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A good example!
International Journal of Infectious Diseases (2009) 13, 535—536
http://intl.elsevierhealth.com/journals/ijid
EDITORIAL
A good example! In this issue, Jun Yuan and colleagues report their investigation of an outbreak of Mycobacterium abscessus.1 As they describe, they searched for all cases, determined the various procedures received by cases and non-cases, and interviewed and observed healthcare staff. Their investigation identified lapses in infection control that were likely responsible for the outbreak, and guided specific changes in procedures to prevent future similar cases from the responsible clinic. In a nosocomial outbreak, patients incur costs in the form of ill health. With a successful investigation, these costs are not wasted, but instead contribute to benefits for others in the form of avoided future infections. This journal’s publication of Jun Yuan and colleagues’ report extends these benefits far beyond one Chinese village, guiding healthcare workers throughout the world to avoid similar events. Their report touches on several key issues related to the conduct of outbreak investigations, and also stimulates thoughts about investigations not done.
Who decides to investigate? Jun Yuan and colleagues report ‘‘a request to investigate’’, but they do not describe the process that led to the request. As in most other investigations, I suspect that a government health officer decided to investigate based on information about adverse events assembled and assessed by government health staff. But the trail from realization of adverse events to an investigation does not — and should not — always stay within the government’s health services. The World Alliance for Patient Safety (WAPS), an arm of the World Health Organization, notes that ‘‘Many health-care organizations are actively encouraging patient engagement to reduce errors and help understand the causes of harm’’, and recommends that healthcare workers ‘‘embrace the concept of patient engagement’’.2 In recent years, most states in the USA have adopted laws and/or regulations requiring hospitals to report hospital-acquired infections, and most states make this information available to the public.3
DOI of original article: 10.1016/j.ijid.2008.11.024.
Forward-looking vs. backward-looking investigations Jun Yuan and colleagues ‘‘trained and required staff to follow correct injection techniques’’. Notably, they do not report negative outcomes for those who made errors, or compensation for injured patients. The focus of their intervention was forward-looking, to prevent future infections. In any nosocomial outbreak, the first people to realize their infections may favor a backward-looking process to generate compensation for themselves by identifying and penalizing the perpetrators. Victims’ efforts to collect compensation may motivate healthcare workers to obstruct a search for more victims and a thorough elucidation of infection control lapses. While victims pursuing their self-interest may undermine efforts to learn from adverse events, an informed public acting in its self-interest — for safer healthcare — will press for investigations that prioritize identifying and correcting mistakes. Such investigations include a search for all cases. The more cases found, the more certain it is that an investigation will identify and remedy contributing errors. Similarly, health officials committed to safe care share the public’s interest in forward-looking and thorough investigations. However, this shared interest can be undermined by fear and ignorance. Health officials may fear that investigations will lead to public criticism. The public may not hear of adverse events, or may not be aware that a few such events signal a threat to their health.
Investigations not done In general, I suspect estimates of disability-adjusted life years saved due to outbreak investigations would show there are too few investigations. Lack of investigations is particularly troubling in sub-Saharan Africa, where high prevalence of hepatitis B, hepatitis C, and HIV infection coincides with frequent unsafe injections4 and with unreliable sterilization of medical instruments.5—8 Throughout sub-Saharan Africa, I have found only one outbreak investigation for hepatitis B (in South Africa during the early 1990s9) and none for hepatitis C or HIV (although unexplained HIV infections are ubiquitous10,11).
1201-9712/$36.00 # 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2008.11.025
536 Year-by-year, clusters of unexplained HIV infections come to light in Africa. Some of these clusters are reported among participants in foreign-funded research, so that not only host governments but also foreign institutions (who bear some responsibility to protect research participants) should consider whether to investigate. For example, a randomized controlled trial of male circumcision for HIV prevention in Kisumu, Kenya, in 2002—06 reported four men with incident HIV infection within 1 month after circumcision (three reported no sexual contacts during the month).12 Similarly, a case—control study of HIV incidence among women in Malawi in 2003—05, found that 23 of 27 cases had received recent hormone injections for birth control, and the adjusted odds ratio for HIV incidence associated with such injections was 10.4.13 It is not too late to investigate unexplained infections in these two studies. Money is available; US law lists outbreak investigations among the activities eligible for US foreign aid authorized for HIV prevention in 2009—13.14
How to promote investigations? What could be done to promote more forward-looking investigations? One option might be for governments to legislate guidelines for investigations that protect cooperating healthcare workers. Another might be for concerned citizens to bring public interest lawsuits, requesting courts to order investigations of suspected nosocomial infections. A successful public interest lawsuit in India — which led the Supreme Court to order the Government to improve testing of blood before transfusion — provides an inexact precedent.15 Public awareness of risks in air travel — from reports of plane crashes — ensures that governments and airline companies prioritize safety. More outbreak investigations could do the same for healthcare. The report by Jun Yuan and colleagues points the way, and that is the real strength of their study. Conflict of interest: I have no conflict of interest with respect to this article.
