In a pandemic, hospital staffers need to get better at hand-washing

After visiting Ellis Island in 1906, President Theodore Roosevelt noted the lack of hand-washing by doctors and wrote the Public Health Service that he was “struck by the way doctors made the examinations with dirty hands,” turning the examinations themselves into “a fruitful source of carrying infection.”

Fast forward 114 years: Today’s hospitals aren’t doing much better at hand-washing. That’s a serious problem in ordinary times; during the Covid-19 national emergency it could become extraordinarily dangerous. One way the government can protect public safety is by immediately setting specific hand hygiene standards for doctors, nurses, and hospital staff.

There’s not even monitoring of a national compliance rate, although hand-washing remains “the most important intervention” to reduce the “staggering mortality” associated with hospital infections, according to an article in an infection control journal.

The most recent hand hygiene data — an 18-year-old study from the Centers for Disease Control and Prevention — is discouraging. It concluded that adherence “has remained low.”

How low is “low”? According to the CDC, health care providers in U.S. hospitals clean their hands less than half the time they should. In comparison, people using bathrooms in New York train stations washed their hands afterward 80% of the time.

The medical literature doesn’t show much systemic improvement in hand-washing since the CDC last looked at the issue or, for that matter, since the Public Health Service issued an educational video showing hospital staff how to wash their hands back in 1961!

Hospitals with hand hygiene compliance in the 50% to 60% range include the kind of large, urban medical centers designated by the CDC as “first tier” treatment centers during the 2014-16 Ebola outbreak. After reviewing hundreds of inspection reports, ProPublica recently reported that “infection control has been a recurring problem at some of the very hospitals that would likely be called upon to treat Covid-19 patients.”

Better hand-washing won’t solve all infection control issues, of course, but it would significantly improve safety. The first step to achieving it is valid measurement.

A new standard from the Leapfrog Group, a nonprofit focused on improving patient safety where one of us (L.B.) works, encourages hospitals to measure hand hygiene using electronic monitoring of clinician compliance. This kind of technology is commonplace in retail and other industries.
Related:
‘We didn’t follow through’: He wrote the Ebola ‘lessons learned’ report for Obama. Now he weighs in on coronavirus response

Hospitals traditionally measure hand hygiene by having someone spot violations and report them, a technique with questionable reliability. Monitoring hand hygiene in a way that yields accurate data is vital. The Leapfrog standard is evidence-based; the government should adopt it.

The next step, getting to universal compliance with hand hygiene best practices, is even more crucial.

Based on what hospitals have already shown they can achieve, the secretary of Health and Human Services should call on all hospitals to meet an 85% hand hygiene goal within 90 days. While President Trump’s well-known use of hand sanitizer even before the Covid-19 crisis should make this an easy step for the administration to take, its obvious importance should also draw support from both parties in Congress.

Meanwhile, the Centers for Medicare and Medicaid Services should start the process of issuing formal regulations that would include an aggressive time frame for 100% hand hygiene compliance by any health care facility receiving Medicare payments — which is virtually all of them.

It took 98 years from the time President Roosevelt pointed out the hand-washing problem at Ellis Island until U.S. hospitals were required to institute a hand hygiene program that followed the CDC’s recommendations. If a deadly pandemic doesn’t justify urgently demanding accountability for making patients safer by the simple act of clinicians washing their hands, it’s hard to imagine what will.

Leah Binder is CEO of the Leapfrog Group. Michael L. Millenson is a patient safety activist, researcher, consultant, and author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age” (University of Chicago Press).

 

 

By Leah Binder and Michael L. Millenson

Published March 25, 2020
https://www.statnews.com


Hand hygiene a key defence in Europe’s fight against antibiotic resistance

Antimicrobial resistance (AMR), and resistance to antibiotics in particular, continues to grow in the WHO European Region and hundreds of thousands of patients die or are considerably affected each year by health care-associated infections (HAI) and diseases caused by germs that are resistant to antimicrobial medicines.

This year’s SAVE LIVES: Clean Your Hands campaign on 5 May uses the slogan “Fight antibiotic resistance – it’s in your hands” to highlight the fact that health-care workers and the public have a responsibility to prevent and control AMR and HAI, in turn helping to prevent related complications and deaths.

