Questions over implementation of SA’s new infection control planSouth Africa has a new infection control policy aimed at reducing and preventing healthcare-acquired infections but questions remain over implementation of this policy framework. PHOTO: Nuwan Niyadurupola/Community Eye Health

Questions over implementation of SA’s new infection control plan

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Whether it is in the queue outside a community healthcare clinic, in a GP’s waiting room, or in the ICU at a private sector hospital, healthcare-acquired infections (HAIs) pose a threat to people’s health. These places are after all where people go if they are struggling with infectious diseases.

Measures taken to reduce these infection risks are referred to in healthcare circles as infection prevention and control (IPC) practices. Though the COVID-19 pandemic has firmly placed the spotlight on infection control – particularly as it relates to personal protective equipment and limited access to COVID-19 wards – challenges with IPC are much older and much broader than just COVID-19. Last year, for example, Spotlight took an in-depth look at the problem of infants getting infected with dangerous germs such as Carbapenem-resistant Klebsiella in South African hospitals.

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IPC policy and implementation

During International Infection Prevention Week in October 2021, the National Department of Health launched the National Infection Prevention and Control Strategic Framework and Manual that it first published back in March 2020. It was launched to “reinforce the introduction of these documents (framework and manual) for comprehensive implementation across the public and private sector”, the department said.

The document outlines government’s strategy to prevent, reduce, and control the development of HIAs and Antimicrobial Resistance in order to improve patient safety and health outcomes. It also stipulates that IPC programmes in health facilities must be led by IPC-trained professionals – implying that implementation of the framework will be difficult without such dedicated staff and expertise.

An IPC practitioner, according to the Infection Control Society of Southern Africa (ICSSA), is “any health worker that has a qualification equivalent to the minimum of fundamental or post-graduate diploma or degree in IPC”.

“IPC in our health facilities is erratic,” says retired Professor Shaheen Mehtar, who is responsible for education at the Infection Control Africa Network (ICAN). “There are untrained persons at our health facilities and they need training and support. Tertiary hospitals have some IPC practitioners. However, they seem to be more at district level,” she says. “Government has not made enough effort to ensure that the National Strategic Framework is being implemented. A national IPC coordinator has been seconded for two years but there is no permanent post at national nor is there a budget. This matter needs to be addressed urgently.”

healthworker sanitising equipment
A rapid survey by the national Department of Health in 2020 found at hospital level (central, provincial, regional, and district-level hospitals) the average provincial compliance with the target ratio of one appointed IPC practitioner per 250 beds ranged from 11% to 44%, with district health facilities performing the best. PHOTO: Elmien Wolvaardt-Ellison/Community Eye Health

Training challenges

According to Mehtar, IPC practitioners are marginalised and the field is yet to be recognised as a clear career path in the health sector.

“The World Health Organization (WHO) recommends that there should be one fully trained IPC practitioner per 250 beds, [so] more work needs to be done for us to reach global health standards. We are still very far from this. Some of the reasons we are still behind are because there is no clear career path in IPC and this field is not recognised as a speciality in Africa particularly in South Africa,” says Mehtar.

She says that despite efforts to get the IPC career path recognised, the South African Nursing Council (SANC) has not given approval.

In her presentation during the launch webinar, chair of ICSSA, Yolandi Van Zyl, said SANC has published the competencies as well as the exit level outcomes on their website under education and training but the regulation, however, is still outstanding. “This regulation,” van Zyl said, “is needed for the qualification to be recognised. We are losing qualified IPC practitioners and specialists because the qualification is not part of occupational specific dispensation (OSD).”

By time of publication, the SANC has not responded to Spotlight’s request for comment on the above issues. (The article will be updated when SANC responds)

The numbers

In July 2020, about three months after the framework was initially published, the National Department of Health did a rapid survey to determine the number of IPC practitioners at national and provincial levels. At hospital level across provinces, the survey showed that an IPC practitioner was appointed and designated at 22% of tertiary facilities and 89% of district facilities surveyed. Designated refers to part-time IPC persons who are seconded to IPC responsibilities but who have other official duties. The ideal, according to Mehtar and other IPC experts, is to have a fully trained person appointed for IPC specifically and not just designated.

