HAI. In 2011, there were an estimated 721 800 HAIs in U.S. acute care hospitals, with C difficile, S aureus, Enterococcus species, and gram-negative bacilli being the most common pathogens (3). To address the burden of these infections, evidence-based infection prevention strategies, including "bundles" or combinations of interventions, have been developed and successfully implemented in many hospitals to prevent HAIs (4–8). For example, bundles have been created to decrease CLABSI (4), CAUTI (5, 9), and MRSA bloodstream infection (6, 7). In U.S. intensive care units, there has been a substantial reduction in CLABSIs, thought to be in large part due to implementation of bundles (4, 10).Many U.S. hospitals, unfortunately, continue to experience high rates of HAI (11) because of low compliance with infection prevention practices, poor organizational culture, financial limitations, limited engagement from front-line personnel, and limited leadership support (12). Of note, assistance from external sources, such as local, state, and national groups (including public health departments, quality improvement organizations, hospital associations, and academic medical centers), can help reduce HAI (13, 14). However, the ways and extent to which these entities engage with hospitals to improve HAI rates vary, resulting in heterogeneity of outcomes (12). Comprehensive solutions to this complex dynamic within and across hospitals, states, and the country have not been developed. In particular, strategies to help hospitals that continue to have high rates of HAI are needed.To reduce infections in hospitals with high rates of HAI, the Centers for Disease Control and Prevention (CDC) funded a prospective, interventional, nonrandomized, quality improvement program that spanned multiple hospitals and states. Development, implementation, and execution of the program was performed by the Health Research & Educational Trust (HRET), a not-for-profit research and education affiliate of the American Hospital Association, along with several partners, such as state hospital associations (SHAs), professional societies, and scientific experts from academic medical centers. Collectively, the program was titled CDC STRIVE (States Targeting Reduction in Infections via Engagement). This article provides a summary of how STRIVE constructed the building blocks for a national effort intended to reduce HAIs in participating hospitals.Program Goals and StructureThe STRIVE initiative focused on bringing national health care professional societies, subject-matter experts, and state-level health care organizations together with short-stay and long-term acute care hospitals to improve infection prevention and control practices. The overall objective of the program was to identify, partner with, and collaborate with hospitals struggling to reduce HAI by pairing national subject-matter experts with state, regional, and local organizations to effect sustainable change (Figure 1).Figure 1. Overall flow of the CDC STRIVE program.CDC = Centers for Disease Control and Prevention; STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint To deliver on this ambitious goal, the STRIVE initiative had 3 specific aims: 1) strengthen infection control practices through dissemination and implementation of CDC's Targeted Assessment for Prevention (TAP) strategy; 2) strengthen relationships among SHAs, state health departments, and other state HAI partners, such as the Centers for Medicare & Medicaid Services Quality Innovation Network–Quality Improvement Organizations, to create a structure to facilitate durable implementation of best infection control practices; and 3) provide technical assistance to facilities to improve implementation of infection control practices in existing and newly constructed health care facilities. Reductions in C difficile infection (CDI), CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection in participating hospitals were chosen as measures to determine initiative success.Program planning for STRIVE began in September 2015. Subject-matter experts from multiple organizations were identified by CDC and HRET and brought together to form a national program team to provide oversight for the program and build educational content. Members of the national program team included representatives from CDC, HRET, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, and University of Michigan Health System.Stakeholder Considerations in Designing STRIVE InterventionsThe CDC outlined several objectives to increase alignment and coordination of HAI prevention efforts across stakeholders: First, identify strategies to improve infection control implementation activities on a state- and facility-level; second, identify indicators of capacity (infrastructure, staffing, partnerships, and training), ongoing regional collaboratives, and other contextual factors (such as state-level mandates) that may affect implementation of infection prevention efforts; and third, identify roles of state partners (state health departments, SHAs, Quality Innovation Network–Quality Improvement Organizations) in the coordination, integration, and alignment of infection prevention and control activities.Eligibility and Selection of Participating HospitalsThe CDC STRIVE initiative focused specifically on hospitals with a disproportionately high burden of HAI. To target these facilities, the CDC used National Healthcare Safety Network (NHSN) data from the first 2 quarters of 2015 to identify states with hospitals that had a high burden of CDI and a high burden of at least 1 of the following HAIs: CLABSI, CAUTI, or hospital-onset MRSA bloodstream infection. "High burden" was defined by examining the cumulative attributable difference (15) (using the U.S. Department of Health and Human Services' 2020 HAI goals as the standardized infection ratio target). Hospitals with a cumulative attributable difference above the first tertile (that is, the top one third) were designated as having a high burden of HAIs. Data for all 4 infection types were combined to identify hospitals with CDIs plus at least 1 other HAI with cumulative attributable differences above the first tertile.Three methods were used to identify eligible states. First, CDC identified states with the largest number of hospitals that met inclusion criteria. These states thus became the main focus of STRIVE efforts. Second, to include sites that may also benefit from STRIVE, HRET applied the CDC approach with publicly available Hospital Compare state-specific data to identify additional hospitals with a high burden of HAIs not included in the cumulative attributable difference first tertile. Finally, a few interested states not included in the above were allowed to volunteer to participate in STRIVE. Using these methods, 34 states and the District of Columbia were identified for possible inclusion in STRIVE.Rather than approach hospitals directly (and in keeping with the STRIVE goal to strengthen state and local partnerships to combat HAI), HRET shared the list of potentially eligible hospitals with SHAs and asked them to recruit sites. In this way, the CDC and HRET engaged SHAs to reach out to hospitals to inform them about the program, solicit their interest, and recruit them to participate. As word of the intervention and program spread, a few states that were not identified by the CDC also requested to participate in the STRIVE program, because they viewed this program as important to help improve hospital infection control practices.To better consolidate efforts and understand the impact of