Perspective
The
17th
International
Congress
on
Infectious
Diseases
workshop
on
developing
infection
prevention
and
control
resources
for
low-
and
middle-income
countries
Sangeeta
Sastry
a,*
,
Nadia
Masroor
a,
Gonzalo
Bearman
a,
Rana
Hajjeh
b,
Alison
Holmes
c,
Ziad
Memish
d,
Britta
Lassmann
e,
Didier
Pittet
f,
Fiona
Macnab
g,
Rachel
Kamau
h,
Evelyn
Wesangula
h,
Paras
Pokharel
i,
Paul
Brown
j,
Frances
Daily
k,
Fatma
Amer
l,
Jaime
Torres
m,
Miguel
O
’Ryan
n,
Revathi
Gunturu
o,
Andre
Bulabula
p,
Shaheen
Mehtar
p aVirginiaCommonwealthUniversity,Richmond,Virginia,USA
bDivisionofBacterialDiseases,USCentersforDiseaseControlandPrevention,Atlanta,Georgia,USA c
ImperialCollegeLondon,London,UK
d
AlfaisalUniversityandKingSaudUniversity,Riyadh,SaudiArabia
e
InternationalSocietyforInfectiousDiseases,Brookline,Massachusetts,USA
f
InfectionControlProgrammeandWHOCollaboratingCentreonPatientSafety,UniversityHospitalofGeneva,Geneva,Switzerland
g
Elsevier,London,UK
hPatientSafetyUnit,MinistryofHealth,Kenya iBPKoiralaInstituteofHealthSciences,Dharan,Nepal j
TheUniversityoftheWestIndies,Mona,Kingston,Jamaica
k
DiagnosticMicrobiologyDevelopmentProgramme,Cambodia
l
ZagazigUniversity,Zagazig,Egypt
m
UniversidadCentraldeVenezuela,Caracas,Venezuela
n
UniversityofChile,Chile
oTheAgaKhanUniversityHospital,Nairobi,Kenya
pUnitforIPC,FacultyofMedicineandHealthSciences,StellenboschUniversity,CapeTown,SouthAfrica
ARTICLE INFO Articlehistory:
Received8November2016
Receivedinrevisedform30January2017 Accepted31January2017
Corresponding Editor: Eskild Petersen, Aarhus,Denmark
Keywords: Infectionprevention Infectioncontrol International
Low-andmiddle-incomecountries Workshop
SUMMARY
Hospital-acquiredinfections(HAIs)areamajorconcerntohealthcaresystemsaroundtheworld.Theyare
associatedwithsignificantmorbidityandmortality,inadditiontoincreasedhospitalizationcosts.Recent
outbreaks,includingthosecausedbytheMiddleEastrespiratorysyndromecoronavirusandEbolavirus,
have highlighted the importance of infection control. Moreover,HAIs, especially those caused by
multidrug-resistant Gram-negative rods, have become a top global priority. Although adequate
approachesandguidelineshavebeeninexistenceformanyyearsandhaveoftenproveneffectiveinsome
countries,theimplementationofsuchapproachesinlow-andmiddle-incomecountries(LMICs)isoften
restrictedduetolimitedresourcesandunderdevelopedinfrastructure.Whileevidence-basedinfection
prevention andcontrol(IPC)principlesand practicesareuniversal,studiesare neededtoevaluate
simplifiedapproachesthatcanbebetteradaptedtoLMICneeds,inordertoguideIPCinpractice.Agroup
ofexpertsfromaroundtheworldattendedaworkshop heldatthe17thInternationalCongresson
InfectiousDiseasesinHyderabad,IndiainMarch2016,todiscusstheexistingIPCpracticesinLMICs,and
howbestthesecanbeimprovedwithinthelocalcontext.
©2017TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.
ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(
http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Hospital-acquiredinfections(HAIs)areamajorconcernacross all healthcare systems,1 contributing significantly to patient
morbidity and mortality, particularly in developing countries.2
According to a multistate prevalence survey of
healthcare-*Correspondingauthor.
