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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 43-47

Coronavirus disease-2019 pandemic: Masks use/misuse at tertiary health-care center in northern India


1 Department of Microbiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Community Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission05-Jun-2020
Date of Decision07-Aug-2020
Date of Acceptance16-Oct-2020
Date of Web Publication2-Feb-2021

Correspondence Address:
Asfia Sultan
Department of Microbiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_133_20

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  Abstract 


BACKGROUND: Coronavirus disease (COVID-19) can spread via a cough or respiratory droplets, contact with bodily fluids, or from contaminated surfaces. Aerosol-generating procedures, such as noninvasive ventilation, high-flow nasal cannula, bag-mask ventilation, and intubation are of particularly high risk. Standard precautions, including strict hand hygiene and appropriate use of mask are vital preventive measures. The objective of this study was to assess the adherence rate among the health-care workers (HCWs) to the judicial use of masks during the coronavirus pandemic (COVID-19) at a tertiary health-care center in northern India.
METHODS: Institution-based descriptive cross-sectional study was done to evaluate the proper utilization of masks and hand hygiene practices at the tertiary level of healt care in India. Data were collected and analyzed using Epicollect 5 app and the WHO hand hygiene audit tool.
RESULTS: Among the 252 total opportunities for performing hand hygiene, only 72 (28.6%) moments were utilized. One hundred and eighty one (39.87%) HCWs applied the mask inappropriately, i.e., other than the one indicated. Overall adherence to guidelines for mask use was found in 195 (34.7%) HCWs, whereas nonadherence was among 366 (65.2%) HCWs.
CONCLUSION: Proper hand hygiene and judicious use of mask are crucial for preventing the transmission of infection. However, the utilization of masks is under or mis-utilized for most of the time. We suggest didactic training and educational interventions to be followed for capacity building and motivating the HCWs for infection prevention practices.

Keywords: COVID-19, hand hygiene, health-care worker, mask


How to cite this article:
Sultan A, Kumar P, Khan F, Chaudhary B, Shah MS, Khan HM. Coronavirus disease-2019 pandemic: Masks use/misuse at tertiary health-care center in northern India. Int J Health Allied Sci 2021;10:43-7

How to cite this URL:
Sultan A, Kumar P, Khan F, Chaudhary B, Shah MS, Khan HM. Coronavirus disease-2019 pandemic: Masks use/misuse at tertiary health-care center in northern India. Int J Health Allied Sci [serial online] 2021 [cited 2021 Mar 8];10:43-7. Available from: https://www.ijhas.in/text.asp?2021/10/1/43/308580




  Introduction Top


The 2019 novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome CoV-2 emerged in China in December 2019 and was declared as a pandemic by WHO.[1] At the time of writing (2020 June 3) COVID-19 has spread to 213 countries and territories with 6,482,695 confirmed cases and 383,072 deaths[2] around the world since it was first identified. The case fatality rate may be as high as 3.4%.[3]

Health-care workers (HCWs) are on the frontline dealing with COVID-19 and are at high risk of getting the infection while treating their patients[4] and are also a common vehicle for the transmission of infection from patient to patient and within the health-care environment. Studies have shown that COVID-19 can spread via a cough or respiratory droplets, contact with bodily fluids, or from contaminated surfaces.[5] Aerosol-generating procedures, such as non-invasive ventilation, high-flow nasal cannula, bag-mask ventilation, and intubation, are of particularly high risk.[6]

Considering the above carriers of transmission, personal protective equipment (PPE) are being utilized as an isolation precaution to prevent droplet and contact transmission. Their effectiveness depends on adequate and regular supplies, adequate staff training, proper hand hygiene, and in particular appropriate human behavior. The appropriate use of PPE serves to further decrease the risks of transmission of respiratory pathogens to HCWs. It is important to stress that standard precautions and strict hand hygiene are vital parts of all of these preventive measures. The key element of droplet precautions is wearing a surgical mask whenever HCWs come within 1 m of the patient.[7] Face masks are being used globally as the first and foremost measure to limit the spread of COVID-19 transmission, as a result, there has been emerging demand of surgical masks and N95 respirator worldwide. Despite the use of mask, maximum compliance with hand hygiene and other infection prevention and control (IPC) measures are critical to prevent human-to-human transmission of COVID-19.[8]

