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>> Hello; and welcome to
International Infection Prevention Week.
Today's webinar, "Preventing the
Next Avoidable Catastrophe in Low
and Middle Resource Countries," is hosted by
the Centers for Disease Control and Prevention,
in collaboration with APIC, the
Association for Professionals
in Infection Control and Epidemiology.
My name is Abbigail Tumpey.
I'm associate director for Communication Science
for CDC's Division of Healthcare
Quality Promotion.
CDC's mission is to protect patients
wherever they receive their medical care.
This webinar is part of a series of infection
control-related webinars the CDC is hosted
with a variety of external partners and experts.
The featured speaker on our
webinar today is Dr. Benjamin Park.
Chief of the International Infection Control
Program at the Centers for Disease Control
and Prevention's Division of
Healthcare Quality Promotion.
Dr. Park will discuss healthcare
outbreaks from a global perspective.
Before we get started, there are
a few housekeeping items to cover.
First of all, we welcome your questions.
Please submit any questions or comments
you have via the chat window located
at the lower left-hand side
of your webinar screen.
You may enter these questions at any time.
Questions will be addressed after
all presentations, as time allows.
To ask for help, please press the raise hand
button, located at the top left-hand side
of your screen, if you need to chat with
a meeting chairperson for assistance due
to technical difficulties during the webinar.
As a reminder, to hear the audio
please ensure that the speakers
on your computer are turned with the volume up.
Today's conference should be coming
through your computer or laptop speakers.
Additionally, the slides from
today's presentation will be emailed
to all participants following
today's discussion.
Now, it is my pleasure to introduce
Linda Greene, President-Elect of APIC,
who will provide introductory remarks on
behalf of the Association for Professionals
in Infection Control and Epidemiology.
Linda?
Linda, you can take it from here.
Just make sure that your phone is off mute.
So hopefully we'll come back to
Linda later in the presentation.
It looks like we're having some
technical difficulties hearing her.
Now, I'd like to turn it over to Dr. Ben Park,
who is going to take the conversation from here.
Dr. Park?
>> Thanks, Abbigail.
It's really great to be on this webinar.
Thank you for the invitation,
and thank you to APIC,
and also to our folks here
at CDC for hosting the event.
I'm really excited to be talking to you all.
You know, we got word that there were, you
know, a few thousand people that registered,
so I hope this will go out to a lot of people.
So my name is Ben Park.
I'm the Chief of the International
Infection Program here
at the Division of Healthcare Quality Promotion.
And I'd like to talk to you about some of my
experiences, and some of the priorities for CDC,
and for the US government moving
forward, based on these experiences.
And I think, you know, having International
Infection Prevention Week is great,
and it's great to have so many people around
the world, in the US, and in other countries,
focus on infection prevention
because it's such a critical topic.
And for this talk today, I think, you know, what
I'd like to do is to highlight some experiences
that hopefully will kind of crystallize how
important infection prevention is for you all,
and how the work that you do in your
facilities, whether it's in the United States,
or it's in other countries, how
critical it is for public health.
And I think it's a story that we're sort of
used to hearing about now, but it's always good
to see how -- what the bigger perspective is.
And then I'd also like to talk about how
we can use these experiences and some
of these lessons learned toward the future,
and how we can build structures and systems
so that we might be able to
prevent the next catastrophe.
And, you know, I think hopefully we won't
be seeing the next avoidable catastrophe,
but again, that's what the whole
purpose of this talk is about.
So I'm going to take -- so if
we could all think about --
I know a lot of us are kind of right now in
your office, or at home looking at the computer,
but just kind of imagine that you're getting
on a plane with me and we're going to go
across the world to some places that are
a little bit different from the facilities
that you typically will see,
the ones that you work in.
And these are -- a lot of times these
are the facilities that you'll see in low
and middle income countries, low
and middle resource countries.
And I don't want to make it seem like this is,
you know, everything; that this is, you know,
what we always see in these countries,
because of course, as many of us know,
there are many outstanding
stellar facilities in countries
that have high rates of poverty
and lower incomes.
But I think one of the most crucial
aspects to focus on are those weak links
in the healthcare system, which are typically
some of the lower resource environments.
So --
You'll -- I think well I'll start --
well the story that I'll start off with
goes all the way back to SARS in 2003.
I started at CDC in 2002, and SARS -- I remember
very distinctly SARS being one of the things
that kind of crystallized my
interest in public health.
Again, I was only here at CDC for one year, but
one of the things that I think for those of you
that remember the SARS epidemic,
remember is that one
of the key characteristics was the
amount and number of infections
that occurred within healthcare facilities.
There were these things called "super-spreaders"
that occurred in Asia, Southeast Asia,
East Asia, and also in Canada, and there were
lots of these events that led to a number
of healthcare workers becoming ill.
This is one of the key aspects of
the epidemiology of this outbreak.