E-mailaddress:Sangeeta.Sastry@vcuhealth.org(S.Sastry).
http://dx.doi.org/10.1016/j.ijid.2017.01.040
1201-9712/©2017TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
ContentslistsavailableatScienceDirect
International
Journal
of
Infectious
Diseases
associated infections conducted by the US Centers for Disease ControlandPrevention(CDC)in2011,anestimated722000HAIs occurredinacutecarehospitalsintheUSA,with75000of the patientsdyingduringtheirhospitalization.3
AmongHAIs,device-associatedinfectionsposethegreatestthreat topatientsafety,particularlyintheintensivecareunit(ICU),4with
higher rates observed in low- and middle-income countries (LMICs), as reportedby theInternational Nosocomial Infection ControlConsortium(INICC)36in2016.Thepooledrateofcentral
line-associated bloodstream infection (CLABSI)37 in medical
– surgicalICUsofLMICswhencomparedtoequivalentICUsinthe USA was found to be 4.1 vs. 0.8 per 1000 central line-days. Furthermore,therateofventilator-associatedpneumonia(VAP)37 was13.1vs.0.9per1000 ventilator-daysandtherateof catheter-associatedurinarytractinfection(CAUTI)37was 5.07 vs.1.7per
1000 catheter-days,withsimilardeviceuseintheLMICsandthe USA(high incomecountry).Thisincrease inHAIshasledtoan increase in hospital length of stay, the emergence of bacterial resistance,andincreasedexpenditureofhealthcaredollarsaround theworld.5
In responsetotheurgent needfor infectionpreventionand control(IPC),asexemplifiedbytherecentEbolaoutbreakinWest Africa,theWorldHealthOrganization(WHO)establishedaglobal IPCunitin2016,whichincorporatescoreelementsofIPCstructure, measurestocombatantimicrobialresistance(AMR),and guide-linesonthemanagementofcommonHAIssuchassurgicalsite infections(SSIs)andcatheter-associatedbloodstreaminfections; thislinksupwiththeWHOWater,SanitationandHygiene(WASH) programme and withoutbreak control.A decontaminationand sterilizationmanualhasalsobeenpublishedrecently,alongwitha downloadableapp.6
In LMICs, IPC programmes targeting HAIs are frequently underdeveloped and sometimesnon-existent.7 Themajor
chal-lengesfacedarenotonlyduetolimitedfinancialresources,but alsopoorlyplacedandimplementedsystems,suchasthoseforthe purchase and distribution of supplies, management of health technology, cleaning/sanitation, and management of clinical waste.8 In addition,mostLMICsdonot haverobustnationalor
structuredlocal support touphold IPC programmes. Given the scarcity of resources, infrastructure and low compliance by healthcare workers, the implementation of adequate infection controlactivitiesincludingtheprotection ofhealthcareworkers andvisitorsremainsasignificantchallenge.
Toaddresstheseissues,agroupofinfectiousdiseasesexperts fromaroundtheworld,withrepresentationfromhigh-,middle-, andlow-incomecountries,attendedaworkshopheldatthe17th InternationalCongressonInfectiousDiseasesinHyderabad,India inMarch2016,toassessthegapsinIPCprogrammesinLMICs,such astrainingandeducationrequirements,andtoidentifyapproaches that could be better adapted to the needs of the individual countries,inordertoguideIPCinpractice.Thisarticledescribes thehighlightsofthatdiscussion.
Theworkshop
Theworkshopstartedwithanintroductionoutliningtheneed for applied research and the development of practical IPC guidelinesappropriate tothelocal contextbythechairs of the EducationandPublicationsCommitteeandtheResearch Commit-tee of the International Society for Infectious Diseases (ISID). ParticipantsintheLMICworkshopincludedrepresentativesfrom select countries and regions: South Africa (represented by the InfectionControlAfricaNetwork–ICAN),theDemocraticRepublic oftheCongo,Kenya,Chile,Venezuela,Jamaica,India,Nepal,Egypt,
and Cambodia. IPC gaps and needs were discussed at length. Internationalguidelineswereuniversallyappliedasthebasisfor IPC programmes in their respective institutions. Several pro-grammesfocusontheeducationofhospitalpersonnel,particularly nursesandtrainees,asapivotalpartoftheirIPCpractices,inthe formofformalclassroomteachingfollowedbypractical applica-tioninthespecificclinicalsetting.
