Responding to Emerging Diseases Requires Multi-disciplinary and One Health Training, Egypt.

BACKGROUND: In Egypt, several infectious diseases of zoonotic origin have emerged in recent years like H1N1, MERSCoV and H5N1, the latter now endemic. Responding to these diseases requires a workforce trained in multi-disciplinary approaches to zoonotic disease research and control. It is difficult to deliver multidisciplinary and one health training globally because of the limited number of higher education programs that support such training. In low and middle-income countries where the impacts of emerging zoonotic diseases are felt more directly there is enthusiasm for such training and the use of e-technology can foster international, long-term collaborations. OBJECTIVES: To provide health training for infectious diseases research and to foster multidisciplinary collaboration. METHODS: We designed and simultaneously held two training workshops, one focused on pediatric infectious diseases and another on emerging infectious diseases to meet the objective. Both workshops had pre- and post-workshop activities for multi-disciplinary methods with an emphasis on the use of mobile technologies to enhance emerging infectious diseases surveillance and research for public health professionals in Egypt. Faculty and scientists from all universities in Egypt and from the National Research Center were invited to participate. RESULTS: 85 participants attended, 31 abstracts were submitted, and over a 3 year period 3 international grant applications were submitted, and 4 abstracts were presented at international conferences. An online forum was developed to continue building collaboration. CONCLUSIONS: Interactive on-site workshops are suitable for providing multi-disciplinary training for disease surveillance, research and disease control. Participants shared the opinion that grant proposal and scientific manuscript writing were important skills that they felt they did not have. Long term investments in workshops of this nature are needed to build upon the excitement generated by these activities.

Device-associated infection rates in adult and pediatric intensive care units of hospitals in Egypt. International Nosocomial Infection Control Consortium (INICC) findings.

PURPOSE: To determine the rate of device-associated healthcare-associated infections (DA-HAIs) at a respiratory intensive care unit (RICU) and in the pediatric intensive care units (PICUs) of member hospitals of the International Nosocomial Infection Control Consortium (INICC) in Egypt. MATERIALS AND METHODS: A prospective cohort DA-HAI surveillance study was conducted from December 2008 to July 2010 by applying the methodology of the INICC and the definitions of the NHSN-CDC. RESULTS: In the RICU, 473 patients were hospitalized for 2930d and acquired 155 DA-HAIs, with an overall rate of 32.8%. There were 52.9 DA-HAIs per 1000 ICU-days. In the PICUs, 143 patients were hospitalized for 1535d and acquired 35 DA-HAIs, with an overall rate of 24.5%. There were 22.8 DA-HAIs per 1000 ICU-days. The central line-associated blood stream infection (CLABSI) rate was 22.5 per 1000 line-days in the RICU and 18.8 in the PICUs; the ventilator-associated pneumonia (VAP) rate was 73.4 per 1000 ventilator-days in the RICU and 31.8 in the PICUs; and the catheter-associated urinary tract infection (CAUTI) rate was 34.2 per 1000 catheter-days in the RICU. CONCLUSIONS: DA-HAIs in the ICUs in Egypt pose greater threats to patient safety than in industrialized countries, and infection control programs, including surveillance and guidelines, must become a priority.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009.

The results of a surveillance study conducted by the International Nosocomial Infection Control Consortium (INICC) from January 2004 through December 2009 in 422 intensive care units (ICUs) of 36 countries in Latin America, Asia, Africa, and Europe are reported. During the 6-year study period, using Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infection Surveillance system [NNIS]) definitions for device-associated health care-associated infections, we gathered prospective data from 313,008 patients hospitalized in the consortium's ICUs for an aggregate of 2,194,897 ICU bed-days. Despite the fact that the use of devices in the developing countries' ICUs was remarkably similar to that reported in US ICUs in the CDC's NHSN, rates of device-associated nosocomial infection were significantly higher in the ICUs of the INICC hospitals; the pooled rate of central line-associated bloodstream infection in the INICC ICUs of 6.8 per 1,000 central line-days was more than 3-fold higher than the 2.0 per 1,000 central line-days reported in comparable US ICUs. The overall rate of ventilator-associated pneumonia also was far higher (15.8 vs 3.3 per 1,000 ventilator-days), as was the rate of catheter-associated urinary tract infection (6.3 vs. 3.3 per 1,000 catheter-days). Notably, the frequencies of resistance of Pseudomonas aeruginosa isolates to imipenem (47.2% vs 23.0%), Klebsiella pneumoniae isolates to ceftazidime (76.3% vs 27.1%), Escherichia coli isolates to ceftazidime (66.7% vs 8.1%), Staphylococcus aureus isolates to methicillin (84.4% vs 56.8%), were also higher in the consortium's ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 7.3% (for catheter-associated urinary tract infection) to 15.2% (for ventilator-associated pneumonia).

What is the use? An international look at reuse of single-use medical devices.

Reuse of single-use devices is common in most countries worldwide. We provide an overview of the issue from an international perspective. In many developing and transitional countries reuse of cheap single-use devices (needles, syringes, surgical gloves) is common leading to large numbers of unsafe interventions, specifically injections and, as a consequence, infection with hepatitis B, C or HIV. There are various reasons for reuse: limited resources, insufficient knowledge of healthcare workers and the belief of patients that injection is more beneficial than oral medication. Reuse of cheap single-use devices should cease and both medical staff and the public should be informed about potential safety risks associated with injection. In developed countries, reuse of single-use items is less common but may include expensive technical products. Reuse is regulated in many countries (e.g. US, Canada, some European countries) demanding ethical and legal considerations, high standards of reprocessing and training of staff, risk assessment, management and validation of reprocessing. Well regulated reprocessing can decrease the number of single-use devices reprocessed. In developing as well as developed countries, a decision to reprocess single-use devices should only be made after a critical reflection of advantages and disadvantages.

