- Email: [email protected]
Organisation of hospital infection control in Mongolia
Journal of Hospital Infection 75 (2010) 209e213
Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Organisation of hospital infection control in Mongolia B.-E. Ider a, *, A. Clements a, b, J. Adams a, M. Whitby c, T. Muugolog d, e a
University of Queensland, School of Population Health, Brisbane, Queensland, Australia Australian Centre for International and Tropical Health, Queensland Institute of Medical Research, Australia c Infection Management Services, Princess Alexandra Hospital, Queensland, Australia d Hospital Related Infection Surveillance and Research Unit, National Center for Communicable Diseases, Ulaanbaatar, Mongolia e Mongolian Association of Infection Control Professionals, Ulaanbaatar, Mongolia b
a r t i c l e i n f o
s u m m a r y
Article history: Received 6 December 2009 Accepted 12 February 2010 Available online 30 April 2010
As with other areas of the public sector in Mongolia, the healthcare system has undergone significant structural and policy reforms since the early 1990s. The previous infection control system, characterised as a sanitaryeepidemiological network, was dismantled with no replacement. A new infection control management system was established in 1997 with the adoption of infection control policies and guidelines, establishment of hospital infection control programmes in all major hospitals, training of health professionals and the commencement of passive surveillance of hospital-acquired infections (HAIs). Recent health statistics claim that HAIs occur in 0.01e0.02% of all hospital admissions with the highest percentage (0.05%) in tertiary hospitals in the capital city Ulaanbaatar, but this is very likely to be an underestimate. In 2002 the Government approved a national programme to establish a sentinel surveillance system for HAIs with improved laboratory-based monitoring. However, implementation has been delayed due to insufficient support from stakeholders and a shortage of resources and trained infection control professionals. Non-governmental infection control initiatives are limited by time and coverage. Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hospital-acquired infection Mongolia Organisation
Healthcare system
Infection control in the socialist healthcare system
The Mongolian healthcare system serves a population of 2.7 million. Public healthcare facilities are divided into 18 tertiary hospitals and regional centres, 33 district and provincial general hospitals and 549 primary healthcare clinics (in remote areas) and family group practices (in urban areas). Private healthcare is provided in a total of 1063 private hospitals and clinics, comprising only 15% of the nation’s 17 000 hospital beds. Annually there are 630 000 public hospital admissions with an average duration of 8.5 days. Hospital size varies from 10 to 650 beds. Most medical care is free for those who participate in the National Health Insurance scheme. The Government spent 3.2e4.6% of gross domestic product on healthcare in each of the past eight years.1,2
From the mid-1970s to the end of the socialist era in 1990, every hospital in Mongolia was obliged to have hygienistepidemiologists who formed part of a hospital infection prevention team managed by the hospital director. The primary focus of these teams was to maintain hospital hygiene, coordinate disinfection, implement infection control measures, sterilisation and waste disposal as well as training hospital staff. Prevention, passive surveillance and the reporting of hospitalacquired infections (HAIs) were also part of the team’s responsibility. Emphasis was given to HAIs in newborns and hepatitis virus infections in patients and staff.3,4 Hospitals were required to notify every HAI case to the local Health Department and Sanitary Epidemiological Station (SES) e an independent network of branch stations in every aimag (i.e. province) and district of the capital city, vertically managed by the State Central SanitaryeEpidemiology Institute.5e7 In each SES, a team of three to five hygienist-epidemiologists were responsible for monitoring hygiene standards, environmental health and infections. The hygienist-epidemiologists visited hospitals on a regular basis
* Corresponding author. Address: Room 303, Edith Cavel Building, School of Population Health, University of Queensland, Brisbane, Queensland, Australia. Tel.: þ61733464829; fax: þ61733655442. E-mail address: [email protected] (B.-E. Ider).
