key: cord-0272161-qil9jxxt
authors: Idris, A. B.; Hasabo, E. A.; Badawi, M. M.; Beirag, N.
title: Microbiological Assessment of Health-Care Providers in Africa: Systematic Review and Meta-Analysis
date: 2021-10-16
journal: nan
DOI: 10.1101/2021.10.14.21264931
sha: b17612f70b8973e9b6319d0465e8dcaa779cf5e9
doc_id: 272161
cord_uid: qil9jxxt

Background: Healthcare workers (HCWs) are the safeguards that help prevent illnesses and eliminate them when they occur. This study aimed to scan the related literature and provide pooled data about the level of knowledge, attitude toward infections, vaccination status, and infection prevalence among African HCWs to provide better evidence toward specific detailed determination of gaps to strengthen. A total of 11,038 published articles were identified from the search strategy. Among them, 163 articles met our inclusion criteria and passed the quality assessment procedure. Results: The prevalence of HBV was tested for 6,599 African HCWs;6.00% [95% Cl; 3.66, 8.33] were positive. The question Are you fully vaccinated against HBV? was answered by 12,036 HCWs; 43.22% [95% Cl; 31.22, 55.21] answered yes. The most crucial local factor identified among respondents for the spread of antimicrobial resistance (AMR) was self-antibiotic prescription 42.00 % [18.79, 65.20]. The question (Does the infection prevention and control (IPC) guidelines available in your workplace?) was asked to 1,582 HCWs; 50.95% [95% Cl; 40.22, 61.67] answered yes. Conclusion: This study determined many weaknesses to be addressed for the sake of improving health in Africa. The current pooled data are critically significant to be implemented in planning governmental or NGOs strategies.

Healthcare workers (HCWs) are the safeguards that assist in preventing illnesses and eliminate them when they arise (1) . However, the fact that they are a double-edged sword is not to be underestimated (3) . When standards go low, safeguards are needed to be saved, and more importantly, they may jeopardize others (4) . Several studies indicated that a vast percent of patients (up to 50 %) are admitted to hospitals after suffering from healthcare-associated infections (5).

Moreover, Africa is considered the continent with the lowest Gross Domestic Product (GDP) as most African countries fall within the lower-middle to low-income countries classification, which could be directly altering continuous education for healthcare workers, weak healthcare infrastructure, application of infection control policies in health facilities and vaccination opportunities against vaccine-preventable diseases for both healthcare workers and the community and 6.1% of the adult population are infected, respectively (9). Furthermore, Sub-Saharan Africa was also identified as having an immense burden of human papillomaviruses (HPV) in the world (24.0%) (10). Regarding tuberculosis infection (TB), WHO in 2015 identified two African countries 4 (Nigeria and South Africa) alongside the other three Asian countries to be responsible for 60% of incident cases (6).

Many studies have identified infection prevalence, vaccination status, knowledge level, and attitudes among African HCWs regarding various diseases. Therefore, the current systematic review aimed to scan the related literature and provide pooled data about the level of knowledge/Attitude toward infections, vaccination status and infection prevalence among African HCWs to provide better evidence toward specific detailed determination of gaps to strengthen.

To identify relevant studies, a systematic review of the literature was conducted on July 1, 2020. The review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement (11). A comprehensive search was conducted in PubMed, Embase, Google Scholar, Scopus, Index Copernicus, DOAJ, EBSCO-CINAHL, Cochrane databases without language limits (studies written in French were later excluded). To obtain current situation evidence, only studies published in or after 2010 were included. Furthermore, all studies where the data collection process took place before 2010 were also excluded. The only exception was if the collection process continued months/years earlier than 2010 and ended in 2010 or afterwards as previously described (12) . The keywords used in PubMed was as follow: CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted October 16, 2021. The six domains were: is the study objective clearly defined? is the study sample completely determined? is the study population clearly defined and specified? is participants' response rate above 70%, are the methodology and the data analysis used rigorous?.

The Trim and Fill method was used to assess the risk of publication bias in each question response in the included studies (14). Publication bias was evaluated separately for each question-corresponding responses only if the question was addressed and answered in studies equal to or greater than ten.

Meta-analysis was performed -whenever possible using Review Manager Software (Version 5. 3) . In studies where the Standard Error (SE) is not reported, the following formula was used to calculate it: SE = √ p (1-p)/ n where p stands for Prevalence. The software automatically provided the Confidence Interval (CI) according to the calculated SE, if the CI is provided in a study; it was introduced accordingly. The heterogeneity of each meta-analyses was assessed.

The random effects were favored over the fixed effects model in all meta-analysis established as differences between studies are predicted to be possible due to the diversity of the study populations. Sensitivity analysis was also approached to determine the effect of studies conducted on populations which are proposed to behave in indifferent manners or proposed to be more aware of the overall pooled prevalence. Moreover, subgroup analysis was also conducted -whenever suitable to determine awareness level in a specific country or population.

