Health Facilities Readiness to Implement Standard Precautions for Infection Prevention and Control in Tanzania: Lesson Learnt from SARA Reports

Introduction: Standard Precautions are a set of measures applied in the care of all individuals/patients regardless of their infectious status aiming at preventing healthcare workers and patients from infections, preventing environmental contamination and spread of infections to the community. Many health facilities have not implemented them to an acceptable level. The purpose of the study is to report progress of improvement in health facilities readiness to implement standard precautions for infection prevention and con-trol based on SARA reports. Methods: We generated mean scores of all standard precautions each year and calculated their standard deviations, variances and confidence intervals. One-way ANOVA was used to determine if the mean scores were equal. Finally, the trend of improvement in health facilities readiness to implement the standard precautions was generated. Results: A total of


Introduction
Standard Precautions are a set of measures applied in the care of all individuals/patients regardless of their infectious status with the aim of preventing health care workers and patients from infections as well as preventing environmental contamination and spread of infections to the community.The key elements of standard precautions are: performing hand hygiene; using personal protective equipment; following respiratory hygiene/cough etiquette principles; ensuring appropriate patient placement; cleaning and disinfecting patient care equipment, instruments/devices and the environment; appropriate linen processing; following safe injection practices; and ensuring healthcare worker safety including proper handling of needles and other sharps [1].
The Service Availability and Readiness Assessment (SARA) surveys in the area of standard precautions cover nine indicators which can be grouped into six categories as follows: waste management (sharps and infectious waste); availability of disinfectant; availability of single-use syringe; availability of soap and running water or alcohol-based hand rub; availability of latex gloves; and availability of guidelines [2].Tanzania has made many strides in the area of implementation of standard precautions since the inception of the United States President Emergency Plan for AIDS Relief (PEPFAR) in 2003, which provided funding for the prevention of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) to 14 countries in Africa and the Caribbean including Tanzania [3].Key milestones achieved in Tanzania, which aimed at strengthening the implementation of standard precautions are summarized in Table 1 [3]- [11].
Efforts to improve waste management in health facilities in Tanzania started in 2003 when there was a nationwide health-care waste management-training program that was implemented from 2003 to 2005.During that time, an assessment of facilities found that the methods used for waste disposal were mainly open pit burning (50%) and burying (30%), with a low capacity for incineration in hospitals [4].The Making Medical Injections Safer (MMIS) Project, which was implemented by John Snow Inc., supported the Ministry of Health in Tanzania to address issues of injection safety and health care waste management using

2018
The National Infection Prevention and Control Guidelines for Healthcare Services of 2004 were revised to produce a 2018 edition [8].

2020
The IPC Standards for Hospitals, Health Centres, and Dispensaries were revised coupled with development of Standard Operating Procedures [8].