0195-6701/$ e see front matter Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2010.02.022
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to monitor compliance with sanitary best practice. They were also responsible for case or outbreak investigations when hospitals notified the occurrence of HAIs. HAI hospital data were collected on a monthly basis and aggregated by the State Central SanitaryeEpidemiology Institute. HAIs were very rarely reported. When reported, cases were discussed at the ministerial level often resulting in the administrative sanctions and penalties to healthcare service providers. During the political and economical changes in the early 1990s the SanitaryeEpidemiological Service was dismantled with no replacement.8 In the reorganised public health system, the responsibilities of the former SanitaryeEpidemiological Service were divided between the Ministry of Health (MoH) and the new independent State Inspection Agency. The State Inspection Agency inherited the sanitaryeepidemiological network, taking responsibility for monitoring compliance with sanitary best practice and maintaining environmental health standards, such as water quality, food hygiene, occupational health and work safety, and the quality of drugs. Although HAI control remained with the MoH, no laboratory network, trained health professionals or data collection and management systems remained to support the implementation of HAI control policy.8,9
Infection control in the transition period The current hospital infection control system was established by the MoH in 1997. The MoH adopted order No. 336 on ‘Strengthening prevention and control of hospital acquired infections’ with the aim of significantly reducing the rate of HAI in Mongolian hospitals. It was the first complete legal document to approve HAI control management structures at national and hospital levels (Figure 1), define roles and responsibilities of infection control practitioners (ICPs) and provide guidelines on HAI control, including disinfection and sterilisation policies.10 Accordingly, the National Centre for Communicable Diseases (NCCD) of the MoH became the main professional body to manage the implementation of HAI policies and guidelines. The Hospital Related Infection Surveillance and Research Unit (HRISRU) was established at the NCCD. Initially this unit was run by one ICP and since 2006 it has expanded to a team of four, and a year later to six ICPs. This team is responsible for observing cases and outbreaks of HAI reported by hospitals, and for collecting HAI data. Developing, updating and submitting hospital infection control policy and guidelines for approval by the National Committee and MoH are also core HRISRU responsibilities.10,11
Ministry of Health, Mongolia
Health Related Infection Surveillance and Research Unit, National Centre for Communicable Diseases
National Committee for the Prevention and Control of Hospital Acquired Infections
District’s & province’s Health Departments
Hospital Infection Control Committees
Quality subcommittees
Administrative support
Tertiary level hospitals (specialised centres & teaching hospitals)
Departments & Wards
Secondary level hospitals (district & province general hospitals)
Primary level clinics (FGP and PHC clinics)
Departments & Wards
Professional support
Figure 1. Hospital infection control management system of Mongolia. FGP, family group practice; PHC, primary healthcare clinic.
B.-E. Ider et al. / Journal of Hospital Infection 75 (2010) 209e213
211
National Committee
Infection control policy and plans
In 1997, the National Committee for the Prevention and Control of Hospital Acquired Infections was established at the MoH.10 The Committee consisted of key stakeholders from the MoH, State Inspection Agency, NCCD, City Health Department and leading MoH experts on infectious diseases, hygiene, epidemiology and bacteriology. The Committee was responsible for revising infection control policies and guidelines, approving the HRISRU annual plan and monitoring implementation of the plan at the national level. However, no meetings of the Committee were ever convened due to the rarity of HAI cases. In 2008, the MoH changed the structure of the Committee and since then infection control and prevention activities at the national level are discussed and approved by a committee chaired by the director of the NCCD, and including the director of HRISRU and the director of the Department for National Surveillance of Infectious Disease.11
In 1997, the MoH adopted the first complete set of infection control guidelines. In 2008, the MoH with financial support from the United Nations Global Fund replaced the previous infection control guidelines with the intention of moving closer towards international standards. The new guidelines are a translated version of the free online Infection Control Guideline from the USbased Engender-Health International LLC, with limited adaptation. The degree of implementation of these new guidelines has not yet been evaluated. In 2002 the Government of Mongolia approved the ‘National Programme for Control of Communicable Diseases’. It outlines mid-term directions for HAI prevention and control measures until 2010, emphasising the establishment of a sentinel surveillance system with improved laboratory-based monitoring.12 The establishment of a sentinel surveillance system for surgical and paediatric infections, to be introduced in Ulaanbaatar and selected provinces in a phased manner, and the enhancement of laboratorybased monitoring of multiresistant organism infections, were the main activities of the national programme. As a consequence of both poor motivation at the ministry level and funding at the hospital level, none of these planned activities has been implemented in the last seven years. However, the new approved infection control guidelines require hospitals at all levels of the healthcare system to initiate HAI surveillance, including surveillance of multidrugresistant organisms. There have been no plans to provide additional financial support for implementation of these guidelines. Meanwhile, with support of international donor organisations, other initiatives have been created by the MoH, such as safe injection, improved hospital waste management, quality improvement and hand hygiene programmes, but they have been limited in terms of the number of hospitals covered and duration of each programme.8,13
Hospital Infection Control Committee The Hospital Infection Control Committee (HICC) was established in all tertiary and secondary hospitals in 1997 and comprised the Chief Medical Director, a microbiologist, a quality manager, the Chief Nurse, the head of the logistics department, a health statistician and heads of clinical departments such as surgery, infectious diseases, intensive care and emergency units, internal medicine, and paediatrics. In most hospitals the HICC has a close collaboration with other hospital committees such as the drug committee, the nursing service, cleaning and housekeeping, waste management, disinfection and sterilisation units forming the Hospital Quality Improvement team. The quality subcommittees of clinical wards are responsible for the implementation of directions from the HICC. According to the infection control guidelines, the HICC should meet monthly, but its implementation has varied across hospitals.11 Since 2008, all primary healthcare clinics and family group practices have been advised to establish infection control committees (ICC) with one to three members. It is expected that it will take time and considerable effort for implementation in all 549 small facilities. Implementation of infection control guidelines in private hospitals has been poor, mainly because of weak collaboration with, and control by, the HRISRU and local Inspection Agency. Contributing factors include staff and resource shortages and insufficient attention. Only a few larger hospitals with >50 beds have established a HICC. Infection control practitioners In Mongolia, most ICPs are hygienist-epidemiologists who have completed a five-year university programme. This programme is for food, environment and occupational hygiene control with additional research and epidemiology components. There was no programme for infection control until very recently when the NCCD established a postgraduate course. Some ICPs, mainly in remote hospitals, are infectious disease doctors. Since 1997 all tertiary and secondary level hospitals have been obliged to have one full-time ICP. The recent infection control guideline amendment has tightened this requirement and now hospitals are obliged to have one full-time ICP for every 250 beds. Several tertiary hospitals in Ulaanbaatar with more than 300 beds have recently employed a second ICP. Hospitals with <50 beds have been advised to have a part-time ICP.
