Author Archives: Brett Mitchell @1healthau

About Brett Mitchell @1healthau

Brett Mitchell @1healthau

Infection, prevention & control and Aboriginal and Torres Strait Islander People.

The Snake, the Staff and the Rainbow Serpent : A Call to ‘Fill the Gap’ in research relating to infection, prevention and control and Aboriginal and Torres Strait Islander People.

(Written by Victoria Gregory)1

 

Aboriginal and Torres Strait Islander people are the oldest surviving culture in the world, yet they will live approximately 10 years less than other Australians. Some contributing factors include indigenous people are at higher risk for emerging infectious diseases compared to other populations (Butler et al 2001). Examples of infectious diseases include respiratory tract infections, infections with antimicrobial-resistant organisms, and bacteremia and meningitis caused by Streptococcus pneumoniae, zoonotic diseases, viral hepatitis, Helicobacter pylori and respiratory syncytial virus infections, diseases caused by Group A and B streptococcus, tuberculosis, Haemophilus influenzae type b, and Neisseria meningitides (Butler et al 2001).

Here are some specific examples:

  • According to data from ‘healthinfonet’ between 2009 and 2013 tuberculosis notifications were 11 times higher for Indigenous people than for Australian born non-Indigenous people.
  • In 2014-15, Aboriginal and Torres Strait Islander people were three times more likely that non-indigenous people to be admitted to hospital for influenza and pneumonia.
  • In 2014, there were 170 cases of invasive meningococcal disease notified in Australia with 21 cases (12%) identified as Aboriginal; an increase from 2013 where 13 cases (8.7%) were identified as Aboriginal and one identified as Torres Strait Islander (0.7%).
  • In 2015, hepatitis C notifications were five times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people and the rate of HIV diagnosis was just over twice as high for Aboriginal and Torres Strait Islander people than non-Indigenous people. Notification rates for gonorrhoea were also 10 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. For syphilis, notification rates were six times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. For chlamydia, notification rates were three times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people.
  • Skin infections are also common in Aboriginal and Torres strait Islander Communities (The Lowitja Institute).

These data paint a real and bleak picture, but there are many success stories, including:

  • An initiative by Australians for Native Title and Reconciliation group in 2007 which reported on successful Aboriginal and Torres Strait Islander health projects, such as:
    • ‘Tune into your health: Nunkawarrin Yunti Aboriginal Health Service’ where young people developed lyrics and songs about health issues affecting their community, a song called ‘It’s in your blood’ increased knowledge and awareness of Hepatitis C.
    • ‘Keeping safe with a snake: Marie Stropes International Australia’ an initiative raising awareness of sexual health.
    • ‘Mooditj: Sexual health and positive life skills’ an initiative by the Family Planning Association of Western Australia.
    • Healthworkforce Project and the Shalom Gamarada Ngiyani Yana Residential Scholarship program which has increased the numbers of Aboriginal and Torres Strait Islander students studying medicine and health at UNSW.
  • The implementation of the nationally funded Hib disease vaccination in 1993 which resulted in decrease of notifications of invasive Hib disease by more than 95%.
  • The painting above, ‘Healthcare in the Western Desert’ was created as part of an innovative project building mutual trust and respect involving Aboriginal artists from the Wankatjunka, Kakutja and Walpirri language groups and second year medical students from the University of Notre Dame during the students’ Remote Area Health Placement in the Kimberly. It highlights the 3 ‘snake and staff’ images representing the medical profession as well as symbols depicting women and children from the local communities and coloured squares representing the medical clinics and a number of circular jila (waterholes). The act of painting together transcended cultural differences and led to an evolution of knowledge and understanding for all participants.

Indigenous communities are at high risk for many infectious diseases, but there is limited research specifically relating to Indigenous health in relation to infection, prevention and control in Australia. Culturally appropriate research and ‘bottom-up’ prevention and control strategies, as well as long term commitment to their implementation is urgently required. It is our responsibility to mainstream Aboriginal and Torres Strait Islander equality in all the valuable work that we do in the infection, prevention and control sphere. This blog is a reminder of the alarming statistics around infections and a call to work on closing the gap in health outcomes in Australia.

This blog was written by Victoria Gregory.

References

  1. Australians for Native Title and Reconciliation. antar.org.au
  2. Closing the Gap Prime Minister’s Report 2017. Closing the gap.pmc.gov.au
  3. Australian Indigenous HealthInfonet.http://healthinfonet.ecu.edu.au/ Retrieved 29.11.17
  4.  Butler, J. C., Crengle, S., Cheek, J. E., Leach, A. J., Lennon, D., O’Brien, K. L., & Santosham, M. (2001). Emerging infectious diseases among indigenous peoples. Emerging infectious diseases, 7(3 Suppl), 554.
  5. The Lowitja Institute. http://www.crcah.org.au/search/site/infection
  6. The University of Notre Dame, Australia. http://www.nd.edu.au/news/media-releases/2017/077

 

 

 

The Cerberus of science – dealing with ethics committees

We asked a colleage, Hannah Rosebrock, to write a blog for us, thank you Hannah.

