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Wed 7 Jan 2009 04:00 AM

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Coming clean on infection

No reliable data exists on the prevalence of healthcare acquired infections in the region.

No reliable data exists on the prevalence of healthcare acquired infections in the region. Joanna Hartley looks at the need for well-run and transparent national surveillance schemes.

It's hard to get doctors and healthcare managers in the Middle East to admit that they have a problem with infection control, let alone access to up to date figures on rates of healthcare acquired infections (HAIs).

In general the issue is still cloaked in fear, and hidden from view, because no-one wants to own up to making their patients sicker - whether it's just a simple urinary tract infection (UTI) or septicaemia caused by the scourge of modern healthcare, methicillin-restistant Staphlococcus aureus (MRSA).

Infection control is like a puzzle, every piece is needed to get the full picture. It's everyone's business.

Historically very little research has been done on the extent of HAIs in the region. The limited evidence available  puts prevalence at between 8% and 12% of all those admitted to acute care.

This is far higher then the 20% rates seen in developing countries and nearer prevalence rates seen in Europe and the US - a country that still predicts these infections account for one in 10 deaths.

Unlike more developed countries, however, there are no national surveillance schemes in place in any of the seven GCC countries - making it difficult to reliably determine the likelihood, or not, of people contracting an infection whilst in hospital.

Such lack of data leads many healthcare workers in the region to deny HAIs are a serious problem. But that just isn't the case, warns Dr Iyad Hijjawi, general manager of the Middle East Infection Control Centre based in Jordan.

"We have many problems - no one has a handle on this because there is no monitoring," he tells MT. 

"Of course we should not declare we are free of nosocomial disease and that we have 0% infections. People should admit we have many problems and make statistics and surveys of patients, both in the public and private sector," Dr Hijjawi says.

Going it alone

Without national policies on infection control and mandatory surveillance schemes, it is left to individual healthcare providers to determine their own policies on screening and data collection.

And many have developed well established and well run infection control departments. Rashid Hospital, a government run trauma facility in Dubai, has a dedicated infection control team, including three infection control practitioners who are nurses by profession.

The team carries out monthly surveillance across all medical and surgical areas, including the intensive care units, where they swab for ventilator associated pneumonia, urinary tract infections, bacteraemias and clean surgical site infections.

Around two to three cases of MRSA are picked up each month, a figure that includes nasal colonies, community acquired MRSA as well as the hospital version, according to Virginia Digman, one of the infection control practitioners.

"It is erratic, sometimes we see two, sometimes three. This is a big trauma centre and we deal with people from all over. That figure includes colonisation tests, plus community acquired MRSA, and we do have some infected MRSA too," Digman says.

The team reports its findings each month to an infection control committee that covers all four hospitals run by the Department of Health and Medical Services. But the data is kept in-house and inaccessible to the public.

Local surveillance initiatives are extremely important and essential for identifying specific areas of concern, and targeted action, says Professor Ossama Rasslan, chairperson of the Eastern Mediterranean Regional Network for Infection Control, which is supported by the World Health Organisation (WHO).

"You have to have surveillance in each healthcare facility you have to know your own rates," he comments. "Even in one hospital the infection rates may be 9% in one area and 50% in another, such as critical care, and you may see in the critical care unit there is a lack of compliance and commitment," Professor Rasslan says.

However, working in isolation makes it impossible to build up a national or regional picture of HAI prevalence. Or to pin down universal reasons for high or low infection rates, he adds.

For this comparative data is needed, and that only comes with national surveillance schemes, which everyone has to feed into. "We need to be able to do risk assessment for entire countries. It is a big project and we have to stress that to improve surveillance we have to know your (hospital's) data and compliance," Professor Rasslan tells MT.

A clear view

Such a move will require a far greater willingness on the part of professionals and providers to be open and honest about infection rates, he adds.

"We do not have a culture of transparency. But infection control is like a puzzle, every piece is needed to get the full picture - it's everyone's business and we have to encourage trust."

The collaborative approach may still be a glimmer on the horizon for many healthcare providers, however, it is one that has taken hold at the highest level. All seven GCC health ministers have now signed up to WHO's 2005 agenda on patient safety, which incorporates guidelines for improving infection control.

"There is a major commitment from the top," reveals Dr Ziad Memish, executive director of infection, prevention and control in the National Guard Health Affairs, Saudi Arabia - that is the GCC's collaborating centre for infection control.

Top-to-toe support

"There has been a real change in the last three years," Dr Memish adds. "Before no one was listening to us, but the ministers have been at the WHO assembly, and every year they are pleading about infection control and hand hygiene, and now we have support from the top down."

The grand vision is for a Gulf-wide HAI surveillance system and moves towards that goal are already underway, Dr Memish reveals. The GCC centre for infection control is poised to publish a manual of infection control policies, based on best practice, which will be sent out to all seven countries.

This will be followed later in the year by a surveillance manual, that aims to standardise practice around data collection. "The vision is to standardise the policy and start collecting data, so we can benchmark in the region and prioritise countries, and hospitals, where we need to work hard to bring the rates down," Dr Memish says.

Although such high level commitment is essential for any sort of success, it will still take commitment from individual countries, providers and healthcare staff to firmly place infection control at the top of the healthcare agenda.

The most pressing issue is workforce, Dr Memish believes. "The question is; are there enough qualified people in each country to run the system? And the answer is probably not," he admits.

"There are doctors and nurses out there, but not enough expertise to run the service on a national level. So a large amount of effort will have to go in to training and development," he concludes.

One key persuader might be the immediate cost savings made by cutting infection rates, comments Professor Rasslan. Making a small investment in implementing strict infection control policies, training and surveillance scheme can save a hospital up to 60 times on the amount spent on expensive antibiotics and long-term hospital stays, he concludes.

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