HAI statistics and surveillance The NCCD has been collecting HAI data since establishing the HRISRU in 1998. Reported cases are a collation of: (a) HAI cases and outbreaks that are notified from hospitals (passive surveillance), (b) cases identified through an active revision of patient notes during planned and ad-hoc hospital visits, and (c) cases, mainly hepatitis B and C virus infections, diagnosed by retrospective investigations of patients admitted at the NCCD. Due to limited resources, ICPs from the HRISRU visit mainly Ulaanbaatar city hospitals. Thus, 81.8% of all registered cases were diagnosed in city hospitals (tertiary hospitals 24.8%, district hospitals 43.0%, private hospitals 7.4%) and only 18.2% of HAI cases were diagnosed in provincial hospitals. HAI cases in provincial hospitals are mainly detected through retrospective investigation of patients referred from provincial to city hospitals. From 1998 to 2007, HAIs were reported to occur in 0.01e0.02% of all hospital admissions. The highest percentage (0.05%) occurred in tertiary hospitals in the capital city Ulaanbaatar.14e16 In 2008, the most frequently reported HAIs were neonatal infections (56.9%), hepatitis B and C virus infections (22.5%) and surgical wound infections (12.4%).17 One chapter of the updated infection control guidelines describes the launch of an active HAI surveillance system, which administratively and structurally, will be a component of the current NCCD Infectious Disease Early Warning and Response (IDEWAR) surveillance system. Data will be collected through IDEWAR and the HRISRU will manage the data. This HAI surveillance system will focus on all HAIs including those caused by multidrug-resistant organisms. Currently, the preliminary training and preparation stages are underway.
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Professional associations The Mongolian Association of Infection Control Professionals was established in 2008 with the aim of advancing the field of infection prevention and control through education, professional development of their members, and research. A vast majority of city public hospital ICPs became a member. While the organisation of conferences, conducting research and promoting infection control guidelines have been the main activities of the association, resource limitations and a lack of expertise or support from government organisations have been major challenges to achieving the associations’ aims.
Current and future challenges Although there are many challenges to infection control common to all developing countries, some specific challenges exist in Mongolia.18e20 These are summarised as follows: Insufficient priority has been placed on infection control among stakeholders. This has led to HAI being neglected for many years. No resources, including financial support, have been allocated to the ‘National Programme for Control of Communicable Diseases’ (2002) or implementation of the newly adopted infection control guidelines (2008). Therefore, it is very unlikely that the current national infection control plan and strategies will be implemented in the near future. Many policymakers and hospital managers believe that hospital infections should be completely absent, and subsequently some ministry regulations have probably resulted in falsifying infection control statistics. Current official infection control statistics indicate that HAI occur in 0.01e0.05% of all hospital admissions. This is considerably lower than internationally reported rates and suggests underestimation of the true frequency of HAI in Mongolia. Other than the HRISRU reports, there have been no other published HAI prevalence studies from Mongolia. It is extremely difficult to find resources for HAI research in Mongolia. Laboratory services in Mongolian hospitals are inadequate to support current infection control policy. There are no laboratory facilities in primary level hospitals. Among the seven urban district health services of Ulaanbaatar city, only one has a microbiology laboratory. Laboratories commonly lack essential equipment, specialised laboratory staff and laboratory reagents and consumables. Analytical variation among hospital laboratories is huge and a laboratory quality assurance scheme (both external and internal) is currently being planned. Monitoring of antibiotic resistance is at a very early stage. In most hospitals, insufficient laboratory capacity means that samples cannot be cultured from all suspected HAI cases. Therefore cultures are only taken when empiric antibiotic therapy fails.21 A shortage of trained infection control professionals limits the delivery of effective infection control programmes. Most ICPs are hygienists who graduated between 1960 and 1990 and who did not attend courses on infection control. Until recently, there have been no postgraduate infection control courses. Poor English language skills and limited access to the internet are the main barriers preventing ICPs from upgrading their knowledge. There is lack of awareness and commitment from clinicians and hospital senior management to support ICPs, whose salaries are among the lowest in the hospital system.