Not only was it being transmitted in
the community from person to person,
but importantly, it was being
transmitted in healthcare facilities.
And I think, you know, you don't have to be
in the low-resource setting with, you know,
poor infection control to understand that
this happened in many high-resource settings,
like in Toronto, and also
in areas like Singapore.
Then fast-forward to just two years ago in --
I think we all remember the Ebola outbreak.
And of course I'm going to be
talking a lot about Ebola today.
But two years ago in the summer -- a little
more than two years ago, in the summer of 2014,
Ebola had emerged in Guinea, and it had
spread to the neighboring countries,
primarily Liberia and Sierra Leone.
And, you know, it was kind of largely
thought of as being handled in the summer.
Although, there were some -- as the
summer progressed, there were some signs
that it was maybe kind of
spiraling out of control.
And I think what really galvanized
the international community was
when a gentleman named Patrick
Sawyer flew from Monrovia to Lagos,
which is the most populous city in
Africa, and traveled on the plane,
and was admitted to a hospital with Ebola.
And this, I think, scared a lot of people
because I think that people realized
that if it gets out of control in Lagos,
again, one of the most densely populated cities
in Africa, and then the most populous,
and also a hub for commerce and travel,
if it gets out in Lagos, who
knows what's going to happen.
It could certainly impact, you know,
Western Africa, the whole of Africa,
maybe even other areas outside the world.
And so I actually went to Nigeria.
I was one of the first people to go to
help try to set up infection control.
And one of the things that I found when I
got there was that I think some of the things
that we take for granted around infection
control and infection prevention,
some of the systems were
sworn in place in Nigeria.
And so again, we were trying to make sure that
the outbreak didn't spiral out of control.
And one of the things that we were
doing was helping to provide training
to healthcare workers around what to do if
they were to see someone that were to come in.
Thankfully, I think we all know the end of
the story is that Nigeria ended up being able
to control the outbreak, thankfully, with
a lot of hard work from public health
and from clinicians, and
we didn't experience this.
But certainly the fear was
there, and certainly the fear
about what could happen was a
large part of the motivation
for such a large public health response.
But it didn't even stop there.
I think Ebola is something that's
all fresh in our minds but, you know,
there is also something called "MERS"
that we all might have heard about,
certainly in the Middle East, it's
something that is a regional issue there.
But, you know, what we found after Ebola,
even without these emerging diseases continue.
In Seoul in 2015, a traveler from
the Middle East went to Seoul
and had a respiratory illness,
and ended up causing a number
of infections throughout the
city in many different hospitals.
And there are a lot of reasons why these kinds
of -- this multifocal kind of outbreak happened.
But one of the key components is
really infection control precaution
that weren't adhered to,
and where infection control,
especially in emergency departments,
was lacking.
And so, you know, it's interesting, so I --
you know, I'm Korean American and
my parents actually lived in Seoul,
and it's funny because this is probably
the first time I think in recent memory
that my parents like fully understood what
it is that I do on a day-to-day basis,
because they saw how important MERS
was, and how it impacted their economy.
Actually, in South Korea,
you know, I think the --
you know, actually, the stock market went down.
I think that, you know, millions of
dollars were lost because of the outbreak,
because people were isolating themselves
in their communities, in their homes,
and were not traveling, as well as the
healthcare system, which I'm going to talk
about a little bit later, largely
shut down for a period of weeks.
The story doesn't end with MERS.
It continues.
And I think the next threat
that we're all talking
about right now is antimicrobial resistance,
things like Carbapenem<span style="color:
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>-resistant Enterobacteriaceae, where the
burden of these infections, especially in low-
and middle-income countries, like India and
like Southeast Asia, and also parts of Africa,
is probably quite high, and probably the
mortality and morbidity from these infections
for a number of reasons is quite high.
And this is also the next -- you
know, this could be the next epidemic.
And of course, we all remember what happened
with the colistin resistant superbug of MCR-1,
which was just reported recently, and,
you know, is this kind of the next wave
of antimicrobial resistance, and how
does this relate to infection control?
So all these things we're going to
be talking about as the talk goes on.
Well, you know, I think it's --
when we think about these problems,
and we think about these outbreaks, you
know, a lot of these things are happening
in low- and middle-income countries.
And I think, you know, sometimes it's easy
for us in our facilities to think that we're,
you know, relatively insulated,
relatively safe from some of these things.
But of course we just have to point to
things like what happened in Nigeria
with the one plane ride from Patrick Sawyer
from Monrovia to Lagos, or, you know,
thinking about obviously what happened with
other emerging diseases, about how, you know,
these infections are really just a
plane ride away, and these could pop
up in our emergency departments, they can
pop up on our wards in the United States,
and then it's something that
we're going to have to deal with.
And granted, we have better -- to generalize,
better infection control in the United States,
but still are we prepared to handle these
types of emerging infectious diseases?
And so this picture actually is one that I
love to show, because it's really interesting.
