Infection Control in Countries With Limited Resources
Paul A. Tambyah
Nordiah A. Jalil
Jennifer Ho
Infection control in developing countries that are relatively resource limited is a challenging topic. Rarely do we hear about “road construction in developing countries” or “airplane navigation in developing countries” as there are often basic universal standards that are adopted in all countries regardless of their wealth or affluence in the fields of building construction, road maintenance, and airport safety. Of course, the reality is that the implementation of these standards varies considerably as has been seen with tragic effect in the tremendous death and destruction that have followed natural disasters such as earthquakes in Haiti or Sichuan. These are in contrast with the relatively limited human impact of the higher magnitude earthquake in developed countries with strict building codes and enforcement of regulations. Similarly in the infection prevention and control field, there are those who argue that the standards for infection control for developing countries must be the same as they are for developed countries (1).
While this would appear to be an ideal, the reality is obvious—the gulf in resources is often so great that it would be impossible to expect poor countries to have the same standards in healthcare or building or airports as rich countries. This has been the rationale in the past for avoiding “unattainable targets” and somewhat mirrors the huge debate that is going on in the United States on whether “zero” is an attainable goal for the prevention of healthcare-associated infections (HAIs) (2). Even the opponents of “unrealistic targets” would agree that such goals are ideal. Indeed, a review of process measures and outcomes in central line-associated bloodstream infections (CLABSIs) in US and non-US (including Middle Eastern and Latin American) hospitals showed no significant differences between US hospitals in terms of infection control infrastructure, practices, and CLABSI rates (3). This suggests that given a commitment to improving standards and processes together with adequate resources, there is no reason why healthcare facilities in the “developing” world cannot achieve standards of infection control comparable to the United States. The key issue is thus to ensure that the capacity is built up locally so that these universal standards of infection control can be realistically implemented in stages, if necessary, beginning with the most fundamental.
Often the resources available for healthcare are simply not available at the onset. In many developing countries, healthcare is seen as a lower priority on the national agenda, and even within healthcare, preventing HAIs has a lower priority than preventing infant or maternal mortality, for example, and probably rightly so. In addition, “structural adjustment programs” instituted by international financial authorities have mandated “user fees” and other restrictions on spending on government subsidies for healthcare (4). However, there is light at the end of the tunnel! The recent developments in international relations including the commitment of leading industrialized countries to the Millennium Development Goals, together with the involvements of foundations such as the Gates and Clinton Foundations and programs such as PEPFAR, have put global public health firmly near the top of the international agenda, especially in development circles. Again, while the majority of these goals relate to maternal and child health, it has been recognized that the gains in maternal and child health will be rapidly lost if insufficient attention is paid to the prevention of infections associated with delivery and provision of basic child health services.
Furthermore, the World Health Organization (WHO) has taken the lead in global patient safety with its successive and successful global patient safety challenges (5). The WHO was founded in 1945 together with a number of international bodies including the United Nations out of the embers of the Second World War. It was the successor to the Office International d’Hygiene Publique of the League of Nations that was established primarily to prevent the cross-border transmission of infectious diseases, most notably cholera and plague. The WHO has a distinguished track record, most notably for leading the efforts to eliminate the scourge of smallpox. That was a concerted global effort driven across international and ideological divides—as a result, a disease that once claimed the lives of millions was finally eliminated in 1978. To date, this is the only disease that has ever been eliminated from the face of the earth. It is striking that the last cases of smallpox in history were acquired through laboratory transmission at a university medical facility in Birmingham, United Kingdom (6). This led to marked improvements in biosafety worldwide. In recent years, the WHO has been at the forefront of the battle against emerging infectious
diseases, most notably during the SARS crisis. This was an unprecedented international collaboration that resulted in the rapid identification of a novel emerging pathogen from East Asia and international efforts to prevent its spread (7). Although several agencies were involved in controlling SARS, the WHO was limited by the fact that it was unable to work in Taiwan, one of the affected areas, because Taiwan had been denied representation at the WHO (8). The WHO published guidelines, notably case definitions for epidemiological purposes and issued travel advisories as well as sent experts to the affected areas through its Global Alert and Outbreak Response Network. These all contributed significantly to what was essentially an infection control response to an emerging pathogen and also raised the credibility and status of the WHO.
