Journal of Hospital Infection (2007) 65(S2) 151–154

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Simple measures save lives: An approachto infection control in countries withlimited resources

Nizam Damani*

Department of Medical Microbiology and Infection Prevention & Control, Northern Ireland, UK

KEYWORDS Nosocomial infection; Healthcare-associated infections; Countries with limited resources; Developingcountries

It has been estimated that in developed countriesup to 10% of hospitalized patients developinfections every year. The risk of healthcare-associated infections (HAI) in developing countriesis 2 20 times higher than in developed countries1

and it has been estimated that more than 40% ofthese infections are preventable.2

Reducing HAI infection is now considered tobe an integral part of patient safety and qualityof care. Many healthcare facilities worldwidehave recognised the importance of infectioncontrol and have incorporated this as part oftheir quality improvement programme. However,delivery of infection control services in mostdeveloping countries is either non-existent orineffective. In addition to the barriers highlightedin Box I, most often the senior management ofhealthcare facilities may not be entirely convincedthat infection control is important, and one ofthe main reasons is that there are no localsurveillance data available to assess the scale ofthe problem and perform cost benefit analyses.Although the economic rationale for preventingHAI are published,3,4 most of the good-qualitydata available are from developed countries. Forexample, it has been estimated that annual costsof HAI are US$6.5 billion per year in the USA5 and

* Dr Nizam Damani. Craigavon Area Hospital Group Trust,68 Lurgan Road, Portadown, Co Armagh, BT63 5QQ,Northern Ireland, UK. Tel: +44 028 3861 2654.E-mail: drndamani@cahgt.n-i.nhs.uk (N. Damani).

£1.06 billion (approximately US$1.8 billion) in theUnited Kingdom.6

Despite the publication of guidelines from CDC,WHO,7,8 IFIC9 and various professional bodiesand organisations, some aspects of the practiceof infection control, especially in developingcountries, are still ritualistic and wasteful.10,11

Amongst others, the key barrier in implementinggood infection control practices is the lackof trained infection control personnel and pro-grammes to help educate and increase awarenessof the importance of infection control amongsthealthcare workers.11

In order to achieve these objectives, it isessential that the healthcare facilities initiallyinvest in setting up an effective infection controlprogramme. It can be argued that once theinfection control programme is fully established,resources will be released from the wasteful andunsafe practices by promoting and implementinggood infection control practices that help reduceHAI (Table 1) and thus help fund the programme.The first step in achieving these objectives is toappoint appropriate infection control personnel,especially in healthcare facilities where there areno infection control personnel and/or structures.It is essential that the Infection Control Team(ICT) be adequately trained and resourced andhave full support from the clinicians and seniormanagement.

0195-6701/$ - see front matter © 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

152 N. Damani

Box I. Barriers to the setting up and implementation of effective infection control in countrieswith limited resources.

(1) Lack of strategic direction and poor planning for delivery of healthcare at both the local and thenational 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 controlprogramme.

(5) Lack of availability of simple, practical and affordable infection control guidelines in locallanguage.

(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, pharmacyand occupational health department.

(8) Shortage of trained staff to operate/maintain equipment to recommended standards.

Amongst other duties, one of the main re-sponsibilities of the ICT is to carry out basicsurveillance of HAIs to help identify key issuesand areas of concern which can be communicatedto the senior management to help assess thescale of the problem and set the priorities foraction. Although surveillance is considered oneof the key components of effective infectioncontrol, it is important to note that in developedcountries a considerable amount of ICT resourceis devoted to outcome surveillance. This isexpensive and time consuming and requires trainedinfection control personnel, a good microbiologylaboratory and other support. These resourcesare not usually available in developing countries.Therefore, it is essential that the ICT in developingcountries should carry out only basic surveillancewith the aim of identifying key issues and areasof concern. Once this has been achieved, periodicpoint prevalence surveillance can be used tomonitor the effectiveness of infection controlmeasures. In addition to basic surveillance, theICT must also devote time to regular audits(process surveillance). Audits are usually simpleto perform, and are less resource intensive thanoutcome surveillance. They will help the ICT toidentify inappropriate and unsafe infection controlpractices immediately. In addition, they will alsohelp them to identify wasteful practices andhelp divert resources to implement evidence-basedand cost-effective practices. This is the approachtaken by the Airline industry, which has a wellestablished record on safety, and where the entire