It is estimated that 7–10% of patients will acquire at least one HAI at any given time under treatment. A large percentage of these are preventable by improving hand hygiene practices and other infection prevention and control measures.

Taking action from many sides

HAI, including those resistant to antibiotics, are among the most common adverse events in health care delivery. Such infections can impact quality of life and lead to serious disease or even death. Action across all sectors of society is required to effectively prevent AMR. The following key recommendations will help prevent the spread of AMR and protect people in the Region from HAI:

• Health workers must clean their hands at the right times (see below).
• Chief executive officers and managers of health facilities need to support hand hygiene campaigning and infection prevention and control (IPC) programmes.
• IPC leaders should champion hand hygiene campaigns and comply with WHO’s “core components” for IPC.
• Policy-makers should stop the spread of AMR by demonstrating national support for and commitment to infection prevention programmes.

Cleaning hands at the right times

Protecting patients against HAI can be achieved by improving hand hygiene at five key moments, preferably by using an alcohol-based rub or by hand washing with soap and water if hands are visibly dirty. The “five moments” for hand hygiene comprise:

• before patient contact
• before preparing and administering injections
• after contact with body fluids
• after patient contact
• after touching patient surroundings.

Reinforcing the importance of hand hygiene through policy-making

Making infection prevention and hand hygiene a national policy priority by aligning and strengthening existing programmes will go far in combating AMR and protecting patients from resistant infections.

National authorities should implement or reinvigorate any or all of the following options according to the new WHO recommendations on core components for IPC programmes:

• establish a national IPC programme linked with other relevant national programmes and professional organizations;
• ensure that any national IPC programme supports the education and training of the health workforce as one of its core functions;
• establish an HAI surveillance programme and networks that include mechanisms for timely data feedback;
• consider hand hygiene as a key national performance indicator providing vital feedback data on health-care practices;
• have a system in place to ensure patient care activities are undertaken in a clean and/or hygienic, well-equipped environment to prevent and control HAI.

 

Building momentum in the fight against antibiotic resistance

This year’s campaign builds important momentum ahead of World Antibiotic Awareness Week (WAAW), which takes place on 13–19 November 2017. WAAW encourages all countries, health partners and the public to help raise awareness of AMR and to emphasize that we all have a part to play in preserving the effectiveness of antimicrobial medicines.

 

By WHO Europe
Publihed May 4th 2017
http://www.euro.who.int


Folkehelseinstituttet har oppdaget et nasjonalt utbrudd av mage-tarmbakterien Shigella sonnei

På julaften informerer Folkehelseinstituttet at bakterien så langt har blitt påvist hos åtte personer, og at de nå etterforsker utbruddet sammen med aktuelle kommuneleger og Mattilsynet.

De skriver videre i en pressemelding at bakterien Shigella Sonei ble funnet i alle åtte prøver, hvorav fem personer ble testet i Oslo. Folkehelseinstituttet tror at importerte sukkererter fra Kenya var den sannsynlige smittekilden.- Vi anbefaler at sukkererter som importeres fra eksotiske strøk varmebehandles før servering for å redusere risiko for smitte, sier overlege Didrik Vestrheim ved Folkehelseinstituttet.

Fra ung til gammel

Bakterien har ikke rammet en spesifikk aldersgruppen, men de åtte personene som har blitt smittet er fra alderen 29 til 63 år.

– Vi følger situasjonen nøye. Det er så langt ikke meldt om personer med alvorlig sykdom tilknyttet utbruddet, sier Vestrheim videre.

Sukkerertene som knyttes til utbruddet i Oslo ble distribuert til flere deler av landet. Utbruddsetterforskningen viser at også tre personer i Akershus og Hedmark har vært syke med samme bakterie, skriver Mattilsynet.

«Sugersnaps»

Sukkerertene fra Kenya var merket «Sugersnaps» eller «Sukkererter», 150 gram, pakket av Springfresh og distribuert i Norge av Bernhard Botolfsen Import AS. Det antas at det mistenkte partiet nå er borte fra markedet grunnet holdbarhet.

– Om forbrukere fortsatt skulle ha produktet, bør det kastes, heter det i pressemeldingen.