In Greek mythology, Cerberus guards the gate of the underworld to prevent the dead from leaving. In social and clinical science, this role is fulfilled by ethics committees who stand as guardian between researchers and Cerberusparticipants and prevent the latter to be exploited by the former for the sake of science. The role of the Cerberus is a necessary one – although not very flattering, Cerberus is depicted as a three-headed beast. In the context of ethics committees, its three heads are called bureaucracy, officialdom and inefficiency.

According to the National Health and Medical Research Council (NHMRC) there are more than 200 HRECs operating in organisations and institutions throughout Australia (find a list of human Research Ethics Committees registered with NHMRC here). Although all HRECs base their decisions on the same principles deprived from the same National Statement on Ethical Conduct in Human Research, every HREC has its own application procedures, forms and processes. Further, gaining approval from one ethics committee is no vouch for approval from another ethics committee.

This lack of standardisation specifically affects multi-site projects which led to the founding of the National Mutual Acceptance Scheme (NMA) in 2013. Under the NMA scheme, multi-site research projects do not have to gain ethics approval from every site the project is conducted at but only once, from a NMA certified HREC. As of August 2017 the scope of the NMA scheme covers all human research conducted at a public health organisation in Queensland, New South Wales, the Australian Capital Territory, Victoria, South Australia, and – the latest addition to the scheme – Western Australia. Note: Northern Territory, Tasmania, and private health organisations are not included in the NMA scheme. Still, you might be tempted to think, that the NMA scheme has de-bureaucratised the ethics application process, and to some extent, this is true. There is certainly less duplication (if you don’t count private health organisations, Northern Territory and Tasmania). However, researchers are still fighting with a lack of standardisation, as every state has multiple NMA certified HRECs[1] and application procedures vary between and within states. This multitude in ethics committees, applications processes and forms, seems unnecessarily confusing, given that they are all assessed and certified by the same body (the NHMRC) for their compliance with the same criteria based on the same National Statement of Responsible Conduct in Human Research.

Independent of the HREC approval, researchers have to seek approval from the relevant Research Governance office (RGO) for each site the project is conducted at. There is no such thing as a mutual acceptance scheme for research governance approval, every site has its own assessing criteria for determining the site’s suitability for conducting a given research project. This adds to the generally labour-some and tedious process of gaining ethics approval.  In terms, this uses resources, and most commonly tax payer funded resources. In one Australian study, the cost of obtaining ethics and relevant approvals was $348,000 or 38% of study budget.

Applications for HREC approval are often no less than 63 pages; applications for Research Governance approval encompass about 23 pages – exclusive the extensive supporting documentation required, which can be up to another 150+ pages. Applications to both, HREC and RGO’s vary, with some still requiring submission in hardcopy by snail-mail, (additionally to email, USB and online forms) and will only be assessed, once received in hardcopy. This method is unnecessarily prone to error. To simplify, you must take steps away, rather than adding additional steps. The entire process is so focussed on detail that researchers, as well as assessing HREC and RGO officials can’t see the wood for the trees anymore. So much information is requested that even low-risk research projects that involve none to minimal involvement with participants, and thus hardly justify the use of the term ‘participants’, seem to turn into a second Stanford prison experiment throughout the process.

 

[1] Queensland has 7 NMA certified HRECs, New South Wales has 11, Victoria has 7, South Australia has 5 and Western Australia has 3 (Australian Capital Territory has 1). Find a full list here.

#A Trawl for Trends

In the lead up to the ACIPC conference in Canberra next week, I thought it might be timely to write something about the use of Twitter at infection control conferences. Thanks to Gabby Milgate for assisting with this blog.

Some of you might know that last year, a group of us reviewed tweets from four infection control/ID conferences – UK Infection Prevention Society, ID Week2016, The Federation of Infectious Society/Hospital Infection Society and the Australasian College for Infection Prevention and Control. Read the article here . 

Twitter as a medium for infection control content has grown from 181 Tweets at IPS2011 to 11,457 tweets at IPS2016. This rapid growth seems to suggest the twitter epidemic is contagious! The analysis of tweets from these four conferences identified trends in conference-related twitter activity.

Here are some evidence-based trends to help your infection prevention tweeimagests fly!

