Rajiv Nath, Joint MD, Hindustan Syringes & Medical Devices and Trustee Safepoint India, talks about how right strategies can prevent the spread of bugs in healthcare facilities
Antimicrobial Resistance (AMR) control in most countries like India is just being understood and limited to antibiotics resistance stemming from unrestricted access to antibiotics, and it has not being realised that all encompassing holistic infection prevention control strategies are required to fight this war with bugs ! Not just stronger and newer drugs!
Other than the factor of indiscriminatory self-prescribed antibiotics leading to resistance, the biggest cesspool to breed these bugs are so called healthcare facilities which inadvertently do the opposite. Patients get admitted in hospitals to seek treatment and cure, not realising that they may be exposing themselves to unwanted life threatening infections in hospitals, especially in the developing world. Many of these hospitals can be downright dirty or even if superficially clean may be acting as amplifiers to microbes and blood/ fluid borne or touch-based infections.
You have unsafe injection practices ranging from inadvertently double dipping a syringe reused on an operated patient into a multi-dose vial and then transferring infection into another patient, even on using a new syringe for this other patient or the bad practice of blatant reuse of syringes on multiple patients and other single use devices, to other malpractices of unsafe reuse of IV sets on same patient on change of his IV Catheter, reuse of stainless instruments e.g. vaginal speculum, dental forceps, without proper steam sterilisation etc. Then you need to be cautious about ventilators and dialysis machines where these bugs hide and multiply. All these unsafe practices are common and unfortunately overlooked in the developing world hospitals (at times too in developed world) and these healthcare facilities become infection amplifiers.
You admit a patient for a simple hernia operation for one-two days and he catches secondary infections in post operative care, then you pump him with antibiotic injections to which he may be immune and he gets further exposed to one the 12 dirty life threatening bugs because of poor and unsafe injection or infusion practice and then it’s a downhill battle with his already weakened immune system.
Now imagine a patient with HIV or with drug resistant TB or Hepatitis gets admitted in this hospital which is already contaminated with these dirty bugs and you have recipe for a cocktail of infections – good luck to antibiotics and doctors trying to fight these ever increasing hordes of stronger bugs.
So how do you win this war? Simple — first step is break the cycle of infections and cross infections, isolate and overpower. We have the Infection Prevention and Control – IPC tools but these are not headline grabbers for politicians. Bad news are.
Politicians focus on headline grabbing bad news but we need champions to do serious sincere work on implementation of intervention strategies for healthcare system strengthening and this is actually in practice simple stuff and common sense and what’s common is not fashionable, so announcement to enforce restrictions to freely access medications and antibiotics without doctors’ prescriptions are common but have you heard of announcements for deploying auto disable syringes in curative services in hospitals to help break cycles of cross infections?
Or stated policy that every time an IV Cannulas is changed the IV set needs to be changed? (The wet nozzle of a disengaged IV set touches the contaminated bed, dirty IV stand, the supposedly clean nurses uniform – becomes a bug carrier, and when re-attached to a IV Cannula now you are infusing the innocent hapless patient with bugs swimming on the wet nozzle of the IV Set).
Are you aware that an epidemic of HIV spread from reuse of a syringe used on only one patient in Cambodia as recent as 2014? The entire patients’ extended family and a large number of villagers got infected by a quack.
It is a very rare occasion when the US CDC is called to do an investigation of an HIV outbreak. This was officially made public in 2015 and even published in the MMWR. A few years before that, you had in the US itself, a developed country the infamous Nevada outbreak of Hepatitis C, which was similarly from reuse of syringes with multi dose vials.
Antiretroviral resistance in HIV is building up in all countries, unsafe health care can spread drug resistant HIV from patient to patient. So there are more and more new cases of HIV infection who already have drug resistance.
So what do we need ? Not just policy and access to free curative treatment like free antiretrovirals that gets politicians brownie points for taking care of the hapless infected patients but we need allocated budgets, we need coherent policies on injection safety and implementation on IPC strategies to prevent infection, isolate them, weaken the hordes of bugs if we are talking about tackling AMR. We need periodic monitoring of these intervention strategies and document improvements/ achievements.
In management of problems usually one follows the Pareto 80:20 rule, focus on top 20 factors to achieve 80 per cent success- well in infection prevention you can’t have this luxury of ignoring any factor so all interventions need to be applied simultaneously- and let’s not talk about prices when it comes to war on bugs – e.g. how much more we have to pay to use an auto disable syringes? One cent ! That’s too much – hmmm … and the daily cost of extra day stay in hospital and of antibiotics and daily window to infection to bugs surrounding the patient and feast on him?
WHO estimates that over 6-8 billion injection are unsafely given every year that means daily over 20 million hapless patient are being injected not with life saving antibiotics or medicines but with a cocktail of bugs!
WHO itself stated that for every $1 invested in injection safety the macro healthcare cost savings are $14 and that compares favourably with every $1 spent on immunisation which saves $16!
With such attractive RoI it should be a no brainer but then we have disbelievers and instead of just going ahead with implementation of WHO DG’s advisory to all developing countries to switch to SMART Syringes that are auto disabling we keep on delaying this by conducting further studies to validate this and wait for prices to come down to save a quarter of a cent while daily 20 million patients continue to get infected with HIV or Hepatitis or Drug Resistant TB or anyone of the 12 Super Bugs and we ignore the millions of dollars spent on treatment of these hapless patients.
Regions with poor economic progress who can’t afford organised qualified private healthcare and dependent on public healthcare or ill equipped quacks, the infection related problem is most acute. So clearly we need to focus on strengthening rural and urban public healthcare systems and institutions so that there is no need for villagers and slum dwellers to access quacks. NGOs and public awareness can ensure that quacks do follow better IPC and do not needlessly prescribe antibiotics.
How many people are aware of WHO’s guidance not to inject antibiotics post surgery unless there’s a known infection?
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