Kenya’s adoption of WHO multimodal strategies in response to the COVID-19 pandemic required a pragmatic approach and appropriate leadership in coordinating multiple stakeholders. Kenya enhanced the IPC structure across all levels of government and health facilities, which led to a standardized approach. This approach ensured that, in the face of COVID-19, healthcare workers felt protected, thus improving worker confidence and morale (13). The multimodal approach was shown to improve hand hygiene and other IPC practices in a cross-sectional survey of 17 hospitals in Greece (14). Similar sustainable improvements in hand hygiene were documented by Allegranzi et al. (15). Wang et al. (16) demonstrated that the COVID-19 pandemic highlighted the crucial role a structured IPC program plays in disease outbreak control. In 2020, WHO supported Ukraine to apply the multimodal approach in response to COVID-19 at the facility and national level, resulting in overall improvement of the IPC program (17).

Using standardized tools to assess health facilities enabled officials to identify gaps in IPC policy and guidelines implementation and create specific recommendations for remediation. Immediate targeted interventions were implemented at the facility level on the basis of the work plan. In addition, refresher trainings and national webinars were carried out on the basis of cross-cutting gaps. The WHO recommends use of IPC facility assessments to provide feedback and make IPC program improvements (18). It recommends implementing an assessment framework using a tool to assess 8 IPC core components that scores the IPC measures at the facility as inadequate, basic, intermediate, and advanced. Follow-up assessments should be conducted quarterly, semiannually, or annually. Although the baseline assessment mean score in Kenya of 61% was lower than the score of 86% documented in Germany, the difference could be accounted for by timing, setting, and tools used (19). Sachdeva et al. (20) showed varied compliance to IPC measures among 30 facilities in India. The assessment in Kenya demonstrated that the domains of hand hygiene and mask use scored the highest. This finding is likely because the 2 methods were being emphasized as the key COVID-19 prevention measures. Handling of human remains scored the lowest because no healthcare worker training had been held on that subject. Although risk for SARS-CoV-2 transmission through a dead body is minimal, standard precautions should be practiced and education offered to allay fears (21–24). Other domains that scored low included appropriate use of gloves, monitoring of healthcare workers, and care for COVID-19 patients, which might reflect a knowledge gap because of low access to training, lack of supportive guidance documents, and a shortage of gloves at the time.

In 2020, healthcare workers made up 3.2% of all SARS-CoV-2 infections in Kenya, which was lower than the global percentage of 3.9% (May 2020) and the percentages in Nigeria (6%), Italy (10%), and Spain (15%) (25–29) but higher than that reported in Singapore (1.7%) (30). The infection rate among HCWs in Kenya was 12 times higher than the general population and higher than the 5.5 times higher rate documented in Ontario, Canada (K.L. Shwartz et al., unpub. data, https://www.medrxiv.org/content/10.1101/2020.06.12.20129619v2), an indication that healthcare workers remained at higher risk for infection. Despite the high number of healthcare workers trained in early 2020, the infection rate remained high. Almost two thirds of the trainings were held for 1 day, which was inadequate to cover some practical topics, such as donning and doffing of PPE. Use of PPE in this period was inadequate or improper because of global shortages. Infrastructure renovations to address overcrowding of patients, ventilation, and hand hygiene facilities might have been slow to resolve. Healthcare workers were overstretched and had prolonged exposure to many patients (some of whom were asymptomatic) during the surge periods in June–August and October–December 2020 (Figure 2). Such reasons have been documented in China (31). A follow-up case control study was conducted in Kenya to explore reasons for the high infection rate. Preliminary findings indicated that lack of PPE and lack of IPC trainings were risk factors for infection (M. Njeru, unpub. data). In the absence of COVID-19 vaccines in Kenya at the time, other measures to protect healthcare workers were implemented, such as training, provision of appropriate PPE, and active screening and prompt quarantine or isolation of exposed or infected workers.

This review had several limitations. Simultaneously implementing many of the new interventions and obtaining accurate and timely reports from all facilities and counties was difficult during the pandemic. No active surveillance occurred among healthcare workers; only persons with laboratory-confirmed SARS-CoV-2 were included in the national list. Persons who were asymptomatic and not tested were not considered. In addition, although many guidance documents were developed at the national level, only about half had reached the assessed facilities. Time pressures were intense, and many mitigation activities were happening concurrently. Dissemination of all documents in development was not well streamlined. These factors would have delayed adoption of COVID-19 prevention measures at facilities. Despite these limitations, this article provides a broad picture of Kenya’s COVID-19 IPC response. While the measures were in response to COVID-19, they likely reduced transmission of influenza and other respiratory viruses, as was shown in the United States, Australia, Chile, and South Africa, as well as a reduction in diarrheal disease as demonstrated in Kenya (32,33).

Although some challenges occurred, the IPC multimodal approach was a practical response to the pandemic in Kenya. Consideration can be made for adoption of this approach based on a country’s context. Systems to monitor the effects of implementation and address emerging gaps should be put in place. This approach might reduce the effect of COVID-19 by protecting healthcare workers and patients in current and future pandemics.