interventions, recruitment within STRIVE occurred within waves, leading to 4 cohorts of hospitals (Table): cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Cohort 1 was identified as a pilot cohort in which interventions to reduce HAI were developed and pilot-tested in conjunction with key stakeholders. In total, 443 short-stay and long-term acute care hospitals from 28 states and the District of Columbia participated in 4 overlapping, 10- to 12-month cohorts (Appendix Figure). In 2015 (before the intervention), the median cumulative attributable difference values for cohorts 2, 3, and 4 were as follows: CAUTI, 0.67 (interquartile range [IQR], –0.62 to 4.22); CLABSI, 1.46 (IQR, –0.02 to 5.44); CDI, 5.04 (IQR, 0.16 to 17.48); and MRSA, 0.45 (IQR, –0.15 to 2.67).Table. Characteristics of Hospitals Participating in the STRIVE ProgramAppendix Figure. States that enrolled with the STRIVE program.In total, 443 hospitals from 28 states and the District of Columbia participated. Recruitment occurred as follows: cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Hashing indicates states that participated in more than 1 cohort. STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Informing Change—Designing InterventionsPractice Change AssessmentDuring STRIVE, participating hospitals were asked to complete a survey instrument to identify and address gaps in HAI prevention at the beginning of cohort enrollment (baseline) and at the end of the study wave (comparison) (Figure 2). This gap assessment could be done using either the CDC's Infection Control Assessment and Response (ICAR) survey (16) or the STRIVE Practice Change Assessment (PCA). The ICAR had been previously developed for state health departments to assess infection prevention practices in hospitals. The PCA, based on the ICAR, was modified to focus on 8 domains germane to the STRIVE program. Four of the domains focused on specific HAIs—CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection—whereas the remaining 4 domains focused on hand hygiene, personal protective equipment, environmental cleaning, and antimicrobial stewardship.Figure 2. Education and engagement interventions implemented for participating hospitals.CDC = Centers for Disease Control and Prevention. Download figure Download PowerPoint Baseline surveys were administered by each participating hospital with support and (at times) a site visit by the state partners. If a hospital had completed an ICAR in the year before STRIVE, they were able to reuse that survey for their baseline assessment. A summary report from these assessments was provided to each site, highlighting opportunities for improvement and a list of STRIVE content and resources to assist in addressing these gaps.Education: Foundational and HAI-Specific Web-Based ModulesSubject-matter experts created educational materials for 12 different topics. Development of educational materials by experts occurred via in-person meetings and work group conference calls. Two primary topic domains were identified around which program education would be focused: foundational and HAI-specific elements.The foundational domain emphasized core infection control practices that are known to have variable compliance but are critical for success of any HAI prevention initiative (for example, hand hygiene, personal protective equipment use, and environmental cleaning). Many are considered "horizontal" infection control strategies in that they affect not one but many pathogens and HAIs. Eight elements for the foundational domain were identified: 1) competency-based training, auditing, and feedback; 2) hand hygiene; 3) personal protective equipment; 4) environmental cleaning; 5) antimicrobial stewardship; 6) making an effective infection prevention business case; 7) patient and family engagement; and 8) socioadaptive strategies for preventing infection.The HAI-specific domains were concentrated on best practices for preventing CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection. In total, subject-matter experts created 51 short (10 to 20 minutes), Web-based, on-demand educational modules covering key topics in the 2 domains (Appendix Table).Appendix Table. Overview of the 51 Web-Based Learning Modules Developed for the STRIVE ProgramA 2-tiered intervention approach was developed for the HAIs targeted in STRIVE. Tier 1 interventions were defined as basic, evidence-based interventions that every hospital should have in place (for example, ensuring that central lines are placed aseptically). Foundational elements remained a critical aspect across tier 1 for the HAI-specific modules as these elements generally have demonstrated success, are economically efficient, and have multiplicative effects across HAIs. Foundational elements are also crucial to have in place before more complex technical and social interventions are introduced. Tier 2 interventions were generally considered more complex, "advanced" steps for hospitals to take once tier 1 interventions were reliably in place but not leading to a decline in a particular HAI. In general, tier 2 interventions were considered to require increased human and economic capital compared with tier 1.Engaging Sites: Learning Action ForumsIn conjunction with the Web-based modules, monthly learning action forums were hosted by HRET for all cohorts. These monthly, 1-hour webinars were discussion-based and interactive and were built on supporting the didactic content from the curriculum's on-demand courses. They provided hospitals with an opportunity to share their infection prevention strategies, challenges, and successes, thereby strengthening engagement and learning across member sites. The learning action forums also allowed national subject-matter experts to interact with hospitals and answer questions related to webinar content or materials. The lead for most learning action forums was often an infection preventionist or someone with a role in quality at the local hospital. The lead would distribute the webinar information to staff, which typically included nurse managers, environmental services, frontline clinicians, and other clinical and nonclinical staff, depending on the topic of the learning action forum.Education: TAP StrategyThe TAP strategy (15) developed by the CDC can be used not only to identify facilities and units with a high burden of HAIs, but also to highlight gaps in infection prevention. In this way, finite infection prevention resources can be directed to areas of greatest opportunity. The TAP strategy incorporates the TAP reports generated in the CDC's NHSN, along with standardized assessment tools and implementation strategies for CLABSI, CAUTI, and CDI.Feedback from the cohort 1 pilot revealed that additional, more intense education and training on how best to use TAP reports was needed. Although most hospital infection preventionists had heard of the TAP strategy, most lacked in-depth knowledge, and few organizations were actively using TAP resources. Therefore, many state-level in-person meetings incorporated TAP training, provided by their state health departments, to drive increased understanding of this strategy. In addition, from June 2017 to January 2018, the CDC collaborated with HRET to develop and deliver four 90-minute webinars on how to run and interpret TAP reports and use TAP strategies and resources to maximize HAI prevention. To further support state partner knowledge of this valuable resource, the CDC provided a webinar in December 2017 for state partners, providing additional education around how to use TAP reports and strategies at the state level