diseases, most notably during the SARS crisis. This was an unprecedented international collaboration that resulted in the rapid identification of a novel emerging pathogen from East Asia and international efforts to prevent its spread (7). Although several agencies were involved in controlling SARS, the WHO was limited by the fact that it was unable to work in Taiwan, one of the affected areas, because Taiwan had been denied representation at the WHO (8). The WHO published guidelines, notably case definitions for epidemiological purposes and issued travel advisories as well as sent experts to the affected areas through its Global Alert and Outbreak Response Network. These all contributed significantly to what was essentially an infection control response to an emerging pathogen and also raised the credibility and status of the WHO.
One of the other legacies of the SARS response was the strengthening of the International Health Regulations (IHRs) in 2005. The amendments were made to the regulations because of the recognition that failure to recognize, document, and at least attempt to control an emerging infectious disease outbreak in one part of the globe would have international consequences. The revised IHRs were adopted at the World Health Assembly in 2005 to “prevent, protect against, control and provide a public health response to the international spread of disease.” Details of the revised IHR are available online at http://www.who.int/ihr/en/.
The WHO published its core components for infection prevention, and control programs earlier this year (9). These are the critical elements that have to be incorporated into all countries’ national and local healthcare authorities. This forms a practical framework by which infection prevention and control programs can be structured in developing and developed countries. A summary of the core components is given in Table 100-1. We believe that a stepwise approach to infection control in low-income countries beginning with the basic elements covered by the core components should be part of every country’s national health program.
The rest of this chapter is organized according to the WHO core components.
FORMAL ORGANIZED STRUCTURE
At the national level, this should include a national authority with qualified staff, a budget, and defined functions. This authority should also be tasked with ensuring preparedness and coordination of infection control and prevention activities for communicable diseases. At the local hospital level, each hospital should have dedicated leadership and authority for infection and control programs.
The ministries of health of most countries are concerned with many issues including maternal and child health; regulation and provision of primary, secondary, and tertiary healthcare; and often the training of physicians, nurses, and allied healthcare professionals. Few countries in the developing world have national infection control bodies similar to the different agencies operating within the U.S. Centers for Diseases Control and Prevention (CDC), for example. However, with the advent of the IHR, all countries are required to have some system in place for monitoring, detection, and reporting of outbreaks of international health significance. Some countries such as Egypt have established an infection control program within the Ministry of Health and Population (10).
The Egyptian experience is very instructive. The national infection control program was developed in response to widespread outbreaks of blood-borne pathogens that were widely reported in both scientific and lay media. These included some of the world’s highest rates of hepatitis C as an indirect result of widespread campaigns for population-based eradication of schistosomiasis (11) and outbreaks of HIV infection associated with dialysis centers (12,13). There was the recognition by national health authorities that something had to be done to control the spread of infections in both private and public healthcare institutions. In addition to these highly publicized outbreaks of blood-borne pathogens, there were scientific studies documenting a high prevalence of HAIs in Egypt (14), as well as antibiotic-resistant infections, in particular, those caused by extended-spectrum beta-lactamase-producing gram-negative bacilli (15).
This led to the formation of a working group that included the U.S. Naval Medical Research Unit, the WHO, several Egyptian universities, medical schools, professional bodies, and nongovernmental organizations. This eventually led to the creation of a department within the Ministry of Health and Population and the publication of national guidelines, establishment of training programs, promotion of infection control advocacy, and institution of regulatory measures to ensure attention to critical supplies and occupational health (15).
With a number of variations, the same thing has happened in many other countries in Asia, Africa, and Central and South America. A crisis occurs—most memorably, the SARS and avian influenza outbreaks resulting in huge amounts of media attention, much of it critical. This has led to major changes in most of the affected countries both at the central and the local hospital level to prepare for emerging infectious diseases including healthcare-associated respiratory viral infections (16). In many of these countries, the national health authorities have become much more sensitized to infection control, especially to novel emerging pathogens. This was played out during the recent influenza A H1N1 2009 pandemic when many of the SARS-affected countries reacted very strongly to the new influenza (17).