Kan bli langvarig og alvorlig

Konsekvensene av å bli smittet av bakterien er absolutt ikke hyggelige. Folkehelseinstituttet fastslår at de vanligste symptomene er diaré, hodepine, magesmerter, kvalme og eventuelt feber. De nevner videre at diareen kan vare lenge og bli alvorlig. Det er også en mulighet for å bli dehydrert, skriver FHI.

For å unngå smitte er god håndhygiene etter toalettbesøk viktig, men også før matlaging og måltider. FHI skriver avslutningsvis at hvis du har diaré, skal du ikke lage mat til andre.


Epidemiology and impact of norovirus outbreaks in Norwegian healthcare institutions, 2005–2018

Outbreaks in healthcare settings affect vulnerable populations, disrupt normal routines and may spread to other healthcare institutions (HCIs). Outbreaks can be limited in extent by good routines for detection, management of cases and other infection-control measures [1]. Norovirus infection is most often seen in the winter months and is a common cause of outbreaks in HCIs [2] as it has a low infectious dose, short incubation period, and symptoms such as diarrhoea and vomiting which facilitate spread. Symptoms normally lasts around one to three days, but can be longer in hospital patients [3]; and in this type of setting, infection can lead to slower recovery from other illness and even death [4]. Norovirus can be divided into several genogroups and genotypes [5]. Genogroup II genotype 4 is the most prevalent genotype globally [6] as well as in the Nordic countries [6]. There is no vaccine and immunity is not well understood; at best it is strain-specific but probably only partial and shortlived as the virus readily undergoes mutation [7, 8]. Humans are the only reservoir of the virus and spread of the infection in outbreaks is particularly difficult to control because of the low infectious dose, its stability in the environment and efficient transmission by person-to-person contact and exposure through contaminated surfaces [9]. Norway has national recommendations on norovirus infection in long-term-care facilities (LTCFs) in which the most important measure is isolation or cohort nursing of sick residents. Exclusion of sick staff until 48 h after they are symptom free is also recommended [10]. In a hospital setting, the infection-prevention-control unit will have local procedures. There are around 60 hospitals and 950 LTCFs in Norway [11]. The responsibility for management of local outbreaks lies within the hospital or with the community medical officer (one in each of the 422 municipalities) for outbreaks in LTCFs. All suspected outbreaks in Norwegian HCIs, regardless of the causative pathogen, should be alerted by law to relevant actors, including the Norwegian Insititute of Public Health (NIPH), to facilitate communication and response [12, 13]. The aim of this study was to describe, for the first time, the epidemiology and impact of these outbreaks in order to identify areas which may improve outbreak response.

This study shows that norovirus outbreaks pose an important burden for HCIs all over Norway, especially in the winter months. In addition to affecting an already vulnerable population, this study shows that these outbreaks indeed also impact on the internal workflow and resources, with a conservative estimate of around 1800 days of absenteeism per year due to these outbreaks, during which staff would have to be covered for by other internal or external healthcare staff.

Surveillance of norovirus outbreaks exists in Germany and Scotland. In Germany, reporting of norovirus outbreaks in HCIs has been mandatory since 2001. In contrast to what is seen in Norway, outbreaks were smaller (median nine cases vs 15 in this study) and around 80% of norovirus outbreaks were reported from hospitals (vs 23% in this study) during the first 12 months after introduction of the system [15]. Varying ways of counting interdepartmental outbreaks, better collaboration with the local level or under-reporting from hospitals may explain this. In Scotland, surveillance of ward closures due to norovirus infection has been in place since October 2017. From then until week 26, 2018, 219 wards or bays have been closed due to confirmed or suspected norovirus [16]. This is markedly more than the 16 reported outbreaks in hospitals in Norway 2017/18, in a population of similar size. The occurrence of norovirus outbreaks has also been studied prospectively; Curran et al. [17] aimed to identify the index cases of norovirus outbreaks in the UK and Ireland in 54 acute and non-acute healthcare centres; only five out of the 54 included centres did not experience any outbreak during one winter. Also, Lopman et al. found that 171 inpatients units, had on average 1.3 gastroenteritis outbreaks in the 1-year follow-up period. Of these, 63%were caused by norovirus [2].