Several African countries such as Kenya, South Africa, Zimbabwe,Namibia,SierraLeone,Liberia,and Egypt,tonamea few, have national IPC programmes in place as part of their ministriesofhealth,touniformlyguidehealthcareinstitutionsin their respective countries. These national programmes are responsibleforissuingnationalIPCguidelines,trainingof health-care personnel, and monitoring and evaluation. However, pub-lisheddatafromanumberofLMICsdescribingoutcomesasaresult ofthesenationalprogrammesarescarce.AlthoughappropriateIPC measures have been adapted in various institutions, the focus groupagreed thatit was fundamentallythe implementationof such programmes that posed a major challenge in achieving favourableresults,meetingIPCgoalsandensuringpatientsafety. In view of the recent outbreaks of Middle East respiratory syndrome coronavirus and Ebola virus, as well as HAIs and AMR, the lack of IPC implementation has been a subject of discussionandconcernatvariousrecentinternationalmeetings andisnowgettingtheglobalattentionitdeserves.
InfectioncontrolandpreventionresourcesandgapsinLMICs The variousIPC resourcesandgaps, asdiscussed duringthe workshop, are outlined below. Table 1 presents key points discussedduringtheworkshop.
Kenya
In2013,KenyaformallyestablishedanationalIPCprogramme withintheMinistryofHealth(MoH).Thisprogrammereliesmostly onexternalfundingforbudgetsupport.CoordinationoftheIPC programmeis donebya multidisciplinarynationalIPCadvisory committee,which isreplicatedatthecountylevel.Kenya hasa nationalIPCstrategicplanfor2014–2018andreviseditsnational IPCpolicyandguidelinesin2015.Tofacilitatetheimplementation oftheguidelinesandbridgetheknowledgegapinIPC,theMoH developeda6-dayface-to-facetrainingcourseonIPCforfront-line healthcare workers (nurses, clinicians, pharmacists, laboratory technicians,and microbiologists).CDCKenyahassupportedthe establishmentofIPCworkincollaborationwiththeUSCDC,which hasassistedinstandardizationoftheproject.
The implementation of IPC measures in Kenya has been compromisedbychangesingovernanceandthedecentralization of health services.Surveillancedata areavailable fromsentinel sites,butareverylimitedfromhospitalsacrossthecountrydueto inadequatelaboratorycapacityfordiagnosticsandunder-utilized health information systems. TheNationalPatient Safety Survey 2013 revealed a general lack of IPC knowledge and practices among healthcare personnel (An Assessment of Patient Safety StandardsinKenya—SummaryReportofthePatientSafetySurvey 2013,WorldBank;BridgingtheKnowledgeGaps,poster presenta-tionatthe17thInternationalCongressonInfectiousDiseasesin 2016).ThiswasattributedtothelackoftechnicalexpertiseinIPCat alllevels,poorfinancingforIPCtoensureacontinuoussupplyof commodities,andinadequatephysicalinfrastructure.Thelackof surveillancedatamakesitdifficulttomeasuretheburdenofHAIs in order toadvocatefor more investmentin IPC. However,the establishment of AMRunitsin the MoHand East AfricaPublic
HealthLaboratoryNetworkrepresentsapromisingdevelopment towardsimprovingIPCeffortsinthenearfutureinKenya. SouthAfrica
ArobustnationalIPCprogrammehasexistedinSouthAfrica sincearoundtheyear2000.NationalguidelinesonIPCstructure, standard and transmission-based precautions, and outbreak control have been implemented graduallysince 2007. Prior to thattherewereindividualprovincialprogrammes.Guidelinesfor thepreventionofSSI,CLABSI,CAUTI, andVAP, amongst others, havebeenintroducednationally,witha significant reductionin HAIs(Figure1).SurveillanceofHAIsandAMRissupportedbya robust laboratory service. The MoH has established an AMR ministerialadvisorycommitteeandIPCisanintegralpartofthis vitalprogramme.Eachhealthcareinstitution,including commu-nity-basedfacilities,hasanamedIPCpractitioner.AbasiclevelIPC course(6months)isofferedtoallhealthcareworkers,managers, andnon-clinicalstaff.Morethan89%ofpractitionershavebeen formally trained at the basic level. A diploma (1year) or
postgraduate diploma in IPC (PDIC) (2 years part-time) is also offered.Todate,93IPCpractitionershavecompletedthePDIC.In 2015,thefirst two Mastersin IPC graduatedfromStellenbosch University,SouthAfrica.ThemajordrawbackforIPCinSouthAfrica is that it is not currently recognized as an independent subspecialty in the country, increasing the urgent need for structuredcareerpaths.
