1.
Support to the Republic of Kazakhstan in Infectious Disease Prevention and
Control
is a project funded by the European Union.
Developing
a
Program
to
Prevent
Device-­‐associated
Infections
Background:
The
countries
of
Central
Asia,
as
those
of
much
of
the
former
Soviet
Union,
have
suffered
from
an
under-­‐recognized
incidence
of
health
care-­‐acquired
bloodborne
pathogens,
most
commonly
HIV
and
hepatitis
C.
These
have
long
been
recognized
and,
although
the
exact
magnitude
of
them
is
uncertain,
they
remain
despite
sporadic
efforts
to
end
the
practices
that
lead
to
them.
The
practices,
including
reuse
of
health
care
instruments
and
devices,
likely
persist
because
Central
Asia
is
“caught”
between
newest
technologies
and
not
sufficient
resources
or
knowledge
to
use
these
correctly.
The
existence
of
these
practices
clearly
places
patients
at
risk
of
life-­‐threatening
illness
and
health
care
personnel
and
institutions
in
morally
perilous
positions.
EUNIDA
and
GIZ
have
proposed
a
program
to
target
health
care-­‐associated
HIV
and
hepatitis
virus
infection.
The
practices
that
lead
to
these
infections
can
be
placed
into
two
categories:
1)
transfusion
practices;
and,
2)
device-­‐associated
infections
(DAIs).
The
first
is
a
specialized
area
and
other
programs
are
addressing
it;
EUNIDA/GIZ
propose
addressing
the
second
category.
DAIs
can
be
placed
into
two
categories:
1)
bloodborne
pathogens,
e.g.,
HIV,
hepatitis
B
and
C;
and,
2)
nonbloodborne
pathogens
associated
with
devices,
e.g.,
Staphylococcus
aureus.
The
frequency
of
the
second
category
of
infection
is
undetermined.
Although
EUNIDA
and
GIZ
focus
on
the
first
category,
we
propose
addressing
both
categories
of
infection.
This
makes
sense
because
if
devices
are
used
appropriately,
then
both
types
of
infections
will
be
prevented.
We
therefore
propose
a
program
to
address
the
proper
use
and
care
of
devices.
We
define
a
“device”
as
one
that
is
parenteral,
that
is
invasive,
and
which
might
lead
to
bloodborne
pathogen
transmission.
These
devices
might
be
called
intravascular
but
some
will
be
intramuscular,
e.g.,
injections.
They
have
the
common
feature
of
being
associated
with
blood.
While
some
instruments
can
conceivably
transmit
bloodborne
infections,
e.g.,
colonoscopy
instruments,
we
shall
not
address
such
“devices”
nor
the
cleaning
and
sterility
procedures
that
must
be
performed
to
reuse
them.
Rather,
we
shall
address
devices
that
are
associated
with
blood
and
are
typically
supplied
by
manufacturers
in
sterile
packaging
and
not
meant
for
reuse.
So,
we
include
peripheral
venous
catheters,
intraarterial
catheters,
subclavian
catheters,
etc.
The
types
of
devices
used
is
also
uncertain.
Subclavian
catheters
appear
to
be
commonly
used
and
are
often
implicated
in
recognized
outbreaks
of
HIV.
They
are,
thus,
a
focus
of
our
program.
Associated
paraphernalia,
e.g.,
multidose
vials
or
one
liter
IV
bags
of
fluid
(which
may
be
shared
among
patients,
particularly
in
pediatric
hospitals)
are
also
sources
of
infection
and
for
which
no
guidelines
on
use
exist.
Approach
to
our
program:
Devices
are
undoubtedly
overused,
although
there
are
no
guidelines
in
Kazakhstan
on
when
to
use
them.
A
recent
“injection
safety”
assessment
included
an
assessment
of
the
use
of
devices
and,
while
not
quantifying
how
commonly
they
are
used,
found
that
both
doctors
and

2.
Support to the Republic of Kazakhstan in Infectious Disease Prevention and
Control
is a project funded by the European Union.
nurses
thought
that
they
were
used
only
in
appropriate
instances.
It
is
likely
that
Central
Asia
doctors
and
nurses
believe
that
devices
should
be
used
more
often
than
Western
counterparts.
We
believe
that,
despite
the
EUNIDA/GIZ
mandate
to
target
nurses,
any
program
to
prevention
DIAs
must
involve
doctors.
Doctors
hold
the
power
in
health
care
institutions
and,
unless
they
support
reforms,
any
program
targeting
only
nurses
will
achieve
minimal
results.
Thus,
we
propose
a
program
targeting
the
safe
use
of
devices
and
the
appropriate
use
of
devices.
An
intervention
must
target
not
only
knowledge
of
the
health
care
staff
but
also
culture
of
the
institutions
and
staff.
