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Challenging Infection Control

Dr Shah: Healthcare is a human driven system. Universal implementation of guidelines requires behavioural changes at all the levels i.e. administration, doctors, nurses, technicians, other support staff, relatives and patient themselves. In fact, pharmaceutical and other health care accessory manufacturing companies also play a role in prevention. A significant emphasis is not yet given to prevention during training period of health care personnel like doctors and nurses. It is necessary to consider prevention strategies as important as treatment of the patient. There is a huge lacuna in this holistic approach. Automation in health care is far away unlike many other industries. A huge role hence can be played by government too.

Spread of infection is a result of: Negligence of hospital officials, lack of knowledge, lack of hygiene practices or infection control is expensive…

Dr Mamtora: Spread of infection can never be pin pointed to anything or rather it is a combination of multiple factors. It is primarily related to patient’s medical conditions which are sometimes morbid and even fatal or devastating. Infection can also be related to infectious agents that are drug resistant bugs, antiviral resistant viruses, antifungal resistant fungus, drug resistant parasitic diseases or vectors which are additionally becoming resistant to insecticides. There are some of zoonotic diseases which can be transmitted from animals.

There are also certain diseases which are emerging like SARS, Viral haemorrhagic fevers and recently zika virus. We must note the detailed medical history of patients including travel and occupation which are sometimes difficult to obtain in critical conditions. There are certain infections which were restricted to geographic areas but due to travelling are now seen in new geographic areas.

The epidemiology of infectious diseases itself is changing. With rampant drug resistance, within no time we will land up in post antibiotic era and then only thing which will be available will be infection control practices which are simple yet effective and with bare minimum cost involved. We always speak about prevention which is better than cure. But in majority of cases, we don’t practice preventive medicine because medical field is totally overburdened due to lack of adequate facilities and manpower issues. With increased consumerism and litigation, doctors are forced to practice defensive medicine. Quality of overall education in our country is degrading with evolving time, which is really a major issue, but not given due attention.

Infection control is expensive but at same time it saves on costs resulting from poor quality. There is cost involved in infrastructure for isolation rooms as per international standards. HVAC, water and sanitation practices. There are other expenditures like cost of training manpower, cost of equipment and their maintenance, cost of quality services, cost of disinfection and sterilization practices, cost of qualified staff and above all cost of maintaining all these things in place for sustaining services. Many a time, in organizations, aesthetics is given more importance over infection control which should be other way.

Dr Shah:

a) Negligence of hospital officials

  • Administrative controls in infection prevention are crucial. If adequate hand hygiene products like soap, alcoholic hand rub and gloves are not available, even if a health care personnel is trained and willing; cannot implement hand hygiene.
  • Also, vaccination for all health care personnel should be made mandatory e.g. Hepatitis B and Tetanus vaccine by officials.
  • The infection control data is not being captured uniformly in our country. There is no national requirement for the same. It is a voluntary exercise. Thus, sometimes it is captured in parts and many a times is not captured at all.
  • If one cannot measure the problem, one cannot reduce it
  • It is important to have surveillance mechanism
  • Many laboratories across India are not equipped to test antimicrobial susceptibilities and resistance. Microbiologists are not available for interpretation of the results and its application in many areas. This has an adverse impact on infection prevention and control

b) Lack of knowledge

  • It is crucial to incorporate infection prevention during graduation training and post-graduation training period of all the personnel who will join health care and related field.
  • The patients and relatives need to be trained in their language regarding acquiring and transmission of infection. Personal hygiene of patients and relatives in the hospital many a times is a challenge. Some myths are carried by Indian patients like not to bathe if one has fever. Hand wash by relatives and patient is infrequent too.
  • There needs to be a continuous training program on infection control for in service health care personnel which has been found to be useful across the globe.
  • Patient education program for certain critical group of patients e.g. patients undergoing dialysis or chemotherapy for cancer are required.
  • These are simple measures and do not require huge funds. They require willingness.
  • Few NGOs or patient groups are working towards infection control. A strong liaison between community and hospital for infection control is yet to be formed.

c) Lack of hygiene practices

  • Hospital acquired infections (or nosocomial infection) is an outcome of lack of hand hygiene practices.
  • This problem varies from various types of health care sectors. The implementation is patchy in our country.
  • There are some areas where practices are much better than the other especially in metro cities. The better practices are mostly due to awareness rather than availability.
  • The reasons are of different types which unfortunately include all: unavailability, unawareness, unwillingness or indifferent attitude.
  • Involvement of administration and doctors is essential. The program gets implemented in much better way when it is a multidisciplinary team managing the show.
  • However, there is a golden line on the dark cloud. We are definitely moving ahead and changing for betterment

d) Infection control is expensive

  • We need to agree that nothing is more expensive than the life. And we need to understand that infection is expensive not prevention of infection.
  • Cost of vaccine is not more than the cost of treatment of the disease.
  • WHO provides most costeffective guidelines which can be implemented in resource poor countries like ours.
  • Infection prevention and control needs to be considered as integral part of treatment since giving a new hospital acquired infection(HAI) to a patient is costlier. It requires more expensive therapy, high end antibiotics and can lead to longer stay in hospital and can lead to death of the patient who could have been treated for the primary disease.
  • Consider a patient has come for a simple surgery like hernia and breach in surgical infection prevention practice leading to intra-abdominal infection for which another surgery may be needed, and long-term therapy may be needed. The cost cannot be less than using sterile material and using aseptic precautions.
  • Hospital acquired Infections (HAI) contribute to antibiotic resistance in significant proportion. We need to remember that as far as antibiotics are concerned India is in a very grim situation.
  • Awareness, training, behavioural changes and willingness are most important stepping stone for infection control and definitely do not require huge resources.
Yash Sama
In the last quarter of 2017, Clean India Journal interacted with some of the Government hospitals and small healthcare centres. Speaking to infection control nurses, microbiologists and infection control in-charges on the challenges faced by them in following rules, understanding and implementing processes came to fore. Clean India Journal discussed the challenges with Dr Dhruv Mamtora, MBBS, MD, DHA, Consultant Microbiologist and Infection control officer, S. L. Raheja, A Fortis associate, Hospital, Mumbai and Dr Sweta Shah, Consultant, Microbiology & Infection Prevention, Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute. Here’s a sneak peek into their views…

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