What has COVID-19 taught us about infection prevention and control?

There is nothing like a one-in-100-year pandemic to expose cracks in an infection prevention and control (IPC) strategy — and for parts of the world, the COVID-19 crisis has been no exception.

Although provisions like the two-week hotel quarantine program have been key to reducing community transmission, positive cases — including new overseas variants — have continued to break through.

In Australia, home to one of the most rigorous IPC systems, there were 16 hotel quarantine leaks in the five months between November 2020 and April 2021.¹

Meanwhile, a review into Victoria’s quarantine program found that 90% of the state’s cases were genomically linked to a family that had completed their mandatory stay.²

Within aged care, too, efforts to contain outbreaks have fallen short, with more than three quarters of domestic COVID-19 deaths taking place in aged-care facilities.³

While the healthcare sector was not short of strong IPC guidelines pre-pandemic, what have we learned since about best practice?

Pre-empt the worst case scenario, as early as possible

One key observation about the IPC protocol surrounding COVID-19 globally was that it underplayed the possibility of airborne transmission. Instead, measures like hand hygiene, surgical mask wearing and social distancing were largely centred on the belief that droplets and fomites on surfaces were the main cause of spread.

More than one year since these measures were introduced, evidence for airborne transmission has evolved, with scientists calling for public health guidance — and indoor ventilation systems — to be overhauled. A COVID-19 outbreak in South Korea, for example, is believed to have occurred through faecal aerosols, caused by toilet flushing.⁴

However, the belated finding has cost us, with earlier IPC strategies not pre-empting this outcome — at least, not to the degree that they should. While global leaders, including Australia’s Chief Medical Officer Professor Paul Kelly, have never denied the role of airborne transmission, many have maintained its role is minimal.

Appropriate PPE and training

Meanwhile, other experts have claimed that many pre-existing IPC plans — initially designed for healthcare-associated infections (HAI) like norovirus — were lacking the rigour needed for a respiratory pandemic.

For large parts of the world, early supply of personal protective equipment (PPE) was inadequate, with government-procured gear not fit for purpose, and again reflecting the understated role of airborne transmission.

Research shows that surgical masks and those made from cloth are not effective against aerosols.⁵ Unlike respiratory particles, these droplets are less than five micrometres in diameter, can travel up to 10 metres, and stay in the air for hours. To combat aerosols, P2/N95 masks — respiratory PPE with a close facial fit — are more appropriate.⁶

Many early pandemic plans across the globe also failed to consider the importance of tailored training to ensure PPE was used properly. Within aged care, a sector in which IPC protocol and PPE usage does not feature as prominently as in acute healthcare settings, this approach proved costly.

Meanwhile, training on other aspects of IPC fell short within aged-care homes, with many unclear on their responsibilities.

Strict IPC compliance from the outset

While the broader healthcare sector is no stranger to strict IPC measures, there appeared to be a lag in shifting our collective state of complacency.

“People have been saying that you shouldn’t come into work with a ‘sniffle’ for a while now, but it is only through COVID that we have started to take this advice seriously,” said Kathy Dempsey of the Clinical Excellence Commission in NSW.

“Yes, staff are aware of their obligations surrounding IPC, but at the same time, there is a conflicting narrative that tells us we have to keep going when we feel a tiny bit unwell, otherwise, if we take time off, we’ll make life harder for our colleagues. Thankfully COVID-19 has taught us this approach is not acceptable.”

While COVID-19 did sharpen the focus on IPC measures, widespread behavioural compliance may have come later, with the lag creating leak holes in an otherwise watertight strategy.

At the extreme, non-compliance has also been an issue in some settings. In May 2021, a General Manager of a Victorian hotel quarantine facility was allegedly stood down for breaching IPC protocol and refusing to take a COVID-19 test, after visiting a facility.

Stamina is everything

While the virus may have exploited technical loopholes in IPC strategies around the world, one clear win has been Australia’s sustained resilience — the glue holding it all together.

Behavioural compliance with IPC measures over time involves focus, sacrifice and stamina. For those clinicians tasked with enforcing IPC protocol — patient visitor restrictions, treatment delays, and reduced support — the journey has been equally fraught, with patients and families often directing their frustration at staff.

Despite this, Australia’s approach has not waivered, with strong IPC, and a death toll far lower than that of other western nations.

References

1. https://theconversation.com/more-than-a-dozen-covid-leaks-in-6-months-to-protect-australians-its-time-to-move-quarantine-out-of-city-hotels-159808.
2. https://www.theguardian.com/australia-news/2020/aug/18/hotel-quarantine-linked-to-99-of-victorias-covid-cases-inquiry-told.
3. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32206-6/fulltext.
4. https://pubmed.ncbi.nlm.nih.gov/33346125/.
5. https://www1.racgp.org.au/newsgp/clinical/guidelines-called-into-question-as-research-highli.
6. https://wwwnc.cdc.gov/eid/article/26/10/20-0948_article.

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