Inresponsetotravellerandpilgrimneeds,afreeIPCappfor healthcareworkersandthepublichasbeendevelopedbyICANin collaborationwiththeEasternMediterraneanRegionalOfficeof the World Health Organization (WHO-EMRO). Another app to supplementthedecontaminationmanualforhealthcarefacilities (WHO2016)hasalsobeendevelopedandisavailableinGoogleand Applestores.38
Chile
AnationalprogrammedirectedbytheMoHhasbeeninplacein Chilesince19829;thisprogrammewasrevisedin1993and2011.
OthercountriesinLatinAmericahavesimilarprogrammes.The
Figure1.OverallbundlecompliancesincetheintroductionofthebundleforthepreventionofsurgicalsiteinfectionsrelatedtoC-sectionsurgeryatTygerbergHospital,Cape Town,SouthAfricainMarch2015.Bundleelementsincludeappropriateantibioticprophylaxis,surgicalsiteskinpreparationandnoshavingoftheoperativesite.Casesof severesepsisrelatedtoC-sectionsurgeryper1,000surgeriesperformeddecreasedby47%betweenthetwotimeperiodsMarch2015-August2015andMarch2016-August 2016.DataandanalysisprovidedbyMarinaAucamp,ClinicalProgrammeCoordinatorattheUnitforInfectionPreventionandControlatTygerbergHospital.
Table1
InfectionPreventionandControlinLowandMiddleIncomeCountries.
Topic KeyPoints
IPCCurrentStatusandResources countriesvaryregardingtypeofIPCprogramatnationallevel
TherobustnessofeachprogramvariesbetweenLMICs.HAIsurveillanceexistedinsomeparticipating LMICs,butfewatnationallevel
SeveralcountriesincludingSouthAfricaandKenyahavecreatedantimicrobialstewardshipprograms tomonitorresistance
IPCCurrentGaps IPCprogramshavesignificantfinancialexpenses
WhilenationalIPCguidelinesexist,implementationcontinuestobeastruggle ThereisinconsistentIPCpracticeandsurveillancethroughouteachLMIC
ManyhealthcarefacilitieslackproperandconsistentmethodsofcommunicationforIPCefforts DevelopmentandEnhancementofIPCTrainingMaterials TrainingMaterialsshould
befreeofcharge
beeasilyaccessible(e.g.mobileapp)
ISIDGuidetoInfectionPreventionintheHospital 5theditionofguidehasover7,500downloadsfrommorethan170 countries ContentgenerallyorientedtoNorthAmericanandEuropeanaudience ISIDGuidetoInfectionPreventionintheHospitalEnhancement
forGlobalAudience
PictorialrepresentationsofIPCpractices Translateguideintoregionallanguages Maximizeaccessandportability
Chilean Programmeis mandatory for all hospitals,in both the publicandprivatehealthcaresystems.Theaimoftheprogramme istoreducenosocomialinfectionratesbyformulatingstrategies based on the latest information from local, national, and internationalresources.TheMoHalsoperiodicallypostsupdates onsurveillanceofinfectionsassociatedwithmedicalcare,which assistsincreatingappropriateevaluationprogrammes(http://web. minsal.cl/sites/default/ files/files2/Informe_Vigilancia_Epidemiolo-gica_IAAS_2013.pdf).
DespitetherobustIPCprogrammeinChile,thereisroomfor improvement. Outbreak investigationsare typically slow, espe-cially if they require the collection and analysis of specimens, leadingtodelaysintheimplementationofappropriatemeasures. The communication between institutions is also not optimal, resultingindelayedrecognitionofcommonsourceoutbreaks,a situationthatcouldbeimprovedthroughtheshareduseofonline reportsanddatabases.Theobligatorynotificationofnosocomial outbreaks and MoH alerts has been implemented, but this is suboptimal.Mostimportantly,nationalpoliciesonantimicrobial stewardshipareyettobeaddressed.
Venezuela
The IPC policies in Venezuela are based on the National CommissionofHospital-AcquiredInfectionscreatedbytheMoHin 1984.Epidemiologicalinformationisgeneratedfromsomeofthe largerpublicandprivatemedicalinstitutions.Allmedicalcentres withmorethan50 bedsin thecountryarerequiredtohavean infectioncontrolcommitteepresidedoverbythemedicaldirector of the institution. Formal specialized training courses for IPC personnelareofferedattheteachinghospitalsbutarenotformally endorsedbyacademicinstitutionssuchasuniversitiesornursing schools.