What it shows, all these
yellow lines are air travel,
and these are the primary routes of air travel.
And the darker the line,
obviously the more traveled it is.
But you can just see how
interconnected the world is through this.
All right; so let's talk a
little bit about outbreaks.
I think that one of the things that
is great around infection control
and infection prevention is that you deal
with outbreaks on a day-to-day basis.
You deal with outbreaks in your facilities.
But this actually isn't the case
in a lot of low-resource settings.
You know, a lot of the countries that I've
been to, a lot of the hospitals I've been
to talking to people in the hospitals.
The first thing that you'll
notice is that typically,
there aren't infection preventionists,
and certainly there may be a nurse
that's whose job it is [clears throat] is
to do infection control, but they
don't have the level of training
of an infection -- of an
IP in the United States.
And a lot of times, they are
not also focused on outbreaks.
So what happens in outbreaks -- you know, just
generally speaking, you know, in most outbreaks,
clinicians will recognize
and report an outbreak,
and public health would typically be the group
that is involved in the response and control.
So oftentimes the case, especially with
community-acquired diseases, where, you know,
a clinician will identify a case
of a rare disease or of something,
and will notify public health, and the
public health will look across, you know,
other facilities and look -- and to
see that there are cases or not cases,
and will conduct an investigation, try to
find the source, and identify the outbreak.
But in healthcare-associated
infections, it's a little bit different
because healthcare-associated
infections occur in clinical facilities,
clinicians have a very powerful
role and an integral role
to play in the outbreak investigation.
Clinicians of public health oftentimes
will work together with these outbreaks.
And a lot of times, that works really well.
I think, you know, we can all think about
outbreaks that have happened in our facilities,
and how we've worked with public health
potentially, either at the state level
or at the federal level, to be
able to control an outbreak.
But this isn't actually the same
system that they have in one
of low- and middle-income countries.
As I mentioned, the infection preventionists
or infection control nurses sometimes --
first of all, sometimes, they're not there, but
then even if they are there, they're not trained
on outbreaks, they're not trained
on outbreak detection or control,
and they're certainly are not trained
on how to link up with public health.
So this is one area where there's going to be --
some of the key resources
in the future are going
to be pointed towards how can we strengthen
this linkage between the clinical facility
and public health, especially in
low- and middle-income countries.
Well, let's talk more about outbreaks.
And I want to talk specifically about why
healthcare facilities are so important.
I think that we talked about how they play a
special role in that the people are involved,
and can be closely linked to public health.
But what is it special about
the healthcare facility,
and why is that so important
for outbreak control?
Well, from a public health perspective,
healthcare facilities are unique places,
because I think we know sick
people go to healthcare facilities,
and when these sick people have particularly
transmissible diseases, then they become --
the healthcare facilities become a focal
point for the epidemiology of an outbreak.
And this gets also back not
only to the fact that patients,
sick patients go to healthcare facilities,
and then that obviously becomes a key place
where they are, but healthcare
facilities also are important
for the control of infectious diseases.
Because if you think about what are
the key principles for the control
of transmissible diseases, there's -- you know,
the key things that public health professionals
like to point to, there's isolation,
vaccination and prophylaxis.
And these are the things that public
health professionals will typically point
to in any outbreak.
So if it's an outbreak of influenza, or cholera,
or something like that, these are key tools
in the armamentarium to prevent diseases.
And of course, isolation is something
that happens at healthcare facilities,
as well as in the community, of course.
But for healthcare facilities
this is a key principle.
So in healthcare facilities, there is a need
to be able to isolate patients effectively,
and if this need -- if this key capacity does
not exist, then the healthcare facility can turn
into a place where disease can be transmitted.
And then you've got this kind of perfect storm.
You've got patients who come sick to a hospital.
And there's no isolation capacity,
and furthermore there's no even
ability to identify the patients.
And then healthcare-associated transmission
of transmissible diseases can occur.
And you just have to think about this
perfect storm when you think about low
and middle income countries, because when you
go to healthcare facilities in these countries,
healthcare facilities typically
are under-resourced,
you know, clinicians are overworked.
And what that means is that you
have things like this waiting room,
where they're very crowded,
there are a lot of people there.
And there are kind of, you know,
key setups for disease transmission.
This is what we saw a lot with a lot of
these outbreaks that I talked about earlier
on that I was highlighting, is that
emergency departments, as well as other areas
in the wards, are just areas where
disease can easily be transmitted
from one person to another.
And I think for a lot of us that are familiar
with infection control, we just have to look
at one of these types of settings, and we
can see clearly that if one of the patients
in this waiting room had
MERS, or had the next --
or had Ebola, or had the next
highly-contagious disease,
that this would be a very efficient
way for that disease to spread.
And I don't want to single out emergency
departments as a key problem area,
because there are many throughout
healthcare facilities on the ward.