Despite its many challenges, the infection control system in Mongolia is evolving gradually. Infection control management structures with plans, policy and guidelines have led to dynamic changes during the last two decades. It would be unfair not to acknowledge the efforts of committed professionals in effecting change, whether optimal or not. We also should highlight that there is a growing willingness among health professionals to tackle infection control issues, which is essential for future reforms. For policymakers to make decisions on improvement in current systems for control and prevention of HAI in Mongolia, it is essential to identify the validity of existing HAI statistics and factors influencing their validity. While it is important to appraise and, where appropriate, draw from experiences and recommendations from other countries, research needs to be conducted to establish the current burden of HAI in Mongolia so that HAI control and prevention receive appropriate resources, and to understand constraints and perceptions relating to HAI surveillance so that reliable HAI statistics are generated. To date, there has been little research on HAI in Mongolia, either published or unpublished. Acknowledgements We thank colleagues from the Ministry of Health, Mongolia, who facilitated our search of archived documents. We are also indebted to Dr L. Dashtseren (former Director of HRISRU), Dr S. Dulamsuren (former Director of Aimag’s Health Department and Division of MoH) and Dr A. Buzmaa (former Director of department at the State Central SanitaryeEpidemiology Institute) for sharing information on infection control from 1960 to 1990 in Mongolia. Conflict of interest statement None declared. Funding sources Study partly funded by an Australian Leadership Award Scholarship Program and the University of Queensland, School of Population Health. References 1. National Centre for Health Development. Health indicators 2008. Ulaanbaatar: Ministry of Health, Mongolia; 2009 [in Mongolian]. 2. Ministry of Health of Mongolia. Ministerial order no. 211: defining the maximum limits for hospital beds in 2010. Ulaanbaatar: Ministry of Health; 2009 [in Mongolian]. 3. State Central SanitaryeEpidemiology Institute. Order no. 04: guideline for cleaning and sterilization of syringes, needles and other medical instruments. Ulaanbaatar: Mongolia; 1974 [in Mongolian]. 4. State Central SanitaryeEpidemiology Institute. Order no. 08: sanitarye epidemiological regimes for Ulaanbaatar city maternity clinics and maternity wards of inter-soum hospitals, and guidelines for prevention from Staphylococcus infections in maternity clinics and wards. Ulaanbaatar: Mongolia; 1976 [in Mongolian]. 5. Ministry of Health of Mongolia. Ministerial order no. 162: strengthening the measures on hospital infection control. Ulaanbaatar: Ministry of Health; 1982 [in Mongolian]. 6. Bolormaa T, Natsagdorj Ts, Tumurbat B, et al. Mongolia: health system review. Health Syst Transition 2007;9:87e93. 7. Ministry of Health of Mongolia. Ministerial order no. 09: sanitaryeepidemiological responsibilities of the health and preventive organizations. Ulaanbaatar: Ministry of Health; 1985 [in Mongolian]. 8. Health Sector Strategic Master Plan Initiative Core Group. Synthesis paper. Ulaanbaatar: Ministry of Health of Mongolia; 2004. 9. World Bank. Mongolian health system at a crossroad: the incomplete transition to a post-Semashko model. Washington, DC: East Asian and Pacific Human Development; 2006. p. 57e61. 10. Ministry of Health of Mongolia. Ministerial order no. 336: strengthening prevention and control of hospital acquired infection. Ulaanbaatar: Ministry of Health; 1997 [in Mongolian]. 11. Ministry of Health of Mongolia. Ministerial order no. 85: strengthening prevention and control of hospital acquired infection. Ulaanbaatar: Ministry of Health; 2008 [in Mongolian].
B.-E. Ider et al. / Journal of Hospital Infection 75 (2010) 209e213 12. Government of Mongolia. Government resolution no. 129: approval of the national programme for control of communicable diseases. Ulaanbaatar: Government of Mongolia; 2002 [in Mongolian]. 13. Ministry of Health of Mongolia. Report of the reassessment of injection practice in Mongolia. Ulaanbaatar: Ministry of Health; 2006. 14. National Centre for Communicable Diseases. Health statistics 2005. Ulaanbaatar: NCCD; 2006 [in Mongolian]. 15. National Centre for Communicable Diseases. Health related infection surveillance and prevention unit's annual report, 2007. Ulaanbaatar: NCCD; 2008 [in Mongolian]. 16. National Centre for Communicable Diseases. Health related infection surveillance and prevention unit's report 1998e2007. Ulaanbaatar: NCCD; 2008 [in Mongolian].
