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Factors associated with intensified infection prevention and vaccination practice among Thai health care personnel: A multicenter survey during COVID-19 pandemic

Published:December 27, 2021DOI:https://doi.org/10.1016/j.ajic.2021.12.011

      Highlights

      • High-risk health care personnel have more knowledge in self-protection for COVID-19.
      • No improvement in intensified infection prevention in high-risk personnel.
      • While COVID-19 vaccine uptake was suboptimal, influenza vaccine uptake was high.
      Intensified infection prevention (IP) and health care personnel (HCP) vaccination programs could enhance HCP safety during COVID-19 pandemic. A multi-center survey regarding on intensified IP practices and vaccination uptake among HCP was performed. Working in the emergency medicine department was associated with wearing a double mask and face shield (P = .04). Despite having more confidence in care of COVID-19 patients, there was no significant improvement of intensified IP practices, COVID-19 and influenza vaccination programs among “high-risk” HCP.

      Key Words

      There have been consistent reports of health care personnel (HCP) acquiring COVID-19 as a result of workplace exposure.
      • Nguyen LH
      • Drew DA
      • Graham MS
      • et al.
      Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study.
      ,

      World Health Organization. Prevention, identification and management of health worker infection in the context of COVID-19: interim guidance. 2020. Available at: https://apps.who.int/iris/handle/10665/336265. Accessed December 1, 2021.

      Following the tenets of basic infection prevention (IP) (eg, wearing masks, appropriate hand hygiene, physical distancing) greatly reduces but does not eliminate the risk of COVID-19 acquisition.

      World Health Organization. Prevention, identification and management of health worker infection in the context of COVID-19: interim guidance. 2020. Available at: https://apps.who.int/iris/handle/10665/336265. Accessed December 1, 2021.

      Recently, Centers for Disease Control and Prevention of the United States (CDC) demonstrated wearing a cloth mask over a medical procedure mask (ie, double masking technique), would improve mask filtration and more effectively prevent the spread/acquisition of COVID-19.
      • Brooks JT
      • Beezhold DH
      • Noti JD
      • et al.
      Maximizing fit for cloth and medical procedure masks to improve performance and reduce SARS-CoV-2 transmission and exposure.
      Wearing eye protection (eg, goggles, face shields) in addition to a medical mask for direct patient care is also recommended.

      World Health Organization. Infection prevention and control during health care when coronavirus disease (COVID-19) is suspected or confirmed. 2021. Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2021.1. Accessed July 18, 2021.

      These intensified infection prevention (IP) measures (eg, double mask technique, face shield) and HCP vaccination programs (eg, COVID-19, influenza) could enhance HCP safety during the COVID-19 pandemic. A 13-hospital multi-center survey was conducted to understand the feasibility of implementing these intensified IP measures and vaccination programs during the COVID-19 pandemic.

      Methods

      This survey was developed by experienced hospital epidemiologist of Thammasat University Hospital (TUH). Prior to the survey, content validation was assessed by all investigators to ensure that the survey included relevant issues to achieve all study goals. The data collection was pilot tested in 20 HCP to ensure the reliability of the data collection.  Based on the result of the pilot testing, the survey was revised to improve the understandability and reliability. This survey was performed among HCP employed by Thammasat University network, consisting of 13 hospitals from May 17, 2021 to June 4, 2021. HCP in all specialties were included. Google forms were created and distributed via a LINE application, version 11 (Tokyo, Japan). Data collected included demographics, underlying diseases, confidence in knowledge of COVID-19 transmission and/or self-protection and/or care of COVID-19 patients, awareness of being at-risk, feelings toward COVID-19 vaccination, IP practices, the acceptance/perception regarding intensified IP use and vaccination programs as a condition of employment.
      Respondents rated the frequency of confidence in knowledge and awareness of being at-risk using a 5-point Likert scale (scale of 1 to 5), where 1 indicates “no risk and/or no confidence” and 5 indicates “very risky and/or very confident.” They rated IP practices on a scale of 1 to 5, where 1 indicated “never used” and 5 indicated “always used.” Feelings toward COVID-19 vaccination were assessed using a scale of 1 to 5, where 1 indicated “no worry and/or stress” and 5 indicated “very worried and/or stressed.” HCP were asked to rate (“yes” or “no”) whether they would be willing to practice intensified IP measures, to accept vaccination programs and whether requiring vaccination programs should be a condition of employment. The HCP risk groups were categorized as “high-risk” versus “low-risk”, where “high-risk” group was defined as HCP exposure to confirmed and/or suspected COVID-19 infections ≥5 patients/month and <5 patients/month in “low-risk” group. Institutional Review Board approved this study.
      All analyses were performed using SPSS, version 26 (Armonk, NY). Chi-square tests were used to compare categorical variables. Independent t-tests were used for continuous data. All P values were 2-tailed, and P < .05 was considered statistically significant. A multivariate analysis was conducted to evaluate factors associated with intensified IP practices and vaccination programs uptake. Adjusted odd ratios (aORs) and 95% confidence intervals (CIs) were calculated.

