Journal of Hospital Infection (2007) 65(S2) 151–154                                    Available online at www.sciencedire...
152                                                                                             N. Damani  Box I. Barriers...
Simple measures save lives: An approach to infection control in countries with limited resources                       153...
154                                                                                                                 N. Dam...
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Ic in countries with limited resource

  1. 1. Journal of Hospital Infection (2007) 65(S2) 151–154 Available online at measures save lives: An approachto infection control in countries withlimited resourcesNizam Damani*Department of Medical Microbiology and Infection Prevention & Control, Northern Ireland, UKKEYWORDS Nosocomial infection; Healthcare-associated infections; Countries with limited resources; DevelopingcountriesIt has been estimated that in developed countries £1.06 billion (approximately US$1.8 billion) in theup to 10% of hospitalized patients develop United Kingdom.6infections every year. The risk of healthcare- Despite the publication of guidelines from CDC,associated infections (HAI) in developing countries WHO,7,8 IFIC9 and various professional bodiesis 2 20 times higher than in developed countries1 and organisations, some aspects of the practiceand it has been estimated that more than 40% of of infection control, especially in developingthese infections are preventable.2 countries, are still ritualistic and wasteful.10,11 Reducing HAI infection is now considered to Amongst others, the key barrier in implementingbe an integral part of patient safety and quality good infection control practices is the lackof care. Many healthcare facilities worldwide of trained infection control personnel and pro-have recognised the importance of infection grammes to help educate and increase awarenesscontrol and have incorporated this as part of of the importance of infection control amongsttheir quality improvement programme. However, healthcare workers.11delivery of infection control services in most In order to achieve these objectives, it isdeveloping countries is either non-existent orineffective. In addition to the barriers highlighted essential that the healthcare facilities initiallyin Box I, most often the senior management of invest in setting up an effective infection controlhealthcare facilities may not be entirely convinced programme. It can be argued that once thethat infection control is important, and one of infection control programme is fully established,the main reasons is that there are no local resources will be released from the wasteful andsurveillance data available to assess the scale of unsafe practices by promoting and implementingthe problem and perform cost benefit analyses. good infection control practices that help reduceAlthough the economic rationale for preventing HAI (Table 1) and thus help fund the programme.HAI are published,3,4 most of the good-quality The first step in achieving these objectives is todata available are from developed countries. For appoint appropriate infection control personnel,example, it has been estimated that annual costs especially in healthcare facilities where there areof HAI are US$6.5 billion per year in the USA5 and no infection control personnel and/or structures. It is essential that the Infection Control Team* Dr Nizam Damani. Craigavon Area Hospital Group Trust, (ICT) be adequately trained and resourced and 68 Lurgan Road, Portadown, Co Armagh, BT63 5QQ, Northern Ireland, UK. Tel: +44 028 3861 2654. have full support from the clinicians and senior E-mail: (N. Damani). management.0195-6701/$ - see front matter © 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
  2. 2. 152 N. Damani Box I. Barriers to the setting up and implementation of effective infection control in countries with limited resources. (1) Lack of strategic direction and poor planning for delivery of healthcare at both the local and the national level. (2) Lack of awareness and commitment from clinicians and senior management. (3) Absence or inadequate/ineffective infection control infrastructure. (4) Shortage of trained infection control personnel to set up and deliver effective infection control programme. (5) Lack of availability of simple, practical and affordable infection control guidelines in local language. (6) Inadequacy/unavailability of supply chain/logistics of products, e.g., hand disinfectants, Personal Protective Equipment (PPE), antimicrobials and immunization. (7) Lack of basic diagnostic