  1. Tweets with web-links are more likely to be retweeted, all things considered
  2. Picture are out – these are less likely to be re-tweeted, all things considered
  3. Tweeting on topics such as ‘Cleaning’, “Media@, ‘Clostridium Difficile’, ‘Antiseptic’, ‘Infection prevention and control’ and ‘Hand hygiene’ are more often retweeted.

I’ll be talking more about this at the ACIPC conference next week – the abstract is here

Not only has Twitter been used to broaden conference exposure and encourage attendees to further engage with content but the Royal Society of Chemistry hosted an entire conference on Twitter. The conference had an audience of 380,000 online users, without a ‘face-to-face’ component.  The conference was both cost-effective and far-reaching.  Additionally, its virtual delivery eliminated risks of airborne or droplet transmission of infections!

Twitter may serve as a useful tool for infection control professionals and enthusiasts to broaden their networks, providing a platform for infection related discourse and a mode of communication for health promotion and education to the general public of social media users.

Perhaps a future trending topic: ‘Twitterer’s twiddling their thumbs on their devices practice excellent hand hygiene’.

TwitterFor those attending the Australasian College for Infection Prevention and Control or want to follow what is happening from a distance, follow #ACIPC17 – and of course the authors of this blog!

 

Network Analysis: A line (edge) between usernames, indicates a relationship – a tweet sent by one person that included the username the other.  (IPS = Infection Prevention Society)

Variation in hospital cleaning

Hospital cleanliness has a number of implications for patients and staff in addition to simply preventing the spread of infection. Aside from infection, for patients and their families, a tidy and sanitary ward greatly improves comfort and provides assurance of the quality of their treatment. For staff, a hygienic environment means a more appealing workplace.

Throw in numerous studies demostrating and articulating links between the environment and infection [1-5], it’s easy to see why effective cleaning is of utmost importance when it comes to maintaining safe and quality hospital care. In light of this, it is difficult to believe that we have no uniformity across Australian hospitals when it comes to cleaning practices, staff training, products used or even standards by which to evaluate whether a hospital environment is clean and safe.

Variation in hospital cleaning practice and process in Australian hospitals: a structured mapping exercise [6] is the first paper to identify the variations in cleaning practices present among Australian hospitals. It describes in detail a range of discrepancies found in cleaning processes used across the country, in a study of 11 private and public Capturehospitals.

This paper is the latest from The ‘Researching Effective Approaches to Cleaning in Hospitals’ (REACH). The REACH study uses a bundle of standardized interventions in an attempt to combat healthcare-associated infections, with a view of gathering evidence that could be used to inform better and more standardized cleaning methods in the future.

The variation in cleaning practice and processs highlighted in this paper, demonstrates  the need for nationally recognised standards in hospital cleaning and outlines the challenges associated with the current system – or lack thereof.

 

References

  1. Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J. Hosp. Infect. 2009;73:378-385
  2. Mitchell BG, Dancer SJ, Anderson M, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J. Hosp. Infect. 2015;91:211-217.
  3. Hayden, M. K., Bonten, M. J., Blom, D. W., Lyle, E. A., van de Vijver, D. A., & Weinstein, R. A. (2006). Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clinical Infectious Diseases, 42(11), 1552-1560.
  4. Donskey CJ. Does improving surface cleaning and disinfection reduce
    health care-associated infections? Am J Infect Control. 2013;41(5):S12–9.
    http://dx.doi.org/10.1016/j.ajic.2012.12.010.
  5. Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and
    disinfection in reducing the spread of Norovirus contamination via
    environmental surfaces. J Hosp Infect 2004; 58(1): 42–9. doi:10.1016/
    j.jhin.2004.04.021
  6. Mitchell, B. G., Farrington, A., Allen, M., Gardner, A., Hall, L., Barnett, A. G., . . . Graves, N. Variation in hospital cleaning practice and process in Australian hospitals: A structured mapping exercise. Infection, Disease & Health. doi:10.1016/j.idh.2017.08.001

 

 

 

The burden of HAIs in Australia

Today, we published an article in Infection, Disease and Health estimating the number of HAIs occuring in Australia each year. [1]

To do this, we undertook a systematic review of the peer reviewed literature between 2010 and 2016. We identified 24 articles that reported the incidence of HAIs in Australian hospitals.

Overall, data from these multi centred studies suggested 83,000 HAIs per year in Australia. UTIs are were the most common, followed by C.difficile, SSIs, respiratory infections and Staphylococcus aureus bacteraemia. HAI burden.png

Of course, these numbers are a very  large underestimate given the lack of or incomplete data on common infections. It is also limited to data published in the peer reviewed literature.

Incidence data on infections such as pneumonia, gastroenterological and bloodstream infections (other than SAB) were not identified, thus potentially
missing up to 50% of infections. That being the case, the

PPS blog incidence of HAIs in Australia may be closer to 165,000 per year.