      Results

      Overall, 407 HCP from 13 hospitals (N = 30/hospital) consented to study participation. The survey response rate was 90.44% (407/450). The median age was 30 years (IQR, 25-44 years); 280 HCP (68.80%) were women. Most HCP were physicians (66.09%). Most participants were from the emergency medicine department (ED) (30.96%). The vaccination acceptance rate was 82.56% for COVID-19 and 95.58% for influenza. Majority of HCP expressed concern about efficacy/effectiveness (88.73%) of COVID-19 vaccines. Details on intensified IP practices and perception regarding on vaccination programs are summarized (Table 1).
      Table 1Characteristics of study population
      VariableNo. (%) (N = 407)
      Age, median y (IQR)30 (25-44)
      Sex, female280 (68.80)
      Underlying diseases
       None340 (83.54)
       Diabetes mellitus10 (2.46)
       Hypertension17 (4.18)
      Dyslipidemia, Allergic rhinitis, thyroid disease, old cerebrovascular accident, coronary artery disease.
      Others
      40 (9.83)
      Occupations
       Physicians269 (66.09)
       Nurses113 (27.76)
       Pharmacists25 (6.14)
      Departments
       Emergency medicine126 (30.96)
       Internal medicine96 (23.59)
      Surgery, Pediatrics, Obstetrics and gynecology, Orthopedics, Otolaryngology, Ophthalmology, Psychiatry, Radiology, Anesthesiology, Physical medicine and rehabilitation.
      Others
      185 (45.45)
      Acceptance of vaccinations
       COVID-19336 (82.56)
        Nonacceptance (N = 71): efficacy concern63 (88.73)
        Nonacceptance (N = 71): safety concern8 (11.27)
       Influenza389 (95.58)
      Feelings toward COVID-19 vaccination
       Worry43 (10.57)
       Stress25 (6.14)
      Practice infection prevention in hospitals versus community
       Hand hygiene379 (93.12) vs 360 (88.45)
       Physical distancing289 (71.01) vs 348 (85.50)
       Mask403 (99.02) vs 403 (99.02)
       Goggles155 (38.08) vs 0 (0.00)
      Intensified infection prevention
       Double mask technique291 (71.50)
       Face shield261 (64.13)
      Perception regarding on vaccination program as a condition of employment
       COVID-19255 (62.65)
       Influenza265 (65.11)
      Level of hospital survey
       University hospital233 (57.25)
       Government hospital150 (36.86)
       Private hospital24 (5.90)
      IQR, interquartile range.
      low asterisk Dyslipidemia, Allergic rhinitis, thyroid disease, old cerebrovascular accident, coronary artery disease.
      Surgery, Pediatrics, Obstetrics and gynecology, Orthopedics, Otolaryngology, Ophthalmology, Psychiatry, Radiology, Anesthesiology, Physical medicine and rehabilitation.
      Overall, 117 HCP were categorized as “high-risk” and 290 HCP as “low-risk”. Demographics and characteristics of participants in both groups were compared (Table 2). Compared to “low-risk” HCP, “high-risk” HCP were more likely to wear goggles (P < .001) and have more confidence in their knowledge of disease transmission (P = .013) and self-protection (P = .032) (Table 2). However, there was no significant improvement of intensified IP practices among these HCP (Table 2). Factors associated with intensified IP compliance included those employed as nurses (aOR, 1.84; 95% CI, 1.08-3.13) and those assigned to the ED (aOR, 1.75; 95% CI, 1.02-3.00). Factors associated with acceptance of influenza vaccination include awareness of being at-risk (aOR, 5.18; 95% CI, 1.21-22.16).