to April, 2021
On-going dissemination of the guidelines, standards and standard operating procedures accompanied with IPC standards compliance assessment using SBM-R tool [11].adapted strategies designed by the World Health Organization's Safe Injection Global Network including: "Capacity building and training; commodity management and procurement; behavior change communication and advocacy; es-tablishing standardized systems for safe health care waste management; establishing policy environment which supports injection safety and health care waste management; increasing health care workers safety; and monitoring and evaluation" [6].Its baseline data collected in 2004 indicated that injection safety prac- tices in Tanzania were poor, as noted in the following indicators: handling without washing hands was 50%; poor disposal of sharps immediately after use was 54.2%; recapped needles was 45.8%, and did not use safety boxes was 50.0%[12].
Compliance with standard precautions is key for healthcare workers' protection.If those are not well adhered to, it leads to exposure of healthcare workers and eventually the community at large to infections.In a study conducted in 14 hospitals (district, regional and zonal referral) in 2006, "Needlestick injuries accounted for the largest part of the most common accidents (52.9%) among health care workers, followed by splash of blood from patients (21.7%), burn injury from chemicals (10.6%), and slippery floors (5.9%)" [13].
Also, a study by Chalya, et al. ( 2015) which was conducted in zonal referral hospital (Bugando Medical Centre) in Nyamagana Council in Mwanza found that out of 436 healthcare workers who participated in the study, 212 (48.6%) reported incidents of needlestick injuries and splash exposures within the previous 12 months.Needlestick injuries were reported by 65.1% (n = 138) and splash exposures by 27.4% (n = 58).Sixteen (7.5%) respondents had both needlestick injuries and splash exposures (which means total needlestick injuries were equal to 16 + 138 = 154/436), making the prevalence of needlestick injuries in the past 12 months to be 35.32.In addition, the majority of healthcare workers, 185 (87.3%), were not adequately immunized for hepatitis B virus and only 17 (8.0%)were fully vaccinated, having received three doses of the vaccine.Only 16.7% of exposed healthcare workers received post-exposure prophylaxis for HIV; and subsequent six-month follow-up for HIV showed zero seroconversion [14].Despite the challenges of unsafe disposal and reuse of contaminated syringes, which affect safe injection practices in low-and middle-income countries [15]; the trend of unsafe injections in sub-Saharan Africa was shown to improve between 2000 and 2010 whereby on average people received only 0.04 -0.05 unsafe injections per year [16].Also, Hayashi and colleagues, in the analysis of demographic and health survey data of 2011-2015, for Tanzania, the frequency (defined as the number of health care injections per person per year) was 0.90 (n = 16,780) and the safety of injections as measured by "use of an unopened syringe or needle" was 97.6% (n = 4786) [17].This indicates that the efforts that were put in place by the Ministry of Health in collaboration with stakeholders with funding support from US-PEPFAR since 2003 have helped to improve injection safety practices in Tanzania.Also, the introduction and implementation of the 5S-(sort, set, shine, standardize and sustain)-KAIZEN-Total Quality Management approach [18] [19] has complemented the efforts to improve health care waste management, especially during this error of emerging and re-emerging infectious diseases [20].
The increasing burden of emerging and re-emerging infectious diseases has highlighted the need for more focus on the implementation of standard precautions for IPC in health facilities in order to protect the health care workers and users.One of the key elements of standard precautions-preventing needle stick injuries is still an issue that requires at most attention.In a recent review by Mengistu and colleagues, (2021), which "Aimed to determine the career time and previous one-year global pooled prevalence of occupational exposure to needle stick injury among healthcare workers", they found that the "Worldwide pooled prevalence of needle stick injuries among healthcare workers during career time and previous one year was 56.2% (95% CI: 47.1, 64.9) and 32.4% (95% CI: 22.0, 44.8), respectively" [21].For Tanzania, the prevalence of needle stick injuries among healthcare workers in the previous one year is 35.32 [14] [21].
Also, the government has constructed, renovated and or upgraded health facilities in the past five years (2015-2020) in various councils countrywide; therefore, there is a need to understand if the new facilities are ready to implement standard precautions [22].
In that context, studying the "Service Availability and Readiness Assessment (SARA)" data for 2012, 2017 and 2020 will help to inform the Ministries responsible for health issues in Tanzania (Ministry of Health; and President's Office Regional Administration and Local Government) and all Partners on the trend of facilities readiness and provide some recommendations to address the situation on standard precautions implementation in general.Therefore, the objective of the study is to report on: the progress of improvement in health facilities readiness to implement standard precautions for IPC; and scores attained by health facilities based on SARA survey reports of 2012, 2017 and 2020.

Methods
In 2012 the SARA survey was conducted in a nationally-representative sample of In 2020, the data collection for the 2020 SARA survey was conducted from 23 rd June to 14 th July 2020 by the Ifakara Health Institute in collaboration with the Monitoring and Evaluation Section in the Policy and Planning Division of the then MoHCDGEC.Twenty-six districts, one from each of the 26 regions were selected in which a total of 612 health facilities were selected.
In all three years, the SARA reports do not show how the facilities were sampled.Hence, we can't report the methodology of sampling which was used.
However, all levels of health facilities were included based on the health system of Tanzania, that is, primary facilities (Dispensaries, Health Centers and Level one Hospitals) and referral hospitals (levels two, three and four hospitals) [8].
The data were collected by the then MoHCDGEC's Division of Policy and Planning -Monitoring and Evaluation Section in collaboration with partners and consultants.The data were collected using a standard questionnaire instrument and indicators developed by the World Health Organization (WHO).

