Prevention of Healthcare Associated Infections in Developing
Introduction: Developing countries are normally defined as those lacking the level of nationwide industrialization, infrastructure and technological advances normally found in Western Europe and North America.The vast majority of countries in Africa, Asia, Central & South America, Oceania and the Middle East fall in this developing category and often face addition challenges in terms of lower levels of literacy and standards of living.Nevertheless, within this broad group, there are various sub-categories, each having different characteristics as well as economic strengths.
Indeed some are relatively wealthy oil exporting nations or newly industrializing world economies; a considerable number are middle income countries.
At the end of the development scale lie around fifty very poor nations with predominantly agricultural economies, which tend to be heavily dependent on external aid. From a medical perspective, many developing countries are often characterised by significant health and hygiene issues. Indeed it has been estimated that more than 1 billion inhabitants in these countries do not have access to safe water and even less to basic sanitation (1).
Around 1. 5 million children in the developing world die per year; diarrhoea is responsible for more than 80% of these deaths (2). One of the reasons for this state of affairs is the low expenditure and budgetary allocation within the poorer countries of the world towards health. Indeed the proportion of annual expenditure for health related initiatives in many developing countries is often less than 5% of Gross Domestic Product (GDP), sometimes less than 0. 1% (3). Healthcare associated infections in developing countries
Unlike more affluent countries, infectious diseases continue to pose a heavy burden of morbidity as well as mortality in developing nations (4). Amongst the more important disease entities are a wide range of respiratory diseases including tuberculosis, various gastrointestinal infections, AIDS and HIV plus a spate of parasitic infestations of which malaria is the most significant. However this situation is not limited to ambulatory settings and is equally relevant within healthcare institutions.
Deficient infrastructures, rudimentary equipment and a poor quality of care contribute towards incidences of nosocomial infections which have been estimated to be between 2-6 times higher than those in developed nations (5). In many instances, such figures are often guesstimates because surveillance systems are often either non existent or else unreliable. However, the limited studies on prevalence of healthcare associated infections in some developing countries in the world suggest that up to 40% of these are probably preventable (5).
This situation appears to particularly severe within intensive care settings where up to 60 to 90 infections per 1000 care-days have been reported; excess mortality rates in more severe infections such as blood stream and lower respiratory infections approaches 25% in adults and more than 50% in neonates (6). The challenges of infection in healthcare facilities within developing nations is also of a wider spectrum than that normally found in equivalent hospitals in the western world.
Numerous publications have highlighted the frequency by which normally community infections, such as cholera, measles and enteric pathogens, spread nosocomially within such institutions (7, 8). In many instances outbreaks are traceable to an index case who would have been inappropriately managed in a background of overcrowding and limited hospital hygiene. Similar cases of transmission have also been reported in the case of respiratory infections including measles (9).
Tuberculosis transmission in healthcare facilities is a major occurrence in many African countries as well as parts of Asia and Latin America (10). In many instances this disease is strongly related to the rise of HIV within these same geographical regions and is not uncommonly complicated by increasing prevalence of multi drug resistant mycobacteria. Blood borne infections are not restricted to HIV alone. Hepatitis B remains a major nosocomial pathogen in many hospitals within the developing world (11).
More dramatic and life threatening have been outbreaks of viral haemorrhagic fevers in institutions within several countries in the African continent (12). Hospitals are also liable to healthcare associated infection caused by more conventional pathogens which, just like in their western counterparts, can carry the additional burden of antimicrobial resistance (4). Unfortunately data on the prevalence of resistance in nosocomial pathogens is poorly documented in the developing world. However recent publications suggest that this may be even more common than in developed countries.
Recent publications from the Mediterranean region have highlighted proportions of meticillin resistance Staphylococcus aureus to exceed 50% in several countries in the Middle East with resistance to third generation cephalosporins in E. coli exceeding 70% in some participating hospitals (13). There may be diverse and often complex backgrounds to this epidemiological situation. Factors facilitating transmission and management of nosocomial infections The infrastructure of healthcare facilities in some of the poorer nations often lacks basic requirements for the prevention of transmission of infectious diseases.
Inadequate or unsafe water supply together with lack of resources or equipment for affective environmental cleaning is often compounded by significant overcrowding due to inadequate beds to cope with demand (14). There is often lack of strategic direction as well as effective planning for healthcare delivery at both national as well as local levels. A functional sterilisation department is by no means a standard occurrence in every hospital, even in the larger urban institutions.
Other areas of concern include poor awareness or knowledge about communicable disease transmission amongst healthcare workers and lack of commitment within senior management (15). This is particularly relevant in developing countries where nurses, doctors and patients are often unaware of the importance of infection control and its relevance to safe healthcare (16). Medical practitioners may have a tendency to be heavily committed towards individual patients and disinclined to think of them in groups, a concept which is the antithesis of basic infection prevention and control (17).
They are often unaware of risks of nosocomial infections, attributing such possible developments to be natural or inevitable (18). On the other hand, nurses have more intimate contact with patients and are trained to take care of patients in groups.Although this increases the potential to serve as sources of cross-transmission, nurses are likely to more positive towards infection control policies. However this is hindered by the comparatively lower status offered to nurses in the developing world and also complicated by a gender bias in environments where emancipation of women has been slow.