to promote HAI prevention work.Strengthening Partnerships Through Coaching and CollaborationState health departments and SHAs collaborated to support hospitals in administering the PCA or ICAR, interpreting results, and finding resources to address identified gaps. In addition, state health departments were instrumental in educating hospitals on running and using TAP reports, utilizing STRIVE venues, such as in-person meetings and site visits in each state, along with the SHA. In addition, the SHA program lead (and often their health department partners) supported hospitals via monthly one-on-one calls, webinars, or office hours open to all STRIVE hospitals. These touch points were used for shared learning and coaching from the state mentors and experts around barriers and action planning to reach goals. Upon request, subject-matter experts from the national program team would also join such calls to add expertise. The state partners often acted in the role of encourager and cheerleader for teams to support momentum as well.State In-Person MeetingsOn the basis of feedback from cohort 1 pilot sites, state-level in-person meetings were implemented for all participating states in cohorts 2 to 4. Although the online and virtual materials were felt to be helpful, sites in cohort 1 felt that bringing hospitals and state partners together in person was necessary to support building relationships. Such meetings also provided protected time and space for hospital participants' learning and networking with peers as well as state and national experts.ImplementationIn contrast to single-unit interventions often found in infection control projects, the focus of this program was large-system transformation (17) to influence multiple hospitals, organizations, and health care providers. The national program team developed a full STRIVE implementation plan focused on leveraging content for both foundational and HAI-specific practices. The curriculum was divided into 3 phases: onboarding to the STRIVE program, foundational infection prevention strategies, and education targeted to the program's 4 HAIs.In May 2016, onboarding started for cohort 1, which included a general program overview, team formation, and education regarding ICAR/PCA assessments and TAP strategy. The rollout for Web-based modules then occurred for cohort 1 as follows: July to October 2016 (foundational elements modules), November 2016 to January 2017 (HAI-specific tier 1 modules), and February 2017 to March 2017 (HAI-specific tier 2 modules). These modules were available to all subsequent cohorts throughout their 12-month collaborative after their onboarding. Web modules for STRIVE can be found at www.cdc.gov/infectioncontrol/training/strive.html.ConclusionThe STRIVE initiative, coordinated by the HRET and funded by the CDC, brought together state-level organizations with short-stay and long-term acute care hospitals across the country to improve infection prevention and control practices for hospitals with a disproportionately high burden of HAIs. Federal funds for this initiative were in part in response to the lessons learned with Ebola and how stakeholders were interested in strengthening state partnerships and infection control measures in preparation for any future emerging infectious disease. Through the STRIVE initiative, the architecture of preventing HAI shifted from hospital-based to instead utilizing national efforts to effect local improvement efforts in hospitals across the United States.

Infections acquired in a hospital (HAI) often referred to as nosocomial infections are related with increasing morbidity and death among patients that are hospitalised and are predisposed to an elevated risk of infection by health workers (HCWs). The need to maintain an effective infection prevention and control program is therefore essential for quality health care. This study sought to assess the knowledge and compliance of infection control practices of Cardiovascular Perfusionists in theatre at a private healthcare facility in KwaZulu-Natal (KZN) in the city of Durban. We conducted a qualitative study based on in-depth interviews with 12 Cardiovascular Perfusionists (CP) who were purposively selected from private sector. The interviews lasted between 20 to 25 minutes and were transcribed, and then thematic analysis were applied using NVivo. The study found that there is a need for Clinical Technologist specialising in Cardiovascular Perfusion to undergo training in infection control and prevention practices at the higher education and training level. Subsequently, the study reveals that Cardiovascular Perfusionists have a good overall understanding of pathogens and the implications thereof. The study also notes that there is considerable compliance to infection control practices in theatre irrespective of the knowledge pertaining to infection control and prevention policies. We concluded that there is an overall good knowledge and understanding regarding infection control practices, although many felt that there exists an inequitable application of infection control policies due to professional biases.

To determine the relation of the availability of personal protective equipment (PPE) and engineering controls to infection control (IC) practices in a prison healthcare setting, and to explore the effect on IC practices of a perceived organizational commitment to safety. Cross-sectional survey. The study population was drawn from the 28 regional Correctional Health Care Workers Facilities in Maryland. All full-time Maryland correctional healthcare workers (HCWs) were surveyed, and 225 (64%) of the 350 responded. A confidential, self-administered questionnaire was mailed to all correctional HCWs employed in the 28 Maryland Correctional Health Care Facilities. The questionnaire was analyzed psychometrically and validated through extensive pilot testing. It included items on three major constructs: IC practices, safety climate (defined as the perception of organizational commitment to safety), and availability of IC equipment and supplies. A strong correlation was found between the availability of PPE and IC practices. Similarly, a strong correlation was found between IC practices and the presence of engineering controls. In addition, an equally strong association was seen between the adoption of IC practices and employee perception of management commitment to safety. Those employees who perceived a high level of management support for safety were more than twice as likely to adhere to recommended IC practices. IC practices were significantly more likely to be followed if PPE was always readily available. Similarly, IC practices were more likely to be followed if engineering controls were provided. These findings suggest that ready availability of PPE and the presence of engineering controls are crucial to help ensure their use in this high-risk environment. This is especially important because correctional HCWs are potentially at risk of exposure to bloodborne pathogens such as human immunodeficiency virus and hepatitis B and C viruses. Commitment to safety was found to be highly associated with the adoption of safe work practices. There is an inherent conflict of "custody versus care" in this setting; hence, it is especially important that we understand and appreciate the relation between safety climate and IC practices. Interventions designed to improve safety climate, as well as availability of necessary IC supplies and equipment, will most likely prove effective in improving employee compliance with IC practices in this healthcare setting.