Due to this enormous demand, there is a global shortage of surgical masks as well as an N95 respirator.[9] Surging global demand–driven not only by the number of COVID-19 cases but also by misinformation, panic buying, and stockpiling–has resulted in further shortages of PPE globally. The capacity to expand PPE production is limited and therefore unable to meet the current demand of respirators and masks.[8]

Guidelines for proper and efficient use of mask have already been published by the WHO, which provides HCWs a standardized approach to the effective use of medical masks for the prevention of COVID-19 transmission based on currently available clinical indications and emerging issues.[10] But, are the health care personnel using it in a proper way that it supposed to be?

This study was planned to assess the adherence rate among the HCWs to the judicial use of masks during the coronavirus pandemic (COVID-19) at tertiary health care center in northern India. Adherence of HCWs to hand hygiene practices were also assessed along with the primary objective of the study.


  Methodology Top


The study was conducted at a tertiary health-care center in western Uttar Pradesh, India for 1 month during the early pandemic period (March–April). Physicians, Surgeons, Nurses and health-care staffs indulged in patient care were the study population. All health care providers (doctors, nurses, and technicians) who had >1 year of experience were included. Hospital staffs who were not directly involved in patient care were excluded from the study. Institution-based observational cross-sectional study was done to evaluate the proper utilization of masks and hand hygiene practices at the tertiary level of health care in India. The adopted sampling method was a convenient sampling technique. Before the actual data collection, approval was obtained from the Jawaharlal Nehru Medical College Hospital administrators and Hospital Ethics committee. The study population was evaluated for the compliance of hand hygiene and mask use during the ongoing COVID 19 pandemic. The guidelines provided by the ministry of health and family welfare (MOHFW) (India) on the use of mask was considered as noncompliant if mask was not properly worn, i.e., not covering mouth, nose and chin or any of straps laying loose or mask was not worn according to the indication of its use.[11]

Data were collected using Epicollect 5 app and analyzed using SPSS version 20.0. Audit for hand hygiene practice was done using the WHO hand hygiene audit tool.[12] Data collection for the WHO hand hygiene audit tool was done by direct observation method by the Hospital Infection Control Committee (HICC). Moments were the opportunities described by the WHO for performing hand hygiene.[12] These are the 5 golden moments when HCWs should perform hand hygiene, as mentioned in [Table 1]. The data collected was checked regularly for clarity, completeness, consistency, accuracy, and validity. For statistical analysis, SPSS v20.0 (IBM Corp., Armonk, NY, USA) was used to characterize the population parameters, and study variables and appropriate tests were applied.
Table 1: Hand hygiene audit analysis during corona virus disease -19 pandemic (percentage in parentheses)

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  Results Top


A total of 561 HCWs were included in this study. Assessments for the basic precautions to be taken for preventing COVID-19 infection, i.e., hand hygiene and correct use of mask were done in different locations in the hospital. During the period of observation, a total of 252 opportunities were noted for performing hand hygiene, of which proper compliance was noted in only 72 (28.6%) moments. Of all the 5 moments suggested by theWHO, maximum compliance (60%) was for the 3rd moment of hand hygiene i.e., after body fluid exposure, followed by the 2nd moment, i.e., before any aseptic procedure (57.7%). Zero compliance was noted for hand hygiene after touching the patient's environment [Table 1].

HCWs included in the study at different locations consist of 102 (18.18%) posted in fever outpatient department (OPD), 29 (5.17%) from isolation ward, 21 (3.74%) from intensive care unit (ICU), 56 (9.98%) from general wards, 35 (6.24%) from Casualty, 96 (17.11%) from hospital corridors, while 222 (39.57%) from other nonspecified locations in the hospital. As per guidelines, N95 respirator was indicated only at two locations (fever OPD and isolation ward) where chances of contact with COVID patients were assumed high, while in ICU, its use was only indicated during aerosol-generating procedures [Table 2]. At the time of survey 133 (23.7%), HCWs were wearing the N95 respirators while 321 (57.2%) were donning surgical mask. Despite the MOHFW guidelines regarding mask use by all at all places of gathering, 107 (19.07%) HCW were roaming in the hospital without mask. However, of the total 454 (80.93%) HCWs wearing mask, only 304 were following proper technique (232 [72.2%] 3ply surgical mask, 72 [54.1%] N95 respirator) of donning mask [Table 3].
Table 2: Adherence to mask/respirator use at different locations during corona virus disease -19 pandemic (percentage in parentheses)