A question to participate in the meta-analysis must be included in at least three studies, and questions with similar outcomes were proposed to be the same. 

A total of 11,038 published articles were identified from the search strategy. Also, we involved the hand search of reference lists of included original research articles and reviews. Among these articles, 163 articles met our inclusion criteria and passed the quality assessment procedure. Twenty-nine articles have reported the prevalence of microbiological infections, while 34 articles have determined the vaccination status among African HCWs. Furthermore, 108 included studies have assessed the awareness and attitude toward different microbial infections. The oldest studies were published in 2010, while the most recent ones were published in 2020. Figure 1 shows the PRISMA flow diagram. The included articles in this meta-analysis and the assessment of their quality are illustrated in S1 Table and S2 Table, respectively. Three hundred forty-seven questions were summarized, among which 96 questions were analyzed and synthesized.

Publication bias assessment indicated no major asymmetry. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.14.21264931 doi: medRxiv preprint from the participants, and 12 of them were analyzed and synthesized. Variables analyzed, their corresponding articles' data, the pooled prevalence and the confidence intervals are illustrated in Table 1 . The prevalence of HBV (HBsAg) was tested for 6,599 African HCWs;6.00% [95% Cl;

3.66, 8.33] were positive. While the prevalence of HCV (anti-HCV) was investigated for 1,489 African HCWs; 0.81% [95% Cl; -4.27, 5.89] were positive, see Table 1 , Figure 2 and . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 1 1 Table 3 . Heterogeneity was high in all questions (I 2 more than 89%), except for the question "Did you take two doses of hepatitis B vaccine?" where I 2 = 40%.

Twenty-nine included studies have assessed the awareness and attitude toward HBV among 5,761 African HCWs. These studies were conducted in Tanzania Table 3 . . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted October 16, 2021. Table 4 . Heterogeneity was high in all questions (I 2 more than 80%). Except for the question "Do you agree that surgical masks do not protect the wearer against TB infection?" where I 2 = . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted October 16, 2021. ; 1 4 40%. Questions asked, their corresponding articles' data, the pooled prevalence, value of Heterogeneity, P-value and the confidence intervals are shown in Table 5 .

Eight studies have assessed the awareness toward antibiotics among 1,761 African HCWs in Ethiopia (101) Table 6 for more illustration.

According to our analysis, the most crucial perceived factors that were determined by articles' data, the pooled prevalence, value of Heterogeneity, P-value and the confidence intervals are shown in Table 6 .

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Table 7 .

Eighteen studies have assessed awareness and attitude of African HCWs toward different aspects, including Ebola virus, Influenza virus, Zika virus, zoonotic diseases (rabies, anthrax, dengue, and chikungunya), Buruli ulcer disease, human papillomavirus (HPV), atopic dermatitis, Lassa fever, aflatoxin contamination in groundnut and its ingestion risk, . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. synthesized. The question was, "do you agree that Influenza is more serious than a "common cold", and patients to be hospitalized or die from influenza?". It was asked for . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted October 16, 2021. ; 1 7

This systematic review has attempted, for the first time, to collate all research conducted in Africa reporting any aspect of microbiological assessment among HCWs. The results presented analyzed data about the prevalence of microbial infections, vaccination status and awareness and attitude toward microbial infections among African HCWs to plan and implement adequate preventive measures, optimize practitioners' knowledge and inform researchers what is done in this area while simultaneously identifying potential gaps in knowledge on this area of study.

The current study has assessed the prevalence of different types and causes of microbial infections among 12,342 African HCWs in 12 countries. The prevalence of HBV (HBsAg), HCV (anti-HCV) and HIV were 6.00%, 0.81% and 9.06%, respectively. The risk of HBV, HCV or HIV infecting HCWs is higher than general populations because they are frequently exposed to potentially infectious biological materials. However, HBV and HCV epidemiology exhibits considerable geographical differences, and accordingly, the prevalence of HBV and HCV among HCWs varies as well (for a review, see (131)).

Regarding HIV epidemiology, the Sub-Saharan African belt bears the brunt of HIV infection (132)(133)(134), and HCWs are at high risk of HIV infection from both occupational exposure and sexual transmission (135). Moreover, in this study, the evidence base shows a high burden (59.82%) of occupational Latent TB (LTB) among African HCWs. However, high LTB incidence was also reported in India among HCWs (136)(137). Although HCWs potentially expose to a different type of occupational hazard, many HCWs lack awareness about prevention and control. In African and developing countries, prevention policies are unclear, inaccessible, or attitude problem . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted October 16, 2021. ; 1 8 that made HCWs suffer (138). In this study, 81.20% of African HCWs were occupationally exposed to blood-borne viruses (HBV, HCV, and HIV). The global burden of blood-borne diseases from occupational exposure, based on the world health organization estimation, is around 40% of the hepatitis B and C infections and 2.5% of the HIV infection (139)(140)(141). In addition, occupational exposure to sharp and needlestick injuries represents a global problem. In the USA, According to the CDC report, the annual number of injuries among the hospital staff is 385,000 (142 CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted October 16, 2021. ;

48.1% (155) and USA 63.4%, and is the highest in French healthcare students (91.8%) probably for mandatory vaccination (156)(157). Therefore, because of excellent vaccination coverage in France and compulsory vaccination and given that high hepatitis B infection rate among African HCWs offset by low vaccination coverage, we strongly recommend HBV vaccine to be an obligatory prerequisite for work. This policy will greatly value HCWs regarding their health state and, therefore their service.

