Journal of Hospital Infection (2007) 65(S2) 148–150

Available online at www.sciencedirect.com

www.elsevierhealth.com/journals/jhin

Infection control in countries with limitedresources

Patricia Lyncha, Didier Pittetb, Michael A. Borgc, Shaheen Mehtard

aInternational Federation of Infection Control, and Epidemiology Associates, Redmond, WA, USAbInfection Control Programme, University of Geneva Hospitals, Geneva, Switzerland, and First GlobalPatient Safety Challenge, WHO World Alliance for Patient SafetycInfection Control Unit, St. Luke’s Hospital, and Faculty of Medicine and Surgery, University of Malta,Malta, and ARMed ProjectdUnit for Infection Prevention and Control, Tygerberg Hospital, and Department of Community Health,Faculty of Health Sciences, Stellenbosch University, South Africa

KEYWORDS Healthcare-associated infection; Hand hygiene; Worldwide priorities

Patricia Lynch; Chair, InternationalFederation of Infection Control

Infection control (IC) in countries with limitedresources potentially affects healthcare in all coun-tries; infectious diseases have spread around theglobe very efficiently but infection prevention haslagged behind. Control of healthcare-associatedinfections (HAIs) is one of the great successes: itreduces illness and mortality and saves money forpatients and hospitals. Yet, today only 57 of 192countries have national IC societies and there isstill no global planning for managing this plaguewhich is largely preventable, and which spawnsa host of related problems including multidrug-resistant organisms and bloodborne infectionsamong patients and healthcare workers (HCWs). Infact, infection problems continue to be amplifiedin hospitals rather than reduced. For example, theSevere Acute Respiratory Syndrome (SARS) began asa community-acquired, severe respiratory diseasebut ultimately, almost half of cases were due tohospital transmission.

Global health constraints that affect infectionprevention include insufficient financial resourcesfor healthcare in general, failure of facilities touse proven prevention strategies, and inadequatetraining for HCWs, especially nurses; a dispro-portionate burden falls on the least developed

facilities. There is such a major failure in termsof global planning that the essential natureand function of infection control programmesare virtually invisible. To emphasise the positiveaspects however, rates for HAIs in ICUs are reportedby Rosenthal and others to be 3 4 times thebenchmark National Nosocomial Infections Study(NNIS) in the USA, but these fall to the benchmarkwhen surveillance data is provided to HCWs insufficient detail. In the USA, two very largeinfection prevention projects, “Keystone Project”and “100,000 Lives Campaign” have reportedprecipitous declines in HAIs when proven strategiesare implemented.

Activities related to infection risk reduction, andglobal health planning that includes appropriateantibiotic use, preventing transmission of blood-borne pathogens are essential.

Didier Pittet; Director, Infection ControlProgramme, University of GenevaHospitals, Geneva, Switzerland, andLead, First Global Patient SafetyChallenge, WHO World Alliance forPatient Safety

Healthcare-associated infection affects hundredsof millions of people worldwide in developed,

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

Infection control in countries with limited resources 149

transitional, and developing countries and isa major, global issue for patient safety. Itcomplicates a significant proportion of patient caredeliveries, adds to the burden of resource use,and contributes to unexpected deaths. Whetheracquired during home, ambulatory, institutionalor hospital care, healthcare-associated infections(HAIs) constitute one of the greatest challengesof today’s medicine. According to the Institute ofMedicine, hospital-related adverse events in theUSA, including HAIs, are responsible for 44,000to 98,000 deaths annually and represent a costof $17 29 billion. Among these, HAIs now affect5 15 per 100 hospitalized patients and can leadto complications in 25 50% of those admitted tointensive care units. In the United Kingdom, HAIscost around £1 billion a year and contribute toat least 5000 deaths. Importantly, these estimatesonly concern infections acquired in acute-carehospitals and take no account of those resultingfrom ambulatory care or acquired in other settings.Infection rates are higher in transitional anddeveloping countries than in developed countries.Worldwide, HAIs affect as many as 1.4 millionpatients at any point in time in healthcareinstitutions.

The World Health Organization (WHO) supportedthe creation of an international alliance to improvepatient safety as a global initiative, and theWorld Alliance for Patient Safety was launchedin October 2004. The six actions areas of theAlliance are: Patients for Patient Safety; Taxonomy;Research; Solutions for Patient Safety; Reportingand Learning; and a biennial Global Patient SafetyChallenge. HAI is the topic chosen for the firstChallenge, covering 2005 2006, and the FirstGlobal Patient Safety Challenge “Clean Care isSafer Care” was launched in October 2005.

The First Global Patient Safety Challengeembraces existing WHO strategies to reduce HAIand also creates the momentum for new actionsto improve hand hygiene during patient care. Themajor objectives of “Clean Care is Safer Care” are:to raise awareness of the impact of HAI on patientsafety and promote preventive strategies withincountries; to build commitment from countriesto prioritise reducing HAI; and to test theimplementation of the new WHO Guidelines onHand Hygiene in Health Care in specific areasworldwide as part of an integrated package ofactions derived from existing WHO strategies in thefields of blood safety, injection and immunisationsafety, clinical procedure safety, and water, basicsanitation and waste management.