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Table 3: Assessment of adherence for correct mask/respirator utilization during corona virus disease -19 (percentage in parentheses)

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Despite of the continuous emphasis on judicial use of mask, 73 (13.01%) were donning N95 respirators in corridors and other nonpatient locations. Around 59 (10.52%) HCW were wearing the double mask in the form of either one surgical with N95 respirators or a pair of 3ply surgical mask. The reason they gave was to prevent N95 from being humidified (those wearing N95 and surgical mask combination), while other group was wearing to be over cautious and protective. The first combination was mainly observed in ICU, whereas the second combination was mainly seen in casualty and general wards. For calculation purposes we counted them as one.

On scrutinizing the use of N95 respirator, 99 (74.4%) HCWs used it inappropriately/nonjudiciously, while 34 (25.6%) used it appropriately. However, the observed rate of judicious and nonjudicious use of 3-ply surgical mask among HCWs were 161 (50.1%) and 160 (49.9%), respectively [Figure 1]. Over all 195 (42.9%) masks/respirators were used judiciously as per the recommendations, while in 259 (57%) instances were not used as per standard guidelines (P < 00001 using Chi-square test). Overall adherence to guidelines was found in 195 (34.7%) HCWs, whereas nonadherence was amongst 366 (65.2%) [Table 3].
Figure 1: Analysis on judicious and nonjudicious use of mask/respirator

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  Discussion Top


In health-care settings, the main IPC strategies to prevent or limit COVID-19 transmission include the following: ensuring triage, early recognition, and source control (isolating suspected and confirmed COVID-19 patients); applying standard precautions for all patients and including diligent hand hygiene; implementing empiric additional precautions (droplet and contact and wherever applicable for aerosol-generating procedures and support treatments, airborne precautions) for suspected and confirmed cases of COVID-19; implementing administrative controls; using environmental and engineering controls.[8]

Although the use of PPE is the most visible control used to prevent the spread of infection, it is only one of the IPC measures and should not be relied on as a primary prevention strategy. In the absence of effective administrative and engineering controls, PPE has limited benefits. It has been observed that most of the HCWs consider PPE and in particular, masks as the primary prevention tool against the COVID-19, considering hand hygiene as secondary. This study was conducted to assess the impact of the COVID-19 pandemic on the judicious use of mask/N95 respirator and on hand hygiene practices by direct observation and hand hygiene audits, respectively. To the best of our knowledge, very few literature is available on proper/improper use of PPE particularly masks and no study has been done till date to evaluate all this during this COVID pandemic.

On regular audits by the HICC for hand hygiene practices, it was observed that there was poor compliance for the same even during the COVID-19 pandemic. Among the 252 total opportunities for performing hand hygiene, only 72 (28.6%) moments were utilized. This may be due to the reasons that since this is a respiratory illness, HCWs were more concerned with the use of mask and PPE and they considered hand hygiene as secondary to these precautions for prevention of COVID-19. Among the five golden moments of hand hygiene, highest compliance was seen after body fluid exposure followed by performance of any aseptic procedure. This may be due to the high risk of transmission during these moments as compared to simply touching the patients.