It was seen that a small proportion of residents at LTCFs were admitted to hospital during norovirus outbreaks. This may be necessary in severe cases despite the risk of spread from one institution to the next. Our results suggest that hospitals are affected by norovirus outbreaks earlier in the epidemiological year than LTCFs. Potentially because there is a greater influx of patients from the community, where norovirus circulates, to and from hospital than between the community and LTCFs as also suggested by Sadique et al. [18]. This finding, however, could only be evaluated on the national level, as the number of reported outbreaks is low. That the start of the outbreak season seemed to start earlier in hospitals than in LTCFs, at least at the national level, suggests an opportunity that with improved communication, hospitals could alert LTCFs within the same area in order to prepare for the outbreak season and limit the extent of further outbreaks.

Slightly more cases were seen amongst healthcare staff in hospitals compared to LTCFs, though no information about the number of healthcare staff at risk during the outbreaks is available. The patient or resident:healthcare-staff ratio varies with the level of care needed and type of department and will most often be higher in hospitals. Whether this explains the slightly higher proportion of staff affected in hospital outbreaks is unknown. Nevertheless, healthcare staff do represent a big proportion of cases in the reported outbreaks, indicating a need for improved compliance with infection prevention and control measures. Outbreaks are an economic burden for HCIs, both as infected staff need to be covered for during illness and ‘quarantine’ and cohort nursing may require extra staff.

The relatively high number of people infected during an outbreak underscores the infectiousness of norovirus and norovirus can serve as a worst-case scenario for introduction of other, more virulent, person-to-person transmitted pathogens into HCIs. With the current information captured in the alert system, it was not possible to assess the extent to which national recommendations were followed and/or which infection prevention control procedures are in place locally. But the high number of people infected do suggest a potential for limiting spread, for example by having systems and routines in place before outbreaks happen, as advised in the national recommendations.

Even though NIPH routinely promotes the web-based outbreak alert system and teaches outbreak management, both at the regional and national level, in order to strengthen local capacity and encourage the use of the alert system, under-reporting is still apparent. If the under-reporting of outbreaks reflects a lack of awareness concerning outbreak management, or a lack of communication between the LTCF and the municipal doctors about ongoing outbreaks, it is worrying. The alert system serves to alert relevant stakeholders so that outbreak support and advice can be given in an early phase. The alert system can also be used for statistical purposes to get a national overview of outbreaks which will facilitate targeted capacity building, guideline development and communication messages in order to increase awareness and investigate whether there are any changes in trends.

Limitations
This study has three main limitations: the sensitivity of the norovirus outbreak definition and under-reporting of number of outbreaks and number of cases in each outbreak. Classification as a norovirus outbreak is dependent on local definitions. The infection prevention measures for diarrhoea and vomiting are the same for all the common pathogens in this setting. Samples were submitted for testing in two thirds of the outbreaks and most were confirmed as norovirus at the time of reporting or updating. Information about the genotypes of the isolated strains from each outbreak or of dominant strain of the season was not available. For this reason, it was not possible to evaluate the effect of the genotype.

Concerning under-reporting, the number of outbreaks notified through the outbreak alert system and reported here, most likely represent only a proportion of all norovirus outbreaks occurring in Norwegian HCIs. Although outbreaks were reported from all parts of Norway, some areas had not reported any outbreaks of any kind during the 13-year study-period.

The alert system is used for the mandatory alerting of suspected outbreaks. Reporting should happen as soon as the outbreak is suspected and before the full extent of the outbreak is known. Even though the system sends a reminder to update the details about the outbreak, including the case numbers, three weeks after the initial alert, some under-reporting of the extent of each outbreak is expected.

This is the first comprehensive description of norovirus outbreaks in HCIs in Norway. Even though the analyses revealed under-reporting that is unlikely to reflect the real epidemiology, this study clearly shows that these outbreaks affect both hospital and LTCFs all over Norway. Norovirus infection may delay medically important procedures and recovery, but also presents a major challenge to the functional ability of an HCI and its resources as up to one-half of cases were healthcare personnel.

It is recommended that NIPH promotes the outbreak alert system to increase reporting and improve the quality of the data and strengthen local capacity for outbreak management and general infection control. It is also recommended to investigate possibilities for improving communication between hospitals and LTCFs regarding when the norovirus season starts and progresses, for hospitals and LTCFs to be prepared and to take early action to prevent and limit further spread.