While these highly publicized outbreaks followed by strong public health-driven responses can provide a boost for infection control efforts in a country, it is the follow-up after the initial burst of attention that is the most challenging. The situation in Egypt was aided by international collaborations as well as strong participation by local experts. This is likely to be a sustainable approach in many middleincome countries as well as those with strong international collaborations or with well-developed domestic medical expertise such as India or the Philippines. The challenge is greatest in the least developed countries where medical resources are extremely limited, especially in those countries that are currently beset by civil war where even the provision of basic healthcare is severely constrained. Paradoxically, those are the settings with the greatest needs for infection control.
TABLE 100-1 Essential Requirements for Infection Control for ALL Countries Based on the World Health Organization’s Core Components | ||||||||||||||||||||||||||||||||
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This need in the least developed countries is best illustrated by the cholera outbreak in Goma a decade ago. During the Rwandan genocide, thousands of refugees fled their homes and were assembled in refugee camps, most notably in Goma, eastern Zaire (now the Democratic Republic of the Congo). The camps in Goma were affected by a devastating outbreak of cholera that claimed more than 10,000 lives (18). Case fatality rates were as high as 48% on a single day, while the pandemic cholera in the neighboring country of Burundi had a case fatality rate of 6% to 1% (19). While the majority of the deaths in Goma were ascribed to problems with the clinical management of individual cases of cholera, it is quite likely that failures in infection control led to an exacerbation of an already difficult situation in the camps.
In “peacetime” as well as in disasters, in many of these countries with very limited resources, basic healthcare is often provided either by traditional healers or
by international aid organizations. In the absence of a well-functioning national health authority, it is critical therefore that the international organizations that provide disaster or emergency relief have well-established infection control guidelines and policies that can be transferred to the local situation and even perhaps transmitted to traditional healers. This has been well recognized for outbreaks of viral hemorrhagic fevers—Ebola and Marburg—but should perhaps be part of the standard operating practice for all international aid organizations providing emergency and disaster assistance. The renowned international aid organization Medicins Sans Frontiers (MSF) was involved in the response to the Marburg virus outbreak in Angola in 2005 (20). When the first few cases were recognized by the doctors in Uige, Angola, in March 2005, an international response was coordinated by the Angolan Ministry of Health and the WHO. MSF helped to establish an isolation facility—a Marburg ward—to ensure the isolation of patients with viral hemorrhagic fever and to ensure that those patients received some care. The ward was eventually handed over to the local authorities in June 2005, and the outbreak officially ended in July 2005. In the process, 18 healthcare workers (HCWs) died from Marburg hemorrhagic fever. There were many challenges in the MSF response to that outbreak including attempting to alter existing protocols, providing psychological support and providing supportive care for patients infected with viral hemorrhagic fevers.
by international aid organizations. In the absence of a well-functioning national health authority, it is critical therefore that the international organizations that provide disaster or emergency relief have well-established infection control guidelines and policies that can be transferred to the local situation and even perhaps transmitted to traditional healers. This has been well recognized for outbreaks of viral hemorrhagic fevers—Ebola and Marburg—but should perhaps be part of the standard operating practice for all international aid organizations providing emergency and disaster assistance. The renowned international aid organization Medicins Sans Frontiers (MSF) was involved in the response to the Marburg virus outbreak in Angola in 2005 (20). When the first few cases were recognized by the doctors in Uige, Angola, in March 2005, an international response was coordinated by the Angolan Ministry of Health and the WHO. MSF helped to establish an isolation facility—a Marburg ward—to ensure the isolation of patients with viral hemorrhagic fever and to ensure that those patients received some care. The ward was eventually handed over to the local authorities in June 2005, and the outbreak officially ended in July 2005. In the process, 18 healthcare workers (HCWs) died from Marburg hemorrhagic fever. There were many challenges in the MSF response to that outbreak including attempting to alter existing protocols, providing psychological support and providing supportive care for patients infected with viral hemorrhagic fevers.