On observing the appropriate choice of mask, it was noted that 181 (39.87%) HCWs applied the mask inappropriately, i.e., other than the one indicated. Of those wearing the surgical mask or N95 respirator, 304 (66.96%) HCWs were donning it properly, whereas 150 (33.04%) HCWs were not wearing it in a proper fashion. Overall adherence to guidelines for proper type and method of mask use was found in just 195 (34.7%) HCWs, whereas 366 (65.2%) HCWs made error in either selection or donning technique of the mask/N95 respirator. The error in the choice of selection of mask may be disruption in availability of the required mask/respirator and apprehension due to COVID 19 and discomfort while wearing the mask required. Studies like Aguwa et al. and Jawaid et al. have quoted discomfort and nonavailability as the reason for improper use of PPE.[13],[14] Other studies have also shown that HCWs, especially those who are working in more indigent parts of the world, are faced with using substandard options such as cloth masks and even extended use or reuse of respirators and surgical masks.[15] Justified and proper use of masks/N95 respirator if donned judiciously would have reduced the burden on health care system.

This irrational use of mask/respirators is not only putting the economical burden on health care but also causing deprivation of PPE resources in impoverished areas of world and hampering the IPC practices in health care system. It also leads to a false sense of security, causing a reduced to hand hygiene and other infection control practices.


  Conclusion Top


Proper hand hygiene and judicious use of mask are crucial for preventing infection transmission, however they are most of the time under or mis-utilized. We suggest didactic training and educational interventions to be followed for capacity building and motivating the HCWs for infection prevention practices. Each HCW should be trained in IPC practices including doffing and donning of PPE especially masks. Regular reinforcement and monitoring is also necessary followed by incentives and warnings. Administrative commitment at all levels is required to strengthen and empower IPC practices in the hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO director-general's opening remarks at the media briefing on COVID-19. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-March-2020. [Last accessed 2020 Mar 11]  Back to cited text no. 1
    
2.
Worldometers.info Delaware. Available from: https://www.Worldometers.info/coronavirus/?utm_campaign=homeAdUOA? Si. [Last accessed on 2020 Jun 03].  Back to cited text no. 2
    
3.
World Health Organization Director-General's opening remarks at the media briefing on COVID-19-3 March 2020-World Health Organization. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---3-March-2020. [Last accessed on 2020 Mar 03].  Back to cited text no. 3
    
4.
Chang , Xu H, Rebaza A, Sharma L, Dela Cruz CS. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med 2020;8:e13.  Back to cited text no. 4
    
5.
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020;395:514-23.  Back to cited text no. 5
    
6.
Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 6
    
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Infection Prevention and Control of Epidemic and Pandemic-Prone Acute Respiratory Diseases in Health Care. Geneva, World Health Organization, Global Alert and Response, 2007(WHO/CDS/EPR/2007.6). Available from:https://www.who. int/csr/bioriskreduction/infectionn_control/publication/en/.  Back to cited text no. 7
    
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WHO-Rational Use of Personal Protective Equipment for Coronavirus Disease (COVID-19) and considerations during severe shortages: Interim guidance. COVID-19: Infection prevention and control/WASH. Available from: https://www.who.int/publications-detail/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-and-considerations-during-severe-shortages. [Last accessed on 2020 Apr 06].  Back to cited text no. 8
    
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Livingston E, Desai A, Berkwits M. Sourcing personal protective equipment during the COVID-19 pandemic. JAMA 2020;323:1912-4.  Back to cited text no. 9
    
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WHO:-Coronavirus Disease (COVID-19) Advice for the Public: When and How to Use Masks. 2019. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks.  Back to cited text no. 10
    
11.
Guidelines on Use of Masks by Public– MoHFW. 2020 March. Available from: http: www.mohfw.gov.in'pdf'Useofmaskbypublic.  Back to cited text no. 11
    
12.
WHO guidelines on hand hygiene in health care. 2009 Aug. Available from: https://www.who.int/gpsc/5 may/tools/en/.  Back to cited text no. 12
    
13.
Aguwa EN, Arinze-Onyia SU, Ndu A. Use of personal protective equipment among health workers in a tertiary health institution, South East Nigeria: Pre-Ebola period. IJHSR 2016;6:12-8.  Back to cited text no. 13
    
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Jawaid M, Iqbal M, Shahbaz S. Compliance with standard precautions: A long way ahead. Iranian J Public Health 2009;38:85-8.  Back to cited text no. 14
    
15.
Abd-Elsayed A, Karri J. Utility of substandard face mask options for health care workers during the COVID-19 pandemic. Anesth Analg 2020;131:4-6.  Back to cited text no. 15
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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