Michael A. Borg; International ProjectLeader ARMed Project, Malta

Antibiotic resistance continues to pose an ever-increasing threat to effective healthcare delivery.This is more so in developing and low-resourcecountries and in facilities where financial limi-tations add another dimension to the problem.Developing countries often face a burden frommulti-resistant infections that is even greater thanthat in more affluent nations. Such infectionsconstitute an even higher monetary burden and theaverage cost for a single multi-resistant infectioncan be equivalent to the gross national incomeper capita. Furthermore, restricted availability ofantibiotics may result in inadequate therapeuticoptions.

Despite its relevance, knowledge about thestatus of antibiotic resistance in the developingworld remains on the whole lacking, as a result ofinadequate emphasis on research and surveillance.However, recent studies suggest that the situationin developing countries is often more acutethan that already reported in the west. In par-ticular, meticillin-resistant Staphylococcus aureus(MRSA) has possibly become the major resistantpathogen, particularly in hospitals and healthcareinstitutions and resistance. Equally serious arethe ever increasing reports of extended-spectrumb-lactamase (ESBL)-producing Enterobacteriaceae,especially Escherichia coli, where prevalence inexcess of 50% has been reported from middleeastern countries.

The efforts required in order to address this everincreasing problem within low-resource countriesresemble those required to address the sameproblem in their more developed equivalentsand focus primarily on prevention and controlof cross-transmission together with improvedantibiotic stewardship. However it is in theseefforts that developing countries may encountergreater and at times insurmountable obstacles. Notuncommonly health systems in these regions arecurative-orientated with the result that the funds,personnel and training required for preventiveefforts are difficult to obtain.

However, progress appears to have been made inthe past years as more hospitals in these nationsnow report having infection control committeesin place. Infection control teams, composed ofdesignated and trained infection control doctorsand infection control nurses, and which are widelyregarded as the cornerstone of an effectiveIC programme, are however less common and thissituation constitutes a potential drawback whichoften hampers outcome. A need for improved

150 P. Lynch et al.

training of IC personnel is another critical issue.Whilst it may be simple for infection controlcommittees (ICCs) to be set up within hospitals,these require an effector mechanism to producethe most appropriate recommendations and toensure that clinical staff take responsibility forthese and put them into practice. This has beenreported to be particularly relevant in developingcountries where nurses, doctors and patients maybe less aware of the importance of IC and itsrelevance to safe healthcare.

The causal link between antibiotic resistance andconsumption has been well established. Studieshave documented parallel changes in antimicrobialusage and in the prevalence of antimicrobialresistance. Recent data suggest there is a signif-icant consumption of antimicrobials in developingcountries, which may be a factor contributing tothe high prevalence of resistance. Mathematicalmodeling suggests that, in environments wherethere is both a high prevalence of antimicrobialresistance as well as evidence of considerableantibiotic consumption, the area of improvementthat is likely to have the biggest impact onresistance is control of antibiotic use. Suchimprovement can be obtained through antibioticstewardship programmes, which aim to ensure thatthe use of antibiotics particularly in hospitals iscommensurate with the clinical circumstances andthe local resistance epidemiology. To this end,feedback to prescribers of local antimicrobialresistance information, as well as the develop-ment and dissemination of antibiotic prescribingguidelines based on the local circumstances, arecritical interventions that will have a major impactin combatting the documented high prevalenceof antimicrobial resistance in the low resourcecountries.

Shaheen Mehtar; Head of Academic Unitfor Infection Prevention and Control,Tygerberg Hospital & StellenboschUniversity

Injection safety refers to practices that reduce therisk of transmission of bloodborne viruses (BBVs)to patients and providers. Although transmission ofBBVs occurs in healthcare facilities, the true extentis unknown but thought to be highly variable infacilities with limited resources. Most of the riskto HCWs and to patients can be prevented.

As part of the Year 2000 Global Burden of Diseasestudy, the WHO quantified death and disability frominjection-associated infections with hepatitis Bvirus (HBV), hepatitis C virus (HCV) and humanimmunodeficiency virus (HIV). In the year 2000,in 10 regions that included developing countriesonly, it was reported that persons visiting a generalpractitioner received an average of 3.4 injectionsper year, 39.3% of which were given with reusedequipment. In the same year, contaminatedinjections caused an estimated 21 million HBVinfections, two million HCV infections and 260,000HIV infections, accounting for 32%, 40% and 5%,respectively, of new infections. Many studies havedocumented that HCWs lack knowledge aboutsafe practices, risk for transmission and wastemanagement.

Injection overuse and unsafe practices accountfor a substantial burden of death and disabilityworldwide. There is a need for policies and plansfor the safe and appropriate use of injections incountries where practices are poor.