However,neither general norspecificnational guidelines to standardizeIPC practices areavailable. Actions fromthehealth authorities to ensurethe application of good IPC practices are usually only reactive to specific epidemiological situations or outbreaks. The sterilization and decontamination of reusable medicalinstrumentsisnotproperlyregulated.Also,theconceptof IPCisnotincludedintheregularcurriculaofmedicalornursing schools,thereforereducingIPC exposureand knowledgeduring theformativestagesoftrainees.
JamaicaandtheCaribbean
The IPC resources in Jamaica and the Caribbean are both government- and hospital-based. There is a good surveillance systemfor bacterial,viral,andfungal pathogensinthehospital environment,including confirmation ofmajor epidemic viruses suchas theinfluenzaH1N1virus, chikungunyavirus, and most recently the Zika virus. There are local epidemiological inves-tigationsandreportingviatheMoHinmanyCaribbeancountries, withsharedresourcesforcountriesthatlackdiagnosticfacilities. Morebroadly,thereisregionalepidemiologicalreportingfromthe CaribbeanPublicHealthAgency(CARPHA)andthePan-American HealthOrganization(PAHO),whichprovidesmonthlyandyearly updates.10WeeklybulletinsorupdatesareissuedinJamaica.Most Caribbeanhospitals have IPC teams,which aremore robust in teaching hospitals. In Jamaica, while traditional media is the mainstayforthedisseminationofinformationaboutHAIs,social media has become important for public discourse. This was highlightedin the 2015outbreak of bacterialinfections among neonates(#deadbabyscandal).
Gaps in IPC resources are multifactorial and multilayered, includingbutnotlimitedto(1)oldfacilities/infrastructure(some
buildingsover50yearsold),whichmightcompromiseeventhe best IPCefforts;(2) insufficientfunding(from governments)to manageIPCeffectively;(3)trainingissuesfordifferentIPCteam members; (4) union issues for different categories of staff (academicconsultantsvs.nursesvs.techniciansvs.servicestaff); and (5) lackofinformation aboutresources.Theremayalsobe complianceissuesrelatedtocultural,financial,andenvironmental factors.39InmanagingIPCissues,thereistherecognitionthatone
size may not fit all, although most of the IPC strategies are modelledafterNorthAmericanandBritishstandards.
Nepal
Nepal has an IPC reference manual that serves more as a resourcefortrainingpurposesthanfortheactualdevelopmentof IPCprogrammes.11TherearesomeIPC-specificmaterialsavailable
forbothHIVandwastemanagementinthecountry12;however,
comprehensivenationalguidelinesonIPC,reflectingperformance indicators,donotcurrentlyexist.Asaresult,overtwo-thirdsofthe healthcare workersin Nepalaredeficient inspecifictraining in IPC.13 The health sciences curriculum lacks an integrated IPC
curriculum,withrestrictedoptionsforprofessionaldevelopment. DataonAMRsurveillance,HAIs,andthefunctioningofhospitalIPC committeesarelimited.Epidemiologicaldatafromprivateclinics andsmallhospitalsarealsonotavailable.Unfortunately,private healthcare settingsinNepalconsiderstandard infectioncontrol practicesasafinancialinvestmentwithnoimmediateprofitand hencearenotmadeapriority.
Egypt
Egyptestablishedanationalinfectioncontrolprogrammein 1999.45EvolutionofinfectioncontrolinEgypt:Achievementsand
challenges), which has developed national guidelines that are revisedandupdatedregularly.Theseguidelinesareoftenadapted to meet specific requirements at university-affiliated and large healthcarefacilities.
TheMinistryofHealthandPopulation,theMinistryofHigher Education, the Ministry of Scientific Research, national and international organizations, as well as civil societies in Egypt sponsor IPC implementation. IPC master degree programs are offeredbyseveralFacultiesofMedicineinEgypt.Thecountryis alsointheprocessofestablishinganationalsurveillancesystem for HAIs but is still in need of a country wide antimicrobial stewardship program. Egypt’s progress in implementing IPC measures has been internationally acknowledged.41 The main
challengeinEgyptistonarrowthegapbetweenwhatisknownand available and what is actually implemented. Changing the behaviourofhealthcareworkerswouldbeofbenefitinimproving and sustaining adherence to infection control guidelines, with specialimportancegiventothedirectorsoftheIPCprogrammeto maximizeutilizationoftheresourcesattheirdisposalandobtain thebestpossibleresults.
