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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

 

 

 

Some take aways from #ACIPC17 Conference, Canberra

Congratulations to the organisers of ACIPC Conference 2017 Parliament_House_Canberra_Dusk_Panoramain Canberra. Well done to the Conference Committee and the Scientific Committee. A great program and venue adding to the always enjoyable catch up with colleagues local, national and international.

There were many highlights. Due to other commitments, I missed a few of the major plenaries. Nevertheless, I came away with some clear take home messages from those I did get to, here are just a few of them…

  1. An emerging theme from the presentations was that of public reporting and financial penalties (PR&FP) associated with healthcare associated infections (HAIs). The likelihood that Australia needs to accept that these are inevitable for a range of HAIs is clear. In case you missed it, Benjamin Magid presented an excellent talk touching on the Australian Commission for Safety and Quality in Health Care use of what are called Hospital Acquired Complications, that use administrative coding data to detect healthcare associated infections, and which I have blogged about previously.
    One of the many advantages of living and working in Australia and hosting keynotes from the US is that they often provide a window to the future. At various stages, Prof Pat Stone, A/Prof Dev Anderson and Dr Susan Huang all related stories about their experience of PR&FP. From their experience it would seem, at some point in time, the implementation of PR&FPs does eventually turn into a positive for infection prevention (and hence our patients). From what we hear, PR&FPs seem to result in a recognition of infection prevention that subsequently provide opportunities to increase resources. Thats not to say there was no pain during the “journey”, and we should be prepared for that. Although Dev Anderson did argue against the notion of PR&FPs in the final debate, he was quick to tweet afterwards that in fact he does support it! Finally on this point, we should continue to explore better use of existing data if validated, strive to minimise the burden of data collection, and consider whether current HAI definitions are suitable for the PR&FP environment.
  2. The quality of the free papers gets better every year. The addition of the quick poster presentations and the new format of the 3 minute research presentations was a celebration of the excellent research being undertaken in our field. Updates on current studies (e.g. the large and complex REACH project) further added to our awareness of exciting work being undertaken by our colleagues. The next few years will see many of these projects yield new knowledge and fill sessions of conferences to come!
  3. The consumer voice is powerful. The presentation delivered by Mathew Ames left many in the auditorium not only in tears, but also resolute about the work we undertake.
  4. Finally for now, I believe the pop up sessions during lunch were a big winner. Informal yet intimate, a great way to get close to those people who are always hard to find at conferences. A great initiative hopefully here to stay..

But thats just some of my impressions from the sessions I saw. You might have seen something completely different. If so, comment below and let us know…

Looking forward to Brisbane in 2018.

TIP: Next year, if you have trouble remembering the correct Twitter hashtag, think  character count efficiency...save the character count by dropping the “20” from “2018”

#ACIPC18

 

Phil
Disclosure – ACIPC Board member (President Elect) and member of the ACIPC Conference Scientific Committee 2017

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

 

 

 

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).

 

 

 

 

 

What can $6m buy you?

The ability to run a children’s hospital for a year of course.Image result for angkor childrens hospital

I am in Siem Reap (Cambodia) at present and spending some time at Angkor Children’s Hospital. The hospital run entirely on donations and is the only children’s hospital in Cambodia. All services provided free. I won’t bore you with some stats, but here are some impressive figures considering the budget:

  • 27,000 ED patients a year
  • 132,000 outpatient visits
  • 880 intensive care admissions a year
  • Average cost of an ER visit $7, ICU $820 a stay.

Cambodia is a very poor country with a neonatal mortality of 18 per 1000 live births. 32% of children under 5 are stunted, 24% are underweight. Just $500 will is enough to provide weekly lectures to nurses for year; $5000 enough to buy medication for all ICU patients for 6 weeks.Image result for angkor childrens hospital

The most common hospital diagnosis are respiratory infections, asthma, gastro and sepsis. Over the next few days, I am meeting the Cambodia Oxford Medical Research Unit team, spending some time looking at infection control issues and challenges and similarly with nursing education and development. On infection control, the issues are significant, Gram negative resistance is a real problem (more on that to come in another blog).

If you want to know more about Angkor Children’s hospital, try this Angkor Hospital Video

More to come on infection control successes and challenges.

Brett

(Note: Pictures were not taken by me, rather publicly available)

 

#ACIPC16 Melbourne (part II)

screen-shot-2016-12-12-at-20-47-20In case you weren’t aware, many of the slides presented at #ACIPC16 are now available for viewing on the conference website

A/Prof Deb Friedman (@friedmanndeb) from Barwon Health had the unenviable task of presenting the Top Infection Control papers of 2016. Always a tough ask depending on your interests…however Deb covered pretty much everything including:

  • —Hand hygiene
  • IC activities
  • Contact Precautions/ Infection transmission/ CPE screening
  • Decontamination/ M. chimaera
  • —HCW vaccination
  • —Acinetobacter, RSV spread by air
  • —Norovirus spread
  • —Antimicrobial stewardship
  • —Chlorhexidine bathing/ FMT for MDROs
  • —Ebola virus/ PPE doffing
  • —Zika virus inactivation

It was all presented within time and with a story line! Clearly I cant mention them all, so here’s a couple. Pelat et al (1) demonstrated through the use of modelling that improving HH compliance from 55% before patient contact and 60% after patient contact to 80% before and after patient contact, would reduce the proportion of patients who acquire ESBLs within 90 days by 91%, they also found that antibiotic restriction had the lowest impact. Testament to the quality of local research, another top pair quoted was Mitchell et al (2) that identified from a survey of 40 infection prevention units: 36% of IP time was spent doing surveillance: 56% collecting data, 27% collecting data on compliance with IC activities, 17% feedback of HAI data. Casanova et al (3) demonstrated contamination post doffing recommending effective hand  hygiene afterwards.