To the Editors: Standard infection control precautions and centralized prevention/education has improved health care outcomes for patients and health care workers (HCWs).1–3 In resource-limited health care settings, implementation of these practices is challenging and transmission of highly resistant organisms within health care facilities is described.4–7 High rates of needle stick injuries8 and unsafe injection practices9 occur in clinics and hospitals where blood borne infections such as hepatitis and HIV are common; postexposure prophylaxis is infrequently accessed.10 Alcohol gels are perceived as expensive and may be unavailable, and many settings lack appropriate hand-washing facilities.11 Personal protective equipment is often absent, and medical equipment may be old and in disrepair. Strict standards for environmental controls are difficult to maintain, and health care facilities themselves are often archaic. International recommendations are available for infection control, but programs are not consistently regulated and have few monitoring and enforcement programs.12–14 The National Institute of Allergy and Infectious Diseases (NIAIDs) supports 6 networks conducting HIV-related clinical research. Many clinical research sites (CRSs) are located outside of the United States in resource-limited settings. CRS that have access to the patients and resources necessary to perform high-quality research are limited and usually engage in diverse research. A single site might have studies focusing on the prevention of mother-to-child transmission of HIV, intensive pK studies involving new drugs for multiresistant organisms, and protocols testing second-line antiretroviral therapy. Standard clinical care is provided in often-crowded facilities, where research subjects are present for many hours. Anecdotal observations have suggested that there are significant variations in infection control practices among the sites. METHODS A survey of the infection control resources and practices at the CRS outside of the United States was undertaken, led by the Office of HIV/AIDS Network Coordination. Sites were asked about a formal infection control program, staff safety, respiratory hygiene and tuberculosis control, hand hygiene capabilities, injection practices, and blood safety. RESULTS Overall, 74 sites were offered the survey, and 32 returned completed surveys. Twenty-three of 32 AIDS Clinical Trials Group sites completed the survey. Selected results are summarized in Figure 1.FIGURE 1: Selected infection control practices at international NIAID-funded HIV clinical research sites.Infection Control Organization Eighty-six percent of sites had an infection control policy, of these 55% were specific to the CRS. Seventy-five percent of sites had an infection control officer, directly employed by the sites, half the time. The sites without an infection control policy frequently did not have policies addressing the domains surveyed. Respiratory Sixty percent of sites reported a triage system to identify participants with potential respiratory infections. Commonly, the study participant was placed in a well-ventilated area and provided a mask. Less than half of respondents (45.2%) conduct protocol procedures with participants with known or suspected tuberculosis (TB) in a separate clinical area. Natural and mechanical ventilation were common methods of ensuring respiratory hygiene. N95 masks were available in the general clinic, in 39% of sites (12/31). Ultraviolet lights were present in 8/29 general clinical areas and 4/13 dedicated sputum collection areas indoors. A dedicated space for sputum collection was present in 55% of the CRSs. Space for sputum collection was most commonly an area outside (approximately 55%) or a dedicated sputum collection area inside (approximately 45%). In the space for sputum collection, natural and mechanical ventilation were used as infection control measures. Twenty-five percent of sites reported surgical masks worn by patients. Staffs were provided N95 masks 50% of the time in the dedicated sputum collection area; 2/11 sites reported that N95 respirators were available. Educational material on cough hygiene was available at 40% of the respondent sites. Forty-five percent of sites had TB surveillance programs for staff and routinely screened staff for TB infection 71% of the time. Hand Hygiene All sites reported sinks with running water; most had manual soap dispensers (25/32) and paper hand towels (27/32). Hand sanitizers were available at half of the sites. Water basins filled remotely were used in some areas in 15/32 sites, bar soap in 13/32 sites, and cloth hand towels in 11/32 sites. Blood Safety All sites reported a policy for management of needle stick injuries, and all sites had appropriate postexposure prophylaxis for HIV. The source patient is tested for hepatitis B at 58% of sites and hepatitis C at 39% of sites. Postexposure protocols for hepatitis B were present in 42% of sites. Most sites reported a needle recapping policy (71%), and 58% used safe needle systems. Sharps containers were generally available. DISCUSSION Healthcare-associated infections are an important cause of morbidity for patients, and health care providers in resource limited settings. A recent meta-analysis suggested that rates of indicator healthcare-associated infections might be more than double those of resource rich settings.15 Our survey suggested important areas for improvement in the delivery of health care associated with NIAID-sponsored clinical trials. There is good evidence that organizational support for infection control reduces the transmission of infectious agents and reduces mortality and morbidity in the acute care setting.16,17 Critical elements include staff trained in the principles of infection prevention, surveillance, and enforcement of preventative measures. Prevention of occupational illnesses requires preemployment assessments and immunization for vaccine-preventable illnesses. A quarter of the sites did not have appropriate personnel tasked with infection prevention. Those sites that did not have specific policies related to infection control also did not have policies to address most of the infection control domains. TB transmission in the health care environment is well described. The association with HIV infection is important, and instances of transmission clusters of highly resistant TB have been documented.18,19 A review examining the incidence and prevalence of latent TB infection among HCW in low- and middle-income countries suggested that HCW were at significant risk for TB disease compared with the general population.20 Even in areas where transmission of TB has been described, infection control procedures may be lacking. In eThekwini Municipality, Durban, RSA, only a quarter of primary health clinics triaged patients with cough. This is consistent with our experience. Patients with known or suspected TB are seen in the same facility as patients without TB, and segregation of individuals who might be infectious is not commonly undertaken. Cough hygiene has been promoted in resource-rich settings as a way of reducing spread of respiratory pathogens, fewer than half the sites had information available about cough hygiene. Hand hygiene is a critical measure to reduce health-care-acquired infections. Improvement of hand hygiene practices has been associated with reduced infection rates in hospitalized patients.21 In 2009, the WHO described best practices for hand hygiene and methodologies for local manufacture of inexpensive hand sanitizing gel.22,23 The multimodal strategy was tested in a reference hospital in Mali and found to be feasible, affordable, and effective.24 The WHO has ongoing efforts to promote hand hygiene using alcohol-based hand rubs throughout the world; however, a recent survey in Uganda of attitudes toward infection control gel for hand hygiene was perceived to be expensive and unavailable.11 In our survey, hand hygiene practices varied widely; alcohol-based gel was not generally available. The use of hand basins with standing water accompanied by bar soap and multiuse towels was striking. HCW are at risk for infection with blood borne pathogens, and needle stick injuries are common. One survey in Malawi suggested that half of nurses had a needle stick injury within the previous year.25 This rate is similar to rates in resource-rich settings before the widespread adoption of engineered needle-safe solutions.26 The consequences of outdated needle practices combined with high prevalence rates of HIV, hepatitis B, and hepatitis C may be catastrophic.27 Although postexposure prophylaxis is available for injuries that might be capable of transmitting HIV, it is unknown to what extent the work force is at risk for hepatitis B, as the information is not collected before employment. Participation in research should not place patients at more risk when compared with the local standard of care. The concentration of patients with communicable diseases drawn to the research site to participate in clinical protocols and the need for prolonged face-to-face interactions could lead to an increased risk for preventable infections in the research setting compared with the clinical environment. Arguably, research settings should set and demonstrate higher standards for clinical care, even when these levels cannot be implemented immediately throughout the health care system. Ethicists have commented that researchers should not replicate unacceptably low local standards but should seek to establish competent levels of care that can ultimately be feasibly implemented in the health system, for the benefit of all patients.28,29 Our survey demonstrated important areas for improvement in infection prevention. There are good precedents in the resource-limited setting for developing standards for hand hygiene and the prevention of blood borne illnesses. The most pressing need is for a protocol for the prevention of TB transmission. This has been developed and is being implemented at our sites. TB infection control, however, is best undertaken in an environment of other infection prevention efforts. NIAID and other research sponsors have a unique opportunity to model better health care infection control practices; it is hoped that this will lead to improved health care outcomes.

