AIHA Infection Control Initiative

“Germs are a part of nature and we cannot conquer nature, so we know that we will never be able to eradicate hospital-acquired infections. Instead, we have to learn either how to make friends with nature or how to fight it more effectively. Our work with AIHA has taught us how to do that.”

— Slava Lyubimenko, chief neonatologist at St. Petersburg City Children’s Hospital No. 1 in St. Petersburg, Russia, who received training through AIHA’s Infection Control Program

AIHA’s Infection Control Initiative was a cross-partnership project designed to support our USAID Health Partnership Programs in Eurasia from 1992 through 2008. At that time, considerable media attention was focused on tuberculosis and HIV/AIDS in the countries of Eastern Europe and Central Asia, but much less consideration was given to nosocomial infections, also known as hospital-acquired infections.

Hospital-acquired infections are a significant problem in healthcare facilities the world over. They have widespread negative impact on patient mortality, morbidity, and the overall quality of care. In the transitioning health systems of Eurasia, however, they also represented an enormous and unnecessary drain on already limited resources.

Hospital-acquired infections were the leading adverse outcome of hospitalization in Eastern Europe and Central Asia with an average hospital stay for surgical procedures lasting 30-55 percent longer there than in the United States. In a hospital setting, communicable diseases can be spread through casual contact among patients, healthcare staff, and visitors with alarming ease — especially if proper infection control practices that are a standard part of evidence-based medicine are not implemented.

A few short months after AIHA established our first hospital-based partnerships, the need to implement comprehensive infection control programs became apparent. A hospital-acquired infections was the likely outcome of even the simplest of surgeries, which necessitated longer hospital stays and the extended use of antibiotics. This, in turn, justified large and costly facilities with many beds and the further waste of limited resources. Because infection control emerged as a universal concern at facilities throughout Eurasia at this time, AIHA launched the Infection Control Initiative to support the changes being made through our healthcare partnerships.

In several countries where AIHA partnerships selected infection control as a priority activity, their efforts coincided with — and in many cases catalyzed — regulatory changes at both regional and national levels. In 1993, for example, the Russian Ministry of Health issued the first mandate for the formal establishment of a hospital-based infection control program that included the creation of physician-nurse hospital epidemiology teams to oversee related policies and practices at their institutions. Following the Russian example, other countries of the former Soviet Union have also attempted to institutionalize hospital infection control.

All AIHA partnerships in the region — particularly those that focused on clinical care — addressed infection control in some manner; about 22 partnerships in Albania, Armenia, Croatia, Kazakhstan, Russia, Tajikistan, and Ukraine also participated directly in our Infection Control Initiative.

Infection Control Training Centers

In close collaboration with the Russian Ministry of Health, AIHA established in 1997 the first Infection Control Training Center in the former Soviet Union at the St. Petersburg Medical Academy. Licensed by the Russian Ministry of Health and Ministry of Education, the facility served as an epidemiological center of excellence providing training and practical advice to infection control practitioners, hospital epidemiologists, and clinicians in the Russia’s northwest region.

In 2001, AIHA opened Infection Control Training Centers in Almaty, Kazakhstan; Kyiv, Ukraine; and Tbilisi, Georgia, in cooperation with each country’s Ministry of Health to facilitate improved infection control practices within the hospitals and laboratories.

While hospital infection control in the former Soviet Union had a strong hygienic tradition — most hospitals in the region are kept sufficiently clean — nosocomial infections were more likely to be spread through person-to-person contact, so additional emphasis on patient care practices was needed.

Building on the successful training center model used for our Emergency and Disaster Medicine and Neonatal Resuscitation programs, AIHA created a comprehensive plan for establishing Infection Control Training Centers (ICTCs) that addressed issues such as developing targeted curricula, educating faculty in evidence-based infection control standards and adult-learning techniques, and compiling appropriate reference and teaching materials. By the time the project concluded we had established four of these Training Centers, one each in Georgia, Kazakhstan, Russia, and Ukraine.

The cornerstone of each of ICTC was a one-week Basic Infection Control Course that was developed for hospital epidemiologists, assistant epidemiologists, and other physicians and nurses who are responsible for infection control practices in their hospitals. This course was introduced by the national ministries of health of Georgia, Kazakhstan, and Russia into the continuing education curriculum for all hospital epidemiologists.

In addition, the first edition of AIHA’s Basic Infection Control Manual for nations in the region — co-authored by U.S. and Russian infection control experts — was published in 1997 and distributed to all partnership hospitals, major teaching institutions, and national and regional health authorities.