Professor Gill Harvey from the University of Adelaide presented a keynote talk on Moving from Evidence to Practice, highlighting that good research is not enough to guarantee its uptake in practice. To improve the chance of interventions being implemented we need to get better at understanding what is being implemented, who is involved in the intervention, the culture and characteristics of the environment it is to be implemeted, and how the intervention effects everybody.

Finally, I really enjoyed the session on Communication. Presentations from Dr Becky Freeman (@DrBFreeman) from The University of Sydney, on Social Media and Public Health  who added to Maslow Hierarchy of Needs with “WiFi” holding up the pyramid! Becky posed the question, how many screens do we have in the house? (in a household of 5 adults I just counted 12 and thats not including TV’s). Mr Paul McNamara (@meta4RN) from Cairns presented on all the delights of using Twitter for professional purposes, Ms Claire Hewitt (@ClaireyHewitt) from St.Vincents Private Melbourne presented on the benefits of blogging, with a reminder that blogging allows you to control your own message, and demonstrated the excellent blog at St.Vincents, even the CEO blogs! This excellent session finished with Mr Anthony Carr from NPS presenting Communication in Practice  demonstrating the many ways NPS uses media to communicate.

Thanks to all those mentioned above, enjoyed your work.

Phil

Declaration – I am a Director of ACIPC and a member of the ACIPC Conference Scientific Committee.

  1. Pelat C et al Infect Control Hosp Epidemiol 2016;37(3):272-80.
  2. Mitchell et al, Infection,Disease and Health 2016;21(1):36-40
  3. Casanova LM, Infect Control Hosp Epidemiol. 2016 Oct;37(10):1156-61

 

 

#ACIPC16 Melbourne

screen-shot-2016-11-29-at-20-21-11Congratulations to all associated with the organising of the #ACIPC16 conference.

Once again we were privileged to hear from excellent international and local speakers. Without doubt, the quality of the free papers and posters at this annual conference continues to escalate, and I was impressed by all of those I was able to get to.

This brief blog is by no means a comprehensive round up of the conference, there were many sessions I just couldn’t get to. I believe a good blog is a quick blog, so for now I wanted to mention just a couple I attended, with more to come in future posts.

Congratulations to Oyebola Fasugba (Australian Catholic Univesity) who presented on behalf of Jane Koerner and was the recipient of the Elaine Graham Robertson award this year. Oyebola is an emerging infection prevention researcher and we look forward to her output in years to come. Her presentation on the systematic review undertaken on the effectiveness of antiseptic cleaning before and during catheter insertion for prevention of CAUTI will prove to be a resource for us all moving forward.

Holly Seale (@hollyseale) from the University of New South Wales presented on patient empowerment in preventing HAIs. For me, this is an emerging and welcome issue we need to embrace (including involving consumers in research, which Heather Loveday addressed on the final day of the conference, see below). Holly’s research found that although the majority of patients indicated they wanted to be involved in activities like reminding HCWs to wash their hands, when it came to the crunch, very few actually did. Holly emphasised that the authority of HCWs is very strong and patients remain uncomfortable in these situations. This doesn’t surprise me much, as I, and probably many of you, have lived that very experience. Sometimes I wonder if this is more reflective of the Australian (or inherited British) culture that we live in? I suspect the same study repeated in the USA would yield difference results. Good work Holly et al, important points.

I will finish this blog with Heather Loveday‘s (@loveebhc) talk as mentioned above, involving the public in research. This is not about consumers being subject to research, but involving them in everything from design, method, analysis and dissemination of findings. Some of the key messages to come from Heathers talk is that public involvement in research adds value to the findings of the research, particularly when identifying what is important to them. It is also essential the public be involved in disseminating the findings of the research. Peer reviewed journals usually aren’t the best way to provide information to the public, more relevant forums need to be used to get key message out to the public. Magazines did I hear?

As mentioned, this is not intended to be a comprehensive review or a best of. Just a comment on a few that I was fortunate to get to. More to come…

Again, congratulations to all involved in the conference. We look forward to #ACIPC17 in Canberra next year!

NB: adding to Bretts earlier blog on the debate, it was great to see a large number of delegates in attendance. The last session of any conference always presents a challenge to maintain delegates interest. It was clear from the presenters view that those in attendance were keen to discuss the next initiative, as noted by the many questions. And thanks to Mary Dixon-Woods (@MaryDixonWoods) for her excellent insight and Martin Kiernan (@emrsa) for the twitter summary. For the record, despite the outcome of the voting, we need all three initiatives ASAP!

 

Phil

Declaration – I am a Director of ACIPC and a member of the ACIPC Conference Scientific Committee.