The survey found at hospital level (central, provincial, regional, and district-level hospitals) the average provincial compliance with the target ratio of one appointed IPC practitioner per 250 beds ranged from 11% to 44%, with district health facilities performing the best.

a healthcare worker helping with donning PPE
Personal protective equipment and donning and doffing stations in health facilities are crucial for effective infection prevention and control. PHOTO: Joseph Kerkula/Community Eye Care

Department of Health responds

Director of Quality Assurance at the national health department Catherine Mbuyane, says that infrastructure challenges, inadequate IPC training, and staff-patient ratios are stumbling blocks for adequate healthcare delivery.

“Historically designed facilities that did not take consideration of airflow, ventilation, and air changes in the growing trends of airborne diseases are creating exposure risk. Growing demand for healthcare services by the uninsured patrons in South Africa are placing a greater burden on existing healthcare infrastructure. The design of the facilities that do not align to current health needs are also a problem,” says Mbuyane.

Mabuyane says the department appointed Ayanda Dakela as the new Chief Director for Infrastructure and Facilities Management this year (2022). Dakela tells Spotlight that the department plans to have contracts for maintaining and installing boilers, ventilators, and generators at facilities across the country. “We are currently drafting our annual performance plan which suggests that there should be special contractors who are dealing with various aspects of infrastructure because most institutions do not have the capacity to handle that. Specialised service providers are going to be appointed for a term of three to five years and they will report to the department on a quarterly basis.” Dakela says there is already a budget allocated for infrastructure.

According to Mabuyane, management at the health department has also proposed that “IPC becomes a standalone programme and not under the budget of quality assurance”. “Since the pandemic, we have ramped up IPC training across all provinces. Every Wednesday there are international webinars on IPC training. We are working with the CDC (African CDC) and ICAN (Infection Control Africa Network) to ensure that there is effective training on IPC.”

We have never felt safe

Despite all this, however, frontline healthcare workers say they don’t feel safe especially now during the COVID-19 pandemic.

Rich Sicina, a paediatric nurse and president of the Young Nurses Indaba Trade Union (YNITU) says he hoped that the pandemic would have improved health systems but instead the situation went from bad to worse. “By May 2020 we were forced to buy our own face masks and sanitisers. We thought that the pandemic would improve our healthcare systems because of international funding but things just became worse,” he says.

“Infection is rife in the hospital setting. We have never felt safe at work. During the second and third wave, we buried [many] of our colleagues and many of them have resigned. Nurses and doctors with co-morbidities are worse affected because their immune systems are not strong enough to fight the virus on its own.”

Sicina says they have lost a lot of staff members due to immediate resignations because some were not able to deal with the physical and mental strain the pandemic has brought upon them. This has worsened the issue of staff shortages leading to burnout. He says in an ideal health setting, there are supposed to be donning and doffing stations (change rooms) for nursing staff members who treat COVID-19 patients but many hospitals across the country do not have such facilities as they are only limited to operating theatres.

PPE stacked on a table at tygerberg
PHOTO: Joyrene Kramer/Spotlight

“We are exposed to risk on a daily basis, there are no donning and doffing stations at our facilities, and at the beginning of the pandemic, we did not even receive the adequate PPE. We were just thrown in[to] the deep end. There is not enough protection for frontline workers we just go in and attend patients,” says Sicina.

He tells Spotlight that many healthcare workers did not receive adequate training on PPE when the pandemic began but at least there are IPC practitioners at most facilities. “At our facility, we do have people responsible for infection control but they are not IPC specialists. Most of them have only been trained for one day and they are also responsible for other duties at the hospital.”

Political will needed

According to TB Proof, an organisation that aims to spread awareness and education on tuberculosis, the spread of infectious diseases in healthcare facilities is unacceptable.

Erika Mohr-Holland of TB Proof says healthcare workers face disproportionate risks of acquiring tuberculosis (TB) and COVID-19, both of which are transmitted by small particles produced through coughing, speech, and singing.

“Despite exposure to multiple respiratory illnesses at work due to the high burdens of TB and now COVID-19 in South Africa, healthcare workers are not receiving the protective equipment they deserve and are legally mandated,” she says.

TB Proof Director Ingrid Schoeman, says she fell ill with extremely drug-resistant TB (XDR-TB) while working as a dietitian in the Eastern Cape. “This was the toughest experience I ever faced. Political will is needed to ensure that all healthcare facilities are safe working environments for healthcare workers and also safe for the patients being cared for.”

Schoeman says the country also needs to note the importance of the urgent release of the National TB & HIV Occupational Health Policy for Healthcare Workers. She says it will make a critical contribution to ensuring that healthcare workers do not fall ill because of occupational diseases. She says it is unacceptable that this policy has remained in draft for five years.