Survey of National Surgical Site Infection Surveillance Programs in Low- and Middle-Income Countries

Abstract

Background:

Surgical site infection (SSI) surveillance programs are strongly recommended as a core component of effective national infection prevention and control (IPC) programs. Participation in national SSI surveillance (nSSIS) programs has been shown to decrease reported SSIs among high-income countries (HICs), and it is expected that the same is possible among low- and middle-income countries (LMICs). We sought to determine what, if any nSSIS programs exist among LMICs.

Methods:

A cross-sectional survey was performed to evaluate existence of nSSIS of World Bank-defined LMICs. A digital survey assessment for presence of national IPC and nSSIS programs was delivered to persons capable of identifying the presence of such a program. Statistical analysis was performed using STATA. Institutional Review Board approval was obtained for this study.

Results:

Of the 137 countries identified, 55 (40%) were upper middle income (UMI), 47 (34%) were lower middle income (LMI), and 34 (25%) were low income. Representatives from 39 (28%) LMICs completed the survey. Of these respondent countries, 13 (33%) reported the presence of a national IPC program. There was no difference between countries with IPC programs and those without with respect to country income designation, population size, World Health Organization region, or conflict status. Only five (13% of all respondents) reported presence of a nSSIS program.

Conclusions:

National surgical site infection surveillance programs are an integral component of a country's ability to provide safe surgical procedures. Presence of nSSIS was reported infrequently in LMICs. International governing bodies should be encouraged to guide LMIC leadership in establishing a nSSIS infrastructure that will help enable safe surgical procedures.

Public health surveillance is “the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice” [1]. Surgical site infection (SSI) surveillance programs are strongly recommended as a core component of effective national infection prevention and control (IPC) programs [2], and IPC programs commonly include SSI surveillance in high-income countries. It is not known how many low- or middle-income countries (LMICs) actually have national SSI surveillance (nSSIS) programs. While there is published guidance available for establishing local SSI surveillance programs in LMIC settings, there is less information available for national level programs [3].

The Lancet Commission on Global Surgery failed to identify the quantification of SSI through surveillance as a quality marker when providing surgical care [4]. Participation in nSSIS programs has been shown to decrease reported SSI among high-income countries (HICs), however, and it is expected that the same is possible among LMIC [5]. The presence of a nSSIS program can encourage responsible antibiotic use, establish national quality metrics, and be used to identify outbreaks of existing, emerging, re-emerging, or anti-microbial resistant (AMR) SSI pathogens. Conversely, when no nSSIS program is present, the burden of SSI pathogens is impossible to quantify at the population level [6]. To begin to address the LMIC nSSIS program deficit, the Surgical Infection Society Global Health Committee sought to determine what, if any, nSSIS programs exist currently among LMIC.

Methods

A cross-sectional survey was performed to evaluate the existence of nSSIS programs in LMICs. A digital survey was delivered to persons capable of identifying the presence or absence of such a program in each country (online supplement). This survey evaluated presence of an IPC program, nSSIS program, year of nSSIS program implementation, data transmission logistics, presence of a national reference laboratory, and frequency of data reporting. The LMIC were defined according to the World Bank and were grouped according to World Health Organization (WHO) regional grouping [7,8].

Capable persons were defined as Ministry of Health directors or their appointees, surgeons or infection preventionists practicing in the country in question, or an individual working for a non-governmental organizations (NGO) providing healthcare in a given LMIC. Contact information for these persons were identified through the American College of Surgeons “Find a Surgeon” function, the Surgical Infection Society members list, personal contacts of committee members, Ministry of Health or academic institution or NGO websites, ResearchGate, and LinkedIn. A capable person in a given LMIC was sought at least twice by committee members until a response was obtained to maximize coverage and response rate. When possible, multiple individuals in a country were contacted. A country was defined as being in conflict according to the Uppsala Conflict Data Program [9].