And I'm going to talk about
-- when we talk about Ebola,
I'm going to talk about that a little bit.
All right; well let's talk about Ebola.
Let's talk about what happened.
And I think one of the key narratives
that came out of the Ebola epidemic was
that the healthcare system collapsed.
And, you know, I think for those of us that were
following this closely, you know, there was --
initially there was disease
transmission, and then it got worse.
And then what we heard was that the healthcare
system was collapsing and, you know --
but I think it's worthwhile to examine that
further, because what does it really mean
when the healthcare system collapsed.
You know, and I think we should talk about that.
Now, with Ebola -- care for Ebola
patients happened in two different areas.
There was the general healthcare
facilities like a general hospital,
and then there were the what we call the
"ETUs," the Ebola treatment units, where --
these are the areas where
patients with Ebola were treated.
And these ETUs were generally staffed by
nongovernmental organizations like Doctors
Without Borders, like WHO, like, you
know, other governmental organizations
that had pretty good stocks of PPE and had
the layout of the ETUs already designed,
because they were essentially constructed.
And many of you may have seen pictures of
this where there was, you know, a big field
and there were these kind of big tents set
up with, you know, this white sheeting,
and people kind of beyond the fence
had, you know, full, you know, tyvek on.
And that is primarily where the
patients with Ebola were treated.
And those actually were not where
the dangerous settings where.
If you actually look at the epidemiology of
Ebola and the healthcare-associated cases,
by and large, the healthcare
workers in these ETUs were safe
and patients did not typically transmit
Ebola from one patient to another.
And healthcare workers were
generally pretty safe
because they had good PPEs,
and they were well-trained.
And there was good environmental cleaning.
The dangerous areas, really, were
the general healthcare facilities.
And these are the places where people because
they didn't know if there were a contact
or not because there was
such general transmission,
people came to the healthcare facilities with a
fever, and they had no idea that they had Ebola.
They could have had malaria.
But because there wasn't this good
recognition at the healthcare facilities,
the healthcare facilities -- the
general healthcare facilities is
where Ebola became transmitted.
And so what happened was that Ebola
actually turned out to be a story about IPC
and general healthcare facilities.
In the general healthcare facilities,
IPC was not being practiced well enough,
and what happened was that disease transmitted
from patient to patient, from patient to doctor,
from doctor to patient, and doctor to doctor.
And when I say doctor, I mean healthcare
professional, because it wasn't just doctors,
of course there were nurses,
there were cleaners,
and many other people that were impacted.
And then this led actually to an amplification
of the outbreak, instead of control.
So when healthcare providers left these
facilities, went to the community,
they could transmit it to their community.
And this actually led to -- again,
as I said, an amplification,
whereas healthcare facilities should be --
as I talked about, should be an area
where they can control the disease
through good isolation, good recognition.
Without that, it turned into
actually an amplification.
And so as a result, you know, these healthcare
facilities were quite dangerous places.
You know, early -- and especially
at the height of the outbreak --
and this is a picture taken from a hospital
in Liberia in the height of the outbreak,
these are literally places where
there were -- there was a lot --
there were extremely dangerous places where
it was unsafe to go into these facilities.
And as you can imagine, these are -- would be
areas where if we could recognize a danger,
clearly patients understood and doctors
understood, and the nurses understood,
and cleaners understood that
these were dangerous areas.
And as a result, patients stopped
going to healthcare facilities.
A lot of physicians, a lot of nurses, a lot of
cleaners, a lot of staff refused to come to work
because there was no -- there were
little PPE, there was little training
around how to protect themselves.
And, you know, they were
extremely dedicated individuals.
But at the same time, you know, they understood
that, you know, they were highly risky areas.
And so what happened was that
patients, as I mentioned,
stopped going to healthcare facilities.
Staff stopped coming to work.
And this impact was felt
across the healthcare system.
So core essential services like
immunizations and like deliveries
at healthcare facilities declined rapidly.
These are two figures taken from an
evaluation of the impact of the Ebola outbreak
on health systems in Sierra Leone.
And the table on the left
shows the hospital admissions
and consultations during the outbreak, kind of
pre and post, showing that maternity admissions
and pediatric admissions, and basically all
admissions dropped precipitously during the
height of the outbreak.
And the graph on the right shows the
number of children that were vaccinated
in this one area called "Koinadugu"
in Sierra Leone,
showing the tremendous drop-off in vaccinations.
So what this means is essentially that,
you know, core public health functions,
like delivering babies in a hospitals,
like vaccinating children, you know,
these were things that fell by the wayside
because people stopped accessing healthcare.
So fundamentally, all of this was a
ripple effect from poor infection control.
So when we talk about the healthcare system
collapsing, what we're really talking about was
that IPC collapsed, infection control
collapsed, leading to a further deterioration
of the healthcare system, and
the public health in general.
