Germane issues

My friend at university had a classic problem: she was obsessive compulsive when it came to cleanliness. And I'm not just talking the dishes here - I'm talking about her obsession to wipe her table top with sanitising solutions, wash her hands as often as was humanly possible and never being too far away from the hand sanitiser in her handbag.

Being somewhat messy students (by her standards anyway, having only done the needful one bath a day and only attacking the kitchen counter once the ants set in) we thought she was positively off her rocker. We teased her relentlessly about it, particularly when it came to the hand washing. She avoided staircase rails like the plague, and when on an escalator, would tuck her arms in closely to her chest terrified that she might end up touching all and sundry's germs. As for hospitals, they were simply a non-entity in her life - a grey area best left ignored.

But looking back, particularly now as hand sanitising stations have mushroomed in several public spaces in the face of the H1N1 virus threat, I realise that there was something particularly unique about that seemingly-crazy OCD friend...

She never got sick.

While the rest of us in the student house were snivelling with colds and bogged up sinus every few months, she (while steering clear of the germ cesspool that was our living room in winter) would continue to dart about in annoyingly good health, washing and wiping her hands incessantly.

In hindsight, there seems to be a message to her madness: hand hygiene and the regular use of sanitisers is the most basic and, indeed, the most effective means of infection control. The simple truth is: immunity begins with clean hands, air and surfaces.

In fact, this is the dictum that is followed in hospitals as well.

"There is a pressing need to address the spread of microorganisms in hospitals and in the community," says Caroline Bilen, who heads 3M's infection prevention platform in the Middle East and Africa's Health Care Division.

Once an operating room manager and nursing director in Lebanon, today she is keen to ensure that the community is well educated in the way of infection prevention. With the H1N1 virus outbreak this year, she's had her hands full working at improving health consciousness in the UAE.

"Having worked for years in hospitals, I understand the daily situations that health workers face. I want to contribute to safety by adding value in terms of raising awareness regarding the importance of infection prevention," she says.

People have a long-standing fear of hospitals in part due to the more ready exposure to germs and disease. The first person to advocate the importance of infection prevention was Florence Nightingale, the near-legendary Italian nurse who tended soldiers in the early 1900s. She believed that there were measures that needed to be taken to guarantee patient safety to ensure minimal complications. And a lot of what she advocated about sterilisation and hygiene still hold true.

"We should never panic," says Bilen. "Every year there is another virus that surfaces. Like everything, we need to be equipped with knowledge. Today it may be H1N1, tomorrow it will be something else. But as far as possible, we need to make a concerted effort to understand what it is that we are fighting and we need to take every precautionary measure possible, through basic daily hygiene to protect ourselves against pathogens."

On a micro level

Bilen shares information on infections and germs. "Basically, there are infectious agents - germs, bacteria and viruses. Bacteria can survive on their own, whereas a virus needs a host. And unfortunately the hosts are us. We then have the reservoir - the environment in which we are exposed to pathogens."

Then there are high-risk and low-risk hosts. High risk hosts include children under the age of five, the elderly (people over the age of 65), pregnant women, people with low levels of immunity and people who have certain diseases and health conditions such as cancer and cardiac issues.''

That said, not all microorganisms are bad. "We should not live in fear of microorganisms, but we need to prevent an increase in the amount of microorganisms that we may come into contact with," says Bilen.

Hospital acquired infections

Hospitals worldwide provide guidelines for the prevention of hospital acquired infections.

There are several types: surgical site infections, bloodstream infections, respiratory tract infections and urinary tract infections.

"To reiterate, the most common way for infections to be transported is via the skin, so the simplest means of prevention is hand hygiene," says Bilen. We need to wash our hands properly - especially between the fingers, an oft-neglected area. "We need to keep our nails clean too. We need to know how to dry our hands properly - wiping your hands on your clothes is a big no. After you've dried them with a towel, avoid touching surfaces, particularly those in public spaces.

"Use soap and water, or an anti-septic solution and sanitisers particularly before and after eating. By keeping your hands clean, you keep the levels of microorganisms [on your hands] to a minimum and thus reduce the risk of transmitting [germs] to other people. This is what we mean by isolating a virus. Hygiene is about how we create a barrier between ourselves and microorganisms thus reducing transference in all areas."

Mapping the hospital

In hospitals, to reduce the risk of surgical site infections, the air needs to be clean. Five per cent of infections are contracted from surrounding air, so hospitals need to ensure that air filters are cleaned and replaced regularly. Ten per cent of infections are contracted from the instruments used, so sterilisation of instruments and the operating environment is crucial.

But the main carrier of microorganisms is the human skin. About 35 per cent of infections come from hospital staff with 50 per cent being traced back to patients. Hospitals need to readily provide cleansing solutions and facilities for patients and health workers to wash their hands regularly.

Hair is a haven for microorganisms. Patients' hair, particularly in the area where a surgery is to be performed, is clipped prior to surgery because more microorganisms are likely to be found in hair than on the skin.

"By removing hair, the area is decontaminated. A wound dressing cannot be applied post-surgery if hair is present," says Bilen.

A major development in reducing the risk of surgical site infections is that the hair of patients is no longer shaved, but clipped prior to surgery. WHO made the recommendation that razors no longer be used because microscopic injuries can occur as a result of shaving and this opens a portal of entry for infections. The patient must be aware of this and if a razor is presented, must insist that the health care worker use a clipper instead in order to minimise the risk of microscopic cuts.