Our survey was provided in both English and Spanish editions. The Fisher exact test was used for comparisons when appropriate. Stata 12.0 (StataCorp, College Station, TX) was used for statistical analysis. Stanford Institutional Review Board approval was sought for this study and was considered exempt.

Results

Of the 137 countries identified, 55 (40%) were upper middle income (UMI), 47 (34%) were lower middle income (LMI), and 34 (25%) were low income (LI) (Table 1). The WHO regions represented included: East Asia and Pacific (n = 23, 17%), Europe and Central Asia (n = 21, 15%), Latin America and Caribbean (LAC) (n = 24, 18%), Middle East and North Africa (n = 13, 9%), South Asia (n = 8, 6%), and sub-Saharan Africa (n = 47, 34%). Of the 39 countries listed as experiencing conflict in 2017–2018, 37 (95%) were LMICs, which corresponded to 27% of all LMICs during survey administration. When combined, LMICs comprised 84% (n = 6,297,003,000 persons) of the world's population with 50% of LMICs having populations of 10 million persons or more. Contact information for a person capable of responding to the survey was identified in all 137 countries.

Table 1.

Demographics of Low- and Middle-Income Countries Reporting Presence of Infection Prevention Programs and National Surgical Site Infection Surveillance Programs

	All LMIC (%)	Respondent LMIC (%)	p
Income designation
UMI	55 (40)	20 (51)	0.3
LMI	47 (34)	10 (26)
LI	35 (26)	9 (23)
Population size (1,000 persons)
<100	21 (15)	4 (10)	0.5
100–9999	47 (35)	13 (33)
>10,000	68 (50)	22 (56)
WHO grouping
EAP	23 (17)	3 (8)	0.01
ECA	21 (15)	2 (5)
LAC	24 (18)	13 (33)
MENA	13 (10)	5 (13)
SA	8 (6)	2 (5)
SSA	47 (35)	14 (36)
Conflict	35 (26)	11 (28)	0.7
National infection prevention program	—	13 (33)	—
National Surgical Site Infection Surveillance program	—	5 (13)	—

LMIC = low- or middle-income country; UMI = upper middle income; LMI = lower middle income; LI = low income; WHO = World Health Organization; EAP = East Asian and Pacific; ECA = Europe and Central Asia; LAC = Latin American and Caribbean; MENA = Middle East and North Africa; SA = South Asia; SSA = sub-Saharan Africa.

Representatives from 39 (28%) LMICs completed the survey. Twenty (51%) respondent countries were UMI, 10 (26%) were LMI, and nine (23%) were LI. The WHO regions represented among respondent programs included: East Asia and Pacific (n = 3, 8%), Europe and Central Asia (n = 2, 5%), Latin America and Caribbean (n = 13, 33%), Middle East and North Africa (n = 5, 13%), South Asia (n = 2, 5%), and sub-Saharan Africa (n = 14, 36%). The proportion of LAC countries among respondents was significantly greater than among non-respondents (p = 0.01) Eleven (28%) respondent countries were designated as having experienced conflict from 2017–2018. The combined population of respondent countries was 1,373,889,000 persons (22% of the total LMIC population).

Of these respondent countries, 13 (33%) reported the presence of a national IPC program (Table 2). Among respondent countries, there was no difference between countries with IPC programs and those without with respect to country income designation, population size, WHO region, or conflict status. Only five (13%) countries reported the presence of nSSIS programs. Similar to LMICs with IPC programs, no difference was observed between the country demographics of programs with nSSIS programs and those without. Among those countries with nSSIS, all were reported as being a part of the countries' IPC program. Inception years for nSSIS programs ranged from 2014–2017.

Table 2.