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17. National Centre for Communicable Diseases. Health related infection surveillance and prevention unit's annual report, 2008. Ulaanbaatar: NCCD; 2009 [in Mongolian]. 18. Damani N. Simple measures save lives: an approach to infection control in countries with limited resources. J Hosp Infect 2007;65(Suppl. 2):151e154. 19. Allegranzi B, Pittet D. Healthcare associated infection in developing countries: simple solutions to meet complex challenges. Infect Control Hosp Epidemiol 2007;28:1323e1327. 20. Huskins WC, Soule B. Infection control in countries with limited resources. Curr Opin Infect Dis 1998;11:449e455. 21. Ministry of Health of Mongolia. An overview of hospital laboratory services in Mongolia. Ulaanbaatar: Ministry of Health; 2007.
Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Organisation of hospital infection control in Mongolia B.-E. Ider a, *, A. Clements a, b, J. Adams a, M. Whitby c, T. Muugolog d, e a
University of Queensland, School of Population Health, Brisbane, Queensland, Australia Australian Centre for International and Tropical Health, Queensland Institute of Medical Research, Australia c Infection Management Services, Princess Alexandra Hospital, Queensland, Australia d Hospital Related Infection Surveillance and Research Unit, National Center for Communicable Diseases, Ulaanbaatar, Mongolia e Mongolian Association of Infection Control Professionals, Ulaanbaatar, Mongolia b
a r t i c l e i n f o
s u m m a r y
Article history: Received 6 December 2009 Accepted 12 February 2010 Available online 30 April 2010
As with other areas of the public sector in Mongolia, the healthcare system has undergone significant structural and policy reforms since the early 1990s. The previous infection control system, characterised as a sanitaryeepidemiological network, was dismantled with no replacement. A new infection control management system was established in 1997 with the adoption of infection control policies and guidelines, establishment of hospital infection control programmes in all major hospitals, training of health professionals and the commencement of passive surveillance of hospital-acquired infections (HAIs). Recent health statistics claim that HAIs occur in 0.01e0.02% of all hospital admissions with the highest percentage (0.05%) in tertiary hospitals in the capital city Ulaanbaatar, but this is very likely to be an underestimate. In 2002 the Government approved a national programme to establish a sentinel surveillance system for HAIs with improved laboratory-based monitoring. However, implementation has been delayed due to insufficient support from stakeholders and a shortage of resources and trained infection control professionals. Non-governmental infection control initiatives are limited by time and coverage. Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hospital-acquired infection Mongolia Organisation
Healthcare system
Infection control in the socialist healthcare system
The Mongolian healthcare system serves a population of 2.7 million. Public healthcare facilities are divided into 18 tertiary hospitals and regional centres, 33 district and provincial general hospitals and 549 primary healthcare clinics (in remote areas) and family group practices (in urban areas). Private healthcare is provided in a total of 1063 private hospitals and clinics, comprising only 15% of the nation’s 17 000 hospital beds. Annually there are 630 000 public hospital admissions with an average duration of 8.5 days. Hospital size varies from 10 to 650 beds. Most medical care is free for those who participate in the National Health Insurance scheme. The Government spent 3.2e4.6% of gross domestic product on healthcare in each of the past eight years.1,2
From the mid-1970s to the end of the socialist era in 1990, every hospital in Mongolia was obliged to have hygienistepidemiologists who formed part of a hospital infection prevention team managed by the hospital director. The primary focus of these teams was to maintain hospital hygiene, coordinate disinfection, implement infection control measures, sterilisation and waste disposal as well as training hospital staff. Prevention, passive surveillance and the reporting of hospitalacquired infections (HAIs) were also part of the team’s responsibility. Emphasis was given to HAIs in newborns and hepatitis virus infections in patients and staff.3,4 Hospitals were required to notify every HAI case to the local Health Department and Sanitary Epidemiological Station (SES) e an independent network of branch stations in every aimag (i.e. province) and district of the capital city, vertically managed by the State Central SanitaryeEpidemiology Institute.5e7 In each SES, a team of three to five hygienist-epidemiologists were responsible for monitoring hygiene standards, environmental health and infections. The hygienist-epidemiologists visited hospitals on a regular basis
* Corresponding author. Address: Room 303, Edith Cavel Building, School of Population Health, University of Queensland, Brisbane, Queensland, Australia. Tel.: þ61733464829; fax: þ61733655442. E-mail address: [email protected] (B.-E. Ider).