Cambodia
Since 2009, Cambodia has had policies, strategic plans,42 guidelines, and regulations in place for IPC, healthcare waste management,43andcombatingAMR.44Atrainingcurriculumfor
allhealthcarestaffwasdeveloped in2012and acurriculum for undergraduate students is currently under development. Cambodia has developed anIPC structure atthe national level forallpublichospitalsundertheresponsibilityoftheMoH.Despite theseefforts,thereremainsalackoftrainedIPCprofessionalsatall levels,aswellasinfrastructureinhealthcarefacilitiestoallowan enabling environment forgood practices.The consumablesand
suppliesrequiredtoensurean effectiveIPC programmeremain suboptimal.Datacollectedfromthefewmicrobiologylaboratories ingovernmenthospitalsarenotcurrentlybeinganalyzedorused by IPC committees for programme development. Also, IPC activitiesthroughoutthecountryremaininadequatelyfunded. DemocraticRepublicoftheCongo
IntheDemocraticRepublicoftheCongo,therearenonational programmesorguidelinestohelp direct IPCpractices. Insome tertiary care hospitals, the microbiologists and/or infectious diseasesphysiciansguideIPCpracticesbasedonrecommendations fromtheWHOand/orCDC.However,theMoHoftheDemocratic Republicof theCongo,throughitsGeneralSecretariatofPublic Health,providesdisease-specificprogrammes(forexamplethat fortuberculosis)withsomeguidanceonthenecessaryIPC-related precautionstoensurepatientsafety.Throughmedicaltrainingand nursing schools, healthcare professionals acquire very basic knowledgeonIPC-relatedtopics.AswithmostotherLMICs,the implementation of these insufficient measures is almost non-existent;forexample,compliancewithhandwashingwasaslow as9%in2004beforeasensitizationcampaignwasconductedata generalhospitalintheDemocraticRepublicoftheCongo.40
GuidanceforIPCresourcesfromtheworkshop
To facilitate the implementation of IPC efforts in LMICs, educational materials should be made easily accessible and availableforfreeinWeb-basedandmobileformats.Thecontent needstobesimplifiedtoreachadiverseworkforceandwillneedto include graded recommendations, based on different levels of existingresources.Asgradedresourcesaredeveloped,priorities forappliedresearchandinnovativeapproachesforIPCmeasures applicablein countries withlimited resourceswill need tobe defined.
TheISIDguideforinfectioncontrolinthehospital
ThescienceofIPCisinconstantevolution.TheISIDpublished itsfirstguide–AGuidetoInfectionControlintheHospital–in1998 tosummarizethemostup-to-dateprinciples,interventions,and strategies for maximizing a reduction in healthcare-associated infectionsinhospitals.14Thisguideisapopular,freeresourcefor
healthcareworkersaroundtheworldandisupdatedevery4years. Thefiftheditionwasmadeavailableinprintandinpdfformaton May 15, 2015, and there had been more than 7500 unique downloadsfrom170countriesbyMay9,2016.
Theworkinggroupmadecertainrecommendationsforthenext editionofthisguide.First,theguidemustbewidelypublicizedvia variousnetworks. The guide should include increasedpictorial representationtomake iteasy tofollow,thecontentshouldbe simplifiedtoincludegradedrecommendationsbasedondifferent levels of existing resources such as basic, standard, and high, should include assessments and checklists as examples to standardize the evaluation of practices, and finally the guide should be translated into regional languages for non-English speaking countries. The ISID will take the working group’s recommendationsintoconsiderationwhen developing thenext editionoftheguideforinfectioncontrol.
Discussion
Most IPC strategies are modelled afterNorth American and Europeanstandards.Unfortunately,manyLMICshavelittletono representation in the current IPC English-language literature.
Accordingtothediscussionsamongtheexpertsattheworkshop, mostLMICshavedevelopedsomesortofnationalIPCstrategyfor theirhealthcarefacilities,howevermanyLMICslacktheproper resourcestoproperlyimplementsuchplans.Kenya,Cambodia,and SouthAfrica,forexample,havedevelopednationallyrecognized andcontinuouslygrowingIPC programmes,which includeboth HAI surveillance and antimicrobial stewardship. Similarly, the national Chilean IPC programme is mandatory for all hospitals including both public and private healthcare facilities. Egypt, Venezuela,andJamaicahavealsodevelopednationallyrecognized IPCprogrammes.It shouldbenotedthat mostIPC programmes havebeencreatedbyandarecurrentlysupportedbythecountry’s MoH.