Despite widespread concern and knowledge about the need for infection prevention and control in health care, it is clear that adherence to strict infection control procedures is not always at an optimal level (El-Masri and Oldfield, 2012). Hospital Acquired Infection (HAI) may occur when these standards break down, and HAI is a commonly discussed media topic (Bates, 2012). Alarmingly, a recent outbreak of Hepatitis C in the USA, resulting from inappropriate interference by health staff with equipment (needles) (Ramer, 2012) reminds us that even when vigilant approaches are used to combat the spread of infection, the potential for contamination from blood-borne infections remains a real possibility. Blood-borne viral infections include human immunodeficiency virus (HIV), Hepatitis C virus (HCV) and Hepatitis B virus (HBV). Taking precautions alone is not sufficient; staffs need to be knowledgeable in the disease and spread of disease. It is important to note that the risk of disease spread is to both staff and patients, although most staffs are vaccinated to prevent HBV (DoHC, 2005). While discussion papers and research studies on the topics of blood-borne diseases such as HCV, HBV and HIV/Aids are reduced in number compared with the 1980s and 1990s, current literature appears to indicate that knowledge deficits exist among nurses with regard to both HCV (Frazer et al., 2011) and HIV/Aids (Delobelle et al., 2009), and education and training specifically on these topics seems to be inconsistent and in some cases minimal (Delobelle et al., 2009; Frazer et al., 2011). This editorial discusses how blood-borne viruses (BBVs) can be best prevented in the health care setting in order to highlight the need for ongoing vigilance. An increased incidence of HBV and HCV transmission in the USA is associated with unsafe medical practices (Moore et al., 2011) particularly in those persons aged over 55 (Perz et al., 2012). These two viruses are the most prevalent in the USA with an estimated 1·4 million persons chronically infected with HBV and 3·2 million persons chronically infected with HCV (Weinbaum et al., 2008). A BBV is transmitted through contact with blood or body fluids typically through sexual or household contact, intravenous drug use or other parenteral exposures (Wise et al., 2012). Within health care settings, BBV transmission occurs through direct percutaneous inoculation of infected blood via needlestick or sharps injury or by blood splashed onto broken skin or mucous membranes (Stein et al., 2003). Health care workers (HCWs) undertaking exposure-prone procedures (EPPs) are also at risk of contracting BBVs (DoHC, 2005). The average risk of occupational HIV transmissions associated with percutaneous exposure to blood is 0·32% (approximately 1 infection in 325 documented exposures to blood from HIV-infected individuals) and for mucosal exposures it is 0·03% (approximately 1 infection for each 3300) (Henderson, 2012). The risk of occupational HBV infection following a parenteral exposure from an HBV-infected source patient with circulating e antigen is between 19% and 37% (Werner and Grady, 1982). The risk of occupational infection with HCV following parenteral exposure to blood from HCV-infected source patient is estimated at 1·9% per exposure (Henderson, 2003). In 1985, following an HIV epidemic, the Centre's for Disease Control (CDC) developed recommendations for prevention of HIV transmission in health care settings known as universal precautions (UP) (CDC, 1987). Blood was identified as the single most important source of HIV and HBV (Garner and Hospital Infection Control Practices Advisory Committee, 1996). As it is impossible to identify all patients that are sero-positive to HIV, HBV or HCV, UP dictates that all patients should be regarded as a potential biohazard (Garner and Hospital Infection Control Practices Advisory Committee, 1996; DoH UK, 1998). However, body substance isolation precautions (aimed at regarding all moist and body substances as potentially infectious) are familiar to all nurses as they are in use since 1987 (Garner and Hospital Infection Control Practices Advisory Committee, 1996). CDC then produced a two tier isolation precaution system known as standard precautions (SP) (Garner and Hospital Infection Control Practices Advisory Committee, 1996; Siegel et al., 2007). The first tier is designed for the care of all patients in hospitals, regardless of diagnosis or presumed infection status. The second tier, ‘Transmission-Based Precautions’ is for patients known or suspected to be infected by a transmissible infection (Garner and Hospital Infection Control Practices Advisory Committee, 1996; Siegel et al., 2007). SP principles include hand hygiene, patient isolation, personal protective equipment (PPE), personal and environmental hygiene, appropriate management of linen and health care waste, including sharps. Hand hygiene is the most important principle to prevent the spread of infection (WHO, 2009; HPSC, 2011a, 2011b). Hand hygiene includes hand-washing with soap (or antimicrobial soap) and water or alcohol gel. It also prescribes that cuts and abrasions are covered with waterproof dressings (WHO, 2009; HPSC, 2011a, 2011b). Stein et al. (2003) illustrated that while doctors understood the importance of hand hygiene, only 7 in 10 followed it frequently in practice. Patients with a BBV should be risk assessed to determine the type of isolation required. Patients that are actively bleeding or with large open wounds require contact precaution isolation (Siegel et al., 2007). Signs alerting staff to the type of isolation should be placed on the door and appropriate PPE should be available. PPE such as gloves and/or apron are required in the event of exposure to blood or body fluids (Siegel et al., 2007). Seventy-one percent of doctors do not wear gloves when taking blood despite 83% believing it important (Stein et al., 2003). Masks are not usually necessary unless to protect from other active infectious diseases, e.g. a patient with pulmonary tuberculosis. The environment should be cleaned daily with detergent and water and disinfected in the event of blood or body fluid spill. Blood spills require appropriate action, e.g. use of spill kits with PPE; appropriate disinfection agents to kill any viruses present; disposable scoops and yellow health care waste bags. Blood spills must be managed and decontaminated to prevent persons becoming contaminated (Siegel et al., 2007). The environment and instruments can also become contaminated with blood. This can lead to infection outbreaks such as the case of podiatry instruments that were the source of an outbreak of HBV in a long-term care facility (Wise et al., 2012). Health care waste is divided into health care risk waste and health care non-risk waste (DoHC, 2010). Health care risk waste includes any item contaminated with blood. Blood-stained products must be appropriately discarded in the yellow health care risk waste stream. If blood is in liquid form, a yellow rigid spill-proof container is used. Needles and sharps should be discarded in designated sharps containers (DoHC, 2010). Needlestick injuries (NSI) or sharps injuries must be managed appropriately. US surveillance indicates more than 380 000 parenteral annual exposures to blood. This equates to nearly 1 in 10 US HCWs receiving a needlestick exposure annually (Panlilio et al., 