Attitudes of senior medical staff may further compound the problem through personality clashes, resistance to change or improvement as well as reluctance to work in tandem with other health professionals. Non existent litigation further accentuates lack of accountability at various levels. Furthermore, many patients have limited expectations, already regarding themselves fortunate to have any sort of institutional care and as a result accept a significant degree of morbidity as part of their hospital stay. It must be emphasised that even in the poorer countries, this set of circumstances is by no means universal in all hospitals.
It is not uncommon that, even where most of the hospitals in a country lack all these basic requirements, individual institutions (often either private or NGO managed) would be in a position to offer healthcare as well as infection control standards of the highest quality. However it would only be a small minority of patients, often coming from a more affluent background, that would be able to benefit from them. The risks of infection in hospitals within the developing world are not only restricted to the patients who receive care within them.
Occupational health is an equally low priority in many of these facilities and, as a result, it is not uncommon for healthcare workers to also be exposed and become infected by pathogens causing healthcare associated infections, including viral hepatitis, HIV and tuberculosis. In such limited resource environments and in situations where medical practice is biased towards intervention rather than prevention, it is not surprising that basic infection control programmes are often lacking, particularly in smaller hospitals in rural areas (18).
Even within larger urban facilities, infection control teams, composed of both an infection control nurse as well as doctor, who have been trained and have managerial backup are very much in the minority. They are often restricted to academic institutions, heavily funded government or private tertiary care units. Even where present, these teams tend to encounter numerous logistical obstacles including lack administrative, clerical and IT support. Infection control output therefore tends to be significantly variable; policies and procedures are either absent or lack consultation, evidence base or suitable addressing f local needs. Healthcare professionals also face significant challenges in the diagnosis and treatment of infectious disease (4). Diagnostic facilities are often lacking. Laboratories may be absent or limited as a result of inadequate resources of both a material as well as human resource nature. Trained laboratory scientists are very much in the minority whereas the implementation of quality control programs to ensure validity in the laboratory’s output is not viewed as a crucial.
This situation is worsened by possible lack of confidence in the laboratory from clinicians who would prefer to undertake treatment blindly, based only on clinical judgement or recommendations from other countries rather than local epidemiology. One reason for this is the lack of feedback of local resistance data (20). This risks inappropriate treatment which would not properly cover local resistance prevalence patterns. Another major factor hindering the treatment of infectious disease is the presence of poor quality antimicrobials, even counterfeit, with little or no active ingredient within the formulation (21).
Addressing the challenge It is therefore clear that in order to improve the effectiveness of infection control in many developing countries, a multifactorial set of initiatives needs to be undertaken that are both feasible as well as achievable in this background of economical and social deficits (15). It is essential that infection control teams increase their presence within hospitals in these regions. These key personnel must be provided with the necessary training as well as administrative support and facilities in order to deliver the required services.
Such teams would be able to identify the major challenges and assess relevant risks through tailored surveillance programmes. Surveillance constitutes a challenge in such environments since it is often time consuming and resource dependent (22). In addition it requires a reasonable level of laboratory support. Nevertheless it is possible using simplified definitions of healthcare associated infections, as suggested by the World Health Organisation, to achieve a surveillance programme even with very limited resources (23).
Such initiatives need to concentrate on the more serious infections and document their impact in the respective facility. Trained infection control personnel would also be appropriate drivers to eliminate wasteful practices which siphon resources away from truly effective practices. Dogmas include routine use of disinfectants for environmental cleaning, use of unnecessary personal protective equipment such as overshoes, excessive waste management procedures which treat all waste generated in the hospital as infectious.
Infection Control teams will be able to spearhead cost-effective interventions based on training of healthcare workers to comply with relevant infection control measures related to standard precautions, isolation together with occupational health and safety. It is possible to achieve significant reduction in the prevalence of healthcare associated infections through low cost measures; interventions aimed at preventing cross transmission of infection are particularly effective. There is no doubt that one of the most cost effective interventions in limited resource environments is improved compliance with hand hygiene.
The World Health Organisation has indeed designated improvement of health hygiene within healthcare facilities worldwide as a priority and chose this topic for its first Global Patient Safety Challenge under the banner ‘Clean Care is Safer Care’ (6). A comprehensive set of tools have been tested worldwide in pilot hospitals, the majority of which were in developing countries. The emphasis of this initiative focuses on the availability and utilisation of alcohol hand rub for patient contact situations where hands are physically clean.
This is made possible through local manufacture of inexpensive, good quality products according to a validated formula. A multimodal strategy requires these alcohol hand rub containers to be available at point of care and for the staff of the hospital to receive adequate training and education in their use. Hand hygiene practices are monitored and feedback on performance regularly provided to the users. Reminders in the workplace sensitise awareness and belief amongst healthcare workers in general.
Infection prevention and control in healthcare facilities within the developing world continues to offer numerous challenges as a result of reduced resources related to socio-economics, infrastructure and human resources. However it is possible to achieve substantial progress even within such challenging circumstances through a programme led by trained and empowered infection control professionals. Such initiatives need to concentrate on low cost, high impact interventions and emphasis on training, backed by interaction and networking with colleagues and societies within the country itself and beyond.
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