Respondent Low- and Middle-Income Countries with National Infection Prevention and Control Programs and National Surgical Site Infection Surveillance Programs Compared with Those Without

	Presence of IPC program (%)	No IPC program (%)	p	Presence of nSSIS program	No nSSIS program	p
Income designation
UMI	7 (54)	13 (50)	0.8	3 (60)	17 (50)	1.0
LMI	4 (31)	6 (23)		1 (20)	9 (26)
LI	2 (16)	7 (27)		1 (20)	8 (24)
Population size (1,000 persons)
<100	1 (8)	3 (12)	1.0	1 (20)	3 (9)	0.6
100-9999	4 (31)	9 (35)		1 (20)	12 (35)
>10,000	8 (62)	14 (54)		3 (60)	19 (56)
WHO grouping
EAP	1 (8)	2 (8)	0.5	0 (0)	3 (9)	0.3
ECA	1 (8)	1 (4)		1 (20)	1 (3)
LAC	4 (31)	9 (35)		2 (40)	11 (32)
MENA	1 (8)	4 (15)		0 (0)	5 (15)
SA	2 (15)	0 (0)		1 (20)	1 (3)
SSA	4 (31)	10 (38)		1 (20)	13 (38)
Conflict	2 (15)	9 (35)	0.3	1 (20)	10 (29)	1.0

IPC = infection prevention and control; nSSIS = national surgical site infection surveillance; UMI = upper middle income; LMI = lower-middle income; LI = low-income; WHO = World Health Organization; EAP = East Asian and Pacific; ECA = Europe and Central Asia; LAC = Latin American and Caribbean; MENA = Middle East and North Africa; SA = South Asia; SSA = sub-Saharan Africa.

Both active and passive surveillance was performed among the four countries with this information. Two countries with nSSIS had capacity to transmit data electronically and by hard copy, two others relied on hard copy alone. Three of the five countries endorsed the presence of a reference laboratory. Participating hospitals provided data to the respective nSSIS programs at a frequency ranging from four times per month to every six months.

Discussion

A low percentage of respondents from LMICs report having IPC programs, and an even lower percentage report having nSSIS programs. Developing these nSSIS programs should reduce the burden of nSSIS in a country. Calls for establishing nSSIS programs have been registered by WHO since 2011 [10]. Initiation of nSSIS programs or equivalent in HICs was associated with a steady decrease in SSI relative risk (RR) by year after program inception, stratified by National Nosocomial Infection Surveillance Risk Index [5]. By year nine after a nSSIS program or equivalent was started, SSI RR had dropped to 0.65 (95% confidence interval [CI] 0.63–0.67) compared with year one [5]. The impact of nSSIS programs in LMICs is anticipated to have a similar impact.

The nSSIS program deficit observed in LMICs represents a huge unmet need, an obstacle to provide safe surgical care, and an opportunity for collaboration between infection preventionists, surgeons, and political leaders from LMICs. Developing nSSIS programs that are deployable, maintainable, and analyzable should be a critical component of national surgical, anesthesia, and obstetric plans in LMICs designed to increase access to surgical care. Presence of nSSIS programs will empower surgeons and infection prevention practitioners in LMICs to track their own outcomes, detect their own outbreaks, and publish meaningful data describing their response.

The burden of SSIs in LMICs is likely enormous [6]. At least one in 10 persons undergoing a surgical procedure in LMICs will experience a SSI, and in many settings, the frequency is much higher [3,6,10]. Because of the paucity of nSSIS programs, however, existing estimates are largely based on single institution series with few exceptions [6,10,11]. Equally as concerning is the development of AMR. In many LMIC settings, antibiotic agents are ubiquitously prescribed for a range of ailments, and prescription practices are often unregulated [11,12]. Because there are no mechanisms in place to surveil effectively for development of AMR among common SSI pathogens in LMICs, the burden of AMR is largely unknown [10,11].