References 1. Yuan J, Liu Y, Yang Z, Cai Y, Deng Z, Qin P, et al. Mycobacterium abscessus post-injection abscesses from extrinsic contamination of multiple-dose bottles of normal saline in a rural clinic. Int J Infect Dis 2009;13:537—42. 2. World Health Organization. Patient Safety Workshop: learning from error. WHO/IER/PSP/2008.09. Geneva: WHO; 2008, p. 16—7.
Editorial 3. Meier BM, Stone PW, Gebbie KM. Public health law for the collection and reporting of health care-associated infections. Am J Infect Control 2008;36:537—51. 4. Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004;15:7—16. 5. Macro ORC. Rwanda service provision assessment survey 2001. Calverton: ORC Macro; 2003. 6. Macro ORC. Kenya service provision assessment survey 2004: Maternal and child health, family planning and STIs. Calverton: ORC Macro; 2005. 7. Macro ORC. Zambia HIV/AIDS service provision assessment survey 2005. Calverton: ORC Macro; 2006. 8. Macro ORC. Ghana service provision assessment survey 2002. Calverton: ORC Macro; 2003. 9. Hardie DR, Williamson C. Analysis of the preS1 gene of hepatitis B virus (HBV) to define epidemiologically linked and un-linked infections in South Africa. Arch Virol 1997;142:1829—41. 10. Gisselquist D, Potterat JJ, Brody S. HIV transmission during pediatric health care in sub-Saharan Africa: risks and evidence. S Afr Med J 2004;94:109—16. 11. Hiemstra R, Rabie H, Schaaf HS, Eley B, Cameron N, Mehtar S, et al. Unexplained HIV-1 infection in children–—documenting cases and assessing for possible risk factors. S Afr Med J 2004; 94:188—93. 12. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369: 643—56. 13. Kumwenda NI, Kumwenda J, Kafulafula G, Makanani B, Taulo F, Nkhoma C, et al. HIV-1 incidence among women of reproductive age in Malawi. Int J STD AIDS 2008;19:339—441. 14. Tom Lantos, Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. Public Law 110-293, 122 Stat. 2917 (July 30, 2008). Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_public_laws&docid=f:publ293.pdf (accessed January 2009). 15. Tawani V. Curbing medico-legal activism. Ind J Med Ethics 1998;6:1.
David Gisselquist*, Independent Consultant, 29 West Governor Road, Hershey, PA 17033, USA *Tel.: +1 717 533 2364 E-mail address: [email protected] 31 October 2008
http://intl.elsevierhealth.com/journals/ijid
EDITORIAL
A good example! In this issue, Jun Yuan and colleagues report their investigation of an outbreak of Mycobacterium abscessus.1 As they describe, they searched for all cases, determined the various procedures received by cases and non-cases, and interviewed and observed healthcare staff. Their investigation identified lapses in infection control that were likely responsible for the outbreak, and guided specific changes in procedures to prevent future similar cases from the responsible clinic. In a nosocomial outbreak, patients incur costs in the form of ill health. With a successful investigation, these costs are not wasted, but instead contribute to benefits for others in the form of avoided future infections. This journal’s publication of Jun Yuan and colleagues’ report extends these benefits far beyond one Chinese village, guiding healthcare workers throughout the world to avoid similar events. Their report touches on several key issues related to the conduct of outbreak investigations, and also stimulates thoughts about investigations not done.
Who decides to investigate? Jun Yuan and colleagues report ‘‘a request to investigate’’, but they do not describe the process that led to the request. As in most other investigations, I suspect that a government health officer decided to investigate based on information about adverse events assembled and assessed by government health staff. But the trail from realization of adverse events to an investigation does not — and should not — always stay within the government’s health services. The World Alliance for Patient Safety (WAPS), an arm of the World Health Organization, notes that ‘‘Many health-care organizations are actively encouraging patient engagement to reduce errors and help understand the causes of harm’’, and recommends that healthcare workers ‘‘embrace the concept of patient engagement’’.2 In recent years, most states in the USA have adopted laws and/or regulations requiring hospitals to report hospital-acquired infections, and most states make this information available to the public.3
DOI of original article: 10.1016/j.ijid.2008.11.024.
Forward-looking vs. backward-looking investigations Jun Yuan and colleagues ‘‘trained and required staff to follow correct injection techniques’’. Notably, they do not report negative outcomes for those who made errors, or compensation for injured patients. The focus of their intervention was forward-looking, to prevent future infections. In any nosocomial outbreak, the first people to realize their infections may favor a backward-looking process to generate compensation for themselves by identifying and penalizing the perpetrators. Victims’ efforts to collect compensation may motivate healthcare workers to obstruct a search for more victims and a thorough elucidation of infection control lapses. While victims pursuing their self-interest may undermine efforts to learn from adverse events, an informed public acting in its self-interest — for safer healthcare — will press for investigations that prioritize identifying and correcting mistakes. Such investigations include a search for all cases. The more cases found, the more certain it is that an investigation will identify and remedy contributing errors. Similarly, health officials committed to safe care share the public’s interest in forward-looking and thorough investigations. However, this shared interest can be undermined by fear and ignorance. Health officials may fear that investigations will lead to public criticism. The public may not hear of adverse events, or may not be aware that a few such events signal a threat to their health.