Read full article: https://www.journalofhospitalinfection.com/article/S0195-6701(19)30268-3/fulltext?dgcid=raven_jbs_etoc_email

© 2019 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society.


Enterococcus hirae, Enterococcus faecium and Enterococcus faecalis show different sensitivities to typical biocidal agents used for disinfection

– Ethanol and other alcohols such as iso-propanol or n-propanol are typically used for hand disinfection or surface disinfection. An ethanol concentration of 40% will not be found in alcohol-based hand rubs because the bactericidal efficacy will be too low to fulfill European efficacy standards such as EN 1500. Even hand rubs based on 60% or 70% often fail to meet the EN 1500 efficacy requirements although the alcohols are effective against E. faecium and E. faecalis [11, 14, 15, 16]. In that respect it is of concern that the use of E. hirae may yield a sufficient efficacy against enterococci although E. faecium and E. faecalis are less susceptible.

Nosocomial infections or hospital-acquired infections (HAIs) are a major patient safety issue in hospitals.

The most frequent nosocomial infections are pneumonia (usually ventilator-associated), urinary tract infection (usually catheter-associated) and primary bloodstream infection (usually associated with the use of an intravascular device) [1]. Virtually every pathogen has the potential to cause infection in patients but only a limited number of bacterial species is responsible for the majority of HAIs. Among them Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and enterococci are the most common [2]. Enterococci account for about 10% of hospital-acquired bacteremia cases and are a major cause of sepsis worldwide [3]. HAIs caused by enterococci are difficult to treat due to acquired resistance to many classes of antibiotics [4]. Considering the severity of the consequences of nosocomial infections, such as morbidity, mortality, prolonged stay, costs, and treatment problems, it is all the more important that preventive measures in hospitals and other health facilities are fully effective [5]. Targeted disinfection, with species that are considered to be the most resistant representatives of a whole range of human pathogenic microorganisms and, due to their role in nosocomial infections, also include enterococci. As part of the standardization efforts to determine the efficacy of disinfectants at European level, the enterococcal strain Enterococcus (E.) faecium, formerly used for chemical and chemo-thermal disinfection processes, was replaced by E. hirae. E. faecium is currently only used for testing thermal disinfection processes, such as for instance for testing laundry disinfection processes at temperatures above 60 °C [6]. The differences in heat tolerance between the enterococcal species is already well described resulting in the use of E.hirae for testing chemical disinfectants and E. faecium for chemo-thermal and thermal processes [7, 8]. Pidot et al. have shown in 2018 that some multidrug-resistant E. faecium isolates isolated recently are more tolerant to 23% iso-propanol than older isolates suggesting an adaptive cellular response [9]. Overall, the chemical susceptibility of two common clinical species (E. faecalis and E. faecium) and the commonly used test species (E. hirae) has not yet been sufficiently investigated [10, 11, 12]. The aim of this study was therefore to find out whether E. hirae is a suitable species to evaluate the efficacy of biocidal agents against the clinically relevant species E. faecalis and E. faecium. Therefore, we determined the in vitro bactericidal efficacy of five substances from commonly used groups of biocidal agents (aldehydes, alcohols, surfactants, oxidizing agents and halogens) on E. hirae, E. faecium and E. faecalis according to the European Norm EN 13727 [13].effective procedures and correctly performed, is one of the most important measures to interrupt the transmission of pathogens in hospitals. In Europe, the microbicidal effectivity of any disinfection procedure must be evaluated and confirmed in accordance with national or international standards and norms in vitro and under practical conditions before it can be used in hospitals [6]. These efficacy tests are performed with defined test

Our data show that the testing of disinfectants based upon a culture collection E. hirae strain alone may not represent the sensitivity of other collection Enterococcus spp. with more clinical relevance. At a 5 min exposure time the current EN 13727 test species E. hirae was found to be more tolerant to 0.2% glutaraldehyde and 0.0125% peracetic acid compared to E. faecium and E. faecalis whereas it was more susceptible to 40% ethanol and 3% sodium hypochlorite. Only with 0.00125% benzalkoniumchloride (15 min) the susceptibility of E. hirae was between E. faecium and E. faecalis. Based on these data E. hirae is a suitable species when bactericidal activity needs to be determined against enterococci with the biocidal agents glutaraldehyde and peracetic acid. It may, however, not be a suitable species for ethanol at 40% or sodium hypochlorite at 3% if the bactericidal activity shall include the clinical pathogens E. faecium and E. faecalis.

