ECHO India. Moving Knowledge, Not people

Infections acquired during healthcare delivery, more appropriately called Healthcare-Associated Infections (HAI), are a significant public health problem around the globe. Healthcare-Associated Infections are defined as: “An infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the hospital, but appearing after discharge, and also occupational infections among the staff of the facility.’’

It is estimated that in developed countries, 5-10% of patients admitted to acute care hospitals acquire one or more infections. In developing countries, on the other hand, the risk of infection is 2-20 times higher and the proportion of patients affected by HAI can exceed 25% [1]. In the last decade, large Ebola virus disease outbreaks, the Middle East Respiratory Syndrome epidemic, and the COVID – 19 pandemic, have demonstrated some of the dramatic consequences of epidemic-prone pathogens often spreading through healthcare settings [2].

A WHO report highlights that globally, out of every 100 patients in acute-care hospitals, seven patients in high-income countries and 15 patients in low- and middle-income countries will acquire at least one HAIs [3, 4]. Up to 30% of patients in intensive care can be affected by HAIs, with an incidence that is two to 20 times higher in low- and middle-income countries than in high-income countries. This is particularly true among neonates [5, 6]. Approximately one in four (23.6%) of all hospital-treated sepsis cases are healthcare-associated. Almost half (48.7%) of all cases of sepsis with organ dysfunction treated in adult intensive care units are hospital-acquired [7].

In the past few years, India has witnessed outbreaks of eight novel as well as re-emerging infectious diseases, six of which have been of zoonotic origin (Plague, Diphtheria, Nipah virus, CHP virus, Chikungunya virus, H1N1 virus, Crimean Congo Haemorrhagic Fever, Acute Encephalitis Syndrome and most recent being COVID-19). To be able to prevent and control widespread outbreaks of emerging or re-emerging infectious diseases, a multi-pronged approach will be required, including - effective application of sophisticated epidemiologic and molecular biologic technologies, changes in human behavior, early detection and rapid response to emerging infections and a plan of action [8].

In 2018, during the Nipah virus outbreak in Kerala, a nurse caring for a patient died from cross-infection [9]. This has brought a sense of urgency to strategies and implement evidence-based measures to control Healthcare-Associated Infections.

Studies indicate the prevalence of HAIs ranges from 7 to 18 per 100 patients in India, which is similar to that reported in other low and middle-income countries. The high incidence of HAIs in India can be attributed to inadequate healthcare infrastructure, lack of training for health workers in Infection Prevention and Control (IPC) practices, hospital overcrowding, and low nurse-to-patient ratios even in intensive care units. These factors result in patients’ longer hospital stays, increased mortality, and added costs [10].

Challenges posed by HAIs are all-pervading as no hospital or healthcare infrastructure in any country in the world can claim to have solved this problem completely. An effective solution to this problem needs a holistic approach as HAIs can be acquired anywhere along the continuum of healthcare settings, including long-term care, ambulatory care, and home care [11].

According to available evidence, the impact of HAIs includes prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, the massive additional financial burden for health systems, high cost for patients and their families, and preventable deaths. A high or low prevalence of HAIs is also considered an important indicator of the quality of patient care. The growing emergence of antimicrobial resistance is proving that without appropriate IPC practices, healthcare facilities may act as permanent reservoirs of drug-resistant bacteria and a source of their transmission. (12)

Preventing HAIs and antimicrobial resistance avoids this unnecessary harm, lowers preventable mortality, and saves scarce resources that can in turn be applied to solving other pressing health challenges. Evidence-based research demonstrates that a considerable proportion of the burden of diseases attributable to HAIs can be prevented with low-cost interventions [13].

However, the translation of evidence into reliable and sustainable practice in healthcare systems remains a major roadblock. Despite the availability of low-cost interventions for infection prevention and control, compliance with standard IPC practices remains very low, particularly in low-income and middle-income countries. The current opportunities to improve patient safety and quality of care and to significantly reduce healthcare costs with low-cost, high-yielding interventions are thus being barely utilized [14].

As a silver lining, there has been a growing recognition by the Government of India, which is the largest healthcare provider in the country, for framing and implementing broad-based policies to address HAIs. Under the Swachh Bharat Abhiyan (Clean India Mission) and the National Health Mission, the Kayakalp initiative was launched in 2015 with an aim to promote and reward cleanliness, hygiene, and infection control practices in public healthcare facilities [15].

With an aim to collect surveillance data on medically indexed microbes, the Indian Council of Medical Research (ICMR) has established an “Antimicrobial Resistance Surveillance Network”. The data is collected from more than twenty state medical college laboratories with a dedicated national coordination center. Additionally, ICMR and the National Centre for Disease Control, with technical support from the US Centres for Disease Control and Prevention, have helped their existing Antimicrobial Resistance Surveillance Networks to develop models that can strengthen HAI surveillance and reporting infrastructure as well as for continuous evolution and improvement of standard IPC practices to be used for building public health strategies [16].

Infection Prevention and Control is a clinical and public health specialty that provides practical solutions grounded in scientific evidence on infectious diseases, epidemiology, social and implementation science, and health systems strengthening. Rigorous compliance with IPC practices is critical to ensure patients and healthcare workers don’t get harmed by avoidable and preventable infections.

The ongoing COVID-19 pandemic and the recent re-emergence of some existing zoonotic diseases have reinforced the fact that implementing IPC practices cannot be ignored in healthcare and allied services to prevent and contain outbreaks of infectious diseases [17].

The starting point for preventing HAIs is to appreciate the burden of such infections, including the associated costs to healthcare, as an emerging public health problem, and to increase awareness that the majority of these infections are preventable by measures that are simple, feasible, and achievable in any economic setting. Evidence has shown that even standard precautions - hand hygiene, use of personal protective equipment, injection safety, bio-medical waste management, safe blood transfusion, safe laboratory practices, and proper application of isolation precautions – play a very vital role in preventing and containing infections, thus improving healthcare outcomes and saving lives [18, 19].

About the author: Dr. Haresh Chandwani is a seasoned public health professional with more than 18 years of experience in planning and implementing high-impact capacity-building programs for healthcare systems strengthening. His recent focus areas have been Infection Prevention and Control (IPC) Practices and primary healthcare. Dr. Chandwani earned his MBBS from Government Medical College, Bhavnagar, and his MD in Community Medicine from M.P Shah Medical College, Jamnagar. He is currently working in the role of General Manager of Projects at ECHO India.

References:

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  9. “Ministry of Health and Family Welfare Government of India National guidelines For infection prevention and control in healthcare facilities, January 2020” Accessed Dec 16, 2022. [https://www.mohfw.gov.in/pdf/National%20Guidelines%20for%20IPC%20in%20HCF%20-%20final%281%29.pdf] (https://www.mohfw.gov.in/pdf/National%20Guidelines%20for%20IPC%20in%20HCF%20-%20final%281%29.pdf)

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