Study Variables
The standard precautions items assessed as study variables in the SARA report were as follows: safe final disposal of sharps; safe final disposal of infectious waste; appropriate storage of sharps waste; appropriate storage of infectious waste; disinfectant; single-use-standard disposable or auto-disable syringes; soap and running water or alcohol-based hand rub; latex gloves; and guidelines for standard precautions [2].

Outcome
The outcome of the study is the mean scores of standard precautions for IPC.

Data Analysis
We performed secondary data analysis of SARA reports of 2012, 2017 and 2020 and were informed by the literature on the situation of some of the key components of standard precautions as listed on the study variables above.The scores of the SARA report were categorized using the categories used by the WHO IPC Assessment Framework (IPCAF), which is an international tool to score adherence to IPC; in which the scores 0 -200 maximum 25% is considered inadequate, 201 -400 maximum 50% is considered as basic, 401 -600 maximum 75% intermediate and 601 -800 maximum 100% as advanced [23].The mean scores of all standard precautions in each year were generated, and their standard deviations, variances and confidence intervals were calculated.One-way ANOVA was used to determine if the mean scores were equal.Finally, the trend of improvement in health facilities readiness to adhere to standard precautions was generated.

Results
The scores show percentages of health facilities that had had those elements of standard precautions in their health facilities.The safe final infectious waste disposal was being done in only 11% and single-use-standard disposable or auto-disable syringes were available in 87% of all facilities that were sampled in 2012.The safe infectious final waste disposal was done in only 30% and single-use-standard disposable or auto-disable syringes were available in all facilities (100%) that were sampled in 2017.The safe final waste disposal was done in only 23% and single-use-standard disposable or auto-disable syringes were available in 99% of all facilities that were sampled in 2020.The mean score of the facilities was 52.22% in 2012, 64.55% in 2017 and 69.66% in 2020.The mean scores were not different statistically with p = 0.3217.The summary of the percentage scores obtained during the surveys conducted in 2012, 2017 and 2020 is shown in Table 2.

The trend of mean scores of health facilities with Standard Precautions compliance
There has been improvement in terms of more health facilities that have the requirements necessary for complying with standard precautions for IPC while providing health care.There has been linear progress from 2012 to 2020 as far as the standard precautions are concerned in health facilities in Tanzania based on SARA reports, even though the mean scores are not statistically different.The linear trend is shown in Figure 1.

