Abstract
The authors of the paper under review have described how pivotal infection prevention and control (IPC) are if we are to expect good health outcomes for people through quality universal health coverage (UHC). They discuss the global- and policy-level architecture that exists in support of the IPC agenda and present a logical addition to the World Health Organization (WHO) UHC-Patient Safety and Quality Wheel that illustrates the contribution of IPC.
The contribution of IPC towards better health outcomes is clear, as presented in the paper. Today, we no longer need to convince stakeholders of the need to improve IPC – what we need now is more evidence on how to achieve good IPC, and the challenge lies in how to implement IPC effectively. This requires changing behaviours and practices both clinically or in making appropriate decisions about policy or resources, and this is complex because people are involved, and people do not change easily. They have a multitude of issues to factor into deciding whether or not to modify practices or other ways of behaving. There is no one panacea to achieving good IPC, but it is achievable.
A statement is made in the paper, that in the countries in West Africa affected by Ebola there ‘appeared to be no reliable application of IPC’. This strong statement highlights the importance of two issues, the first of which is defining clearly what we are talking about when discussing IPC, and the second is the claim about no reliable application of IPC. The paper places considerable emphasis on water, sanitation and hygiene (WASH) measures, but IPC is a series of inter-linked and multiple measures. IPC necessarily warrants different degrees of precaution; for example, in most settings, standard precautions are the basic level of infection control precautions that are to be used, as a minimum, in the care of all patients ‘to reduce the risk of transmission of blood borne and other pathogens from both recognised and unrecognised sources’ (WHO, 2007: 1). However, additional, more elaborate, sets of measures and IPC are required in some settings, for example, where highly transmissible infections are prevalent, and the precise measures depend on the mode of transmission.
This brings us to the second issue raised by the strong statement; whilst in agreement with the authors that WASH and IPC are often not fully achieved, we have seen good examples of reliable application. For example in Sierra Leone where Lassa fever is endemic, there is a specialist Lassa fever hospital in Kenema district with vast experience in dealing with this and other haemorrhagic fevers. We could assume that the heavy loss of health workers in this district at the start of the outbreak was not due solely to poor application of IPC, but to the fact that Ebola is highly virulent, and even precautions including personal protective equipment were not adequate to protect health workers without additional specialised measures. In total, 718 health worker infections were reported in the West Africa Region between January 2014 and May 2015, and serious deficits in IPC are acknowledged to have contributed largely to this (WHO, 2015a). However, it is not clear how many of them occurred during a care interaction or in the community through non-care interactions (WHO, 2015a). Further, it is testimony to the success of stringent IPC measures and use of specialised personal protective equipment that there have been no further deaths among health workers since 17 February 2015, whilst the epidemic continued beyond this (WHO, 2015b). Other examples of best practice in IPC in lower-income countries exist (Soule et al., 2012).
Examples also exist demonstrating that the economic case for IPC is not nascent in resource-poor settings. For example, firm resolutions by 32 African countries placed sanitation and hygiene at the top of the development agenda in Africa. This culminated in the eThekwini Declaration (AfricaSan+5, 2008), in which, among other undertakings, they pledged to create separate budget lines for sanitation and hygiene in their countries and to commit at least 0.5% of the total gross domestic product (GDP) for this purpose, although it can be said that many countries have not yet met their commitment. Taking Sierra Leone again as an example, where Options has worked with the partners in the Health Budget Tracking Consortium and the WASH Network, there is a well-developed narrative to advocate for the government of Sierra Leone to achieve its commitment to meet double that of the eThekwini pledge (The Budget Tracking Working Group, 2013; WASH Network, 2013).
The authors offer key points of action to support better IPC policies, but these need to be implemented by adapting conceptual frameworks for local contexts to make it easy to interpret, and they need to be tangible and achievable for health facilities in low and middle income countries. Further, we need to take into consideration other ways to reduce infections, including healthcare-associated infection and antimicrobial resistance. For example, reducing the number of caesarean sections or vaginal examinations that are conducted unnecessarily, or adopting clinically-proven practices that are non-invasive and just as effective, such as the use of misoprostol and mifepristone for the management of abortion or post-abortion care, rather than invasive procedures.
There are many important concepts introduced in the paper, such as integration, patient-centred care and resilient health services. However, many such concepts have not been defined concretely or consistently, so we should not assume consensus on the use of these terms when considering the dialogue. Further, many terms may seem abstract and academic to front-line health workers, so when considering this paper at a practical level, the models need to be carefully defined to make sure that every person at every level can understand them and that they are working towards a shared understanding. Even those ideas that may seem to be tangible and understandable concepts can be misunderstood – and therefore applied differently. For example, IPC and quality are central themes in the paper, but without a clear definition of how the authors understand these, they are open to misinterpretation.
Finally, nurses cannot and should not be expected to achieve IPC alone; they are key in achieving effective IPC, but only if support and collaboration of all other healthcare workers can be solicited, including the cleaners, auxiliaries, doctors, receptionists, laboratory workers, managers, policy makers, etc., and who all have a role to play in achieving IPC. However, for nurses and other health providers to achieve IPC, they need to be able to access information about it easily and free from technocratic language. Where nurses could play a key role is in sharing or reading more examples of best practice from their clinical areas in less technocratic language, and I look forward to seeing more case studies in the future.