Hand Sanitation – Lessons learned and the way forward
By mapping and scrutinizing the studies in the scientific literature, a global picture of the endemic burden of HCAI can be captured for the first time with compiled data from many countries and, importantly, an assessment of differences between high-, low and middle-income countries. The key finding is that the burden of HCAI worldwide is very high in terms of morbidity, mortality, extra-costs, and other outcome indicators. This is particularly true for developing countries where awareness of the problem remains extremely limited, and because other health priorities take precedence over patient safety considerations.
Of every 100 hospitalized patients at any given time, 7 and 10 of them will acquire a HCAI in developed and developing countries, respectively. According to high-quality studies, this proportion increases to 15 per 100 patients in developing countries. 3 HCAI is more frequent in critically-ill patients admitted to ICUs. In this patient population, the increased risk in settings with limited resources is particularly disturbing with an overall frequency of infection as high as 42.7 episodes per 1000 patient-days in developing countries vs. 17.0 episodes per 1000 patient-days in industrialized countries. Furthermore, in these high-risk settings, incidence densities of infections associated with the use of invasive devices (central vascular lines, ventilators and urinary catheters) are on average at least three-fold higher in low- and middle-income than in high-income countries. Pooled incidence density of CR-BSI and VAP in some developing countries were even shown to be up to 19 and 16 times higher than those reported from Germany and the USA. 3 Newborns are also at higher risk of acquiring HCAI, with infection rates in developing countries three to 20 times higher than in high income countries.
Interestingly, UTI, especially related to urinary catheter use, is the most frequent infection detected hospital-wide in mixed patient populations in high-income countries. However, this type of infection has usually less severe consequences than other device-associated infections in terms of attributable mortality, related complications, and associated costs. Conversely, in low and middle-income countries, SSI is the most frequent HCAI and affects up to one-third of operated patients. Frequencies reported for SSI are probably largely underestimated as, according to some studies, most are detected through post-discharge surveillance, which is very difficult to perform in developing countries. 32-38 SSI can prolong hospital stay up to 21 days in settings with limited resources. In addition, it can bring a huge burden in terms of medium-term sequelae, personal suffering for the patient, and additional financial costs. With regard to data availability, this report shows that information at the national level is regularly provided by several national surveillance systems and international networks in high-income countries. By contrast, very few national studies are available from low- and middle-income countries and the vast majority has no regular HCAI reporting system in place. Furthermore, even when considering studies related to single institutions, data are not available for many developing countries and some regions are poorly represented overall.
Although national figures on the burden of HCAI are available only for a few countries, based on data from Europe and the USA, it can be estimated that hundreds of millions of patients suffer from HCAI every year worldwide. However, it is important to note that infections acquired by health-care workers, data on outbreaks and blood-borne pathogens transmitted through transfusion, contaminated injections, and other procedures are not included in these estimates. For this reason, and because of reporting gaps even when surveillance systems are in place, the burden of HCAI is certainly greatly underestimated. Raw data related to the number of affected patients and number of episodes per patient, together with a valid and accurate denominator (e.g. number of patients hospitalized for more than 48 hours) are not available from most countries. In addition, no system exists to collate these data on a global level, as is the case for other diseases annually reported by WHO. This is mainly due to constraints inherent to HCAI surveillance that include: the complexity of HCAI diagnosis (including lack of specific diagnostic tests, such as those available for human immunodeficiency virus © University of Geneva Hospitals (HIV), tuberculosis, and malaria); neglected use of standardized definitions; lack of expertise and dedicated personnel; and the overall lack of financial resources to invest in this field. Further research is very much needed to identify mathematical models in order to obtain more predictive global estimates of HCAI. Although these should be partly based on findings from published epidemiological reports, the reliability of the study results must be considered as the quality can be very poor, particularly those conducted in developing countries. In addition, minimum requirements and standards should be set to allow countries to establish robust surveillance systems and report national figures. Case definitions need to be homogenized, together with the method of calculating the denominator, e.g. calculation of days at-risk until the first infectious episode or for the entire period of hospitalization. Adaptation of definitions to make HCAI detection more feasible in settings with limited resources should be considered and validated through scientifically sound investigations. Standardization would help to gather a more comprehensive picture and to optimize inter hospital and international comparisons. Ideally, countries should adopt definitions and methods used by prominent surveillance networks, such as HELICS, NHSN, KISS and INICC. It would be also important to encourage these networks to join their efforts and use the same definitions, and even to explore possibilities to merge their data on a regular basis.
Evaluation of the key determinants of HCAI burden is complex, but it remains an essential step to identify strategies and measures for improvement. In advanced settings in high-income countries, HCAI may occur as a potentially expected adverse event of sophisticated care techniques and treatments typical of modern medicine. However, it is also evident that frequently it represents a health-care delivery system failure. Despite the broader availability of resources in these settings, awareness and knowledge of HCAI are often poor, and well-known, evidence-based, infection prevention and control strategies could be enforced and implemented more effectively. In developing countries, the nature of this problem is partially different because, in addition to general determinants similar to high-income countries, a combination of numerous unfavourable factors play an important role to increase the risk of HCAI. These are much more inherent to the situation and reality of these countries, such as poor hygiene and sanitation, lack or shortage of basic equipment, inadequate infrastructures, unfavourable social background, and a population largely affected by malnutrition and other types of infection and/or diseases. Data from this report highlighting the serious burden of HCAI bring strong evidence that these determinants, as well as surveillance issues, must be carefully assessed and tackled as much as possible at all levels if any significant progress is to be made in the future.
Original Report Credit: http://www.who.int/gpsc/5may/EN_PSP_GPSC1_5May_2016/en/