Antibiotic consumption as a driver for resistance in Staphylococcus aureus and Escherichia coli within a developing region.

BACKGROUND: This study aimed to provide insight into possible antibiotic drivers of methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli resistant to third-generation cephalosporins (3GCREC) in southern and eastern Mediterranean institutions. METHODS: MRSA and 3GCREC susceptibility proportions from 19 regional hospitals, previously published by the ARMed project, were correlated with antibiotic use data from the same institutions. RESULTS: Hospitals reporting below-median MRSA proportions had significantly lower total antibiotic use. MRSA proportions increased with greater use of carbapenems (P=.04). In multivariate analysis, a positive correlation was identified with the use of carbapenems (P=.002), combination penicillins (P=.018), and aminoglycosides (P=.014). No difference was ascertained between 3GCREC proportions and total antibiotic use. In multivariate linear regression, a correlation was identified only for 3GCREC (P=.005), but a negative association was evident for beta-lactamase-resistant penicillins (P=.010) and first-generation cephalosporins (P=.012). CONCLUSIONS: The results suggest an association between resistance and antibiotic use, especially for carbapenems and third-generation cephalosporins. These data support the urgent implementation of antibiotic stewardship initiatives in hospitals in developing countries that focus on more judicious use of broad-spectrum formulations.

Health care worker perceptions of hand hygiene practices and obstacles in a developing region.

A structured self-assessment questionnaire was distributed to 8 southern and eastern Mediterranean hospitals to identify perceived obstacles to hand hygiene (HH). An insufficient number of sinks and alcohol handrub stations was rated by the vast majority of respondents as the most critical impediment, whereas improved availability of HH products was deemed the key intervention to increase compliance. The least importance and relevance were given to HH auditing and collegial reminders. While initiatives to improve HH compliance clearly must address infrastructural inadequacies, sociocultural issues also need to be considered when transposing initiatives found to be successful in Western countries to less-developed regions, to ensure that campaigns are not compromised by perceptual undercurrents.

Self-protection as a driver for hand hygiene among healthcare workers.

A total of 2,725 healthcare workers in 8 Mediterranean countries replied to a self-assessment questionnaire that assessed their perceptions on hand hygiene. Responses revealed that rates of hand hygiene compliance before patient contact were significantly less than rates after patient contact (P < .001) and that use of soap and water was preferred over use of alcohol-based hand rub. These findings suggest that self-protection could be a major subliminal driver for performance of hand hygiene.

Self-medication with antibiotics in the ambulatory care setting within the Euro-Mediterranean region; results from the ARMed project.

Anecdotal data from the southern and eastern Mediterranean region suggests that self-medication with antibiotics is commonly practiced in many countries. In order to provide proper information on the situation, we undertook short structured interviews in out-patients clinics or primary health centres in Cyprus, Egypt, Jordan, Lebanon, Libya, Tunisia and Turkey. A total of 2109 interviews were undertaken of which 1705 completed the full questionnaire. Self-medication was reported by 19.1% (<0.1% in Cyprus to 37% in Lebanon) of respondents. Intended self-medication ranged from 1.3% (95% CI 0%, 3%) in Cyprus to 70.7% (95% CI 64%, 77%) in Jordan. Upper respiratory tract symptoms were the most frequent reasons for which respondents indicated they would self-medicate. 48.4% of the whole group replied that they kept antibiotics at home, being highest in Lebanon (60%, 95% CI 51%, 69%). We found a significant association between antibiotic hoarders and intended users of antibiotics for self-medication. Our data confirms that non-prescribed antibiotic use is high within ambulatory care in southern and eastern Mediterranean countries, being almost twice that reported in a similar European study. Corrective efforts are clearly required in the region to ensure proper use of antimicrobials so as to reduce pressure for antimicrobial resistance.

Evolution of infection control in Egypt: achievements and challenges.

BACKGROUND: The high prevalence of hepatitis C virus (HCV) infection in Egypt highlighted the urgent need for implementing infection control (IC) programs in Egypt. OBJECTIVES: The Ministry of Health and Population (MOHP), in collaboration with the US Naval Medical Research Unit No. 3, and the World Health Organization (WHO), developed a national plan to initiate an IC program with the objectives of improving quality of care and reducing transmission of hospital-acquired infections. METHODS: The strategic plan for this program included setting up an organizational structure, developing IC national guidelines, training health care workers, promoting occupational safety, and establishing a system for monitoring and evaluation. Implementation of the program started in late 2001. RESULTS: The achievements to date include developing a national organizational structure, IC guidelines, and a comprehensive IC training program. To date, a total of 72 hospitals in 13 governorates have been enrolled in the program, and 235 IC professionals have been trained. CONCLUSIONS: Many challenges were faced, including administrative, financial, and motivational difficulties. Future plans include expansion of the program to cover all 27 governorates of Egypt and establishment of a surveillance system for hospital-acquired infections. The process of developing the IC program in Egypt may serve as a model for other resource-limited countries that seek to initiate similar programs.