HEALTHCARE-ASSOCIATED INFECTIONS AT SELECTED HOSPITALS IN THAILAND.

This study aimed to determine the prevalence of healthcare-associated infections (HAIs), all-cause mortality, document the bacterial pathogens isolated in HAIs, and determine the risk factors associated with HAIs and all-cause mortality at selected hospitals in Thailand. A survey with a total time frame of 10 days was conducted at selected 50 hospitals across Thailand during January 2014: 19 primary government hospitals, 15 secondary government hospitals, 13 tertiary government hospitals, 2 private hospitals and 1 government university hospital. Of 15,475 cases reviewed, 688 patients had 791 HAIs (1.1 HAI per infected patient). The rate of HAI was 4.4% (95%CI: 4.1-4.8): 7.3% (95%CI: 4.6-9.3) at the university hospital surveyed, 5.0% (95%CI: 4.6-5.4) at the tertiary hospitals surveyed, 3.9% (95%CI: 3.4-4.6) at the secondary hospitals surveyed, 2.0% (95%CI: 1.3-2.7) at the primary hospitals surveyed, and 1.6% (95%CI: 0.5-2.8) at the private hospitals surveyed. The ward with the frequent number of HAI was the intensive care unit (17%). The two most commonly affected age ranges were those aged >60 years and <1 year. Of the 791 HAIs found in this survey, the 3 most frequently reported types of HAI were: respiratory tract infections (n=377, 48%), urinary tract infections (n=176, 22%) and surgical site infections (n=55, 7%). Of the 688 patients with a HAI, 24% died within three months of this survey. The most frequently reported bacterial pathogen was Acinetobacter species (17%). On multivariate analysis, HAIs were significantly associated with patient age <1 year, a university hospital, having major surgery, urinary catheterization, being on a respiratory ventilator, having a tracheostomy, and having central venous catheterization (p <0.05). Death was associated with patient age <1 year, a university hospital, being on a surgical or medical ward, being on a ventilator, and having a central venous catheter (p <0.05). HAIs are major public health problems in the studied hospitals and result in substantial mortality.

Health-care associated infections in Thailand 2011.

OBJECTIVE: To study the recent trend of health-care associated infections (HAIs) across Thailand. MATERIAL AND METHOD: Using the modified international HAI definitions, the investigators conducted a prospective, nationwide, multi-centered survey to determine a 1-day point-prevalence of HAIs among hospitalized patients in the 47 acute care, primary to tertiary hospitals in January 2011. RESULTS: Of total 10,762 patients (female 50.6%, mean age 44.2 +/- 27.3 years) enrolled in the study, 780 had HAIs or the average prevalence of HAIs was 7.3% (range 2.8-8.5%). Highest rates of HAIs were found in other hospitals (other type of tertiary-care facilities), intensive care units and lower respiratory tracts when stratified by type of hospital, unit of service and site of HAIs, respectively. Gram negative bacteria remained predominant among etiologic agents causing HAIs, as in prior studies. Acinetobacter spp., however emerged as the most common organism. At the time of study, 49.3% of all patients received one or more antimicrobial agents. Among the patients with HAIs, cephalosporins were the most commonly used. CONCLUSION: Recently, no significant change on nationwide prevalence and trend of HAIs in Thailand were demonstrated. Notably, Acinetobacter spp. emerged as the most common etiologic agents of HAIs.

Contribution of examiner subjectivity and patient heterogeneity on long case examination.

OBJECTIVE: To evaluate the effect of examiner subjectivity and heterogeneity among the cases on scores from the Royal College of Physicians (RCPT) long case examination. MATERIAL AND METHOD: Data from internal medicine candidates who performed clinical part of RCPT board certifying examination in academic year 2008 were collected. For each candidate, scores from pair of examiners for each of the long case was stratified based on disease category according to the course syllabus into 3 groups; very common, common and uncommon diseases. The scores also categorized according to difficulty level subjectively and rated by the examiners into 3 levels; easy, moderate and difficult. Mean scores in each group of encounters were compared using ANOVA. RESULTS: There were 21 examination centers involved with 1,840 number of encounters by 232 candidates. Among 437 patients that have been used for the long case, common scenarios (27.6% of the total) were cirrhosis, hyperthyroidism, cerebral thrombosis, bronchogenic carcinoma, rheumatic heart disease and thalassemia. Mean and SD of scores from the very common, common and uncommon diseases were 75.5 +/- 11.6, 75.6 +/- 10.6 and 74.7 +/- 11.3 respectively, with no statistical significant difference between the groups. Mean and SD of scores from the easy, moderate and difficult cases were 76.1 +/- 10.5, 74.8 +/- 11.0, 75.5 +/- 10.9 respectively. The moderate group has the lowest score with a statistical significant difference from other groups (p = 0.042). CONCLUSION: In current RCPT long case examination, difficulty of the case appears to contribute to variation in scores derived from the examiners. Measures for score adjustment and examiner calibration should be implemented in the future.