Incontrast,two ofthecountriesrepresentedattheworking group–theDemocraticRepublicoftheCongoandNepal–both lack robustIPC programmes. In Nepal for instance,there is no nationalprogrammeforIPCpracticeinhealthcarefacilities.Thus, healthcareproviders andmicrobiologistshaveresortedtoWHO and CDC guidelines for best IPC practices. Although these referencesmaybeuseful,IPCpracticemaynotbeconsistenton anationalscale.In Nepal,anIPCreferencemanualexistsbutis usedfortrainingpurposesandnotfornationalregulations.Thus, IPCpracticesmaydifferthroughoutthecountry.
AlloftherepresentativesfromLMICsindicatedthattherewasa lackofinfrastructureandadministrativesupport,representingan important barrier to IPC programmes. In addition, proper implementationand regulationofIPC programmescontinuesto beachallenge.InKenya,whichhasaratherrobustIPCprogramme, inadequate laboratorycapacity fordiagnostics and underdevel-opedmedicalrecordssystemsimpedeconsistentIPCsurveillance anddatageneration.IPCisnationallyrecognizedinSouthAfrica, yetstructuredIPCcareeropportunitiesarenon-existent. Repre-sentativesfrombothChileandVenezuelanotedthelackoftimely andconsistentcommunicationbetweenhealthcarefacilitieswith regardstoIPCmatters.InNepal,IPCprogrammesareexpensive anddonotprovideimmediatefinancialbenefitsandthusarenot consideredapriorityinhealthcarefacilities.Lastly,inCambodia, Jamaica, and the Democratic Republic of the Congo, financial support continues to be a limiting factor for IPC programme implementation.
Therecentliteraturesuggestsvariousstrategiestoassistinthe preventionofHAIs,includingtheimplementationofbundlesand other infection control measures. The INICC is a non-profit organization established in 15 developing countries to reduce infection rates in resource-limited hospitals by focusing on education and feedback from outcome surveillance (infection rates) and process surveillance (adherence to infection control measures). This consortium has described a multidimensional approachtoinfectionpreventionthathasresultedinasignificant reductioninHAIswhenimplementedinvariousLMICs,bothinthe adultpopulationandthepaediatricpopulation.[15–21
ToimproveIPCimplementationandevaluationeffortsinLMICs, educationalresourcesshouldbesimplified,readilyavailable,free of charge, and possibly include graded recommendations from basicthroughintermediatetoadvancedlevelsofIPCprovisionand resource.Ideally,theremustbepracticesinplacetoevaluatethe effectivenessofthesegradedmeasuresinagivenwork environ-ment.Suchevaluation,aswellasinnovativemeasuresforIPCthat canmoreeasilybeappliedintheLMICsetting,couldbesupported by the ISID research grant programme (http://www.isid.org/ grants/grants_research.shtml) or other initiatives that support capacitybuildinginLMICs.TheISIDGuidetoInfectionControlinthe HospitalservesasafreeresourceforIPCprogramme recommen-dationsandimprovingprogrammeimplementationefforts.Future editionsofthisguidemaybeappliedasanevidence-based, multi-modal,point-of-caremobileresourcetoassistintheprioritization
and implementation of local infection prevention strategies. Another important resource is the INICC multidimensional infectioncontrolapproach.
Theadequateimplementationofinfectioncontrolmeasuresin the healthcare setting is more important now than ever. This articleillustratesthecurrentstatusofIPCprogrammesinselected countries,includingthemaingapsandchallenges.Itisimportant tohaveasystematicprocesstoevaluatetheIPCstatusinLMICs overall, and to ensure that basic IPC and AMR strategies are implemented.Opentrainingresourcesandguidelinesneedtobe easilyaccessible.StudiesfromLMICsareurgentlyneededtobetter describethelocalepidemiologyofHAIsandtoidentifysuccessful approachesbettersuitedtotheneedsofthesecountries. Conflictofinterest/funding
None.
Acknowledgements
WethankMarinaAucampwhoprovidedthedataandanalysis forFigure1.
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