While traditional healers have been recruited for the control of sexually transmitted infections and HIV/AIDS (21) to our knowledge, there are limited efforts to engage traditional healers in the practice of infection control. There is evidence that many people in developing countries would seek traditional healers before “Western” medicine for symptoms that might be related to contagious respiratory illnesses such as tuberculosis (TB) (22). It does make sense that national health authorities are trusted and consulted far more often than modern medical facilities in the overall infection control program. The specifics of how to go about doing this are a challenge and remain to be worked out.
In between these extremes of deadly viral hemorrhagic fevers in remote hospitals, and middle-income countries with the potential to develop mini-CDCs, the majority of limited healthcare resource facilities have the potential to develop a national infection control authority that can establish at least some kind of reporting system for hospital mortality, ensure that there is a national plan for preparedness for diseases of international health significance as defined by the WHO’s IHR, and have trained individuals who can enforce these plans. International agencies that provide assistance to these countries have the opportunity to assist in the development of these national authorities by providing training and short attachments with their own national infection control agencies that can be invaluable to developing country leaders in infection control.
At the local hospital or healthcare facility level, each hospital needs at least an infection control officer or a senior clinician, a laboratorian, or an administrator who reports to the chief of the facility who has at least 50% of his or her time devoted to infection control and prevention. Although the WHO document does not specify the specific fraction of time that needs to be dedicated to infection control and prevention, there are data from the SENIC study that show that hospitals with a dedicated healthcare epidemiologist have a reduced risk of HAI (23).
In reality, most hospitals in developing countries, and many hospitals in developed countries, especially in rural or inner city settings, do not have a full-time healthcare epidemiologist. In countries where regulatory requirements mandate the designation of a healthcare epidemiologist or “infection control doctor,” often, the person so designated does not have the required training or expertise. In the best of cases, the hospital microbiologist is designated as the infection control officer. In hospitals without a fulltime microbiologist, often some other clinician—an internist, an intensive care unit (ICU) doctor, or a senior nurse clinician—is assigned the responsibility.
This is an opportunity for international agencies and professional scientific societies to provide training to HCWs from developing countries who have an interest in infection control so that they can take on the role of the infection control officer and lead an infection control team (ICT) at their own local healthcare facility.
In Brazil (24), the Brazilian Ministry of Health mandated the establishment of hospital infection control committees in 1983, but the impact was limited. Subsequently, two other decrees were issued that led to the introduction of hospital infection control services with mandated staffing levels and independence. Physicians assigned to infection control are to be paid for 4 hours daily, while nurses are paid for 6 hours daily. Over the years, the structure and organization of infection control have evolved in Brazil, so that in many centers, interventions have been practiced that have a marked impact on patient care (25).
The minimum that every developing country should have in terms of infection control infrastructure are as follows:
In the absence of a national infection control authority, a designated section of the Ministry of Health responsible for infection prevention and control.
At the local hospital, each hospital should have a significantly senior physician or administrator designated as the infection control officer for the hospital, who is empowered to take action for infection prevention and control activities.
Each healthcare facility should have an ICT made up of nurses, physicians, laboratory staff, and those with the expertise required for effective infection control and prevention activities.
It would be good to integrate the activities of the ICTs and authorities with international bodies including aid agencies and local medical facilities including traditional healers.
TECHNICAL GUIDELINES
Technical guidelines should be developed and disseminated at the national level for prevention and control of infections.
As mentioned above, national infection control guidelines have been developed and published in many developing
countries such as Egypt (15) and Brazil (24). While countries might not have their own local infection control guidelines, regional bodies, such as the regional offices of the WHO, have issued guidelines primarily aimed at novel influenza. For example, the Western Pacific and Southeast Asian regional offices (WIPRO and SEARO) have published guidelines that are freely available online at http://www.wpro.who.int/NR/rdonlyres/006EF250-6B11-42B4-BA17-C98D413BE8B8/0/practical_guidelines_infection_control.pdf.
countries such as Egypt (15) and Brazil (24). While countries might not have their own local infection control guidelines, regional bodies, such as the regional offices of the WHO, have issued guidelines primarily aimed at novel influenza. For example, the Western Pacific and Southeast Asian regional offices (WIPRO and SEARO) have published guidelines that are freely available online at http://www.wpro.who.int/NR/rdonlyres/006EF250-6B11-42B4-BA17-C98D413BE8B8/0/practical_guidelines_infection_control.pdf.