Reliability and validity of long case and short case in internal medicine board certification examination.

OBJECTIVE: To be certified for the Thai Board of Internal Medicine, each candidate must pass both written and clinical examinations performed in different academic years. The present study aimed to assess the reliability and validity of the long case and short case which contribute major fractions in the clinical part of board certifying examination. MATERIAL AND METHOD: Data from 585 internal medicine residents entering a first-attempt clinical part in board certifying examination during the academic year 2005-2007 were collected. Inter-rater reliability and construct validity of the long case and short case were then examined. RESULTS: Good to excellent intraclass correlation (ICC) of scores from different examiners was demonstrated (ICC between 0.71 and 0.97) and the variation ranged from 15.3 to 27.3%. For different occasions of examination, class normalized gain was between -0.7 and -9.0% and negative individual normalized gain was observed in 45.6% to 48.2% of the candidates. CONCLUSION: Acceptable inter-rater reliability was demonstrated in long case and short case in clinical examination for the Thai Board of Internal Medicine. But construct validity for this type of clinical assessment was not established.

Prevalence of nosocomial infection in Thailand 2006.

OBJECTIVE: To study the prevalence of nosocomial infection (NI). MATERIAL AND METHOD: A point prevalence study was done in 20 hospitals across the country in August 2006. RESULTS: The present study was done in 20 hospitals: three university, five regional, five provincial, and seven other hospitals. 9,865 patients were included Male and female patients were almost equal in number with an average age of 42.7 years. The NI proportion was 6.5%, 7.0% in male and 5.9% in female patients. The prevalence rate of NI was highest in university and other hospitals (7.6%), followed by provincial (6.0%), and regional hospital (4.9%). There were two hospitals, one regional and one other hospital with NI prevalence rates over 10%. All three university hospitals had NI exceeding 7%. The infection rate was highest in ICU (22.6%), followed by surgical (6.8%), medical and orthopedic (6.7% each) departments. The commonest site of NI was lower respiratory tract (36.1%) followed by urinary tract (25.5%). Causative organisms were identified in 70.8% of all sites of infection and over 63% were by bacteria. Gram-negative bacteria were responsible for 70.2% and gram-positive bacteria for 19.9% of all pathogens. Pseudomonas aeruginosa, Klebsiella spp., Acinetobacter baumannii, MRSA, and enterococci were the leading bacterial isolates. At the time of the present study, 47.0% of patients were receiving antimicrobials. Cephalosporins, penicillins, and aminoglycosides were most commonly used CONCLUSION: The prevalence rate of NI in Thailand in 2006 was 6.5%, similar to previous studies. Changes in NI rates in certain hospitals, even though subtle, need additional studies to improve the efficacy of NI control.

Risk factors for multi-drug resistant Acinetobacter baumannii nosocomial infection.