Don’t believe me? Have a look at the results of point prevelance studies in Europe (right). Respiratory tract infections, bloodstream infections and others account for a large proportion of HAIs.  Of course, Australia has not had a PPS undertaken in 30 years, so we don’t really know. However, for readers of this blog, you will know that will soon change.

A figure of 200,000 HAIs per year in Australia is commonly cited, however, this figure was derived from one study undertaken several years ago (a sign of what was available at the time). Our study, may, in part, demonstrate the increasing number of publications on HAIs in Australia. We are certainly not suggesting a reduction in HAIs and any such claim based on the findings of our study should be immediately dismissed.

There are some other equally important findings from our study:

  • There needs to be a determination and action by state and national government bodies to achieve consensus on national HAI definitions
  • We need national approaches to HAI surveillance and transparent regular reporting. Australia is so far behind other countries in this regard [2] [3]
  • In the absence of action by government, we call on those undertaking HAI surveillance (especially incidence) to report your data in the peer reviewed literature

We also found there is little information about healthcare associated respiratory infections, such as pneumonia. Maybe it is in the too hard basket (nice blog by Martin Keirnan which says it all). Well, I think we should do something about healthcare associated pneumonia – at the very least, understand the incidence and risk factors a little better. I am working on it…..

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Footnote: Some of the research I have been involved with has been supported by donations from the public. For that, I am very grateful. Should you or your company wish to make a tax deductible donation, you can do so here.

References

  1. Mitchell, BG., Shaban, R., MacBeth, D., Wood, CJ., Russo, PL (2017). The burden of healthcare-associated infection in Australian hospitals: A systematic review of the literature. Infection Disease and Health. https://doi.org/10.1016/j.idh.2017.07.001
  2. Russo, P. L., Cheng, A. C., Richards, M., Graves, N., & Hall, L. (2015). Healthcare-associated infections in Australia: time for national surveillance. Australian Health Review, 39(1), 37-43.
  3. Russo PL, Cheng AC, Mitchell BM, & L, H. (2017). Healthcare associated infections in Australia – Tackling the “known unknowns”! Australian Health Review, (published online 7 March 2017), http://dx.doi.org/10.1071/AH16223

 

Australian HAI Point Prevalence Study is Coming

Followers of this blog will know how passionate Phil Russo and Brett Mitchell are about the need for national surveillance and a point prevalence study (PPS). Map Aus2We are very pleased to let you know that a HAI PPS is coming, by way of a research project.

For more information, please see www.ipcca.com.au/pps

 

 

Would you like some antibiotics?

This is part two of my blog from Cambodia. The first part is here What can $6m buy you

I have spend some time at Angkor Hospital for Children and have been amazed. Amazed at the challenges faced and amazed at the quality of infection control given the limited resources. The IC program consists of continous prospective surveillance of all HAIs, hand hygiene, feedback of infection data, environmental cleaning (twice a day), cleaning audits, training, good governance and the list goes on.  Hand hygiene compliance is above 80%, but not all moments have been introduced yet (1000+ moments a month observed). IMG_2308

The fact that a hospital here can undertake continous surveillance of all HAIs is quite amazing. They asked if I could benchmark them against some Australian hospitals/what the rates are in Australia. And there we ended back to where this blog always seems to – a lack of co-ordinated, meaningful HAI surveillance at the national level in Australia.  But enought of that, see Phil’s blog for the pub test.

Not all is of course perfect, but given the resources, I think it is quite extrordinary. Another difficultly (apart from ovecrowding, lack of resources, limited clean water etc etc) is a some local work suggesting 60+% of patients coming into the hospital are colonised with a MRGN, mainly resistant in some form. That got us talking a lot about strategies and future work, but I also have myself an challenge….

This test invovled me trotting up to a local pharmacy. It went like this “My wife has a cut on her arm, it is inflammed/red”. That is pretty much it. The response:

  • Pharmacy 1 – topical cream that consistent of gentamicin, erythromycin and clotrimazole, all combined in one convenient tube. I asked about oral amoxicillin and was told “antibiotics you swallow are only for infections on the inside, the don’t work anywere else”.
  • Pharmacy 2 – Ciprofloxacin was handed to me.

Dishartened, I changed my tack. I went to another pharmacy and said “My wife has a cough and fever”. They asked if it was a dry cough. I said no, productive sputum. I was handed paracetamol. Yeah! There is hope.

This blog, I hope, illustrates the challenges  in infection control (&AMR) in a resource deprived country. We need to support our colleagues in our region, in any way we can. OneHealth is a global issue.

(By the way, I did not purchase any of the antibiotics, so as not to contribute to the issue).