So I think this is a story -- you know,
now when people think about Ebola,
when people talk about how the
healthcare system collapsed,
and how the healthcare system needs
strengthening, I think it's important for us
to point out, "Well, what do you mean the
healthcare system needs strengthening?
What needs strengthening?"
And infection control should be
a key area of that conversation.
But as I mentioned earlier in the
talk, you know, this is not something
that should be thought of as isolated in low --
in the kind of poorest countries in West Africa.
I think that was certainly a key determinant.
Certainly it was something that helped
the outbreak spiral out of control.
But we see this all the time, and we see --
of course for those of you that
work in healthcare facilities,
you see outbreaks that happen all the
time in your healthcare facilities.
And as I pointed out with MERS, this can happen
in strong healthcare systems, too, of course,
SARS in Toronto, in Singapore, you
know, of course, issues around CRE
and other transmissible diseases.
These can happen in our healthcare facilities.
And it's not -- I don't think it
would be wise to think that, "Okay,
my healthcare system has enough PPE, and
my healthcare system has enough training.
It can't happen here."
It can happen in any healthcare facility.
But of course, those without training, and those
without the key material are at higher risk.
So this brings us to the issue around
preparedness, and it brings us to the issue
around what is the world doing
to help to prepare to respond?
Well, after the SARS epidemic
in 2003, there was something --
the world came together and developed something
called the "International Health Regulations."
And the International Health
Regulations were designed in 2005 --
and all 194 countries of the world signed onto
this -- I think it's a treaty through WHO,
to essentially provide the core components
around preparedness to prevent the next kind
of catastrophic thing from happening.
And these are -- the International Health
Regulations are a core set of functions
that those healthcare systems and
governments should do in order
to prepare themselves for the next outbreak.
And it was in effect in 2014, so that only
30% of countries were fully prepared to detect
and respond to an outbreak, showing essentially
that, you know, in the 11 years since SARS
and the nine years since IHR was implemented,
there was still a large gap in 2014.
And of course we saw that happened
in 2014 with the Ebola outbreak.
So overall the world generally needs
more work in this preparedness.
And when you talk about preparedness,
of course, one of the key components,
as I mentioned around preparedness,
is around healthcare facility and IPC.
And IPC is one key component around
International Health Regulations.
Of course, International Health Regulations
-- there are other things besides IPC,
but that is one key component of
what we're talking about today.
So there was this study during the height of
the Ebola outbreak trying to look at to see
if hospitals were prepared around
the world for Ebola virus disease.
And this slide focuses on Africa, because I
think it's important to see that, you know,
Africa was clearly one of the areas where --
that we're focusing on in terms
of low and middle resource areas.
And it's also the area -- the continent
that was probably the most at risk
for developing transmission of Ebola.
But even in Africa, at the height of
the outbreak, you know, only about --
only a third of -- so a third of the
respondents from this survey were from Africa,
but of these people, you know, preparedness
for Ebola is really only partially adequate.
And the authors of this study looked
at especially about isolation capacity,
and found that across the world only, you know,
less than 70% had sufficient isolation capacity.
And in Africa it was many fewer hospitals.
They didn't give the exact proportion here,
but I think suffice to say that preparedness
and isolation facilities in Africa,
even at the height of the Ebola outbreak
when everyone was supposed to be
preparing and preparing their facilities,
many fewer than 69% in Africa were prepared.
Well, I think easier said than done, right, I
think a lot of us can say that these things have
to happen, and these things are so important.
But it's difficult to actually
get these things done.
And it's difficult to have
infection control at your facility,
and it's furthermore even more difficult
to be able to have infection control staff
and resource to be able to
effectively investigate
and respond to threats, like outbreaks.
One of the key areas that -- one
of the key weaknesses, I think,
in a lot of low-resource countries
granted I'm generalizing here.
But in many low- and middle-income countries,
the linkage between the clinical facility
and the public health authority is weak.
And I mentioned how important this
was for outbreaks earlier in the talk.
And when this linkage is weak, then what happens
is that public health has very little visibility
into what's going on in healthcare facilities.
And then when healthcare associated
clusters or transmission happens,
the Public Health Authority
has kind of a blind eye.
And so this is one of the key
areas that needs to be strengthened
around preparedness and response for outbreaks.
In addition, and something that I haven't
talked about so far, but it's a reality in low-
and middle-income countries is the
lack of a dependable laboratory.
And laboratories in low and middle
income countries have great investment
in things related to HIV, related
to tuberculosis, related to malaria.
But I think what's fallen by the wayside a
little bit is key laboratory infrastructure
around microbiology.
And I think microbiology -- we all depend
on our microbiology labs to tell us
about not only what the organism is,
but also what the susceptibility is,
and whether -- and then we look at that.
We look at those organisms, and those
profiles, and things like that to be able to see
if there is a cluster of disease.
And microbiology and other things like
serology are not as strong as they could be,
and probably deserve some strengthening.