0195-6701/$ e see front matter Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2010.02.022
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to monitor compliance with sanitary best practice. They were also responsible for case or outbreak investigations when hospitals notified the occurrence of HAIs. HAI hospital data were collected on a monthly basis and aggregated by the State Central SanitaryeEpidemiology Institute. HAIs were very rarely reported. When reported, cases were discussed at the ministerial level often resulting in the administrative sanctions and penalties to healthcare service providers. During the political and economical changes in the early 1990s the SanitaryeEpidemiological Service was dismantled with no replacement.8 In the reorganised public health system, the responsibilities of the former SanitaryeEpidemiological Service were divided between the Ministry of Health (MoH) and the new independent State Inspection Agency. The State Inspection Agency inherited the sanitaryeepidemiological network, taking responsibility for monitoring compliance with sanitary best practice and maintaining environmental health standards, such as water quality, food hygiene, occupational health and work safety, and the quality of drugs. Although HAI control remained with the MoH, no laboratory network, trained health professionals or data collection and management systems remained to support the implementation of HAI control policy.8,9
Infection control in the transition period The current hospital infection control system was established by the MoH in 1997. The MoH adopted order No. 336 on ‘Strengthening prevention and control of hospital acquired infections’ with the aim of significantly reducing the rate of HAI in Mongolian hospitals. It was the first complete legal document to approve HAI control management structures at national and hospital levels (Figure 1), define roles and responsibilities of infection control practitioners (ICPs) and provide guidelines on HAI control, including disinfection and sterilisation policies.10 Accordingly, the National Centre for Communicable Diseases (NCCD) of the MoH became the main professional body to manage the implementation of HAI policies and guidelines. The Hospital Related Infection Surveillance and Research Unit (HRISRU) was established at the NCCD. Initially this unit was run by one ICP and since 2006 it has expanded to a team of four, and a year later to six ICPs. This team is responsible for observing cases and outbreaks of HAI reported by hospitals, and for collecting HAI data. Developing, updating and submitting hospital infection control policy and guidelines for approval by the National Committee and MoH are also core HRISRU responsibilities.10,11
Ministry of Health, Mongolia
Health Related Infection Surveillance and Research Unit, National Centre for Communicable Diseases
National Committee for the Prevention and Control of Hospital Acquired Infections
District’s & province’s Health Departments
Hospital Infection Control Committees
Quality subcommittees
Administrative support
Tertiary level hospitals (specialised centres & teaching hospitals)
Departments & Wards
Secondary level hospitals (district & province general hospitals)
Primary level clinics (FGP and PHC clinics)
Departments & Wards
Professional support
Figure 1. Hospital infection control management system of Mongolia. FGP, family group practice; PHC, primary healthcare clinic.
B.-E. Ider et al. / Journal of Hospital Infection 75 (2010) 209e213
211
National Committee
Infection control policy and plans
In 1997, the National Committee for the Prevention and Control of Hospital Acquired Infections was established at the MoH.10 The Committee consisted of key stakeholders from the MoH, State Inspection Agency, NCCD, City Health Department and leading MoH experts on infectious diseases, hygiene, epidemiology and bacteriology. The Committee was responsible for revising infection control policies and guidelines, approving the HRISRU annual plan and monitoring implementation of the plan at the national level. However, no meetings of the Committee were ever convened due to the rarity of HAI cases. In 2008, the MoH changed the structure of the Committee and since then infection control and prevention activities at the national level are discussed and approved by a committee chaired by the director of the NCCD, and including the director of HRISRU and the director of the Department for National Surveillance of Infectious Disease.11
In 1997, the MoH adopted the first complete set of infection control guidelines. In 2008, the MoH with financial support from the United Nations Global Fund replaced the previous infection control guidelines with the intention of moving closer towards international standards. The new guidelines are a translated version of the free online Infection Control Guideline from the USbased Engender-Health International LLC, with limited adaptation. The degree of implementation of these new guidelines has not yet been evaluated. In 2002 the Government of Mongolia approved the ‘National Programme for Control of Communicable Diseases’. It outlines mid-term directions for HAI prevention and control measures until 2010, emphasising the establishment of a sentinel surveillance system with improved laboratory-based monitoring.12 The establishment of a sentinel surveillance system for surgical and paediatric infections, to be introduced in Ulaanbaatar and selected provinces in a phased manner, and the enhancement of laboratorybased monitoring of multiresistant organism infections, were the main activities of the national programme. As a consequence of both poor motivation at the ministry level and funding at the hospital level, none of these planned activities has been implemented in the last seven years. However, the new approved infection control guidelines require hospitals at all levels of the healthcare system to initiate HAI surveillance, including surveillance of multidrugresistant organisms. There have been no plans to provide additional financial support for implementation of these guidelines. Meanwhile, with support of international donor organisations, other initiatives have been created by the MoH, such as safe injection, improved hospital waste management, quality improvement and hand hygiene programmes, but they have been limited in terms of the number of hospitals covered and duration of each programme.8,13
Hospital Infection Control Committee The Hospital Infection Control Committee (HICC) was established in all tertiary and secondary hospitals in 1997 and comprised the Chief Medical Director, a microbiologist, a quality manager, the Chief Nurse, the head of the logistics department, a health statistician and heads of clinical departments such as surgery, infectious diseases, intensive care and emergency units, internal medicine, and paediatrics. In most hospitals the HICC has a close collaboration with other hospital committees such as the drug committee, the nursing service, cleaning and housekeeping, waste management, disinfection and sterilisation units forming the Hospital Quality Improvement team. The quality subcommittees of clinical wards are responsible for the implementation of directions from the HICC. According to the infection control guidelines, the HICC should meet monthly, but its implementation has varied across hospitals.11 Since 2008, all primary healthcare clinics and family group practices have been advised to establish infection control committees (ICC) with one to three members. It is expected that it will take time and considerable effort for implementation in all 549 small facilities. Implementation of infection control guidelines in private hospitals has been poor, mainly because of weak collaboration with, and control by, the HRISRU and local Inspection Agency. Contributing factors include staff and resource shortages and insufficient attention. Only a few larger hospitals with >50 beds have established a HICC. Infection control practitioners In Mongolia, most ICPs are hygienist-epidemiologists who have completed a five-year university programme. This programme is for food, environment and occupational hygiene control with additional research and epidemiology components. There was no programme for infection control until very recently when the NCCD established a postgraduate course. Some ICPs, mainly in remote hospitals, are infectious disease doctors. Since 1997 all tertiary and secondary level hospitals have been obliged to have one full-time ICP. The recent infection control guideline amendment has tightened this requirement and now hospitals are obliged to have one full-time ICP for every 250 beds. Several tertiary hospitals in Ulaanbaatar with more than 300 beds have recently employed a second ICP. Hospitals with <50 beds have been advised to have a part-time ICP.