2004). Alarmingly, Delobelle et al.'s figure (as reported by the nurses themselves in response to survey) was as high as 7 of 10. The discrepancies in figures could be due to underreporting of NSI, which does occur in health care, and it is believed that doctors are least likely to report NSI (Stein et al., 2003). It is very important for nurses in critical care who are exposed to an NSI to perform first-aid to the injury and report to their supervisor and Occupational Health /Emergency Department. Occupational exposure should be assessed and treated accordingly, for example by immunization, hepatitis B immune globulin and post exposure chemoprophylaxis for exposure to HIV. There are also emotional effects of such exposure such as stress (Henderson, 2012) which need to be dealt with as well as financial implications. The cost of management of occupational exposures to blood and body fluids can vary from $71 to $4838 per exposure (O'Malley et al., 2007). An EU directive (2010/32/EU) was published in May 2010 (Council Directive, 2010). Its objective is to achieve the safest possible work environment for HCWs through the prevention of sharps injuries. All health care organizations must comply with this directive, which becomes legally binding on 11 May 2013 (European Biosafety Network, 2010). Perz et al. (2012) determined that unsafe injection practices account for a proportion of HBV acquisitions in health care settings (e.g. use of multi-dose vials; incorrect administration of injections resulting in microscopic quantities of blood contaminating the environment). An outbreak of HCV was identified in an outpatient's clinic where myocardial perfusion imaging was undertaken (Moore et al., 2011). It was determined that a nuclear medicine technologist routinely drew flushes of saline solution from multi-dose vials using the same needle and syringe as had previously been used to administer radiopharmaceutical doses (Moore et al., 2011). In addition, Fischer et al. (2010) highlighted HCV transmission resulting from contamination of single-use medication vials used on multiple patients during anaesthesia administration. As a consequence, more than 50 000 persons required follow-up by Public Health. This investigation highlighted breaches in aseptic technique and deficiencies in oversight within outpatient settings. BBV outbreaks have also been caused through blood glucose monitoring. Five instances of HBV in UK care homes resulted from poor infection control practice in blood glucose testing (Duffell et al., 2011). HBV outbreak was also noted in a long-stay facility where blood glucose monitoring devices were not decontaminated between patients. This resulted in HBV transmission to at least six residents (Schaffzin et al., 2012). HCV has also been transmitted by shared spring-triggered capillary blood glucose monitoring (Desenclos et al., 2001). Recently, Perz et al. (2012) identified haemodialysis as another risk factor in blood-borne pathogen transmission, while several documented cases of patient-to-patient HCV transmission via colonoscope exist (González-Candelas et al., 2010). Most occupational exposures occur on wards (36%), operating theatres account for 17% of incidents (HPA, 2008). Once a BBV is diagnosed in a health care setting, a local investigation is necessary to determine whether the infection is considered as nosocomial. Under the Infectious Disease Regulations (1981) the Department of Public Health must be notified of HBV and HCV infections. A patient notification exercise (PNE) is undertaken using ‘Guidance on the management and investigation of potential exposure to BBVs in health care setting’ (DoHC, 2005). Surveillance is a key performance indicator in the management of HCAI. Early identification of outbreaks and active surveillance of occupational exposures is also necessary. Occupational exposures include percutaneous exposures, where skin has been broken by a needle or sharp, human scratches or bites and mucotaneous exposures (HPA, 2008). Between 1997 and 2008, 3773 occupational exposures to blood or other high risk body fluids were reported to the Health Protection Agency in the UK (HPA, 2008). Feedback from surveillance and good communication informs staff of risks and of appropriate precautions. A study by Donohue et al. (2012) included recommendations such as enhanced surveillance of BBV notifications; sufficient laboratory resources; improved hospital information systems; the establishment of a national register of possible incidents of BBV transmission and that findings of investigations should be published. These would contribute to the further prevention of BBV within the health care setting. Transmission of BBVs in health care settings was believed to occur most frequently during EPPs; however, there is growing evidence of patient-to-patient transmission via other routes (Donohue et al., 2012) including deficient policies and procedures, improper hand hygiene, preparation of medication in blood processing areas, blood glucose monitoring, common-use saline bags, reuse of syringes, reuse of single-dose vials and use of multi-dose drug vials (Kermode et al., 2005; Greeley et al., 2011; Donohue et al., 2012). Perz et al. (2012) concluded that health care exposures may represent an important source of new HBV and HCV infections among older adults especially in ambulatory care settings through reduced oversight and fewer infection control resources. Strategies associated with injury prevention include avoidance of unnecessary needle use; unnecessary insertion of intravenous catheters; use of needleless or protected needle infusion systems and use of safer needles (Henderson, 2012). Health care associated infections and outbreaks of BBV have occurred in health care settings therefore it is necessary that a good infection control programme is in place (HIQA, 2009). Hand hygiene and adherence to SP are important in the prevention of spread of infections (SARI, 2005; Siegel et al., 2007). Reducing occupational exposure will reduce occupational infections with BBVs (Henderson, 2012). Education of staff is essential. Stein et al. (2003) observed the attitudes and compliance of medical staff to UP and recorded reasons for non-compliance. It concluded that while 86% of nurse's s attested to UP compliance, only 41% of doctors did. Education, monitoring, sufficient resources and disciplinary action for poor compliance are all necessary to improve infection control in hospitals (Stein et al., 2003). Although safety-engineered devices have been designed to cover sharps and eliminate all ‘after-use’ injuries, NSI still occur if these devices are used incorrectly. Thorough training and monitoring of the correct use of these safety devices is required (Perry et al., 2004). This training, together with regular education on blood-borne diseases, and infection prevention and control policies and procedures in the critical care unit lead to better management and prevention of BBV and increased safety for both staff and patients. Where direct educational update on the topics is not readily available, critical care nurses may take the initiative to perform independent learning on the topic in line with the development of their professional portfolio. Professional literature and readings on the topic are widely available and act as a good resource for the nurse looking to explore this topic within their portfolio.