      Table 2Demographics and baseline characteristics of study populations compared “high-risk” versus “low-risk” health care personnel
      VariableTotal (%)(N = 407)
      Low risk, health care personnel exposure to confirmed/suspected COVID-19 infections <5 patients/month
      Low risk (%)(N = 290)
      High risk, health care personnel exposure to confirmed/suspected COVID-19 infections ≥5 patients/month
      High risk (%)(N = 117)
      P Value
      Age, median year (IQR)30 (25-44)29 (24-44)34 (24-41)0.031
      Sex, female280 (68.80)200 (68.97)80 (68.38)0.908
      Underlying diseases
       None340 (83.54)242 (83.45)98 (83.76)0.939
       Diabetes mellitus10 (2.46)7 (2.41)3 (2.56)0.929
       Hypertension17 (4.18)13 (4.48)4 (3.42)0.627
      Dyslipidemia, Allergic rhinitis, thyroid disease, old cerebrovascular accident, coronary artery disease
      Others
      40 (9.83)28 (9.66)12 (10.26)0.778
      Occupations
       Physicians269 (66.09)197 (67.93)72 (61.53)0.218
       Nurses113 (27.76)70 (24.14)43 (36.75)0.010
       Pharmacists25 (6.14)23 (7.93)2 (1.71)0.018
      Departments
       Emergency medicine126 (30.96)66 (22.76)60 (51.28)<0.001
       Internal medicine96 (23.59)57 (19.66)39 (33.33)0.003
      Surgery, Pediatrics, Obstetrics and gynecology, Orthopedics, Otolaryngology, Ophthalmology, Psychiatry, Radiology, Anesthesiology, Physical medicine and rehabilitation
      Others
      185 (45.45)167 (57.59)18 (15.38)<0.001
      Confidence
       Knowledge of disease transmission315 (77.40)215 (74.14)100 (85.47)0.013
       Self-protection320 (78.62)220 (75.86)100 (85.47)0.032
       COVID-19 patients care214 (52.58)125 (43.10)89 (76.07)<0.001
       Awareness of being at-risk for infection186 (45.70)108 (37.24)78 (66.67)<0.001
      Practices infection prevention in hospitals
       Hand hygiene379 (93.12)269 (92.76)110 (94.02)0.650
       Social distance289 (71.01)207 (71.38)82 (70.09)0.795
       Mask403 (99.02)286 (98.62)117 (100)0.202
       Goggles155 (38.08)93 (32.07)62 (52.99)<0.001
      Practices infection prevention in community
       Hand hygiene360 (88.45)256 (88.28)104 (88.89)0.861
       Physical distancing348 (85.50)245 (84.48)103 (88.03)0.357
       Mask403 (99.02)286 (98.62)117 (100.00)0.202
      Intensified infection control
       Double mask technique291 (71.50)201 (69.31)90 (76.92)0.124
       Face shield261 (64.13)185 (63.79)76 (64.96)0.825
      Perception regarding on vaccination program as a requirement of employment
       COVID-19255 (62.65)185 (63.79)70 (59.83)0.454
       Influenza265 (65.11)193 (66.55)72 (61.54)0.337
      IQR, interquartile range.
      low asterisk Low risk, health care personnel exposure to confirmed/suspected COVID-19 infections <5 patients/month
      High risk, health care personnel exposure to confirmed/suspected COVID-19 infections ≥5 patients/month
      Dyslipidemia, Allergic rhinitis, thyroid disease, old cerebrovascular accident, coronary artery disease
      § Surgery, Pediatrics, Obstetrics and gynecology, Orthopedics, Otolaryngology, Ophthalmology, Psychiatry, Radiology, Anesthesiology, Physical medicine and rehabilitation