Functioning nSSIS programs will provide quantifiable data that will allow LMICs to monitor the quality of the surgical services provided and address emergence or spread of new pathogens or antimicrobial resistance mechanisms. Importantly, development of nSSIS programs can help lawmakers reward healthcare systems with low rates of infection and identify systems that need additional support to reach national targets. In resource-constrained settings, investment in a nSSIS program may encourage lean programs with good outcomes and increase attention toward programs with high rates of infection. Finally, accurate surveillance data can be used in combination with cost-of-care data to estimate financial burden of infection, which can be used to leverage political will and external funding sources.

All reported nSSIS programs were established within the last five years and were part of existing IPC programs. This trend was also seen among a cohort of HICs [5]. Given the paucity of guidance from the WHO regarding nSSIS programs and lack of emphasis on nSSIS programs in the Lancet Commission on Global Surgery [4], it is possible that existing IPCs are driving the initiation of these programs.

Thankfully some countries have identified the equal importance of strengthening surveillance capacity concomitantly with surgical capacity. It is possible that tying external funding for surgical capacity building to development and sustainment of nSSIS programs may accelerate growth of nSSIS programs in LMICs. Development of nSSIS programs in LMICs is an opportunity for the WHO and other international public health governing bodies; by supporting LMICs in developing and strengthening nSSIS programs, these governing bodies can take an important step toward ensuring access to safe surgical care for all.

Half of existing LMIC nSSIS programs utilized digital data capture in addition to hard-copy data capture. With increasing ubiquity of cell phone coverage, digital data capture represents an attractive option to improve data flow for fledgling LMIC nSSIS programs [13,14]. Such programs have been shown to be successful among local populations in India, Cambodia, and Tanzania [15 –17]. To our knowledge, such programs have yet to be applied successfully at the national level in LMICs, and this represents an opportunity for program development.

Applying digital capture methods may help reduce the infrastructure and personnel requirements needed for an nSSIS program, although any digital data transfer system should be implemented with adequate data security. These conditions highlight the need for a careful analysis to determine the most cost-effective strategy to collect surveillance data accurate enough to measure changes in local and national rates of SSI and AMR.

There are numerous limitations to this study. First, this was a cross-sectional digital survey, and there is likely selection bias among persons responding to the survey. It is possible that there may be nSSIS programs in the countries from which no response was received. We believe our survey response rate of 28% was reasonable, however, given the challenge of digital communications in many of these contexts. If significant bias were to be present, dependence on electronic communication should bias the sample toward countries with the capacity for nSSIS programs. A more comprehensive, on-site evaluation of nSSIS programs in LMIC could be particularly useful.

Second, it is possible that respondents to the survey may not have been knowledgeable about existing surveillance systems in the country from which they were reporting data. If this were the case, the lack of familiarity of the program by these well-positioned individuals demonstrates the program weakness and poor penetrance within the health system. Third, there was an overrepresentation of LAC LMICs, which could have been because of the availability of the survey in Spanish. This could skew outcomes to more closely represent nSSIS programs in the LAC region, rather than LMICs as a whole.

Conclusion

National SSI surveillance programs are an integral component of a country's ability to provide safe surgical procedures. In LMICs, presence of nSSIS programs was reported infrequently. Existing nSSIS programs are often a component of IPC programs in LMICs. Digital data capture may be a tool that facilitates nSSIS development in resource limited settings. International governing bodies should be encouraged to guide LMIC leadership in establishing nSSIS program infrastructure that will help enable safe surgical procedures.

Footnotes

Acknowledgments

The authors would like to thank all the survey respondents from LMICs for participating in this project.

Author Contributions

JDF: data acquisition, data analysis, manuscript preparation; AEB: data acquisition, data analysis, manuscript preparation; JS: data acquisition; ER: data acquisition; TGW: data acquisition, manuscript preparation; AVC: data acquisition, RGS: data acquisition, data analysis, manuscript preparation; JC: data acquisition; HPK: data acquisition; JYV: data acquisition, data analysis, manuscript preparation; JR: data acquisition, data analysis, manuscript preparation.

Funding Information

No financial/material support was received.

Author Disclosure Statement

No competing financial interests exist.

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