OBJECTIVE: To assess factors associated with multi-drug resistant Acinetobacter baumannii (MDR-AB) nosocomial infection. MATERIAL AND METHOD: This hospital-based case-control study was conducted in patients admitted to Siriraj Hospital, Bangkok, Thailand between January 1, 2005 and December 31, 2005. The study population consisted of 155 cases with MDR-AB nosocomial infection and 310 controls without nosocomial infection. The cases were matched with controls by age and ward of admission with a ratio of 1:2. RESULTS: The average age of the present study population was 63.5 +/- 18.7 years among cases and 62.9 +/- 18.2 years among controls. The mean of length of stay in hospital among cases was 4.9 +/- 1.4 weeks and controls 1.8 +/- 1.0 weeks. The most common site of MDR-AB nosocomial infection was lower respiratory tract (74.8%). The antimicrobial susceptibility of MDR-AB was 3.9% to cetriaxone and 42.1% to cefoperazone/sulbactam. Multiple logistic regression analysis showed the following associated factors with MDR-AB nosocomial infection: duration of admission prior to MDR-AB nosocomial infection > 1 week (OR = 2.06; 95% CI 1.09-3.89), indwelling urinary catheter > 1 week (OR = 8.24; 95% CI 3.81-17.82), mechanical ventilation > 1 week (OR = 5.73; 95% CI 2.96-11.10), central venous line > 1 week (OR = 3.29; 95% CI 1.48-7.31), nasogastric intubation > 1 week (OR = 6.22; 95% CI 3.24-11.93), prior administration of 3rd-4th generation cephalosporins (OR = 1.80; 95% CI 1.04-3.13), metrodazole (OR = 2.59; 95% CI 1.21-5.56), and piperacillin-tazobactam (OR = 4.68; 95% CI 1.93-11.32). CONCLUSION: A case-control study in medical and surgical patients in Siriraj Hospital in 2005 revealed risk factors for AB nosocomial infection. Prolonged admission of more than 2 weeks, use of devices, and prior treatment with certain antimicrobials were found to be significant risk factors for the infection. To reduce the infection, strict infection control measures must be applied to the patients with these risk factors. Education to medical personnel and enforcement of infection control practices are all needed to reduce antimicrobial resistant bacterial nosocomial infection.

Effectiveness of education and an antibiotic-control program in a tertiary care hospital in Thailand.

BACKGROUND: We conducted a study to evaluate the impact of education and an antibiotic-control program on antibiotic-prescribing practices, antibiotic consumption, antimicrobial resistance, and cost of antibiotics in a tertiary care hospital in Thailand. METHODS: A study of the year before and the year after the intervention was performed. Inpatient antibiotic prescriptions were prospectively observed. Demographic characteristics, hospital unit, indication for antibiotic prescription, appropriateness of antibiotic use, reasons for inappropriate antibiotic use, antibiotic consumption (i.e., the rate of antibiotic use), bacterial resistance, and antibiotic cost data were collected. Interventions included education, introduction of an antibiogram, use of antibiotic prescription forms, and prescribing controls. RESULTS: After the intervention, there was a 24% reduction in the rate of antibiotic prescription (640 vs. 400 prescriptions/1000 admissions; P<.001). The incidence of inappropriate antibiotic use was significantly reduced (42% vs. 20%; P<.001). A sustained reduction in antibiotic use was observed (R2=0.692; P<.001). Rates of use of third-generation cephalosporins (31 vs. 18 defined daily doses [DDDs]/1000 patient-days; P<.001) and glycopeptides (3.2 vs. 2.4 DDDs/1000 patient-days; P=.002) were significantly reduced. Rates of use of cefazolin (3.5 vs. 8.2 DDDs/1000 patient-days; P<.001) and fluoroquinolones (0.68 vs. 1.15 DDDs/1000 patient-days; P<.001) increased. There were no significant changes for other antibiotic classes. Significant reductions in the incidence of infections due to methicillin-resistant Staphylococcus aureus (48% vs. 33.5%; P<.001), extended-spectrum beta -lactamase-producing Escherichia coli (33% vs. 21%; P<.001), extended-spectrum beta -lactamase-producing Klebsiella pneumoniae (30% vs. 20%; P<.001), and third-generation cephalosporin-resistant Acinetobacter baumanii (27% vs. 19%; P<.001) were also observed. Total costs saving were USD 32,231 during the study period. CONCLUSIONS: Education and an antibiotic-control program constituted an effective and cost-saving strategy to optimize antibiotic use in a tertiary care center in Thailand.

Inappropriate antibiotic use in a tertiary care center in Thailand: an incidence study and review of experience in Thailand.

The incidence and patterns of and factors associated with inappropriate antibiotic use were studied in a tertiary care center in Thailand. The incidence of inappropriate antibiotic use was 25%. Admission to the surgical department (adjusted odds ratio, 2.0; P=.02) and to the obstetrics and gynecology department (adjusted odds ratio, 2.0; P=.03) were associated with inappropriate antibiotic use, whereas consultation with an infectious diseases specialist was protective against inappropriate antibiotic use (adjusted odds ratio, 0.15; P=.01).

Discriminatory powers of molecular typing techniques for methicillin-resistant Staphylococcus aureus in a university hospital, Thailand.

