Advancing Infection Prevention and Control through Learning and Practice: Lessons from DRASA and CICAPS

Onyinye Oranezi and Chibuike Alagboso (Lead Writers)

Infection Prevention and Control (IPC) measures are integral to every functional healthcare system. Their absence poses significant risks to health workers, patients, and visitors in any health facility, as infections can easily spread in such settings. According to the first-ever global report on infection prevention and control, 70% of these infections could be prevented if appropriate and cost-effective IPC practices are put in place.

A multi-approach and multi-stakeholder strategy is critical to achieving sustainable and successful implementation of IPC programmes in Nigeria. This is exemplified by the collaborative efforts of organisations such as the Dr Ameyo Stella Adadevoh Health Trust (DRASA), the Nigeria Centre for Disease Control and Prevention (NCDC), and the Centre for Infection Control and Patient Safety (CICAPS) hosted at the University of Lagos College of Medicine. Together, these organisations have formed a partnership-like coalition to address the challenges of IPC in Nigeria.

From projects to programmes

During the 2014 Ebola outbreak in Nigeria, gaps in IPC protocols resulted in the death of several health workers in health facilities. In 2018, CICAPS, supported by DRASA and other stakeholders, launched an IPC Diploma programme to equip health workers with the knowledge and skills to establish and maintain IPC programmes in their facilities. The course runs annually and consists of basic, intermediate, and advanced levels, with rigorous assessments and facility-based assignments. Graduates become part of a network of health champions and are engaged in ongoing communities of practice, further education, and implementation of IPC programmes in their respective facilities.

The realisation that Nigeria did not have a cadre of IPC experts put in place served as the drive for the programme, according to Niniola Williams, Managing Director at DRASA Health Trust. She mentioned that the practice of “we wait till there’s an outbreak, then we start trying to do two days, one-day crash courses in IPC, training thousands of people at a time” is neither enough nor sustainable. The training programme, however, is structured to ensure that over the period of 12 to 18 months, participants build the confidence to respond to emergencies when called upon. So far, there have been around 138 participants from 34 states in Nigeria.

During the training, participants acquire skills in stakeholder advocacy, enabling them to work effectively with their colleagues and management to get support for IPC. They also gain knowledge in areas such as planning, monitoring and evaluation, and mentoring colleagues. This is in addition to understanding the science behind IPC and other hands-on exercises, said Dr Usman Abdulrazaq Olagoke, the IPC Focal Person at the Federal Medical Centre, Ebute Metta, Lagos State, who participated in the first cohort.

Following their training, participants are expected to establish IPC programmes in their facilities if such programmes do not already exist. In addition, participants are strongly encouraged to share the knowledge and skills they acquired during the training with their colleagues, creating a multiplier effect. This way, the network grows as a specialist discipline with a trained workforce.

Enhancing knowledge and empowering health workers for effective IPC implementation

According to Williams, the diploma training programme is designed to ensure that the IPC programmes developed by CICAPS participants become centres of excellence where they are expected to mentor other facilities. This is already taking place at FMC Ebute Metta. Olagoke mentioned that they now have Temitope Damilola, employed as an Infection Control Officer in a private hospital in Lagos State, interning with the IPC Unit. Damilola stated that she uses the insights she gets from the FMC to educate and raise awareness around IPC among her colleagues.

The establishment of the hospital’s IPC unit in 2018 was driven by several factors, including support from the NCDC, concerns raised during the Ebola outbreak, and the proactive leadership exhibited by the Medical Director. The unit has since become an integral part of the hospital’s operations. “They instituted a train-the-trainer approach within each department for continuous education and knowledge dissemination around IPC practices,” said Lilian Obinwanne, the Assistant Director of Nursing Services, who heads the maternity and labour ward.