These guidelines were written mainly in response to the SARS epidemic when it became apparent that many countries in the Southeast Asian and Western Pacific region did not have much of the essential infrastructure that has been taken for granted in many developed countries (26). These guidelines are appropriately entitled “Practical Guidelines for Infection Control in Healthcare Facilities” and cover the whole range of infection control activities ranging from establishing an infection control program, the recommended structure and accountability for the infection control program to practical issues such as Standard Precautions, transmission-based precautions, environmental management including air and water, waste management, reuse of devices, disinfection and sterilization, care of HCWs, and special situations such as SARS, multiresistant microorganisms, and viral hemorrhagic fevers. These guidelines bearing the imprimatur of the WHO are accessible to countries in the region and can form the basis for national infection control guidelines.
These guidelines were published in 2004 and did not cover avian or pandemic influenza. The avian influenza zoonotic pandemic began to cause a great deal of concern in 2005 to 2006, and as a result, new guidelines were published to cover infection control for avian influenza and pandemic influenza. These guidelines were updated and, interestingly enough, had differences with the US CDC guidelines that were published around the same time. The differences between the US CDC guideline and the WHO guideline probably reflect the limited resources available to most WHO member countries. In particular, the US CDC recommended N95 respirators for all patients with pandemic influenza, while the WHO guidelines, from the beginning, recommended surgical masks.
At the local hospital level, the WHO core components include a recommendation that each hospital or healthcare facility draw up its own infection control policy (9). Most of these can be devised by adapting the WHO practical infection control guidelines, but other guidelines are available from international organizations such as the International Federation for Infection Control (IFIC; available at http://www.theific.org/) and the Asia Pacific Society for Infection Control (APSIC), among others. Many developing countries in Asia have developed their own local guidelines, some of which are shown in Figure 100-1.
These infection control policies should be published locally in the form of infection control manuals. These manuals can be taken off templates using the WHO, IFIC, or APSIC guidelines and then adapted to local conditions with details such as the contact person for sharps injuries, specifics about waste disposal, and other details added in to make the manuals useful for staff in the local healthcare facility. An example of this is the Infection Control Manual produced by the Christian Medical College in Vellore, India. This has been produced locally at a tertiary hospital in a rural setting in India and is widely disseminated in India through training programs conducted by faculty of the Christian Medical College, Vellore, in collaboration with international organizations such as the Society for Healthcare Epidemiology of America.
 FIGURE 100-1 Infection control guidelines published at the local, national and regional level in Asia. |
Many hospitals, especially in the middle-income countries in Asia, have sought accreditation from international bodies such as the Joint Commission International (JCI). The JCI has highlighted infection prevention and control as one of the key areas in its accreditation process. JCI-accredited hospitals can be found in Bangladesh, Brazil, Egypt, Indonesia, Jordan, the Kingdom of Saudi Arabia, Malaysia, Mexico, Thailand, Turkey, Vietnam, and Yemen, to name a few of the countries where healthcare facilities have met the criteria for JCI accreditation. This perhaps illustrates some of the issues with intracountry differences in the quality of healthcare delivery as some of these countries also have predominantly rural areas with very limited resources for healthcare and little in the way of infection control practices. At the same time, the presence of internationally accredited institutions in many developing countries provides a living demonstration of what can be achieved outside of Europe, Australasia, and North America. Many HCWs or their families will go to these facilities for their own healthcare. They experience the impact of international best practices without having to travel to some remote high-tech international location, but rather in their own country. The impact of JCI accreditation with improvements in medical technology in these hospitals will surely be felt over time. The diffusion of infection control standards thus could potentially be aided by good practices within centers of excellence, private or public in these developing countries.