Discriminatory powers of various molecular techniques were evaluated for typing of methicillin-resistant Staphylococcus aureus (MRSA) isolated in Siriraj Hospital, Bangkok, Thailand. Thirty MRSA isolates were randomly selected in this study. They were characterized by pulsed-field gel electrophoresis, Clal-mecA and Clal-Tn554 polymorphisms, ribotyping, and PCR-based methods including SCCmec typing, spa and coa gene polymorphism, and repeat units in hypervariable region downstream of mecA. Individual molecular typing technique distinguished those MRSA isolates into 2 to 5 types. Eleven genetic backgrounds of MRSA isolates were elucidated by combination of typing methods with trimethoprim/sulfamethoxazole (TMP/SXT) susceptibility. Combination of all typing methods including TMP/SXT susceptibility yielded a discriminatory index of 0.94. Combination of PCR-based methods and TMP/SXT susceptibility, with the discriminatory index of 0.89, is a practical typing approach suitable for rapid epidemiological investigation of MRSA isolates in a hospital setting.

Microbial and heavy metal contamination of treated hospital wastewater in Thailand.

OBJECTIVES: To determine the microbial and heavy metal contamination of treated hospital wastewater MATERIAL AND METHOD: Methods of treating wastewater were acquired by questionnaires. Chlorine concentration, pH, bacteria and parasites in treated wastewater were tested in the individual hospitals. Heavy metal concentrations were measured by atomic absorption spectrophotometry. RESULTS: In 2002, 72 hospitals were included in the present study. The common methods of treating wastewater were activated sludge and oxidation ditch. Bacteria exceeded standard numbers, pathogenic bacteria and parasites were found in two-thirds of the hospitals. Heavy metals, namely lead, chromium and cadmium, in the hospital effluent did not exceed standard concentrations. CONCLUSION: Micro-organisms exceeding standard levels were found in treated wastewater in two-thirds of the hospitals. Lead, chromium and cadmium levels in hospital effluent were in an acceptable range.

Cost-effectiveness and safety of reusable tracheal suction tubes.

OBJECTIVES: To evaluate whether the repetitive use of disposable tracheal suction tubes is cost-effective and safe over the single use. MATERIAL AND METHOD: The cost intrinsic to the washing, cleaning, re-sterilization by ethylene oxide gas, and processing was determined and compared to the cost generated by disposable tubes. The reused disposable suction tubes were also determined for their properties in physical characters and probable contamination and damages. RESULTS: The evaluation showed that cost from single-use disposable suction tubes (8.66 baht) was cheaper than expenses generated from processing steps for recycling of disposable tubes (9.92 baht). The use of a disposable tube only once should minimize the risks posed by the use of the potentially unsafe reused disposable tubes both to the patients and health care workers. CONCLUSION: Recycling of tracheal suction tubes was neither cost-effective nor safe.

Development of quality indicators for sterilization practices of the central sterile supply department.

OBJECTIVE: To develop quality indicators for assessing the performance of central sterile supply department. (CSSD). MATERIAL AND METHOD: Quality indicators for sterilization in CSSD were searched by literature review and by current situation analysis by 79 infection control nurses (ICNs) and 83 heads of CSSD. Quality indicators were drafted and subsequently validated by 5 experts. The feasibility and applicability of the quality indicators were tested in 37 ICNs and 34 heads of CSSD. The quality indicators were finally refined by a forum of 5 experts and 5 representatives from CSSD. RESULTS: A total of 30 quality indicators were developed. These include 9 indicators for structure, 12 for process and 9 for output of CSSD. The quality indicators were deemed appropriate for the assessment of the quality of CSSD in Thailand. CONCLUSION: Thirty indicators were developed for assessing the quality of CSSD.

Quality of nosocomial infection control in Thailand.

OBJECTIVE: To study the quality of nosocomial infection control with respect to structure and process. MATERIAL AND METHOD: Data collection by questionnaire and interview administrators and medical personnel in 57 hospitals in Thailand in 2002. RESULTS: Nosocomial infection control was implemented in all 57 hospitals. In every hospital, there was an infection control committee (ICC) and at least 1 infection control nurse (ICN). The quality of ICNs regarding knowledge, skill and time available for infection control needed to be improved. Surveillance methods of NI were not appropriate in many hospitals. Doctors were not interested in NI control and supply of certain materials was not adequate. Lack of support and co-operation of doctors and nurses was found. Service of certain departments needed to be revised in over 50%. Doctors and nurses not directly involved in NI controlled were not satisfied with current practices. CONCLUSION: Quality of NI control in Thailand has yet to be improved regarding structure and process. Better cooperation between NI control team and healthcare personnel needs to be developed.

Persistence of antimicrobial effect of antiseptics in surgical hand hygiene regimens.