resources are allocated to ‘process’ monitoring(audit) with emphasis on early identificationand immediate intervention rather than counting(‘outcome’ monitoring) preventable disasters.

Ayliffe12 has highlighted that even thoughinfection rates can be drastically improved inmost hospitals in developing countries, they cannotbe reduced below 5% unless excessive costs areincurred, and he described this as the ‘irreducibleminimum’. The SENIC Study13 has highlightedthat 6% of infections can be prevented usingminimal infection control efforts; 32% could beprevented by a well-organised and highly effectiveinfection control programme. The main objectiveof the infection control programme in countrieswith limited resources is to reduce HAIs tothe irreducible minimum by applying minimalinfection control measures. These measures mustbe simple, affordable and cost effective, andshould be designed to suit the local needs andcircumstances. This approach is proven, affordableand achievable. In Pakistan, for example, a studyin the neonatal unit showed that with activeinvolvement of the mother in management of verylow birthweight babies (encouragement of breastfeeding to reduce the need for parenteral feeding,co-bedding of mother and infant to reduce theneed for incubator, etc.), introduction of stricthandwashing and training of healthcare workersin aseptic procedures resulted in a substantialreduction in nosocomial infections and need fornursing staff.14 In Bangladesh, topical emollienttherapy was used to improve the function of skin as

Simple measures save lives: An approach to infection control in countries with limited resources 153

Table 1Summary of measures for improving infection control

Cost saving measures: Wastefulpractices that should be eliminated

No-cost measures: Using goodinfection control practices

Low-cost measures: cost-effectivepractices

(1) Routine swabbing of theenvironment to monitor standard ofcleanliness

(2) Routine fumigation of isolationrooms with formaldehyde

(3) Routine use of disinfectants forenvironment cleaning, e.g. floorsand walls

(4) Inappropriate use of PersonalProtective Equipment (PPE) in ICU,NNU and operating theatre

(5) Use of overshoes, dust attractingmats in the operating theatre,intensive care and neonatal unit

(6) Unnecessary IM/IV injections(7) Unnecessary insertion of indwelling

devices, e.g. IV lines, urinarycatheters, nasogastric tubes, etc.

(8) Inappropriate use of antibiotics forprophylaxis and treatment

(9) Improper segregation and disposalof clinical waste

(1) Aseptic technique for allsterile procedures

(2) Remove indwelling deviceswhen no longer needed

(3) Isolation of patients withcommunicable diseases ormulti-resistant organism onadmission

(4) Avoid unnecessary vaginalexamination of women inlabour

(5) Minimise the number ofpeople in operating theatres

(6) Place mechanically ventilatedpatients in a semi-recumbentposition

(1) Education and practical training instandard infection control, e.g.,hand hygiene, aseptic technique,appropriate use of PPE, use anddisposal of sharps

(2) Provision of handwashing material,e.g. soap and alcoholic handdisinfectants

(3) Single-use disposable sterile needlesand syringes

(4) Sterile items for invasive procedures(5) Avoid multi-dose vials and containers

between patients(6) Adequate decontamination of

equipment between patients(7) Hepatitis B immunization for

healthcare workers(8) Post exposure management

arrangement for healthcare workers(9) Disposal of sharps in robust

containers

a barrier against infections. Overall preterm babiestreated with sunflower seed oil during the first fewdays/weeks of life were 41% less likely to developnosocomial infections.15