Effective infection control (IC) provides a safe environment for staff, clients and animals of veterinary practices by reducing the risk of nosocomial and zoonotic infections, which are associated with increased hospital stays, costs, morbidity and mortality. An equally important issue arising from nosocomial infection is the loss of trust between the client and the veterinary practice that has potential negative impacts on the veterinary practice in terms of economic risk and the well-being of staff. Furthermore, an emerging and significant threat, in this context, is antimicrobial resistance. The aim of this systematic review was to critically review published reports that documented current IC practices and evaluated interventions to improve IC practices. A systematic literature search using ten databases to identify papers published over a 20-year period (February 1996 to February 2016) was conducted for studies that met the inclusion criteria. Included studies were assessed using the PRISMA and STROBE-Vet statements. A total of 14 of 1,615 identified studies met our inclusion criteria. Infection control practices included hand hygiene, sharps handling, environmental cleaning, personal protective equipment and personnel vaccination. Descriptive studies were the predominant research design for assessing IC compliance. Only three studies were interventions. Compliance with IC protocols was poor and only marginally increased with multimodal educational campaigns. There was significant variation in the implementation of IC by veterinary staff. Workplaces that had IC policies, management support and a staff member supporting their implementation were more likely to embrace good IC. Infection control data in veterinary practices were inconsistently reported and collected. Clearly defining IC and determining prevalence of these practices within the veterinary field is important given the limited research in this area. Further, developing and implementing educational campaigns for this sector is needed.

4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections: A challenge for change

Occupational health and safety is a crucial element in every organization, especially in a health care setting. Health care workers (HCWs) play a role as vectors and reservoirs for the spread of infection from patient to patient and staff as well. Infection control and prevention practices are essential elements of quality health care and patient safety in health facilities. Objectives: This study was aimed at assessing the levels of knowledge, attitude, and practice scores of the HCWs towards infection control at three public sector hospitals in Peshawar KPK. The study will help policymakers in the design and development of appropriate infection prevention programs and strategic plans by identifying the gap in infection control practices. Method: An institution-based cross-sectional study was conducted to assess the knowledge, attitudes, and practices of nurses regarding infection prevention and control by using a validated and structured questionnaire in three tertiary care hospitals in KPK. The sample size was calculated by using the Raosoft calculator, and the sample size was 318 nurses from these three hospitals, including those nurses who were willing to participate in the study and nurses who had more than one year of experience. Data was analyzed using SPSS version 22. Result: The participants were 55% male and 45% female; 55% were married, 42% were unmarried, 2% were divorced, 51% were diploma holders, 49% were degree holders, and most of the participants were charge nurses, which is 89%, and 11% were working in different administrative positions. Most of the participants who completed the survey were working in intensive care units, which is 66%, and others working in general wards and OPDs. 61% of nurses got information about safety precautions from training, 61% and 29% from books, and 10% from other resources. Participants who got training were 52%, and 48% of participants did not get any training on infection control precautions. Nurses who had knowledge about safety precautions were 84%; only 16% had not enough knowledge about infection control precautions. In attitude and practice about infection control, 58% were in compliance with practice, and 88% showed a positive attitude regarding infection control practices. Conclusion: In the conclusion, we can say that there is enough knowledge among nurses regarding infection control practice, but implementation of this knowledge in practice should be ensured by doing strict supervision of infection control practices in every health care facility.

