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Facemasks in the Protection of Hospitals

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Facemasks in the Protection of Hospitals FACEMASKS IN THE PROTECTION OF HOSPITALS HEALTHCARE WORKERS (HCW) IN RESOURCE POOR SETTINGS Dr. Abrar Ahmad Chughtai This thesis is in fulfilment of the requirements for the degree of Doctor of Philosophy School of Public Health and Community Medicine UNSW Medicine May 2015 1 THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Fam1ly name Chughta1 F1rst name Abrar Other name/s Ahmad Abbreviation for degree as g1ven m the Umvers1ty calendar PhD School Public Health and Commun1ty Medicine Faculty Medicine T1tle Facemasks m the protection of hosp1tals healthcare workers (HCWs) in resource poor settings Abstract 350 words maximum: (PLEASE TYPE) Currently there is an ongoing debate and a dearth of evidence around the efficacy of facemasks and respirators. Most studies have been observational and there is a lack of trial data around use and re-use of facemasks in the healthcare setting. Due to the lack of high quality studies, I hypothesised that there would be huge variations in the policies and practices around the use of facemasks and respirators in the healthcare setting. This thesis therefore aims to examine the policies and practices around the use of these products in low resource countries. Five studies were conducted at varying administrative levels. In the first study, publicly available policies and guidelines around the use of facemasks/respirators were examined to describe areas of consistency, as well as gaps in the recommendations. In the second study, infection control stakeholders were interviewed from China, Pakistan and Vietnam to further explore the issues, which arose during the guideline review. Next, hospitals from the three countries were surveyed to examine practices around the use of facemasks/ respirators and to examine the translation of policies into practice. Samples of facemasks and respirators were also collected and tested. In the fourth study, focus groups were undertaken to examine the knowledge, attitudes and practices of Vietnamese hospital HCWs towards the use of masks/respirators. The fifth study examined the factors associated with compliance of Vietnamese HCWs with the use of various types of facemasks. In addition, the available evidence around the efficacy and use of cloth masks was reviewed. These studies provide new data around factors impacting on the use of facemasks and respirators in resource poor settings. Inconsistencies and gaps were identified in the reviewed polices, which highlight that there is a need to develop a comprehensive and uniform policy around the use of facemasks/respirators. Practices around the use of facemasks and respirators are influenced by organizational and personal factors and understanding these factors will assist with the development of strategies to improve staff compliance with respiratory protection. On the basis of these studies, recommendations have been developed around the use of facemasks and respirators in low resource settinQs. Declaration relating to disposition of project thesis/dissertation I hereby grant to the Un1vers1ty of New South Wales or its agents the nght to archive and to make available my thes1s or dissertation in whole or in part in the Un1versity libraries m all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent nghts I also retam the right to use in future works (such as articles or books) all or part of this thesis or dissertation I also authonse Un1vers1ty Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this IS applicable to doctoral theses only). ~~ .............. · r-::. ;.~~~-~~-· ......... .. ............ Signature W1tness Date The Un1vers1ty recogn1ses that there may be exceptional Circumstances requinng restrict1ons on copying or cond1t1ons on use. Requests for restnction for a period of up to 2 years must be made in wnting Requests for a longer period of restriction may be considered in exceptional Circumstances and requ1re the approval of the Dean of Graduate Research FOR OFFICE USE ONLY Date of complet1on of requirements for Award 2 ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’ Signed …………………………………………….............. Date: 29-5-2015 3 SUPERVISOR STATEMENT I hereby certify that all co-authors of the published or submitted papers agree to Abrar :~mad Chughtai submit · 1:s~~a~er .. aspart of his/her Doctoral Thesis oate ... 1!:-.o/-=?/(C:.................. .................... 4 Table of contents TABLE OF CONTENTS Acknowledgments…………………………………………………………………………………………………. 7 Abstract ……………………………………………………………………………………………………………….. 9 List of abbreviations …………………………………………………………………………………………….. 11 List of tables …………………………………………………………………………………………………………. 13 List of figures ……………………………………………………………………………………………………….. 14 Ethics approval …………………………………………………………………………………………………….. 15 Publications arising from thesis ……………………………………………………………………………. 16 Publications associated with thesis …….……………………………………………………………….. 17 Conference presentations …………………………….……………………………………………………… 18 Awards and travel scholarships ……………………………………………………………………………. 20 A guide to thesis …………………………………………………………………………………………………… 21 Chapter 1: Literature review ………………………………………………………………………………… 26 Chapter 2: Availability, consistency and evidence-base of policies and guidelines on the use of mask and respirator to protect hospital health care workers: a global analysis ……………………………………………………………………………………………………… 109 Chapter 3: Examining the policies and guidelines around the use of masks and respirators by healthcare workers in China, Pakistan and Vietnam ………………………. 139 Chapter 4: Practices around the use of facemasks and respirators amongst hospital healthcare workers (HCWs) in three diverse populations ……………………….. 159 Chapter 5: Current practices and barriers to the use of facemasks among hospital based healthcare workers (HCW) in Vietnam ………………………………………………………. 184 Chapter 6: Factors affecting compliance of healthcare workers with the use of facemasks ……………………………………………………………………………………………………………. 206 Chapter 7: Use of cloth masks in the practice of infection control – evidence and policy gaps …………………………………………………………………………………………………………… 231 Chapter 8: Conclusion and recommendations ……………………………………………………… 253 5 Table of contents Appendices ………………………………….……………………………………………………………………… Appendix 1: Publications arising from thesis………………………………………………………… 286 Appendix 2: Papers associated with thesis …………………………………………………………… 287 6 Acknowledgements ACKNOWLEDGEMENTS I am indebted to my supervisors Dr. Holly Seale and Prof. Raina MacIntyre for patience, encouragement and outstanding support throughout the candidature. They have been my teachers, mentors, and colleagues, and have also created opportunities for career and professional development. They cared so much about my work and always responded to my questions and queries so promptly. I am also grateful to my co-supervisors Prof Dominic Drawer and Dr Amal Bissili (Late) for technical inputs. I would like to acknowledge the learned contribution and valuable input and support of all colleagues and co-authors on papers in this thesis. It was a great privilege to work with staff from the Beijing Center for Disease Prevention and Control China, the National TB Control Program Ministry of Health Pakistan and the National Institute of Hygiene and Epidemiology Vietnam. I enjoyed excellent coordination and support from these institutes. Special mention goes to Quanyi Wang, Peng Yang, Yang Zheng, Zafar Iqbal Toor, Muhammad Orooj Ashraf, Nguyen Tran Hien, Tham Chi Dung and Phan Thi Nga for collaboration during filed work and contributions to papers as co- authors. I also extend my thanks to individuals and institutions that participated in health department and hospital level studies. Funding of the staff level studies was received from the Australian Research Council (Grant number - LP0990749). Thanks to all staff members and colleagues at School of Public Health and Community - Andew and Bayzid for statistical input and manuscript review, Nina, Catherine, Suzie and Ravit for administrative support, and all research candidates in SAM212 for help and encouragement. I must express my gratitude to my wife Nabila and children Abdal and Taha who experienced all of the ups and downs of my thesis. They were always there to encourage and support me. I am also grateful to other family members and friends who always listen to me and helped me when needed. 7 Acknowledgements I dedicate this thesis to my parents for all the sacrifices they had made for me. They helped me with every step of my life and encouraged me to start the PhD program. 8 Abstract ABSTRACT Currently there is an ongoing debate and a dearth of evidence around the efficacy of facemasks and respirators. Most studies have
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