microbiology laboratory service, sterile supply department, pharmacy and occupational health department. (8) Shortage of trained staff to operate/maintain equipment to recommended standards. Amongst other duties, one of the main re- resources are allocated to ‘process’ monitoringsponsibilities of the ICT is to carry out basic (audit) with emphasis on early identificationsurveillance of HAIs to help identify key issues and immediate intervention rather than countingand areas of concern which can be communicated (‘outcome’ monitoring) preventable the senior management to help assess the Ayliffe12 has highlighted that even thoughscale of the problem and set the priorities for infection rates can be drastically improved inaction. Although surveillance is considered one most hospitals in developing countries, they cannotof the key components of effective infection be reduced below 5% unless excessive costs arecontrol, it is important to note that in developed incurred, and he described this as the ‘irreduciblecountries a considerable amount of ICT resource minimum’. The SENIC Study13 has highlightedis devoted to outcome surveillance. This is that 6% of infections can be prevented usingexpensive and time consuming and requires trained minimal infection control efforts; 32% could beinfection control personnel, a good microbiology prevented by a well-organised and highly effectivelaboratory and other support. These resources infection control programme. The main objectiveare not usually available in developing countries. of the infection control programme in countriesTherefore, it is essential that the ICT in developing with limited resources is to reduce HAIs tocountries should carry out only basic surveillance the irreducible minimum by applying minimalwith the aim of identifying key issues and areas infection control measures. These measures mustof concern. Once this has been achieved, periodic be simple, affordable and cost effective, andpoint prevalence surveillance can be used to should be designed to suit the local needs andmonitor the effectiveness of infection control circumstances. This approach is proven, affordablemeasures. In addition to basic surveillance, the and achievable. In Pakistan, for example, a studyICT must also devote time to regular audits in the neonatal unit showed that with active(process surveillance). Audits are usually simple involvement of the mother in management of veryto perform, and are less resource intensive than low birthweight babies (encouragement of breastoutcome surveillance. They will help the ICT to feeding to reduce the need for parenteral feeding,identify inappropriate and unsafe infection control co-bedding of mother and infant to reduce thepractices immediately. In addition, they will also need for incubator, etc.), introduction of stricthelp them to identify wasteful practices and handwashing and training of healthcare workershelp divert resources to implement evidence-based in aseptic procedures resulted in a substantialand cost-effective practices. This is the approach reduction in nosocomial infections and need fortaken by the Airline industry, which has a well nursing staff.14 In Bangladesh, topical emollientestablished record on safety, and where the entire therapy was used to improve the function of skin as
  3. 3. Simple measures save lives: An approach to infection control in countries with limited resources 153Table 1Summary of measures for improving infection controlCost saving measures: Wasteful No-cost measures: Using good Low-cost measures: cost-effectivepractices that should be eliminated infection control practices practices(1) Routine swabbing of the (1) Aseptic technique for all (1) Education and practical training in environment to monitor standard of sterile procedures standard infection control, e.g., cleanliness (2) Remove indwelling devices hand hygiene, aseptic technique,(2) Routine fumigation of isolation when no longer needed appropriate use of PPE, use and rooms with formaldehyde (3) Isolation of patients with disposal of sharps(3) Routine use of disinfectants for communicable diseases or (2) Provision of handwashing material, environment cleaning, e.g. floors multi-resistant organism on e.g. soap and alcoholic hand and walls admission disinfectants(4) Inappropriate use of Personal (4) Avoid unnecessary vaginal (3) Single-use disposable sterile needles Protective Equipment (PPE) in ICU, examination of women in and syringes NNU and operating theatre labour (4) Sterile items for invasive procedures(5) Use of overshoes, dust attracting (5) Minimise the number of (5) Avoid multi-dose vials and containers mats in the