This article is part of a series of inspiring stories behind the vital work being done to reduce the global burden of this preventable public health challenge.  

In Europe alone, healthcare-associated infections are the cause of 16 million extra days of hospital stay and 37,000 deaths every year. Associated costs are estimated to exceed €7 billion annually. Various prevention and control strategies are being implemented to reduce the global burden of infection.

Healthcare-associated infections are acquired by patients while receiving treatment in a healthcare setting, from in-patient care hospitals, to ambulatory surgical centres and nursing homes. They are caused by  infectious agents – most commonly, bacteria, fungi and viruses. Risk factors include contamination of the healthcare environment, transmission of communicable diseases between patients and healthcare workers, over or improper use of antibiotics, surgical procedures, injections and the use of in-dwelling medical devices such as urinary catheters.

National and multi-center studies on endemic healthcare-associated infections from 1995-2010 showed their prevalence in mixed patient populations averaged over 7 percent in high-income countries. Although data on the developing world is very fragmented, it is estimated that infection rates in low-income countries varied from 5-19 percent. 

In high-income countries, healthcare-associated infections are mostly the result of healthcare delivery system failures. Awareness and knowledge of these infections is sometimes poor, and known evidence based prevention strategies could be enforced more effectively. The main factors placing patients at risk are prolonged and inappropriate use of invasive devices and antibiotics, high-risk and sophisticated procedures, immuno-suppression and other severe underlying patient conditions, and insufficient application of isolation procedures. 

In developing countries, additional factors – such as poor hygiene and sanitation, lack of basic equipment, inadequate infrastructure, overcrowding and pervasive malnutrition and disease – play an important role in increasing the risk of infection. Dr Benedetta Allegranzi, Technical Lead for Patient Safety at the World Health Organization, suggests multiple use of syringes in settings with limited resources is an aggravating factor, including in the context of hepatitis B and C, as well as HIV. Newborns are also a high-risk population, with neonatal infection rates three to 20 times worse than in high-income countries. Similarly, up to one-third of operated patients are affected by surgical site infections, while in intensive-care units infection rates can be up to 20 times higher than in developed country hospitals.

The global impact of healthcare-associated infections, however, goes beyond the financial costs and health consequences for patients and their families. It entails the need for more complex medical treatments, longer hospital stays delaying bed availability for other patients and the prescribing of additional, expensive antibiotics. Indeed, these antibiotics are sometimes less efficient and more toxic, notes Professor Didier Pittet, Director of the Infection Control Program at the University of Geneva Hospitals and Faculty of Medicine.

Encouragingly, research suggests most healthcare-associated infections are preventable and the burden of infection can be reduced by as much as 50 percent or more. Because the ability of hospitalized patients to fight infection is often diminished by a pre-existing disease, it is essential that healthcare facilities comply with safety standards to prevent and control infections. Prevention strategies must combine the efforts of clinicians, scientists, public health leaders and patients themselves.

Surveillance systems for healthcare-associated infections exist in several high-income countries, but are virtually non-existent in most low- and middle-income countries, says Allegranzi. Prevention measures include isolation, environmental cleaning, sterilization and disinfection, infectious waste disposal, and specific procedures for injection safety. Another important factor in the spread of these infections is anti-microbial resistance, as healthcare-associated pathogens often carry patterns of multi-drug resistance known to bring more virulence. 

In a majority of cases, the spread of healthcare-associated infections is connected to the hand contamination of healthcare workers – still a challenging problem in modern hospitals. In 2005, the World Health Organization, in partnership with the University of Geneva Hospitals, launched Clean Care is Safer Care, a global campaign to promote patient safety by improving the hand hygiene practices of healthcare workers.

Staff education through best practices is another key element of any prevention strategy. While a simple and low-cost approach, however, sustained impact requires staff accountability and behavioral change. In March, the European Center for Disease Prevention and Control published a technical report with core competencies to be adopted by infection control and hospital hygiene professionals in the European Union. The report was aimed at standardizing competencies through training courses tailored to different national contexts, while also facilitating the mutual recognition of competencies across member state systems.

Risks of infection at a global level are also exacerbated by increasing travel, medical tourism and shared healthcare across countries. “Inter-country” patients have emerged as a distinct group including military and civilian medical evacuees, medical tourists travelling specifically to seek treatment abroad, and those whose medical care is divided between countries for a variety of social, familial or financial reasons. Travellers and migrants also act as vectors (and victims) of healthcare-associated infections. On a daily basis, medical practitioners are faced with patients who may have been hospitalized in any part of the world in the preceding days.

Ultimately, clinical research highlights the need for infection prevention and control strategies that take into account the various factors and circumstances of each healthcare setting. 

Request the Special ICPIC Edition of The Global Journal. 

Symposium on the Healthcare-Associated Infection Burden in Low- and Middle-Income Countries

 ICPIC, 26 June 2013

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