Achieving
change
of
culture
will
require
not
only
written
materials
but
verbal
interaction.
Targeted
would
be
not
only
decision-­‐makers,
largely
doctors,
but
opinion-­‐leaders,
largely
respected
physicians/leaders.
Symposia
as
well
as
individual
or
small
group
meetings
will
be
appropriate.
Ultimately,
clinical
practice
guidelines
(the
Prikaz)
will
be
needed
and
these
can
be
based
on
the
materials
we
shall
devise.
Our
materials
can
be
either
written
or
electronic.
We
believe
both
are
needed.
Central
Asia,
as
in
likely
the
entire
world,
still
retains
reliance
on
printed
materials.
They
are
easy
to
produce,
always
handy,
do
not
require
computers
or
PDAs,
etc.
These
can,
however,
be
augmented
by
electronic
materials,
particularly
for
teaching
purposes.
Electronic
materials
for
teaching
offer
advantages
and
may
be
successful
in
reaching
distant
audiences,
be
economical,
and
allow
self-­‐study.
They
also
have
disadvantages,
such
as
the
need
for
an
accessible
computer
and
the
need
for
multiple
computers
if
they
replace
symposia
or
written
materials.
We
propose
a
combination
of
electronic
materials
and
written
materials
for
teaching,
along
with
symposia
for
teaching,
discussing,
answering
questions,
and
for
culture
change.
Certification
of
successful
completion
of
training
can
be
used.
An
evaluation
of
our
program
is
needed.
Two
types
of
evaluation
are
needed.
First,
we
must
measure
gain
in
knowledge,
e.g.,
pre-­‐test/post-­‐test
evaluation
of
the
individual.
Second,
we
must
measure
change
in
practice.
The
latter
will
require
a
more
difficult
evaluation,
e.g.,
practice/chart
audit,
on-­‐site
evaluation.
We
propose
doing
both.
Outline
of
our
program:
Phase
1:
Production
(till
February
20,
2013)*
1. Produce
an
electronic
technical
document
according
ICATT
that
will
be
a
stand-­‐alone
training
tool
concerning
appropriate
use
of,
insertion
of,
and
care
of
devices;
2. Produce
a
written
version
of
the
same
document;

3.
Support to the Republic of Kazakhstan in Infectious Disease Prevention and
Control
is a project funded by the European Union.
3. Produce
teaching
materials
for
use
the
electronic
document,
that
can
follow
the
guidance
(see
below)
used
for
Integrated
Management
of
Childhood
Diseases
(IMCI);
4. Pilot-­‐test
and
train
staff
in
pilot
health
care
facilities
in
use
of
ICATT
Phase
2:
Consolidation(till
May
1
2013,
end
of
GIZ/EUNIDA
project,
and
after)*
5. Meet
with
health
care
institution
leaders
and
opinion
leaders
to
gain
their
support;
6. In
pilot
institutions,
evaluate
practices
as
a
baseline;
7. In
pilot
institutions,
hold
symposia
with
staff—either
doctors
alone
and
nurses
alone,
or
combined,
as
appropriate—to
introduce
our
materials
and
begin
to
change
culture
and
practices;
8. Undetermined,
is
then
whether
to
train
entirely
in
symposia/small
groups,
or,
introduce
via
symposia
the
subject
area
and
continue
training
using
electronic
materials.
In
some
trial
situations,
only
electronic
materials
might
be
used.
9. Evaluate
knowledge
gained
and
if
one
approach
might
be
better
than
another;
10. Evaluate
practice
change
at
selected
hospitals;
11. Revise
technical
document
and
teaching
materials
and
finalize;
12. Train
trainers,
to
“roll
out”
program
to
non-­‐pilot
institutions
and
scale
up
repeating
“best
practices”
from
our
pilot
experience;
13. Write
Prikaz;
14. Institutionalize
program:
yearly
electronic
updates
of
contents
by
KNMU,
healthcare
workers
yearly
(self/e-­‐)
tested
and
certificated
by
RSES/KNMU/(MOH?)
George
Schmid,
CDC
CAR
Jadranka
Mimica,
UNICEF
Olga
de
Haan,
GIZ/EUNIDA
*
UNICEF
finances
production
in
Phase
1,
e.g.
the
preparation
and
production
of
the
ICATT-­‐tool,
to
be
distributed
on
CDROM/flash
sticks.
EUNIDA
project
does
not
enable
the
production/distribution
of
written
materials
in
large
numbers
**
The
EUNIDA
project
expires
at
May
31
2013,
input
in
time,
human
and
financial
resources
till
expiry
can
be
only
guaranteed
as
far
as
the
capacities
of
HR
and
the
project
budget
enable
to
execute
all
mentioned
steps.
In
February
2013
parties
involved
will
agree
on
responsibilities
and
follow-­‐up
to
achieve
end
results
as
written
above.