Measuring awareness toward blood born infections in HCWs is vital since their a high risk of contracting them (158) as the incidence of needle stick injuries are high in their work field (147). Opening with HIV as it demonstrated the highest prevalence among African HCWs, our study found that most of them consider themselves at risk for HIV acquisition at their workplace by 75.03%, which is lower when compared to South India (100%) (158) and Serbia (89%) (3), but higher than the 62% recorded among HCWs in In this study, 37.77% screened suspicious TB patients in waiting areas, and 47.21% prioritized TB suspects for prompt service. These poor practices of administrative IPC measures are many pitfalls since these should be implemented at first contact with an infectious patient at a health facility. Delays in screening, diagnosis and treatment of TB would increase the risk of healthcare-associated TB. Environmental IPC measures, which are second-line IPC practices, are dependent on the use of ventilation and irradiation and infrastructural design of the facility; however, more straightforward effective methods have been suggested based on adequate ventilation through the opening of windows (164). in this study, 57.07% of respondents isolate the patients or use of separate TB ward, and 75.40% of respondents open windows for ventilation and sunlight. In addition, the findings regarding PPE were of concern. We found that 49.08% of respondents use a mask when approaching TB suspected patients, which agrees with Biscotto et al. finding that HCWs infrequently used masks (39.5%) when performing procedures or attending patients with a high risk of healthcare-associated TB (167) .

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.14.21264931 doi: medRxiv preprint 1 Antimicrobial resistance (AMR) represents a serious growing challenge, especially in low-income countries such as African countries, because of irrational uses of antimicrobials, lack of clinical microbiology laboratories for antimicrobial susceptibility testing, over-the-counter availability of antibiotics high prevalence of infection (168) .

However, containment of AMR demands changes in HCWs' behavior towards the magnitude of AMR problem, prevention the transmission of resistant microbes, prescribing antimicrobials wisely and promoting awareness on AMR for patients and communities (101). Therefore, information on HCWs' knowledge and awareness of AMR will permit more effective interventions on AMR containment. In this study, the most crucial perceived factors that were determined by African HCWs, contributing to AMR development were widespread or overuse of antibiotics (77.75% by respondents) and patients' poor adherence to prescribed antibiotics (47.18%). Likewise, previous studies conducted in Scotland, France and Spain found these factors among the leading causes of AMR development (169)(170). In addition, this study revealed that the most important local factor for the development and spread of AMR was self-antibiotic prescription (42% by respondents) which is similar to previous studies (171) (168) .

Adherence to IPC guidelines is a key to protect HCWs and prevent transmission of infections, and it becomes even more important when infectious diseases become widespread, such as during the COVID-19 pandemic. In this review, we found that the availability of IPC guidelines in African HCWs' workplaces was 50.95% which is consistent with a study conducted in Italy (172). Strategies in IPC guidelines include stricter cleaning routines, the separation of patients with respiratory infections from others, and personal protective equipment (PPE) such as masks, gloves and gowns.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.14.21264931 doi: medRxiv preprint However, practicing these strategies can be difficult and time-consuming; therefore, authorities and healthcare facilities need to consider the best way to support healthcare workers to implement them. The findings presented in this study regarding the implementation of PPE among African HCWs were 35.86% wash their hands with soap before patient care; 71.62% wash their hands with soap after patient care/contact with fluid; 69.56% wash their hands without soap before and after patient care;61.28% wear fresh gloves before examining new patients; 36.10% are routinely masked before entering the ICU; 43.81% are you routinely gowned before entering the ICU, and 41.91% are routinely worn goggle before entering the ICU (Table 7) . These findings are relatively lower compared with results of other similar previous work (173).

Healthcare workers are god's safeguard of life, especially in continents suffering poverty, conflicts, illiteracy, and fragile infrastructures. The current study determined many weaknesses to be addressed for the sake of improving health in Africa. Therefore, the current pooled data are critically significant to be used in planning governmental or NGOs strategies.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.14.21264931 doi: medRxiv preprint

All relevant data are available within the manuscript and as supplementary materials.

The authors received no specific funding for this work.

The authors have declared that no competing interests exist. Hasabo . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted October 16, 2021. 11. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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