Discussion
In the SARA surveys conducted in Tanzania in 2012, 2017 and 2020, there was an overall increase of health facilities that were ready to comply with the implementation of standard precautions.The scores increased from 52.22% in 2012 to 69.66% in 2020.The survey was in keeping with a study conducted by Abera Beyamo in public health institutions of Dawuro zone, southwest Ethiopia, in Figure 1.Trend of increase in health facilities with standard precautions.The f-ratio value is 1.18936.The p-value is 0.3217.The result is not significant at p > 0.05.Hence the mean scores are not different.
2016, who found 65% of health workers had complied with standard precautions [24].The difference between these two studies is that the SARA surveys looked at the percentage of health facilities that generally comply with the standard precautions while Abera Beyamo et al. looked at the percentage of healthcare workers who complied with standard precautions.The SARA surveys in all three years have found that safe waste disposal in terms of both sharps and infectious waste was very low.At the time when the survey was lastly conducted in 2020, safe disposal was 28%, while that of infectious waste was 23%.The survey is consistent with the study that was conducted by Manyele and Mujuni in 2010 at 135 lower-level facilities (103 dispensaries, 13 clinics, 11 laboratories, and 8 health centers of Dar es Salaam, Ilala Municipality, which showed that only about 39.3% of the facilities utilized on-site single-chamber incinerators for sharps waste treatment, which were of poor design and quality [25].Also, about 59% of the facilities improvised sharps waste containers, sharps waste was transported by hands in 77% of the facilities, and most facilities stored sharps waste for about 72 hours (before treatment), which is beyond the recommended maximum storage time of 24 hours [4].The storage practice differs from what SARA surveys had found out; the survey had found about 80% by 2020, store waste both sharps and infectious waste appropriately.The difference might be due to the duration between the two studies which one was conducted in 2006 and the other one in 2020.There might be a lot of improvements happened in the storage of medical waste in the time interval of about 14 years (2006-2020).
During the surveys, it was realized that the majority of health facilities in the country had disinfectants.In the last survey that was conducted in 2020, it was found that 98% of the facilities had disinfectants.The finding of the presence of disinfectant contradicts the study conducted by Gon and colleagues, who noted that the cleaning and disinfection of health facilities were not at the recommended standard.They found that the proportion of cleanliness (ACC < 2.5 cfu/cm 2 ) was only 19.1% during the pre-training period and 40.7% when using microbiological cleanliness (ACC and S. aureus) during the post-training period [26].The finding of the availability of disinfectants to be 98% in the sampled health facilities could be due to the non-utilization of those disinfectants to the maximum potential.
The availability of soap and running water in Tanzanian health facilities were up to 78%, as shown by the SARA report of 2020.The survey differs from the survey conducted by Malebo et al. in health facilities of Tanzania that found 60.4% were not connected with piped water supply, but only a few hospitals 16.7% are not connected with piped water supply.However, it was alarming that more than 50% of health centres and dispensaries lacked connectivity with piped water supply.Regarding water availability and access in healthcare facilities visited, 46% reported inadequacies in the water supply.Thirty-two of the visited health facilities (34%) they reported irregular supply and that they experienced water shortages for at least one day in a week, whereas 12 healthcare facilities (12.5%) obtain water only seasonally.Availability of handwashing stations with soap/alcohol-based hand rubs within the facility was also a challenge, 44% of consultation rooms and 42% of delivery rooms in the surveyed healthcare facilities didn't have functional hand washing facilities and some had been replaced by plastic water containers without drainage.Soap for hand washing was present in 51% of consultation rooms and 79% of delivery rooms.As for antiseptic hand rub only 9% and 12% of the health facilities surveyed had antiseptic hand rubs present at hand washing points in consultation rooms and delivery rooms respectively [27].The difference might be explained by the sharp improvement of infrastructures of the water system in Tanzania as the country reached a lower mid-level economy.The availability of personal protective equipment including gloves, as well as availability of guidelines and standard operating procedures in health facilities also generally improved.

Conclusions
The study has demonstrated that in Tanzania, there was an overall increase in health facilities readiness to implement standard precautions for IPC based on the trend from the SARA surveys conducted in 2012, 2017 and 2020.The SARA 27 districts, with a target sample of 1908 health facilities and a final sample of 1297 health facilities, representing more than 18% of all health facilities in the country.The sample comprised non-government as well as government-owned health facilities.Field work for the survey was conducted in three rounds: the first in May-June, the second in July-August 2012 and the final round in December 2012.Data analysis and report preparation commenced in September 2012.A final round of data analysis and report editing was conducted in January-February 2013.The 2017 SARA survey in Tanzania was conducted to assist the health sector in assessing and monitoring service availability and readiness and capacity at the district and national levels.The survey was conducted from 2 nd to 21 st October 2017 by the Ifakara Health Institute in collaboration with the then Ministry of Health, Community Development, Gender, Elderly and Children's (MoHCDGEC) through the Monitoring and Evaluation Section in the Policy and Planning Division (from January 2022, the MoHCDGEC has been renamed back to Ministry of Health), and Khulisa Management Services (Khulisa), a South African consultancy company hired by The Global Fund.This was the second SARA survey Advances in Infectious Diseases to be conducted.Data for the study were collected from a sample of 26 districts and 540 health facilities to provide a representative portrayal of health services in Mainland Tanzania.

Table 1 .
Infection prevention and control-summary of key milestones in Tanzania (2003-April, 2021).
[8]9Quality Improvement -Infection Prevention and Control Orientation Guide for Participants was developed (supported by the United States' Agency for International Development [USAID] through the ACCESS program and PEPFAR) with the aim of providing healthcare workers with readable and user-friendly basics of Quality Improvement concepts, IPC practices and logistics management, while incorporating behavior change and communication, to improve quality in health care[7].2010Implementation of IPC Standards for Hospitals using the Standard Based Management and Recognition (SBM-R) approach was started[8].

Table 2 .
Category based on IPCAF tool showing scores obtained in 2012, 2017 and 2020.