operating theatre, people in operating theatres between patients intensive care and neonatal unit (6) Place mechanically ventilated (6) Adequate decontamination of(6) Unnecessary IM/IV injections patients in a semi-recumbent equipment between patients(7) Unnecessary insertion of indwelling position (7) Hepatitis B immunization for devices, e.g. IV lines, urinary healthcare workers catheters, nasogastric tubes, etc. (8) Post exposure management(8) Inappropriate use of antibiotics for arrangement for healthcare workers prophylaxis and treatment (9) Disposal of sharps in robust(9) Improper segregation and disposal containers of clinical wastea barrier against infections. Overall preterm babies 2. Wenzel R. Towards a global perspective of nosocomialtreated with sunflower seed oil during the first few infections. Eur J Clin Microbiol 1987;6:341 343.days/weeks of life were 41% less likely to develop 3. Cohen DR. Economic issues in infection control. J Hosp Infect 1984;5:17 25.nosocomial infections.15 4. Drummond M, Davies LF. Evaluation of the costs and Developing countries also have a very heavy benefits of reducing hospital infection. J Hosp Infectburden of infectious diseases in the community. 1991;18(Suppl A):85 93.It can be argued that reducing infection in 5. Stone P, Braccia D, Larson E. Systematic review ofthe community also helps reduce infection/ economic analyses of health care-associated infections.cross-infection in the hospital setting by leading Am J Infect Control 2005;33:501 509. 6. Plowman RP, Graves N, Griffin MAS, et al. The rate andto the admission of fewer infectious patients. cost of hospital-acquired infections occurring in patientsAccording to the WHO, respiratory and diarrhoeal admitted to selected specialties of a district generaldiseases are the two most common infections in hospital in England and the national burden imposed.children, resulting in millions of deaths each year.16 J Hosp Infect 2001;47:198 209.A randomised controlled trial in Karachi, Pakistan 7. WHO. Prevention of Hospital Acquired Infections:showed that simple handwashing with soap and A Practical Guide, 2nd ed. Geneva: World Health Organization; 2002.water in the community not only resulted in a 8. WHO. Practical Guidelines for Infection Control in50% reduction in pneumonia in children under Healthcare Facilities, SEARO Regional Publication5 years of age, but also achieved a 53% reduction No. 41: New Delhi, World Health Organization WPRO;in diarrhoea and a 34% reduction in incidence 2004.of impetigo in children under 15 years of age.17 9. International Federation of Infection Control. InfectionThese and other simple measures18 suggest that the Control: Basic Concepts and Training, 2nd ed. IFIC; 2003.application of basic infection control measures is 10. Kunaratanapruk S, Silpapojakul K. Unnecessary hospitalachievable and affordable in countries with limited infection control practices in Thailand: a survey. J Hospresources, and that application of these simple Infect 1998;40:55 59.measures can save thousands of lives worldwide.19 11. Talaat M, MD, Kandeel A, Rasslan O, et al. Evolution of infection control in Egypt: Achievements and challenges.References Am J Infect Control 2006;34:193 200. 12. Ayliffe GAJ. Nosocomial irreducible minimum. Infect 1. WHO. Global Patient Safety Challenge: Clean Care is Control 1986;7(Suppl):92 95. Safer Care. Geneva: World Health Organization; 2005. 13. SENIC study. Haley RW, Culver DH, White JW, et al. The
  4. 4. 154 N. Damani efficacy of infection surveillance and control programs in 16. WHO Health Report. Make Every Mother and Child preventing nosocomial infection in US hospitals. (SENIC Count. Geneva: World Health Organization; 2005. study). Am J Epidemiol 1985;121:182 205. 17. Luby SP, Agboatwalla M, Feikin DR, et al. Effect of14. Bhutta ZA, Khan I, Salat S, Raza F,Khan I, Ara H. Reducing handwashing on child health: a randomised controlled length of stay in hospital for very low birthweight infants trial. Lancet 2005;366:225 233. by involving mothers in a stepdown unit: an experience 18. Tietjen L, Bossemeyer D, Mcintosh N. Infection Preven- from Karachi, Pakistan. Br Med J 2004;329:1151 1155. tion for Healthcare Facilities with Limited Resources.15. Darmstadt GL, Saha SK, Nawshad-Uddin-Ahmed ASM, Problem-Solving Reference Manual. Baltimore: JHPIEGO et al. Effect of topical treatment with skin barrier- Corporation; 2003. enhancing emollients on nosocomial infections in 19. Curtis V. Talking dirty: how to save a million lives. Int J preterm infants in Bangladesh: a randomised controlled Environ Health Res 2003;13(Suppl 1):S73 S79. trial. Lancet 2005;365:1039 1045.