In 2003, the manual was updated under the direction of an international editorial committee that included specialists from Eurasia and internationally recognized American experts. It was used by infection control professionals as both a teaching tool and a major resource in their day-to-day practice. Complementing these key elements, are a host of slides, reference materials, and electronic media that enhance the training experience.

Finally, a special “Train the Trainers” program was designed to ensure ICTC faculty remained current on evidence-based infection control practices and continuing education methods. This program allowed for the gradual involvement of faculty from the region in teaching the Basic Infection Control Course, first jointly with their American partners and then on their own.

Occupational Health

Keeping healthcare providers and allied professionals healthy and at work is critical for hospitals and clinics around the globe, but even more so in resource-constrained settings, which may face serious issues with maintaining adequate staffing levels. Most AIHA partnerships that focus on clinical care or health professions education also addressed issues of occupational health as a way to safeguard medical professionals and help ensure service delivery.

Although universal precautions had not been formally adopted in all the nations of Eastern Europe and Central Asia when AIHA’s USAID-supported Health Partnerships Programs were operational, hospitals had begun placing increasingly more emphasis on the prevention and management of occupational exposure to blood-borne pathogens. Even so, there was an ongoing need for improvement in this area, particularly when it came to immunizing healthcare workers and teaching them how to more effectively reduce their risks.

Occupational infection with hepatitis B virus (HBV), for example, was a significant problem for healthcare workers in the region, yet only a small number of physicians and nurses had been immunized against HBV. Exposure to other communicable infections, such as tuberculosis, HIV, and hepatitis C also posed a serious threat to clinicians and allied health professionals.

Most AIHA partnerships and programs addressed the basics of occupational health and offered opportunities for partners to learn how to effectively protect themselves and their patients from unnecessary exposure to infectious pathogens.

WHONET

Through our Infection Control initiative, AIHA worked to assist ministries of health in Eastern Europe and Central Asia to implement interventions that facilitated the appropriate use of antimicrobial agents in their hospitals and reference labs.

Starting in 1997, our partners at 17 institutions in the region began using WHONET, a Windows-based database software developed for the management of microbiology laboratory data and the analysis of antimicrobial susceptibility test results.

Improvements in patient care and clinical outcomes are predicated on an effective infectious disease surveillance system. To facilitate advances in both these areas, AIHA developed a program for continuous quality improvement in hospital microbiology laboratories. This program included:

• Establishing internal quality control systems for media, reagents, and test performance;
• Introducing current methods of antimicrobial susceptibility testing; and
• Creating an antimicrobial surveillance network using the World Health Organization’s WHONET information system.

The AIHA program began early in 1997 with a thorough evaluation of microbiology laboratories in three partnership hospitals and at three central reference laboratories in Russia and Ukraine. Based on these needs assessments, each six pilot laboratories received equipment and supplies that allowed for quality testing of antimicrobial susceptibility and ongoing monitoring of test results.

Since then, a total of 18 AIHA partnership hospitals throughout Armenia, Georgia, Kazakhstan, Kyrgyzstan, Russia, and Ukraine have implemented the WHONET system; 13 of them were currently active in the program when their partnerships concluded.

Laboratory Services Quality Improvement

Microbiology laboratories in transitioning and developing nations are often both severely under-staffed and under-funded. Evidenced-based procedures aren’t always used due, in part, to lack of necessary equipment and supplies, as well as staff who are trained in their use.

Test results from these laboratories are neither readily available to healthcare providers, nor reliably accurate. Consequently, inappropriate antibiotics are often selected and administered, which inevitably leads to the increasing global problem of antimicrobial resistance.

A well-equipped and adequately staffed microbiology laboratory utilized appropriately by clinicians is a key component of any modern infection control program, as well as a basis for evidence-based clinical management of infectious diseases.

With the goal of improving quality of surveillance and patient care practices, AIHA and our partners developed a program for continuous quality improvement in hospital microbiology laboratories throughout Eastern Europe and Central Asia.

This program included the creation of internal quality control systems for the media, reagents, and test performance; the introduction of modern methods of antimicrobial susceptibility testing; and the establishment of an antimicrobial surveillance network using WHO’s WHONET information system.

This program served as the basis for other work in laboratory services quality improvement, including renovation of lab facilities and advanced training for technicians carried out through AIHA’s USAID-funded Strengthening Tuberculosis Control in Moldova Project and a partnership to build lab capacity in Tanzania funded through the HIV/AIDS Twinning Center in support of the President’s Emergency Plan for AIDS Relief.