This was a cross-sectional, observational and descriptive study on the SARS-CoV-2 infection prevention and control (IPC) during medical consultations in the PCU of the Golfe health district in the Greater Lomé health region conducted from July 28 to August 6, 2020. The Golfe Health District covers an area of 90 km² with an estimated population of 342,209 inhabitants and is subdivided into 7 health municipalities with numerous health facilities providing all levels of care in the health pyramid [7] . The district was selected by reasoned choice on the basis of its high incidence rate of active cases of SARS-CoV-2 infection since the pandemic in Togo and the relatively large number of PCU; 31 in total.

The study included any health care provider involved in the medical consultation, as well as any patient who came for a medical consultation in a PCU in the Golfe Health District.

A questionnaire addressed to healthcare providers by direct interview and an observation grid were used for data collection. The observation grid focused on the infrastructure and equipment, the technical facilities of the PCU, the consultation room, and compliance with SARS-CoV-2 infection prevention practices during medical consultations.

The variables studied were as follows:

- The social and demographic profile of the providers (age, gender, qualification, seniority);

- Technical and engineering measures (infrastructure, equipment, inputs) of the IPC;

- Organizational and administrative measures (physical distancing, hand hygiene, taking temperatures upon admission, limiting visitors, disinfection of surfaces and equipment, positioning of patients, etc.);

- Wearing of personal protective equipment (complete gown, overcoat, gloves, visors, masks, cap…);

- Appreciation of provider satisfaction.

The enrollment of patients who came for consultation was done systematically as they presented themselves for consultation during the study period. The evaluation of SARS-CoV-2 infection prevention practices and measures during the consultation was carried out without the knowledge of providers through a silent and discreet observation.

Data analysis was done using SPSS version 21 software. Pearson’s Chi-square test was used for comparison of variables. The differences found were considered significant for a degree of freedom at 1 within a 95% confidence interval.

The Model for the Evaluation of IPC at the Health Care Facility was used. It includes three main components and 40 indicators. The modalities of the structural and procedural IPC variables explored were coded on the 0 and 1 rating scale. The “YES” rating corresponds to “1” and means that the information sought exists and complies with current standards; the “NO” rating corresponds to “0” and means that the information sought does not exist or exists but does not comply with current standards. A percentage YES score ≥ 75% was defined as satisfactory compliance; a percentage YES score between 50% and 75% was defined as unsatisfactory compliance; and a percentage YES score < 50% was assessed as unsatisfactory compliance. Any percentage score of “NO” is considered a lack of compliance generating a high risk of contamination [8] .

The patients were reassured about the confidentiality and anonymity of the information that will be collected and we have obtained informed consent from them to participate in the study. A note explaining the objective and purpose of our study was attached to the questionnaire.

In a study conducted in Ethiopia in 2013 on infection control knowledge, attitudes, and practices among health care workers, 51% were physicians and 49% were nurses [9] . The profile of health care professionals varies according to qualifications, specialization and country standards. In Togo, the doctor is responsible for medical consultations. However, by delegation of tasks, the medical assistants trained to compensate for the shortage of doctors are the first line care providers in the realization of the medical consultation at the PCU level according to health standards. They are assisted by state-qualified nurses, but also sometimes by auxiliary nurses [10] .

The World Health Organization (WHO) in its guidelines on IPC program components in health care facilities, had emphasized on the training of health personnel, as knowledge of a directive that tells what to do without specifying how to proceed is not practical and may be difficult to apply, which does not guarantee compliance [11] .

According to the Joint Occupational Health and Safety Association of the Social Affairs Sector [12] in Canada, the infection prevention program must include a component for training the institution’s personnel so that each person has the required knowledge on infectious risks and the role they can play in preventing the transmission of infection in the performance of their duties. Adequate training of all staff is necessary for the acquisition of skills and allows the standardization of practices, as well as a better collective handling of the problem.

The reorganization of the hospital environment and the availability of IPC resources and inputs were satisfactory.