Investigations not done In general, I suspect estimates of disability-adjusted life years saved due to outbreak investigations would show there are too few investigations. Lack of investigations is particularly troubling in sub-Saharan Africa, where high prevalence of hepatitis B, hepatitis C, and HIV infection coincides with frequent unsafe injections4 and with unreliable sterilization of medical instruments.5—8 Throughout sub-Saharan Africa, I have found only one outbreak investigation for hepatitis B (in South Africa during the early 1990s9) and none for hepatitis C or HIV (although unexplained HIV infections are ubiquitous10,11).
1201-9712/$36.00 # 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2008.11.025
536 Year-by-year, clusters of unexplained HIV infections come to light in Africa. Some of these clusters are reported among participants in foreign-funded research, so that not only host governments but also foreign institutions (who bear some responsibility to protect research participants) should consider whether to investigate. For example, a randomized controlled trial of male circumcision for HIV prevention in Kisumu, Kenya, in 2002—06 reported four men with incident HIV infection within 1 month after circumcision (three reported no sexual contacts during the month).12 Similarly, a case—control study of HIV incidence among women in Malawi in 2003—05, found that 23 of 27 cases had received recent hormone injections for birth control, and the adjusted odds ratio for HIV incidence associated with such injections was 10.4.13 It is not too late to investigate unexplained infections in these two studies. Money is available; US law lists outbreak investigations among the activities eligible for US foreign aid authorized for HIV prevention in 2009—13.14
How to promote investigations? What could be done to promote more forward-looking investigations? One option might be for governments to legislate guidelines for investigations that protect cooperating healthcare workers. Another might be for concerned citizens to bring public interest lawsuits, requesting courts to order investigations of suspected nosocomial infections. A successful public interest lawsuit in India — which led the Supreme Court to order the Government to improve testing of blood before transfusion — provides an inexact precedent.15 Public awareness of risks in air travel — from reports of plane crashes — ensures that governments and airline companies prioritize safety. More outbreak investigations could do the same for healthcare. The report by Jun Yuan and colleagues points the way, and that is the real strength of their study. Conflict of interest: I have no conflict of interest with respect to this article.
References 1. Yuan J, Liu Y, Yang Z, Cai Y, Deng Z, Qin P, et al. Mycobacterium abscessus post-injection abscesses from extrinsic contamination of multiple-dose bottles of normal saline in a rural clinic. Int J Infect Dis 2009;13:537—42. 2. World Health Organization. Patient Safety Workshop: learning from error. WHO/IER/PSP/2008.09. Geneva: WHO; 2008, p. 16—7.
Editorial 3. Meier BM, Stone PW, Gebbie KM. Public health law for the collection and reporting of health care-associated infections. Am J Infect Control 2008;36:537—51. 4. Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004;15:7—16. 5. Macro ORC. Rwanda service provision assessment survey 2001. Calverton: ORC Macro; 2003. 6. Macro ORC. Kenya service provision assessment survey 2004: Maternal and child health, family planning and STIs. Calverton: ORC Macro; 2005. 7. Macro ORC. Zambia HIV/AIDS service provision assessment survey 2005. Calverton: ORC Macro; 2006. 8. Macro ORC. Ghana service provision assessment survey 2002. Calverton: ORC Macro; 2003. 9. Hardie DR, Williamson C. Analysis of the preS1 gene of hepatitis B virus (HBV) to define epidemiologically linked and un-linked infections in South Africa. Arch Virol 1997;142:1829—41. 10. Gisselquist D, Potterat JJ, Brody S. HIV transmission during pediatric health care in sub-Saharan Africa: risks and evidence. S Afr Med J 2004;94:109—16. 11. Hiemstra R, Rabie H, Schaaf HS, Eley B, Cameron N, Mehtar S, et al. Unexplained HIV-1 infection in children–—documenting cases and assessing for possible risk factors. S Afr Med J 2004; 94:188—93. 12. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369: 643—56. 13. Kumwenda NI, Kumwenda J, Kafulafula G, Makanani B, Taulo F, Nkhoma C, et al. HIV-1 incidence among women of reproductive age in Malawi. Int J STD AIDS 2008;19:339—441. 14. Tom Lantos, Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. Public Law 110-293, 122 Stat. 2917 (July 30, 2008). Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_public_laws&docid=f:publ293.pdf (accessed January 2009). 15. Tawani V. Curbing medico-legal activism. Ind J Med Ethics 1998;6:1.
David Gisselquist*, Independent Consultant, 29 West Governor Road, Hershey, PA 17033, USA *Tel.: +1 717 533 2364 E-mail address: [email protected] 31 October 2008