In addition, another obstacle
for this preparedness
in outbreak investigation
is just a lack of training
on outbreak investigations
in healthcare facilities.
So there is an effort underway, and
I'll talk about that a little bit later,
around strengthening outbreak investigations
in low and middle income countries.
But typically the healthcare facility
is not a focus, and it's something
that we are trying to strengthen moving forward.
All right; so now that we've
talked about some of the gaps --
hopefully I haven't depressed all of you,
we're going to talk a little bit about,
"Well, what are some of the solutions?
How do we actually bridge some of these gaps
and how can we address some of these key issues
in low and middle income countries?"
Because I think it's something that even -- that
a lot of us actually have a vested interest in.
I mean, I think in order to keep kind of some of
these emerging diseases out of our facilities,
it's important to be able to address
them at the facilities where they occur.
And sometimes that's in low
and middle income countries.
Of course, I don't want to make it
seem like I'm singling out these areas,
because as we all know, sometimes, it goes the
other way where we have diseases that emerge
and it's transported to these countries as well.
Well, one of the things that we're trying to
focus on is how do we make IPC a priority?
As you can imagine, it hasn't
been a priority in many countries.
Again, I'm generalizing because there
are some shining examples of that.
But in general, IPC needs to be prioritized.
And I think one of the key things to think
about, for those of us that do work in low
and middle income countries,
is how important IPC is,
and how important it is to
many different stakeholders.
It's not just important to us
as infection preventionists,
or as physicians, or as clinicians.
But it's important to a whole
-- a wide array of stakeholders,
including hospitals and hospital administrators.
They have a key role to play.
Also, civil societies and patient advocacy
groups, also professional societies,
like infectious disease clinicians,
or nurses societies.
These are key stakeholders that should
be engaged when we're thinking about how
to strengthen and build a case
for improving infection control.
Certainly, academic groups are a key player and
universities, but also donors thinking about --
you know, I think this is an area where there
hasn't been a lot of donor investment from some
of the key donors in global health.
And how can we make a case that it is important
for donors to think about infection control
as it relates to health security overall?
Well, what do we do once we develop these --
once we've developed our stakeholder group,
and once we have this kind
of momentum behind us?
Well, actually, there have been
documents talking about and discussing how
to implement infection control
programs within countries.
And this is all based on a 2009
document called the "WHO Core Components
for Infection Prevention and Control Programs."
It's actually something that's being updated
right now, and the new one is going to be coming
out sometime later this year,
or maybe early next year.
But most of it will stay the same.
And what this document talks about is
how countries can prioritize and can look
at the different components around what is
needed for an infection control program.
And this is broken down to the national
level and at the facility level.
So it's really kind of a roadmap around
what to do for infection control.
And it touches on basic things like
how do we organize an ICP program
at a facility or at a national level?
You know, what's the importance
of technical guidelines?
And how do we have national guidelines
but also facility-based guidelines?
Prioritizing human resources, doing
surveillance, the importance of the micro lab --
this I've already mentioned, the importance
of the environment and cleaning, and hygiene,
and water, and sanitation, how do we
monitor and evaluate these programs?
And very importantly, as I've
mentioned a number of times already,
how do we link with public health, and how
do we link with the public health authorities
to do things like prepare
and respond to outbreaks?
So this brings me to an initiative by the
US government, as well as other governments
around the world, which was
born out of the Ebola crisis.
I think I painted a picture that shows that
there needs to be a lot of investment within low
and middle income countries
around preparedness for outbreaks.
One key component of that is IPC.
But there are other key components,
including building up laboratories,
building up surveillance infrastructure, you
know, building up laboratory referral networks,
building up information systems
that can help respond to outbreaks.
These are all kind of key components that
were identified in the Ebola outbreak.
And one of the things that has happened
out of this is something called the
"Global Health Security Agenda,"
which is an initiative not just
of the United States government, but also with
many other governments that have signed on,
talking about how do we identify
the key priorities
around what constitutes Global Health
Security, and how can we strengthen those things
to prevent the next avoidable catastrophe?
And what the Global Health Security Agenda
is, it was launched in February 2014
to advance a world safe and secure
from infectious disease threats.
And this is something that the G7 endorsed.
It's something that initially Finland
and Indonesia were the kind
of leaders of this initiative.
But a lot of countries throughout the world have
signed onto this, and signed onto being a part
of the Global Health Security Agenda,
basically committing that they were going
to not only follow the Global Health Security
Agenda goals for their own countries,
but were also going to try to help
other countries meet those goals
for Global Health Security.
And all of these Global Health
Security Agenda activities fit
into the International Health Regulations.
They all are work -- are designed to work with
IHR to be able to strengthen the IHR goals
so that, again, we can all prepare for
the next pandemic, or the next epidemic.
So with Global Health Security there are three
major risks that we're trying to address,
and those are emerging organisms, drug
resistance, and the intentional creation
of a biohazard; three opportunities, including
societal commitment, new technologies,
and success leading to more success.