HAI statistics and surveillance The NCCD has been collecting HAI data since establishing the HRISRU in 1998. Reported cases are a collation of: (a) HAI cases and outbreaks that are notified from hospitals (passive surveillance), (b) cases identified through an active revision of patient notes during planned and ad-hoc hospital visits, and (c) cases, mainly hepatitis B and C virus infections, diagnosed by retrospective investigations of patients admitted at the NCCD. Due to limited resources, ICPs from the HRISRU visit mainly Ulaanbaatar city hospitals. Thus, 81.8% of all registered cases were diagnosed in city hospitals (tertiary hospitals 24.8%, district hospitals 43.0%, private hospitals 7.4%) and only 18.2% of HAI cases were diagnosed in provincial hospitals. HAI cases in provincial hospitals are mainly detected through retrospective investigation of patients referred from provincial to city hospitals. From 1998 to 2007, HAIs were reported to occur in 0.01e0.02% of all hospital admissions. The highest percentage (0.05%) occurred in tertiary hospitals in the capital city Ulaanbaatar.14e16 In 2008, the most frequently reported HAIs were neonatal infections (56.9%), hepatitis B and C virus infections (22.5%) and surgical wound infections (12.4%).17 One chapter of the updated infection control guidelines describes the launch of an active HAI surveillance system, which administratively and structurally, will be a component of the current NCCD Infectious Disease Early Warning and Response (IDEWAR) surveillance system. Data will be collected through IDEWAR and the HRISRU will manage the data. This HAI surveillance system will focus on all HAIs including those caused by multidrug-resistant organisms. Currently, the preliminary training and preparation stages are underway.
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Professional associations The Mongolian Association of Infection Control Professionals was established in 2008 with the aim of advancing the field of infection prevention and control through education, professional development of their members, and research. A vast majority of city public hospital ICPs became a member. While the organisation of conferences, conducting research and promoting infection control guidelines have been the main activities of the association, resource limitations and a lack of expertise or support from government organisations have been major challenges to achieving the associations’ aims.
Current and future challenges Although there are many challenges to infection control common to all developing countries, some specific challenges exist in Mongolia.18e20 These are summarised as follows: Insufficient priority has been placed on infection control among stakeholders. This has led to HAI being neglected for many years. No resources, including financial support, have been allocated to the ‘National Programme for Control of Communicable Diseases’ (2002) or implementation of the newly adopted infection control guidelines (2008). Therefore, it is very unlikely that the current national infection control plan and strategies will be implemented in the near future. Many policymakers and hospital managers believe that hospital infections should be completely absent, and subsequently some ministry regulations have probably resulted in falsifying infection control statistics. Current official infection control statistics indicate that HAI occur in 0.01e0.05% of all hospital admissions. This is considerably lower than internationally reported rates and suggests underestimation of the true frequency of HAI in Mongolia. Other than the HRISRU reports, there have been no other published HAI prevalence studies from Mongolia. It is extremely difficult to find resources for HAI research in Mongolia. Laboratory services in Mongolian hospitals are inadequate to support current infection control policy. There are no laboratory facilities in primary level hospitals. Among the seven urban district health services of Ulaanbaatar city, only one has a microbiology laboratory. Laboratories commonly lack essential equipment, specialised laboratory staff and laboratory reagents and consumables. Analytical variation among hospital laboratories is huge and a laboratory quality assurance scheme (both external and internal) is currently being planned. Monitoring of antibiotic resistance is at a very early stage. In most hospitals, insufficient laboratory capacity means that samples cannot be cultured from all suspected HAI cases. Therefore cultures are only taken when empiric antibiotic therapy fails.21 A shortage of trained infection control professionals limits the delivery of effective infection control programmes. Most ICPs are hygienists who graduated between 1960 and 1990 and who did not attend courses on infection control. Until recently, there have been no postgraduate infection control courses. Poor English language skills and limited access to the internet are the main barriers preventing ICPs from upgrading their knowledge. There is lack of awareness and commitment from clinicians and hospital senior management to support ICPs, whose salaries are among the lowest in the hospital system.