Ethanol and other alcohols such as iso-propanol or n-propanol are typically used for hand disinfection or surface disinfection. An ethanol concentration of 40% will not be found in alcohol-based hand rubs because the bactericidal efficacy will be too low to fulfill European efficacy standards such as EN 1500. Even hand rubs based on 60% or 70% often fail to meet the EN 1500 efficacy requirements although the alcohols are effective against E. faecium and E. faecalis [11, 14, 15, 16]. In that respect it is of concern that the use of E. hirae may yield a sufficient efficacy against enterococci although E. faecium and E. faecalis are less susceptible.

The situation is different in surface disinfection. Many low alcohol products are available for immediate use in the patient environment, often as presoaked tissues [17]. Low alcohol concentration has the advantage of a better compatibility with plastic surfaces which are now commonly found in healthcare such as mobile phones or tablet computers [18]. Based on our data obtained with suspension tests it seems to be possible that low alcohol surface disinfectants which are effective against E. hirae do not provide the same level of bacterial killing against E. faecium or E. faecalis. In 2014 a dramatic increase of infections caused by vancomycin-resistant enterococci has been described [19]. The reasons for the increase are still unknown. But it is known that Enterococcus spp. can survive on inanimate surfaces between 4 days and 4 months [20]. It is therefore important to ensure a sufficient bactericidal efficacy of alcohol-based surface disinfectant against Enterococcus spp. However even with higher concentrations of alcohol it is essential to apply a sufficient volume. Approximately 10% of the solution is released during wiping when a soaked tissue is used [16, 21]. It has been shown previously that the application of a low volume of an effective alcohol results in failure to meet the efficacy requirements [16].

Sodium hypochlorite at 3% was also more effective in 5 min against E. hirae and less effective against E. faecalis and E. faecium. It is a biocidal agent commonly used in many countries for surface disinfection [22]. Our findings with E. faecalis appear plausible because sodium hypochlorite at 2.5% has been described to achieve at least 5 log10 against ATCC 35550 (10 min) and ATCC 29212 (20 min) [23, 24]. The very low effect of 3% sodium hypochlorite even in 15 min against E. faecium is of concern and should be followed up with more research on the possible implications for its use in healthcare.

In this study we have only used culture collection strains from each of the three Enterococcus spp. in order to compare the susceptibility of potential test strains for disinfectant efficacy testing. We have not used any Enterococcus spp. clinical isolates. That is why we cannot evaluate whether the different biocidal agents would reveal a similar bactericidal activity against clinical isolates of each of the three Enterococcus species.

Another limitation of our study is that all experiments were carried out using a low organic load described as clean conditions. That is why we are unable to describe if similar or other results would be obtained under dirty conditions. Clean conditions were chosen because they reflect the majority of applications of these agents. Alcohol-based hand rubs are applied to clean hands, ethanol is a typical biocidal agent used for hand disinfection. Instrument disinfectant should be used on cleaned instruments, glutaraldehyde, benzalkonium chloride and peracetic acid are typical agents used for instrument disinfection. Surface disinfection is often performed without prior cleaning, benzalkonium chloride and sodium hypochlorite are typical agents used for surface disinfection. With sodium hypochlorite it has been described before that the bactericidal efficacy will be impaired in the presence of organic load [25].

E. hirae is a suitable species when a bactericidal activity should be determined against enterococci with glutaraldehyde and peracetic acid. E. hirae may not be a suitable species for ethanol at 40% or sodium hypochlorite at 3% if the bactericidal activity shall include the clinical pathogens E. faecium and E. faecalis.

By Miranda Suchomel, Anita Lenhardt, Günter Kampf, Andrea Grisold

https://www.journalofhospitalinfection.com
https://www.journalofhospitalinfection.com/article/S0195-6701(19)30345-7/fulltext

For references: https://www.journalofhospitalinfection.com/article/S0195-6701(19)30345-7/references