Accreditation does not need to be done by an international agency. In the middle-income countries with established cores of well-trained individuals, accreditation by a credible government or non-governmental body can help to raise standards in infection control and
patient safety. This has been noted in the Lebanon (27). In countries with even more limited resources, assistance from international aid agencies can be tapped to provide hospital accreditation standards to cover infection control practices in both urban and rural healthcare facilities. An example of this is in Uganda (28), where assistance from USAID helped establish the Yellow Star hospital accreditation project in 2000. Although the project was not funded from 2005 onward, there remained a strong desire among leaders of local Ugandan healthcare facilities for an accreditation program for hospitals that encompassed infection control protocols, patient safety, and various infrastructure standards.
patient safety. This has been noted in the Lebanon (27). In countries with even more limited resources, assistance from international aid agencies can be tapped to provide hospital accreditation standards to cover infection control practices in both urban and rural healthcare facilities. An example of this is in Uganda (28), where assistance from USAID helped establish the Yellow Star hospital accreditation project in 2000. Although the project was not funded from 2005 onward, there remained a strong desire among leaders of local Ugandan healthcare facilities for an accreditation program for hospitals that encompassed infection control protocols, patient safety, and various infrastructure standards.
There is clearly a demand from the citizens of lowresourced countries for quality healthcare delivered locally at affordable prices. Governments and healthcare providers will need to respond to this demand, and accreditation of infection control programs will be a critical element in this drive.
At a minimum, each developing country should have the following:
National guidelines on infection control—these can be simple adaptations of the WHO practical guidelines for infection control.
Each healthcare facility should have its own infection control policy—these policies can be based on international guidelines from organizations such as the WHO, IFIC, and APSIC and need to be locally adapted. These policies need to be available to staff and disseminated as widely as possible.
HUMAN RESOURCES
At the national level, there should be standards for adequate staffing of infection preventionists and protocols or opportunities for training of HCWs in infection control.
International medical and nursing education has developed a great deal in recent years. There has been a proliferation of medical and nursing schools, and many of these in Asia, Africa, and Latin America have been established in collaboration with major teaching institutions from Europe, North America, and Australia. While the tertiary education sector is a major site for training of medical and nursing professionals in infection control, continuing education and outreach efforts into primary care settings are critical, because this is where the bulk of healthcare is delivered.
Countries need to establish national standards for training for infection preventionists. This has not been universally done in developed countries, but opportunities abound for developing countries, in particular middleincome developing countries that have partnerships and educational collaborations with developed countries.
Many countries do not have specialized training for infection control nurses or physicians. There are courses available, although these are primarily provided by professional societies such as the Society for Healthcare Epidemiology in America, the Hospital Infection Society, and the Association for Professionals in Infection Control and Epidemiology. Some universities provide postgraduate diplomas or degrees with a focus on infection control, but these are very limited. The experience of South Korea is instructive. Although Korea is not a limited-resource country, there are lessons to be learned from the experience there. In 1992, the Ministry of Health and Welfare in Korea mandated that every hospital with more than 80 beds needed to have an infection control committee. In 2003, a graduate specialist training program for nurses with a specialization in infection control was introduced (29). This has raised the professionalism of infection preventionists and has raised the salaries and status of infection control nurse professionals.
In addition to training and providing the human resources to staff infection control programs, HCW safety is a critical issue in developing countries. HCWs in developing countries are exposed to infectious risks at least an order of magnitude higher than HCWs in developed countries.
Blood-Borne Pathogens
The rates of HIV, hepatitis B, and hepatitis C are much higher in many developing countries compared with developed countries. For example, the rates of hepatitis B in China can be as high as 7% to 9% (30), and in West Africa, hospitalized patients have a hepatitis B seropositivity rate of 15% to 20% (31). Many countries do not have national vaccination programs for hepatitis B vaccination (32,33 and 34). This is critical. Hepatitis B vaccination has been shown to be highly effective in prevention of hepatitis and its complications. HCWs worldwide have a higher rate of death from hepatitis and its complications—this was noted in developed countries before the onset of Universal Precautions and hepatitis B vaccination. Efforts are under way to increase the hepatitis B vaccination rates for healthcare providers in developing countries. A recent study conducted in Uganda (35) found a hepatitis B vaccination rate of only 6%. Nearly half of all HCWs in that Ugandan tertiary hospital were still susceptible to hepatitis B. Volunteers or those who are going to provide healthcare in mission or relief efforts must be aware of the hepatitis risks and should make sure that they are up to date with hepatitis B vaccination.
