Dr Kumar Gaurav, the top official at Jawahar Lal Nehru Medical College and Hospital, speaks to a nurse who contracted COVID-19, Bhagalpur, July 2020. Photo: Reuters/Danish Siddiqui.
Hospital-acquired infections (HAIs), also known as nosocomial infection, are those infections occurring in a patient when they are receiving care in a hospital or other similar healthcare facility, and which wasn’t present or incubating at the time of admission. HAIs can affect patients in different settings where they receive care, can appear after discharge and also include occupational infections among hospital staff.
The current pandemic has exacerbated the problem of HAIs by heightening the risk not only for healthcare workers (HCWs) but also for the family and friends of admitted patients, as well as those visiting the hospital. In addition, millions of Americans have also been jeopardising their health by avoiding hospital care, even in medical emergencies, for fear of contracting COVID-19. The story is no different in India, with several reports confirming similar trends.
According to the WHO, hundreds of millions of patients are affected by HAIs around the world every year, leading to significant mortality and huge financial losses. For every 100 hospitalised patients, seven in high-income and 10 in middle-income countries develop HAIs. And the ICU-acquired infection rate is at least 2-3-times higher in middle-income countries than that in high-income countries, where it’s about 30%. Dr Soumya Swaminathan, the chief of the Indian Council of Medical Research (ICMR) in 2017, and now chief scientist at the WHO, admitted in the British Medical Journal that year that India does not have accurate estimates of the burden of HAIs.
The Indian Medical Association (IMA) has cited government data that 87,000 HCWs have been infected and 573 of them have died due to COVID-19. IMA’s own data accounts for 307 deaths among HCWs. A recent study in the UK and the US, published in The Lancet, showed that HCWs have a threefold greater risk of testing positive for COVID-19 compared to the general population. An ICMR study has suggested that 5% of front line healthcare workers may be getting infected with COVID-19.
Indeed, the pandemic has exacerbated the hitherto known burden of HAIs worldwide in terms of excess costs, prolonged hospital stays, mortality and disability. Today, HAIs have become more challenging to handle, together with the fact that we don’t have proper data nor surveillance protocols.
In addition, an HAI implies the patient’s relatives, hospital staff, other visitors and/or other patients breached infection prevention and control (IPC). All these people also run the risk of being exposed to disease-causing pathogens, with adverse consequences. Quarantine infected HCWs will deplete the facility’s workforce, thus increasing the workload of the HCWs on duty, and create more opportunities for HAIs to occur. Mobilising HCWs from different parts of a hospital to a ward in need may plug the shortage but new workers need time to catch-up.
The International Nosocomial Infection Control Consortium’s chairman Victor D. Rosenthal has discussed higher rates of HAIs in India, following a decade-long study, and advocated for prevention. He also cautioned against overusing antibiotics, doing which could lead to antimicrobial resistance. Dr Swaminathan had urged in 2017 that IPC and surveillance systems would have to be strengthened. The ICMR also published some details in a manual entitled ‘Hospital Infection Control Guidelines’.
WHO has acknowledged the role of defective IPC practices during everyday healthcare delivery, so it floated a campaign asking HCWs, patients’ relatives/friends and other visitors to help save lives starting with good hand hygiene. Some reports have found that hand-hygiene compliance in India before and after a patient comes in contact with HCWs was found to be 66%, 62% and 54% respectively. The overall compliance by patients’ family members was about 46%. This said, there are considerable variations in these figures between different studies. Some also show that compliance with IPC measures improve with a combination of administrative support, education and training, reminders, surveillance and performance feedback. But it tends to ebb with time.
The way ahead
Many resource-constrained health centres across India will obviously be limited in their ability to follow the national guidelines. As a result, the patients at these centres may have to be moved to tertiary hospitals, which are located mostly in cities – resulting in overcrowding, particularly in the emergency department, rendering it fertile ground for HAIs. Instead, hospital emergency services need to be reorganised as soon as possible, to avoid decongestion, with equitable distribution of patient load among departments and hospitals in a region. Failure to do so could imperil all other efforts to minimise HAIs.
Lest we forget, HAIs are not a product of the COVID-19 pandemic; the pandemic only exacerbated HAIs and their consequences. Nearly a decade ago, The Lancet published a systemic review and meta-analysis of 220 articles to assess the burden of HAIs in developing countries. High burdens were attributed to unsafe patient care, and the authors recommended better surveillance and infection control practices. Now, a decade later, where do we stand?
In the absence of data, it’s hard to tell. However, the pandemic has certainly changed medics’ patronising approach towards HAIs, especially they’re also at risk of these infections. Now every stakeholder must be proactive to save others as much as themselves, and make hospitals safe for all.
Dr L.R. Murmu is a professor of emergency medicine (surgery) in the department of emergency medicine at the All India Institute of Medical Sciences, New Delhi. The views expressed here are the author’s own.