The 17th International Congress on Infectious Diseases workshop on developing infection prevention and control resources for low- and middle-income countries

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Article

Reference

The 17th International Congress on Infectious Diseases workshop on developing infection prevention and control resources for low- and

middle-income countries

SASTRY, Sangeeta, et al .

Abstract

Hospital-acquired infections (HAIs) are a major concern to healthcare systems around the world. They are associated with significant morbidity and mortality, in addition to increased hospitalization costs. Recent outbreaks, including those caused by the Middle East respiratory syndrome coronavirus and Ebola virus, 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 approaches and guidelines have been in existence for many years and have often proven effective in some countries, the implementation of such approaches in low- and middle-income countries (LMICs) is often restricted due to limited resources and underdeveloped infrastructure. While evidence-based infection prevention and control (IPC) principles and practices are universal, studies are needed to evaluate simplified approaches that can be better adapted to LMIC needs, in order to guide IPC in practice. A group of experts from around the world attended a workshop held at the 17th International Congress on Infectious Diseases in [...]

SASTRY, Sangeeta, et al . The 17th International Congress on Infectious Diseases workshop on developing infection prevention and control resources for low- and middle-income countries.

International Journal of Infectious Diseases , 2017, vol. 57, p. 138-143

DOI : 10.1016/j.ijid.2017.01.040 PMID : 28216179

Available at:

http://archive-ouverte.unige.ch/unige:99379

Disclaimer: layout of this document may differ from the published version.

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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

cImperialCollegeLondon,London,UK

dAlfaisalUniversityandKingSaudUniversity,Riyadh,SaudiArabia

eInternationalSocietyforInfectiousDiseases,Brookline,Massachusetts,USA

fInfectionControlProgrammeandWHOCollaboratingCentreonPatientSafety,UniversityHospitalofGeneva,Geneva,Switzerland

gElsevier,London,UK

hPatientSafetyUnit,MinistryofHealth,Kenya

iBPKoiralaInstituteofHealthSciences,Dharan,Nepal

jTheUniversityoftheWestIndies,Mona,Kingston,Jamaica

kDiagnosticMicrobiologyDevelopmentProgramme,Cambodia

lZagazigUniversity,Zagazig,Egypt

mUniversidadCentraldeVenezuela,Caracas,Venezuela

nUniversityofChile,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.

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:[email protected](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

j o u r n a lh o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i d

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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-daysandtherateofcatheter- 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),andguide- 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 EducationandPublicationsCommitteeandtheResearchCommit- 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 formofformalclassroomteachingfollowedbypracticalapplica- 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,trainingofhealth- 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,posterpresenta- tionatthe17thInternationalCongressonInfectiousDiseasesin 2016).ThiswasattributedtothelackoftechnicalexpertiseinIPCat alllevels,poorﬁnancingforIPCtoensureacontinuoussupplyof commodities,andinadequatephysicalinfrastructure.Thelackof surveillancedatamakesitdifﬁculttomeasuretheburdenofHAIs in order toadvocatefor more investmentin IPC. However,the establishment of AMRunitsin the MoHand East AfricaPublic

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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 signiﬁcantreductionin HAIs(Figure1).SurveillanceofHAIsandAMRissupportedbya robust laboratory service. The MoH has established an AMR ministerialadvisorycommitteeandIPCisanintegralpartofthis vitalprogramme.Eachhealthcareinstitution,includingcommu- 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

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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, especially 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 norspeciﬁc national 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

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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 effectivenessofthesegradedmeasuresinagivenworkenviron- 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 HospitalservesasafreeresourceforIPCprogrammerecommen- dationsandimprovingprogrammeimplementationefforts.Future editionsofthisguidemaybeappliedasanevidence-based,multi- modal,point-of-caremobileresourcetoassistintheprioritization

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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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