OBJECTIVES: To determine the persistence of antimicrobial effect of antiseptic solutions used in surgical hand hygiene procedure, and the in-house preparation was compared to the commercial solution for its efficacy. MATERIAL AND METHOD: The present study was performed in a 150-bed hospital involving 19 staff from general, orthopedics, KUB, and OB-GYN surgical teams in 48 operations. The antimicrobial effects from 4 different solutions were determined and compared. RESULTS: The study showed that the commercial alcohol-based antiseptic solution was equally or more effective than long-time accepted povidone-iodine or chlorhexidine gluconate solutions and had better persistent effect. The in-house preparation was effective comparable to the commercial solution. CONCLUSION: The commercial alcohol-based antiseptic solution had better persistence of antimicrobial effects compared to the in-house alcohol-based hand rub, povidone iodine and chlorhexidine gluconate.

Endemic Serratia marcescens in a neonatal intensive care unit.

OBJECTIVE: To study the endemicity of Serratia marcescens in a neonatal intensive care unit (N.I.C.U). MATERIAL AND METHOD: During the first 4 months of 2001, neonates in the N.I.C.U. in a teaching hospital were screened for S. marcescens by serial throat swabs and collections of other appropriate clinical specimens. Environmental cultures were also done in the same period. Isolated S. marcescens were tested for antimicrobial susceptibility and for genotyping by pulsed field gel electrophoresis. RESULTS: During the period, 104 neonates were studied. S. marcescens were isolated in 34.6% of the cases. Environmental cultures were positive for S. marcescens in 1.4%. There were 10 patterns of antibiogram of the 190 strains isolated. All strains belonged to pulsotype A. CONCLUSION: The study confirmed that S. marcescens was endemic in the N.I.C.U. and belonged to one genotype.

Antimicrobial susceptibility of community and hospital acquired bacteria.

OBJECTIVES: To study the antibiotic susceptibility of common community- and hospital-acquired bacteria in Thailand. MATERIAL AND METHOD: Eight common bacterial pathogens were studied in 24 hospitals across Thailand in 2002-2003. Isolates of clinically proven infections were tested for their susceptibility by agar-based disc diffusion method. RESULTS: A total of 9,091 isolates of target bacteria were studied. Community and hospital acquired bacteria accounted for 54.9% and 45.1% respectively. Community acquired Escherichia coli, Klebsiella pneumoniae, Acinetobacter spp., Enterobacter spp., Staphylococcus aureus were more susceptible to antimicrobials compared to hospital acquired strains. The difference in susceptibility of community-acquired vs hospital acquired Pseudomonas aeruginosa, Coagulase-negative staphylococci and Enterococcus spp. was less impressive indicating the spread of hospital strains into the community. Bacteria isolated from the blood stream were more susceptible to antimicrobials compared to those from the lower respiratory tract, urinary tract and surgical sites. Acinetobacter spp. and Enterococcus spp. were less susceptible to antimicrobials compared to others. CONCLUSION: Decreased susceptibility to antimicrobials was found in all bacteria tested. The susceptibility to commonly used antimicrobials of community-acquired bacteria decreased to a critical level indicating the widespread resistant bacteria to the community.

Catheter-associated urinary tract infection.

OBJECTIVES: To study the incidence, risk factors, clinical outcomes and antibiotic costs of catheter-associated urinary tract infections (CAUTI) in patients with indwelling urinary catheter for one week and longer MATERIAL AND METHOD: Patients in neurology and neurosurgery wards in a teaching hospital were studied. Patients with UTI before catheterization and in whom the catheter was removed before one week were excluded. Urine cultures were done immediately after catheterization and 3 times a week there after. Patients were followed for symptoms of UTI for 1 week after catheter removal, for 4 weeks without evidence of UTI or until discharge. RESULTS: One hundred and one patients met the inclusion criteria. The incidence of CA UTI was 73.3%. High incidence of CAUTI was found in the first 2 weeks after catheterization. About one-half of the patients with CAUTI had a single episode and were symptomatic. None of the 132 episodes of CAUTI were associated with secondary bacteremia. Risk factors for CAUTI identified were prolonged catheterization and change of the catheter Nosocomial pathogens were found in urine and yeast was the commonest. Eleven patients (14.9%) with CAUTI died and only in 2, CAUTI was considered a contributory factor for mortality. The cost of antimicrobials for treating one episode of CAUTI was 8,180 baht and this rose to 49,983 baht for CAUTI associated with concurrent infections at other sites. CONCLUSION: Catheter-associated urinary tract infection was common. Uropathogens were nosocomial micro-organisms with high incidence of resistance to antimicrobials. Impacts on morbidity, mortality and costs were substantial. Better management of urinary catheter is to be explored and implemented.