Dr. Valenti is from Epidemiology and Infection Prevention, Maine Medical Center, Portland, Maine. Received January 24, 2006; accepted February 10, 2006; electronically published March 6, 2006. Infect Control Hosp Epidemiol 2006; 27:225-227 2006 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2006/2703-0001$15.00. On February 10, six hundred fifty-one years ago, a group of Oxford scholars vociferously objected to the wine they were served at the Swindlestock Tavern. A student launched a flagon at the wine merchant, roiling existing tensions between the university and townies. Three days of deadly rioting ensued. Today, contentious relations between academic medical centers and community hospitals may seem as pointless as the St. Scholastica Day riots, but, although encouraging signs of increasing collaboration among healthcare factions exist, a growing public edginess over hospital-acquired infections is developing into a town-and-gown controversy. The rhetoric surrounding this issue in California, Pennsylvania, and elsewhere in recent years is enough to prompt the innocent observer to watch for flying quart pots. No hospital in the United States, regardless of its size, resources, or location, can ignore the patient-safety movement, which properly views hospital-acquired infections as preventable adverse events. Many state legislatures are under pressure from various groups to enact laws requiring hospitals to disclose “infection rates.” In 2004, the Society for Healthcare Epidemiology of America’s board made the process of public reporting—which is too often driven by impatience and, in some instances, disconnected from sound epidemiologic principles—a priority. Likewise, accrediting bodies have introduced more infection and infection prevention measures into their indicators of quality. Although this intensified scrutiny of nosocomial infections is likely to increase the burden on infection control departments, especially in smaller hospitals, it might lead to a greater appreciation for the role of hospital epidemiology and infection prevention in all healthcare facilities, regardless of size or affiliation. This issue of the journal offers a number of articles that examine some important challenges facing infection control today from the perspective of the community hospital. I will comment on 4 of them here. Of note, 2 of these studies were conducted within small healthcare systems and one within a large healthcare alliance. Regional infection control consortia give small hospitals the opportunity to share valuable resources and expertise with larger neighbors and, as these articles demonstrate, provide arable ground for scientific study. These studies look at how infection control efforts are configured in community hospitals and how these hospitals are dealing with the challenges of resource availability, control of drug-resistant organisms, and antibiotic stewardship. Each of these articles is sure to be of particular interest to readers working in community-based institutions, but they should also stimulate academicians to consider how they might support their colleagues who are striving to bring evidence-based practices, which result from scientific studies, to the community. Though small, the study by Christenson et al. of VHA hospitals in various regions of the country provides insight into the state of infection control in community hospitals. The authors surveyed 31 hospitals ranging in size from fewer than 50 beds to more than 500 beds to assess the staffing, structure, and functions of infection control departments in participating facilities. In addition to the demographic survey, participants were asked to submit data for an observational study of compliance with infection control guidelines. The study used process measures of interest to key accreditation bodies: hand hygiene practices, rates of ventilator-associated pneumonia, catheter-related bloodstream infection, and catheter-related urinary tract infection. A third of the hospitals surveyed had levels of infection control staffing below the level of 1 infection control professional per 100 occupied beds, and only 1 hospital reported data support within the infection control department. It is encouraging that some hospitals felt their infection control program was supported by their administrations and medical directors, but lack of physician support underscored the need to identify and correct the reasons for this resistance. The observational study revealed inconsistencies in infection control practices, as well as in compliance with evidence-based recommendations for reducing specific healthcare-associated infections among participants. This is well analyzed and discussed by Christenson et al. One hopes that larger studies of this type will appear in the future.

To characterize biosecurity and infection control practices at veterinary teaching hospitals located at institutions accredited by the AVMA. Cross-sectional survey. 50 biosecurity experts at 38 veterinary teaching hospitals. Telephone interviews were conducted between July 2006 and July 2007, and questions were asked regarding policies for hygiene, surveillance, patient contact, education, and awareness. Respondents were also asked their opinion regarding the rigor of their programs. 31 of 38 (82%) hospitals reported outbreaks of nosocomial infection during the 5 years prior to the interview, 17 (45%) reported > 1 outbreak, 22 (58%) had restricted patient admissions to aid mitigation, and 12 (32%) had completely closed sections of the facility to control disease spread. Nineteen (50%) hospitals reported that zoonotic infections had occurred during the 2 years prior to the interview. Only 16 (42%) hospitals required personnel to complete a biosecurity training program, but 20 of the 50 (40%) respondents indicated that they believed their hospitals ranked among the top 10% in regard to rigor of infection control efforts. Results suggested that differences existed among infection control programs at these institutions. Perceptions of experts regarding program rigor appeared to be skewed, possibly because of a lack of published data characterizing programs at other institutions. Results may provide a stimulus for hospital administrators to better optimize biosecurity and infection control programs at their hospitals and thereby optimize patient care.

Infection control practices related to Clostridium difficile infection in acute care hospitals in Canada

A point well taken

Corona Virus Disease 2019 (COVID-19) has outbroken in Wuhan since December 2019, and spread fast to all over the country even abroad, which highly threatened people′s health and life. Under the severe situation at present, it is much important to take prevention and control measures. There are some characteristics in oral diagnosis and treatment such as close proximity to patients, long operation time and regular use of high-speed turbine rapid mobile phone, ultrasonic tooth cleaning machine and other equipments which would produce a large number of droplets and aerosols, thus there is a high risk of nosocomial infection in the process. In order to prevent the spread of 2019 novel coronavirus (2019-nCoV) in hospitals, in this paper, some technical recommendations have been put forward for the specifications of oral consultation process as well as the prevention and control during the epidemic period, combining with features of professional oral diagnosis and treatment. Also, we hope it can provide references for the prevention and control of nosocomial infection in the post-epidemic period. Key words: Corona Virus Disease 2019 (COVID-19); 2019 novel coronavirus (2019-nCoV); Oral management; Nosocomial infection prevention and control

Patient and staff safety at healthcare facilities during outbreaks hinges on a prompt infection prevention and control response. Physicians leading these programmes have encountered numerous obstacles during the pandemic. The aim of this study was to evaluate infection prevention and control practices and explore the challenges in Pakistan during the coronavirus disease 2019 pandemic. We conducted a cross-sectional study and administered a survey to physicians leading infection prevention and control programmes at 18 hospitals in Pakistan. All participants implemented universal masking, limited the intake of patients and designated separate triage areas, wards and intensive care units for coronavirus disease 2019 patients at their hospitals. Eleven (61%) physicians reported personal protective equipment shortages. Staff at three (17%) hospitals worked without the appropriate personal protective equipment due to limited supplies. All participants felt overworked and 17 (94%) reported stress. Physicians identified the lack of negative pressure rooms, fear and anxiety among hospital staff, rapidly evolving guidelines, personal protective equipment shortages and opposition from hospital staff regarding the choice of recommended personal protective equipment as major challenges during the pandemic. The results of this study highlight the challenges faced by physicians leading infection prevention and control programmes in Pakistan. It is essential to support infection prevention and control personnel and bridge the identified gaps to ensure patient and staff safety at healthcare facilities.

Guidelines for