"Part of the prepping process prior to surgery is to reduce the amount of microorganisms that the patient comes in contact with, so solutions must be used to cleanse the patient's skin before, during and after surgery," says Bilen.

"Doctors and nurses need to create a completely sterile surface to ensure a protective area that is as limiting as possible to the migration of microorganisms. There needs to be persistent activity during the surgery to guarantee this," she explains.

Health workers also need sufficient time to prepare themselves prior to surgery. They wear masks and caps so as to avoid cross-contamination. The most critical elements of these precautions include facial protection (nose, mouth, and eyes if sprays/splashes of secretions are anticipated) and again, hand hygiene.

"All infection control systems are set up according to a set of international guidelines to ensure safety for the patients and the health care workers. These are recommendations laid down by WHO and all hospitals worldwide operate under these recommendations," Bilen says.

In the ICU, patients also need to wear gowns and covered shoes to protect themselves from any potential infection. Visitors should also exercise caution in this area. They are in contact with patients with a high microorganism count, so they have to keep a certain distance and should avoid touching the patient. It is also highly recommended not to have children visit the hospital, as they are high risk hosts.

"If you're a visitor, utilise the wash points regularly and avoid touching surfaces," says Bilen. "Do not use the patients' bathroom; use the visitor's bathroom instead."

Hospitals have to ensure that the bed space is sterilised, surfaces are sanitised and bed linen is changed once a patient leaves the ICU. Bilen says, "Patients should be aware of procedures so that they know what to look out for in order to protect themselves. Be observant. Demand the regular use of antiseptics and sanitisers."

Nurses and doctors need to brief their patients well regarding their specific case and what to do in the way of prevention before leaving the hospital. "Again, hygiene, whether you're sick, in recovery or in perfect health, has the same standard set of precautionary steps to be followed," says Bilen.

Education, awareness and complianceBilen says that's she's noticed that compliance to WHO's guidelines in hospitals worldwide is increasing, despite reports that general compliance levels for hand washing are generally low - ranging anywhere from 10 to 63 per cent. But she says, health workers in the UAE are working towards education and hold reinforcement sessions highlighting the importance of these guidelines. In UAE hospitals, she assures, health care workers are working on the patient safety platform. "When we have a virus outbreak, such as the H1N1 virus, awareness regarding disease prevention and control increases. It's very important to know the history of the virus we're dealing with and to be informed about the symptoms and the preventive measures that should be taken to curb its spread.

"It's not just in hospitals that we need to exercise these measures. The best place to start is in schools. Conducting sessions with kids, putting up posters in schools, talking to children about hand hygiene, running campaigns in the various media, getting teachers to ensure surfaces are cleaned regularly and informing the family to keep their kids at home when their wards are sick or when they notice early symptoms, are most effective. We need to start at the root and the root is education," says Bilen.

Children who are sent home due to flu symptoms must not return to school for seven days or until they have been symptom-free for 24 hours (without the use of medication), whichever is longer. If symptoms get worse, seek medical attention immediately.

"In the office too, there are a few basic preventative measures which can be used to halt the spread of germs," says Bilen.

"For instance, in the workplace, some people have the habit of chewing the back of their pens. When his/her colleague borrows that pen, he/she comes in direct contact with [potentially disease causing] microorganisms.'' Solution: as far as possible, use your own set of office stationery.

"Make sure that you clean your work area regularly. Clean your computer mouse, keep hand antiseptic next to your desk. Avoid eating at your desk as this raises the risk of spreading bacteria."

The basic level of infection control precautions, when used as recommended, will be effective in preventing transmission of most communicable diseases in health care facilities and in the community at large. Facilitating compliance with these basic precautions should be emphasised at all times.

Terminology explained

So what exactly is infection control? "Infection control refers to all policies, procedures and activities, which aim to prevent or minimise the risk of transmission of infectious diseases. This refers to health care acquired infections (HAI) as well as to infections of public health concern, making it a crosscutting, multi disciplinary activity." (www.who.int).

Keep it clean

Hand hygiene is the primary measure to reduce health care associated infection. Launched by WHO in May this year, the Save Lives: Clean Your Hands initiative aims to support health care workers to improve hand hygiene and stop the spread of infection.

Check it out

WHO has also introduced the Safe Surgery Saves Lives campaign in order to improve the safety of surgical care around the world by ensuring adherence to proven standards of care.

Safety first

The WHO Surgical Safety Checklist has been shown to improve compliance with standards and decrease complications from surgery. The checklist, accompanying manual and guidelines have recently been revised and are available for download on www.who.int.

The checklist and manual will be available in all six WHO official languages by early 2010.

Know your virus

H1N1 influenza can spread in coughs or sneezes, but evidence shows small droplets containing the virus can linger on tabletops, telephones and other surfaces and be transferred via the fingers to the mouth, nose or eyes.

Anyone with flu-like symptoms such as a sudden fever, cough or muscle aches should stay away from work or public transportation and should see a doctor to be tested.

"As far as possible, people should carry a kit with them that includes a respirator and a hand sanitiser. As we've concluded: the major means of transmission is skin contact and the air.

If someone is sneezing or coughing within a metre of you, you should use a respirator - particularly in public confined spaces," says Bilen.