The Group for the Evaluation of Hospital Hygiene Practices according to its practice audit on additional contact-droplet-air precautions in healthcare facilities [13] in France in 2015 had for these IPC measures, obtained a 95.2% rate achievement of objectives. 94.4% of healthcare facilities had patient sorting and isolation stations; 90.6% had a device for signaling and informing patients. Eighty-two percent of providers had resources for IPC. All personnel surveyed in France had gloves, hydro-alcoholic products, 87.3% had single-use gowns, and 98.4% had surgical masks. The organizational measures of the physical and engineering locations provide collective protection at all times and consist of the design and layout of the infrastructures according to the standards established for the prevention of infections in the healthcare environment, as well as the installation of technical equipment that meets the requirements in this area to ensure the safety of the locations against the transmission of micro-organisms. The technical measures taken by the Togolese government with the support of technical and financial partners have enabled all health care institutions to achieve a satisfactory level of compliance.

The hand hygiene technique of hydro-alcoholic friction was the most practiced. Compliance with hand hygiene was satisfactory for both techniques (hydro-alcoholic rubbing and hand washing). Longembe et al. in a study on hand hygiene compliance in general referral hospitals in the city of Kisangani in the Democratic Republic of Congo in 2020 found a fairly low global hand hygiene compliance rate of 39%, including 5% for hydroalcoholic hand rub. Non-compliance was almost the same among nurses (56%) and physicians (51%) [14] . In Burkina-Faso, in a study on the knowledge and practices of healthcare professionals on the infectious risk associated with healthcare, Hien et al. had reported 21.1% compliance of hand hygiene by washing and 5% for hydroalcoholic hand rubbing [15] . The hands of health care providers are in frequent contact with patients and the environment, making this part of the body at risk for contamination or likely to transfer of micro-organisms during health care services. In the context of SARS-CoV-2 infection, contaminated hands can transmit the virus to inanimate objects or surfaces, patients and staff. Regular hand hygiene is recognized as a fundamental means of preventing han-to-hand transmission of this infection. Although recommended by WHO for all providers in hospital facilities, as well as for visitors and families, its compliance often remains low in hospitals [8] [16] . In Togo in 2016, hand hygiene compliance was 12.6% [17] . The high rate of compliance obtained in our study could be explained by staff adherence to hydro-alcoholic hand rubbing, which is one of the strategies recommended by WHO to improve compliance with this practice considered as a major pillar of hand infection prevention [8] .

The disinfection of fomites by providers was not satisfactory. In Ethiopia in 2019, 34.6% of health personnel never disinfected their stethoscope [18] . While a study on the enduring value of the stethoscope in the COVID-19 era reported that only 8% of nurses cleaned their stethoscopes before or after use in the management of patients with COVID-19; stethoscopes contain bacteria with levels of contamination comparable to that of a caregiver’s hand [19] .

Samples taken from surfaces and equipment in hospitals have shown contamination in 40% [20] and growth of bacterial species [21] .

The equipment indexed was the blood pressure cuff, stethoscope, visitor chairs, computer keyboard and mouse, doorbell switches and pushers, and door handles. Fomites are surfaces, materials or objects that are contaminated with a pathogenic microorganism and are likely to contaminate other objects or people, thus playing a role in the spread of a disease. Studies have evaluated the persistence of COVID-19 virus on different surfaces and its probable transmission through fomites [22] .

Compliance with barrier measures (hand hygiene and wearing of personal protective equipment) is generally unsatisfactory due to negligence among healthcare personnel. After a good implementation with good compliance after barrier measures, we always observe weariness a few months later as noticed by Fourquet [23] . The surgical mask was the most used PPE, although not all providers wore it during medical consultations.

The level of PPE compliance was therefore not optimal or total as observed in several studies [13] [15] . PPE is a device or means intended to be worn by a person in order to protect him against one or more risks likely to threaten his safety or health. Primarily worn in the workplace, PPE in the context of protection against SARS-CoV-2 in the hospitals includes gowns, aprons, over-gowns, gloves, surgical masks, goggles or visors, and headgear that must be worn properly.

The overall level of compliance with IPC in its various components for all health facilities was 71% due to the health crisis. The satisfactory performance set at 75% by WHO could not be achieved because of the low compliance with administrative and organizational measures. According to WHO, IPC measures to prevent infections in health facilities are not yet fully implemented in many African countries and only 16% of the 30,000 health facilities on the continent had an evaluation score above 75% [24] .