Developing countries also have a very heavyburden of infectious diseases in the community.It can be argued that reducing infection inthe community also helps reduce infection/cross-infection in the hospital setting by leadingto the admission of fewer infectious patients.According to the WHO, respiratory and diarrhoealdiseases are the two most common infections inchildren, resulting in millions of deaths each year.16

A randomised controlled trial in Karachi, Pakistanshowed that simple handwashing with soap andwater in the community not only resulted in a50% reduction in pneumonia in children under5 years of age, but also achieved a 53% reductionin diarrhoea and a 34% reduction in incidenceof impetigo in children under 15 years of age.17

These and other simple measures18 suggest that theapplication of basic infection control measures isachievable and affordable in countries with limitedresources, and that application of these simplemeasures can save thousands of lives worldwide.19

References1. WHO. Global Patient Safety Challenge: Clean Care is

Safer Care. Geneva: World Health Organization; 2005.

2. Wenzel R. Towards a global perspective of nosocomialinfections. Eur J Clin Microbiol 1987;6:341 343.

3. Cohen DR. Economic issues in infection control. J HospInfect 1984;5:17 25.

4. Drummond M, Davies LF. Evaluation of the costs andbenefits of reducing hospital infection. J Hosp Infect1991;18(Suppl A):85 93.

5. Stone P, Braccia D, Larson E. Systematic review ofeconomic analyses of health care-associated infections.Am J Infect Control 2005;33:501 509.

6. Plowman RP, Graves N, Griffin MAS, et al. The rate andcost of hospital-acquired infections occurring in patientsadmitted to selected specialties of a district generalhospital in England and the national burden imposed.J Hosp Infect 2001;47:198 209.

7. WHO. Prevention of Hospital Acquired Infections:A Practical Guide, 2nd ed. Geneva: World HealthOrganization; 2002.

8. WHO. Practical Guidelines for Infection Control inHealthcare Facilities, SEARO Regional PublicationNo. 41: New Delhi, World Health Organization WPRO;2004.

9. International Federation of Infection Control. InfectionControl: Basic Concepts and Training, 2nd ed. IFIC;2003.

10. Kunaratanapruk S, Silpapojakul K. Unnecessary hospitalinfection control practices in Thailand: a survey. J HospInfect 1998;40:55 59.

11. Talaat M, MD, Kandeel A, Rasslan O, et al. Evolution ofinfection control in Egypt:Achievements and challenges.Am J Infect Control 2006;34:193 200.

12. Ayliffe GAJ. Nosocomial irreducible minimum. InfectControl 1986;7(Suppl):92 95.

13. SENIC study. Haley RW, Culver DH, White JW, et al. The

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efficacy of infection surveillance and control programs inpreventing nosocomial infection in US hospitals. (SENICstudy). Am J Epidemiol 1985;121:182 205.

14. Bhutta ZA, Khan I, Salat S, Raza F,Khan I, Ara H. Reducinglength of stay in hospital for very low birthweight infantsby involving mothers in a stepdown unit: an experiencefrom Karachi, Pakistan. Br Med J 2004;329:1151 1155.

15. Darmstadt GL, Saha SK, Nawshad-Uddin-Ahmed ASM,et al. Effect of topical treatment with skin barrier-enhancing emollients on nosocomial infections inpreterm infants in Bangladesh: a randomised controlledtrial. Lancet 2005;365:1039 1045.

16. WHO Health Report. Make Every Mother and ChildCount. Geneva: World Health Organization; 2005.

17. Luby SP, Agboatwalla M, Feikin DR, et al. Effect ofhandwashing on child health: a randomised controlledtrial. Lancet 2005;366:225 233.

18. Tietjen L, Bossemeyer D, Mcintosh N. Infection Preven-tion for Healthcare Facilities with Limited Resources.Problem-Solving Reference Manual. Baltimore: JHPIEGOCorporation; 2003.

19. Curtis V. Talking dirty: how to save a million lives. Int JEnviron Health Res 2003;13(Suppl 1):S73 S79.