Effect of an education program on the prevention of ventilator-associated pneumonia: A multicenter study.

OBJECTIVE: To evaluate the effect of an educational program targeted on modifiable risk factors on ventilator-associated pneumonia (VAP) rates. MATERIAL AND METHOD: After a preliminary study on VAP risk factors was conducted at one teaching hospital, a pre- and post-interventional study was then performed on 12 hospitals in Thailand from January 1, 2002 to June 30, 2003. Each hospital randomly selected 20 patients, who were on mechanical ventilation to be enrolled The study was divided into two phases; 1) pre-intervention, 2) post-intervention. Data collected included patients 'demography and risk factors for VAP During pre-interventional phase, data on risk factors for VAP was analyzed and fedback to healthcare providers in the wards by an infection control nurse (ICN) of the individual hospital. An educational programme on the prevention of VAP was introduced by the ICN. Ventilator-associated pneumonia rates and their risk factors were continuously monitored during the post-interventionl phase. RESULTS: Two hundred and forty four patients in the pre-interventional phase and 254 patients in the post-interventional phase were included. There was no significant difference in the demography between these two patient populations. After the intervetion, there was a significant improvement in hand-hygiene practices (p<0.001) among healthcare providers and increased use of sucralfate (p=0.05) for stress ulcer prophylaxis. Ventilation-associated pneumonia rate (40.5% vs. 24%; p<0.001) and crude mortality rate associated with VAP (12.3% vs. 8.7%; p<0.001) were also reduced CONCLUSION: The educational programme targeted on modifiable risk factors for prevention of VAP was effective and should be considered as an intervention to reduce VAP rates in developing countries.

Bacterial flora--A potential source of endophthalmitis after cataract surgery.

OBJECTIVES: To study bacteria from eye lids and conjunctival sac of patients undergoing cataract surgery before and after the application of antiseptics. MATERIAL AND METHOD: Patients undergoing elective cataract extraction in one university hospital were randomly enrolled. Cultures for bacteria and candida were done by swabbing the eye lids before and after cleaning with 4% chlorhexidine gluconate. Subsequently 10% povidone iodine was applied on eye lids and conjunctival sacs. Cultures of specimens from eye lids and conjunctival sac were taken after the application of 10% povidone iodine and at the end of the operation. RESULTS: Fifty-one patients were enrolled. Positive cultures were found in 90.2% and 82.4% before and after cleaning the face with 4% chlorhexidine. After topical application of 10% povidone iodine, only 19.6% had positive cultures from eye lids and conjunctival sac; a significant reduction (p=0.001). At the end of the operation, positive cultures were found from eye lids in 10 patients and from the conjunctival sac in 4 patients. Isolates were skin flora and candida species in 2 patients. None of the patients had endophthalmitis. CONCLUSION: Cleaning eye lids with 4% chlorhexidine followed by applying 10% povidone iodine was effective in decreasing skin flora in cataract surgery. The organisms were not completely eliminated. Postoperative follow-up to detect infectious complications is warranted.

Prevention and treatment of infectious diseases in healthcare workers.

OBJECTIVES: To study the prevention and treatment of infectious diseases offered to healthcare workers (HCWs) in Thailand. MATERIAL AND METHOD: Data were collected by interviewing in 2002. RESULTS: A total 1,218 HCWs in 33 hospitals were interviewed. Nurses and doctors were the majority group, accounting for 31.5% and 30.5% respectively. Pre-employement health screenings were done by physical examination in 56.0% and chest X-ray in 55.7% and immunization against hepatitis B and tubuculosis were offered in 17.7% and 11.4% respectively. Annual physical examination and chest x-ray were done in 66.3% and 76.9%. Reported infection with hepatitis A hepatitis B, tuberculosis in HCWs were as high as 16.8%, 4.0% and 2.6% respectively. Only 3.5% to 24.3% of HCWs ever read guidelines on the prevention of infection. Existing laws allowed the implementation of prevention, treatment and compensation in case of occupationally acquired infection in HCWs. CONCLUSION: Prevention of infection in HCWs was implemented far below the ideal level. They should be better protected under existing laws.