Vice-Chancellor of the University of Lagos, Professor Folasade Ogunsola, who is also a Consultant Clinical Microbiologist and strong advocate of institutionalising IPC practices through the Infection Control Africa Network, emphasised the importance of leadership in IPC endeavours. “Healthcare leaders, legislators, and policymakers must recognise the criticality of IPC in patient safety. It should be considered a fundamental component of the healthcare system, requiring policy implementation and sustainable support. Without leadership buy-in, IPC initiatives may lack the necessary support and sustainability to make a lasting impact,” she said.

According to Olagoke and Ogunsola, the most significant hurdle in normalising Infection Prevention and Control (IPC) practices among health workers lies in their attitude, as many tend to perceive it as trivial or insignificant. However, notable mindset transformations have been observed following participation in the IPC Diploma programme. “By seeing IPC as a discipline and profession rather than a reactive response during outbreaks, professionals become empowered to effect change,” Ogunsola said.

These trained IPC professionals also feed into the Orange Network of hospitals with IPC programmes launched by NCDC in 2019. The “Turn Nigeria Orange” project aims to ensure that healthcare facilities are safe spaces for clients and healthcare workers. Dr Tochi Okwor, Antimicrobial Resistance (AMR) and Infection Prevention and Control Programme Coordinator at the NCDC, said appointing focal persons, developing annual work plans, convening a technical working group, and establishing reporting and monitoring mechanisms are some of the strategies that help the programme remain sustainable over time. In addition, by leveraging existing systems, they ensure that IPC programmes are integrated and treated as ongoing efforts by health workers rather than temporary or short-term projects, she said.

DRASA adopts a multifaceted approach of pushing for IPC practices that goes beyond supporting the CICAPS diploma training programme. They are involved in policymaker and stakeholder engagement, raising awareness, and creating networks of IPC health champions. “We conduct site assessments, support the development of guidelines and standard operating procedures (SOPs), and support border health officials,” Williams said.

Hand in hand: WASH enables IPC

Water, Sanitation, and Hygiene (WASH) infrastructure make it possible to keep infections out of hospitals by enabling IPC strategies. Williams likened IPC to the software that runs the hardware. “WASH provides the necessary infrastructure, such as clean running water, waste management systems, and wash hand basins, while IPC operates within this framework, educating and guiding healthcare workers on proper hand hygiene, waste disposal, and infection control measures,” she said.

Across FMC Ebute Metta, efforts by Olagoke and his IPC team to ensure that WASH facilities such as handwashing stations are installed, and working, is evident. They also have messages reinforcing the importance of hand hygiene prominently displayed inside glass enclosures. He mentioned that this ensures messages remain visible for an extended period.

Following the COVID-19 pandemic, the hospital’s pharmacy unit, led by the Director of Pharmacy, Dr Aderonke Olowu, has taken the initiative to produce hand sanitisers and handwash for use within the hospital. “This ensures a consistent supply of these essential items and helps save cost,” said Dr Olowu.

Bridging the gap between training and implementation

Challenges in IPC implementation include inadequate funding, a lack of a defined career path for IPC practitioners, and lack of comprehensive surveillance data on healthcare-associated infections. Furthermore, the inconsistent enforcement of IPC policies as well as the turnover of trained professionals hinders the sustainability of IPC programmes, according to Ogunsola.

According to Dr Okwor, to establish sustainable IPC programmes and ensure safe and high-quality healthcare delivery, addressing complex and systemic issues such as a mindset shift, health worker attrition, adequate infrastructure, behaviour change, and advocacy for WASH improvements is critical.

Despite these issues, organisations like DRASA continues to drive the integration of IPC and WASH practices in healthcare facilities across Nigeria through collaboration, policy advocacy, and contributing to training an IPC workforce through CICAPS. To ensure the sustainability of these efforts, it is imperative for the government to allocate resources for the implementation of Infection Prevention and Control (IPC) practices.

This demonstrates a strong commitment to patient safety and public health and sends a clear message that the government recognises the importance of preventing healthcare-associated infections and is willing to invest in measures to safeguard the well-being of patients in health facilities, citizens and society at large.