Despite its many challenges, the infection control system in Mongolia is evolving gradually. Infection control management structures with plans, policy and guidelines have led to dynamic changes during the last two decades. It would be unfair not to acknowledge the efforts of committed professionals in effecting change, whether optimal or not. We also should highlight that there is a growing willingness among health professionals to tackle infection control issues, which is essential for future reforms. For policymakers to make decisions on improvement in current systems for control and prevention of HAI in Mongolia, it is essential to identify the validity of existing HAI statistics and factors influencing their validity. While it is important to appraise and, where appropriate, draw from experiences and recommendations from other countries, research needs to be conducted to establish the current burden of HAI in Mongolia so that HAI control and prevention receive appropriate resources, and to understand constraints and perceptions relating to HAI surveillance so that reliable HAI statistics are generated. To date, there has been little research on HAI in Mongolia, either published or unpublished. Acknowledgements We thank colleagues from the Ministry of Health, Mongolia, who facilitated our search of archived documents. We are also indebted to Dr L. Dashtseren (former Director of HRISRU), Dr S. Dulamsuren (former Director of Aimag’s Health Department and Division of MoH) and Dr A. Buzmaa (former Director of department at the State Central SanitaryeEpidemiology Institute) for sharing information on infection control from 1960 to 1990 in Mongolia. Conflict of interest statement None declared. Funding sources Study partly funded by an Australian Leadership Award Scholarship Program and the University of Queensland, School of Population Health. References 1. National Centre for Health Development. Health indicators 2008. Ulaanbaatar: Ministry of Health, Mongolia; 2009 [in Mongolian]. 2. Ministry of Health of Mongolia. Ministerial order no. 211: defining the maximum limits for hospital beds in 2010. Ulaanbaatar: Ministry of Health; 2009 [in Mongolian]. 3. State Central SanitaryeEpidemiology Institute. Order no. 04: guideline for cleaning and sterilization of syringes, needles and other medical instruments. Ulaanbaatar: Mongolia; 1974 [in Mongolian]. 4. State Central SanitaryeEpidemiology Institute. Order no. 08: sanitarye epidemiological regimes for Ulaanbaatar city maternity clinics and maternity wards of inter-soum hospitals, and guidelines for prevention from Staphylococcus infections in maternity clinics and wards. Ulaanbaatar: Mongolia; 1976 [in Mongolian]. 5. Ministry of Health of Mongolia. Ministerial order no. 162: strengthening the measures on hospital infection control. Ulaanbaatar: Ministry of Health; 1982 [in Mongolian]. 6. Bolormaa T, Natsagdorj Ts, Tumurbat B, et al. Mongolia: health system review. Health Syst Transition 2007;9:87e93. 7. Ministry of Health of Mongolia. Ministerial order no. 09: sanitaryeepidemiological responsibilities of the health and preventive organizations. Ulaanbaatar: Ministry of Health; 1985 [in Mongolian]. 8. Health Sector Strategic Master Plan Initiative Core Group. Synthesis paper. Ulaanbaatar: Ministry of Health of Mongolia; 2004. 9. World Bank. Mongolian health system at a crossroad: the incomplete transition to a post-Semashko model. Washington, DC: East Asian and Pacific Human Development; 2006. p. 57e61. 10. Ministry of Health of Mongolia. Ministerial order no. 336: strengthening prevention and control of hospital acquired infection. Ulaanbaatar: Ministry of Health; 1997 [in Mongolian]. 11. Ministry of Health of Mongolia. Ministerial order no. 85: strengthening prevention and control of hospital acquired infection. Ulaanbaatar: Ministry of Health; 2008 [in Mongolian].
B.-E. Ider et al. / Journal of Hospital Infection 75 (2010) 209e213 12. Government of Mongolia. Government resolution no. 129: approval of the national programme for control of communicable diseases. Ulaanbaatar: Government of Mongolia; 2002 [in Mongolian]. 13. Ministry of Health of Mongolia. Report of the reassessment of injection practice in Mongolia. Ulaanbaatar: Ministry of Health; 2006. 14. National Centre for Communicable Diseases. Health statistics 2005. Ulaanbaatar: NCCD; 2006 [in Mongolian]. 15. National Centre for Communicable Diseases. Health related infection surveillance and prevention unit's annual report, 2007. Ulaanbaatar: NCCD; 2008 [in Mongolian]. 16. National Centre for Communicable Diseases. Health related infection surveillance and prevention unit's report 1998e2007. Ulaanbaatar: NCCD; 2008 [in Mongolian].
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