And then the three major priorities are
organized around prevention, detection,
and response to infectious disease threats.
So these are organized around
what we call "action packages."
And these action packages are things that we are
targeting for investment for capacity building.
And these vary in terms of,
as I mentioned before,
things like building surveillance capacities,
things like building reporting systems,
laboratory systems, strengthening work forces,
building what we call "emergency
operation centers" that are kind of the hub
for outbreak detection and response.
Also how do we, you know,
deploy medical countermeasures
and link public health with law enforcement.
But then we also have these four
[clears throat] subject matter areas
around antimicrobial resistance,
zoonotic diseases, bio-safety
and bio-security, and immunizations.
And where our infection control fits
in is around antimicrobial resistance,
where antimicrobial resistance
is seen as a key area, again,
to just kind of address the emerging threat
of AR, and how strengthening AR can lead
to strengthening -- to reducing AR,
but also strengthening overall the infection
control networks that we have in a country.
So talking a little bit more about
this action package of AR, again,
this is around the prevention aspect, preventing
the further emergence and preventing more AR,
where there are a number of countries that
have already signed on that really try
to lead this multinational effort.
And actually the leading countries are currently
Canada, Germany, the Netherlands, and Sweden,
and there are a number of
other contributing countries.
And what it means to be a leading or
contributing country really means that --
you know, to provide some of the
technical assistance and knowledge
around not only having our own countries
who have signed on meeting the goals
of this action package target, but also helping
other countries achieve these goals as well.
So what are we trying to do
around this action package?
What we're trying to do is we're trying to
implement an integrated and global package
of activities to combat AR, where each
country has its own plan, surveillance
and laboratory capacity strengthened, both
at the national and international level,
and that we're conserving the existing
treatments, and supporting the development
of new antibiotics, as well as
providing new diagnostics and things
like infection control to combat AR.
Countries are actively working on plans right
now, actively working on their AR action plans,
and this all fits in with what's called the
"WHO Global Action Plan for
Antimicrobial Resistance."
And countries are also actively
participating in twinning frameworks.
And those twinning frameworks
are really important.
A twinning framework is a framework
where one country is providing assistance
to another country to meet some of
the goals around prevention of AR.
And again, the impact, of course, is to
reduce AR, and to prevent the emergence of AR,
through strengthening surveillance and
regulation of appropriate antibiotics,
both in the human and the animal side.
So specifically, what is CDC doing?
You know, I think -- when we started off the
talk, Abbigail had this nice introduction.
But many of you might have been wondering like,
"What is this International Infection
Control Program," because it's something
that maybe probably a lot
of you haven't heard about.
Well, I'm just going to spend a couple
of minutes talking about what this is,
because it's a new program that
also was born out of Ebola.
And it's something I think that --
something to be aware of, because this is one
of the key areas that CDC is helping to
provide this type of technical assistance.
This International Infection Control Program
is built on decades of experience of DHQP,
the Division of Healthcare Quality
Promotion that provides the key domestic
and international support for
improving healthcare quality.
And our purpose and our mission is to protect
patients and healthcare workers globally
by providing expertise, evidence,
and implementation strategies
to sustainably address infectious disease
threats related to healthcare delivery.
And we have three different -- three main areas
where we concentrate, providing rapid assistance
for outbreaks and other adverse
events related to healthcare delivery,
improving infection prevention control
capacity, to prevent and control HAIs
and device-associated HAI outbreaks,
healthcare-associated outbreaks
and device-associated HAI infections,
and reduce the global burden
of AMR associated with healthcare delivery.
So these are the key areas
that we're going to be working.
And in a lot of the countries that we talked
about that have low and middle incomes
and are resource limited, we're
going to be providing some of this
in that twinning framework that I talked
about, to be able to address infection control
to be able to provide a safer security
environment for the United States
and for countries internationally.
So just a summary to wrap up.
I talked about how infection control is a
critical component for outbreak response.
I talked about how infection control,
IPC, and public health must be linked,
and that link must be strengthened.
I've also talked about how we can
focus not only on the national systems,
but on sub-national systems, so like facilities,
and how facilities can focus on building
that outbreak and infection
control capacity for the long-term.
And I've talked about a little bit
how some current global initiatives
through this Global Health Security
and through other efforts can help,
and how there is some effort in this space
to try to build off of the lessons learned
from a lot of these recent outbreaks,
and how we might together be able
to work towards some of the solutions.
Thank you very much, and I'd be happy
to take any questions if they come in.
>> So this is Abbigail Tumpey, and first
before we go to questions, we're going to try
to get Linda Greene from APIC back on the line.
So please hold with us for one second
while we try to transfer her in.
This is Abbigail Tumpey from CDC, and
hopefully we have Linda Greene back with us.
Linda, you there?
>> Yes, I am.
Thank you so much Abbigail.