HIV rates are very high in many developing countries, especially in sub-Saharan Africa. There is evidence that there are high levels of ongoing healthcare-associated transmission of HIV in healthcare facilities in these settings (36). Postexposure prophylaxis for HCWs who sustain sharps injuries in these settings are not often routinely available. This has to be a high priority for any infection control program. Medical students and HCWs from developed countries who travel to areas with a high endemicity of HIV have been known to take along their own supply of postexposure prophylaxis for HIV (37). This raises a number of ethical questions as the local staff are exposed obviously for far longer to greater risks. Other issues that have arisen are the high rates of resistance to antiretrovirals that have been documented in some developed country settings and, more alarmingly, the absence of resistance testing in the vast majority of resource poor settings. If an HCW sustains a sharps injury from a patient with a high viral load of HIV with a resistant virus, the postexposure prophylaxis regime is likely to be far more complicated than most protocols currently extant in developing countries.
It is also more likely to require salvage therapies that might not be available in that country.
It is also more likely to require salvage therapies that might not be available in that country.
Hepatitis C is also endemic in many developing countries. Paradoxically, a large part of this endemicity is due to unsafe injection practices in the first place. Often, this is the unintended consequence of well-intentioned public health programs such as the schistosomiasis eradication program in Egypt (38). Testing for hepatitis C is not widely available although ELISA testing for blood safety has increased the prevalence of hepatitis C testing markedly in many resource poor settings. There may be limited facilities for follow-up of HCWs who sustain sharps injuries from patients who are hepatitis C positive. While hepatitis C treatment is now routine in most developed countries, many developing countries lack access to the expensive agents used to treat hepatitis C and the notion of preemptive therapy as recommended in some centers is thus even more remote.
Other blood-borne pathogens are even more lethal— most notably the viral hemorrhagic fevers—Ebola and Marburg, which have claimed the lives of large numbers of HCWs (39). Other viruses that have had documented transmissions and are endemic in the tropics include dengue fever (40).
Sharps injuries in the developed world have been markedly reduced by the use of safety devices including needleless access devices, blood-drawing equipment with retractable needles, and other safety devices (41). Many of these devices are not available in resource poor settings and HCWs need to take extra precautions to ensure that they do not sustain these injuries. Some simple interventions that can reduce sharps injuries in developing countries include the provision of adequate lighting during procedures; the use of simple, safe sharps disposal containers (Fig. 100-2); destruction of sharps to prevent their reuse; use of containers to transfer sharps in the operating room rather than passing instruments; and training staff to ensure that at least one-handed recapping is done if the process of twohanded recapping cannot be eliminated altogether.
In addition to the issue of patient-to-provider transmission of infection, the other concern about providerto-patient transmission becomes particularly acute in settings with a high endemicity of blood-borne pathogens. In some Asian countries, for example, students are barred from medical school if they are found to be hepatitis B surface antigen positive (42). This potentially acts as a powerful disincentive for HCWs to disclose their status and poses potential risks to patients and the HCWs themselves as they might not be adequately treated for their own infections. There have been very few reports of providerto-patient transmission of blood-borne pathogens from developing countries despite the much higher seroprevalence. This is most likely a result of lack of investigation or detection of these outbreaks. There have been a couple of tragic outbreaks of HIV disease that have led to litigation where HCWs have been blamed for transmission of HIV to patients in Libya (43) and Kazakhstan (44). None has been completely explained, but these cases have caused a considerable amount of distress among HCWs in general and may contribute to increased stigmatization among HCWs looking after patients with HIV/AIDS.
 FIGURE 100-2 An improvised sharps box in East Asia. |
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