      Discussion

      Our study had several implications. First, working in the ED was associated with intensified IP use given the higher risk of exposure to patients with unknown COVID-19 status, while “high-risk” HCP tended to wear goggles. Second, nurses had higher percentages of intensified IP practices which may reflect the fact that nurses spend more time in direct patient care. Third, the percentage of HCP who received COVID-19 vaccine (82.56%) was less than influenza vaccine (95.58%). Concerns about efficacy and safety were the main barrier for suboptimal COVID-19 vaccine uptake among HCP.
      Several studies reported that using double masks can potentially increase the mask's effectiveness by more than 80%
      • Brooks JT
      • Beezhold DH
      • Noti JD
      • et al.
      Maximizing fit for cloth and medical procedure masks to improve performance and reduce SARS-CoV-2 transmission and exposure.
      ,
      • Clapp PW
      • Sickbert-Bennett EE
      • Samet JM
      • et al.
      Evaluation of cloth masks and modified procedure masks as personal protective equipment for the public during the COVID-19 pandemic.
      while face shields were shown to reduce immediate viral exposure by 96%.
      • Lindsley WG
      • Noti JD
      • Blachere FM
      • Szalajda JV
      • Beezhold DH.
      Efficacy of face shields against cough aerosol droplets from a cough simulator.
      While high percentages of HCP followed IP practices both in the hospital and in the community, there was no increase in intensified IP practices among “high-risk” HCP. These findings may be because intensified IP use was recommended by the United States CDC,
      • Brooks JT
      • Beezhold DH
      • Noti JD
      • et al.
      Maximizing fit for cloth and medical procedure masks to improve performance and reduce SARS-CoV-2 transmission and exposure.
      ,

      World Health Organization. Infection prevention and control during health care when coronavirus disease (COVID-19) is suspected or confirmed. 2021. Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2021.1. Accessed July 18, 2021.

      but not recommended by Thai CDC.

      Department of disease control of Thailand. Recommendations for Wearing Hygienic masks. 2020. Available at: https://ddc.moph.go.th/viralpneumonia/eng/file/recommendation/014wearing_a_mask.pdf. Accessed June 28, 2021.

      While vaccination programs for COVID-19 and influenza were recommended for all HCP
      Centers for Disease Control and Prevention
      Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC).
      and should be a condition of employment in the United States,
      • Weber DJ
      • Talbot TR
      • Weinmann A
      • et al.
      Society for Health care Epidemiology of America (SHEA). Policy statement from the Society for Health care Epidemiology of America (SHEA): Only medical contraindications should be accepted as a reason for not receiving all routine immunizations as recommended by the Centers for Disease Control and Prevention.
      ,
      • Weber DJ
      • Al-Tawfiq JA
      • Babcock HM
      • et al.
      Multisociety statement on COVID-19 vaccination as a condition of employment for health care personnel.
      COVID-19 vaccination uptake in Thailand remains suboptimal and indicates the need for additional strategies to enhance COVID-19 vaccination among HCP. Despite the knowledge and awareness of COVID-19 transmission and prevention among “high-risk” HCP, there was no clear translation of prevention methods into real practices. Although double masking is approaching the effectiveness of N95 respirators, we recommend N95 respirators for providing care of suspected or known COVID-19 patients.
      There are some limitations in this study. First, the study was performed using self-reported survey. Second, the small sample size may limit our ability to identify other factors associated with intensified IP practices and vaccination programs. Third, because we only survey 13 hospitals, our results may not represent intensified IP practices and vaccination programs uptake for the whole country. Lastly, since this survey was performed in Thailand's second wave of COVID-19 pandemic, it may not reflect future practices for Thai COVID-19 prevention.
      In conclusion, intensified IP practices remain suboptimal and limited to HCP working in the ED and to those employed as nurses. While influenza vaccine uptake is high, COVID-19 vaccination uptake among HCP remains suboptimal. Practices to prevent COVID-19 featuring intensified IP use and vaccination programs uptake should be reinforced for “high-risk” HCP and should be incorporated in Thai national guidelines.

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