Public Health Highlights
Hospitals in Europe Link for Infection Control through
Surveillance (HELICS)
Antimicrobial resistance and hospital infection are now amongst the
highest priorities in the PHLS and the European Union.
LHI has for several years been involved in European studies. In
1999 there was the completion of the DGV funded HELICS II project
(‘Hospitals in Europe Link for Infection Control through
Surveillance’). The steering group led by Professor Jacques
Fabry from France also has members from Belgium, Denmark, England
(Dr Barry Cookson) and Holland. The two objectives were to
produce an inventory of infection and antimicrobial resistance
control activities in the EU and to propose ways to harmonise these
efforts. Extensive questionnaires were distributed
to all EU member states and a consensus meeting was also held.
In addition, all countries were invited to submit contact names and
relevant details of infection control related activities for the
inventory. All the raw data, inventory and initial report are
available on the INTERNET (www.univ.lyon1.fr/iusi.nice).
A fuller consensus on the report will be sought in early 2000 and
some of the proposed aims are being explored further with the
EU.
There are recommendations in five key areas. The first
comprises the standardisation of surveillance methods, information
and data exchange. Clearly, the more comparable
the surveillance standards and data quality evaluation systems, the
easier it will be to establish collaborative EU projects. Three
other areas comprised: guideline and policy development, a European
training programme in infection control and hospital epidemiology
with educational fellowships and proposals for the review of
mechanisms for the prioritisation and increased funding of research
and development. The final area was the surveillance of
antimicrobial resistance and antimicrobial use, which it was felt
should take advantage of the extensive experience of nosocomial
infection surveillance.
The actions outlined above are mindful of the essential role and
involvement of the local infection control team and healthcare
workers (“thinking globally and acting locally”). LHI staff
considers themselves to be reflective practitioners in this process
and will play key roles in the above actions.
The second EU activity is the DG-XII funded project “HARMONY” (Harmonisation
of Antibiotic Resistance measurement, Methods
of typing Organisms and ways of using these and other tools
to increase the effectiveness of Nosocomial Infection
control). This is led by LHI’s Dr Barry Cookson and will
comprise a resource, facilitating centres, an international network
of opinion leaders and centres of excellence. It will interact
with the emerging hospital infection surveillance networks and
target four areas: antibiotic susceptibility testing, microbial
typing (initially of MRSA), infection control and antibiotic therapy
policy and audit and the establishment of a "State of the Art"
European interactive database on the INTERNET. The project is
in its first year but has already established an EU epidemic MRSA
collection and the first inter-country MRSA typing project is
underway.
Interventions
LHI in their reflective practitioner role receive many requests for
advice on the prevention and control of infection and outbreaks.
These cover infection control in hospitals and other, wider
aspects of healthcare. One example of this was recently
generated in the Infection Control Unit and concerns the
transmission of blood borne infectious agents by jet injectors.
These injectors use a high-pressure focussed jet of fluid to
provide a needleless mechanism for penetrating skin.
They have great potential in mass immunisation campaigns in
areas of limited resources and allow high immunisation
delivery rates. They would eliminate many logistical
problems such as the shipping of single-use syringes and
needles, accidental contaminated needlestick injuries
to immunisation staff, and the burden of safe disposal of
sharps clinical waste. At the request of the World Health
Organisation, we developed a laboratory model of jet injection
safety that could test the capacity of jet injectors to transmit
blood between injection recipients. Hepatitis B is thought
transmissible in volumes of blood as low as 10 picolitres, so a
novel immunoassay (developed in conjunction with Kings College,
University of London) was used that could detect these extremely low
levels. Results from the use of this model indicated jet
injectors can regularly transmit relevant volumes of blood.
Use of this model under field conditions in Brazil (in conjunction
with WHO and the Brazilian Ministry of Health) confirmed the
laboratory model as valid.
As a result of this work, WHO and other major users of jet
injectors have reconsidered their use. A more positive outcome
of this work has been an understanding of previously unsuspected
contamination mechanisms, which is enabling design of new
generations of jet injector whose safety can be assessed in our
model.
Meliodosis
The extensive expertise of LHI staff is also drawn upon for Public
Health activities other than Hospital Infection. One such
example is melioidosis, is a life-threatening infectious disease
prevalent in Southeast Asia and tropical Australia, but it has been
reported in other tropical and occasionally subtropical regions
worldwide. The disease is caused by the bacterium Burkholderia
pseudomallei
which is found in wet soil and water. Clinical manifestations
range from acute overwhelming septicaemia to chronic infections with
abscesses in many organs of the body. Most cases occur during
the rainy season and major predisposing risk factors are occupation
(rice farming) and diabetes. Indeed, in rural northeastern Thailand,
B. pseudomallei is one of the most common organisms causing
septicaemia during the wet season. Treatment with appropriate
antibiotics reduces mortality significantly, but 30-40% of patients
will still die. In the survivors prolonged maintenance treatment is
necessary. Relapse of infection occurs in some patients.
About 400,000 UK residents visit Southeast Asia annually especially
Thailand. The risk of infection is extremely low for ordinary
tourists and melioidosis has most commonly occurred in UK resident
Asian immigrants returning from visits to their homeland. There were
15 cases of melioidosis recorded in the UK in the period 1988-1998
(Dance
et al. Lancet 1999;353:208).
The Public Health Laboratory Service provides a clinical and
microbiological reference service for melioidosis to England and
Wales and occasionally Europe. The Laboratory of Hospital Infection
performs serodiagnostic tests and microbiological confirmation of
B. pseudomallei (Dr T Pitt) and advice on diagnosis and
treatment of melioidosis is provided by Dr D Dance (Plymouth PHL)
and Dr M Smith (Taunton PHL) both of whom worked for some years in
Thailand. We also conduct collaborative research studies into the
epidemiology and pathogenesis of B. pseudomallei leading to a
wide range of publications. This serves to heighten awareness and
ensure the correct diagnosis is made and appropriate treatment is
given to reduce patient mortality.
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