As was mentioned earlier, my name is Linda
Greene, and I'm President-Elect of APIC,
the Association for Professionals in
Infection Control and Epidemiology.
And I'm pleased that everyone joined
today to participate in this webinar,
focusing on infection prevention and
control in international settings.
Because this webinar took place during
International Infection Prevention Week,
I would like to provide some background about
International Infection Prevention Week.
International Infection Prevention Week takes
place the third week of October each year,
and raises awareness of the role infection
prevention plays to improve patient safety.
Since International Infection
Prevention Week was established in 1986
by President Ronald Reagan, APIC has spearheaded
the annual effort to highlight the importance
of infection prevention among
healthcare professionals,
administrators, legislators and consumers.
And over the years, this week of recognition has
vastly expanded to every corner of the globe,
including Australia, the United Kingdom,
the Middle East, and Southeast Asia.
So as the reach of infection prevention
week widens, more patients benefit
from safer healthcare practices, and
reduced threat of healthcare infections.
And I think Dr. Park's presentation
really summed this up.
So the theme of this year's observance
is "Break the Chain of Infection."
APIC has created tools to help
healthcare professionals advocate
and promote infection prevention, give
infection prevention special visibility,
and facilitate conversations about
why infection prevention matters.
From sample social media posts, to infographics,
to podcasts, to interactive quizzes,
APIC has provided materials on
how both healthcare professionals
and consumers can help break
the chain of infection.
So visit apic.org//infectionpreventionandyou
to access these materials,
and sign our infection prevention pledge.
Together, we can break the chain of infection.
Thank you for your commitment
to infection prevention.
We're honored that CDC again partnered with us
on this International Infection Prevention Week,
and we thank you all for listening today.
Thank you so much.
>> Thank you, Linda, and thanks for holding-on
so that we could get you back on the line.
We're going to go to our questions and answers,
and hopefully both Linda and Ben will be able
to get through as many questions as we can.
Our first question, Ben, is, "What
steps are being taken to ensure that low
and middle resource countries are better
prepared to recognize and control the emergence
of antibiotic resistant infections?"
>> Thanks, Abbigail.
That is a great question, and it's something
that we spend a lot of time thinking about
and working on in our program,
and across CDC in general.
You know, I think we are just starting to
see how important AR is on the domestic side.
And I think a lot of us who work in healthcare
facilities think about this every day,
especially from an infection
prevention standpoint.
And there's -- to be honest with you,
there's a lot of work that needs to be done
in the international setting, because,
you know, I think that our perspective
in the United States, you know, we look at
how equipped we are to handle these problems.
And I just want you to think about a healthcare
facility right now, so let's go to, you know,
a country in a low or middle
income country where number one,
your ward you don't have single-patient rooms.
Your ward is an open ward.
So what that means is it's a big
room with, let's say, 20 beds.
And there's one nurses' station at
the end of the room, it's a long room,
and there are curtains between each room.
Well, sometimes there are no curtains,
but a lot of times, there are.
And the beds [clears throat] they're meant
to hold 20 beds, but actually, in this ward,
there are 30 beds because of overcrowding they
need to kind of squeeze more beds in there.
Some of those beds are on the floor
because there aren't enough gurneys.
So they have either a mattress directly
on the floor, or there's a blanket
that a patient is sitting on, on the floor.
Sometimes, there are two people on a bed,
because they need to fit more people.
And both patients are kind
of occupying the same bed.
There's one hand hygiene station that's at
the nurses' station at the end of the room.
There's one bathroom facility
which may or may not be working.
And when you look at this type of situation --
oh and then there's also the laboratory
can do things like a hematology profile,
and it can do a chemistry, but there is
no microbiology, and there's no serology.
And there's very limited ability to be able
to kind of diagnose the exact microorganism.
So that's, unfortunately, the reality in a
lot of low-income and middle-income countries
where -- and of course, that's a generalization,
but I just wanted to paint a picture for you.
So if you think about AR, and you think about
how -- the other thing that's mentioned is that,
you know, a lot -- because
there is no microbiology,
clinicians will typically treat
empirically with antibiotics.
And typically there's going to
be broad spectrum of antibiotics,
because they don't know what they're treating,
so they have to use something
that has a broad spectrum.
So when you're faced with that,
it's really kind of a perfect storm
of developing antimicrobial resistance,
and then spreading it around the facility.
And so the solutions to that are
complicated, but it's certainly something
that we're focusing a lot of
our energies on right now.
It's not just the CDC, or WHO.
Other partners are working toward this.
And hopefully, we'll be able to
make some progress in this area.
But some of the key challenges that we face are
around, number one, just having a laboratory
that can be -- that can help clinicians
identify what these organisms are
so that they can appropriately treat
patients with the correct antibiotics.
And practicum-based infection
control at preventing things
like patients sharing the same bed or, you know,
patients being on the floor, these are some kind
of commonsense things we can --
you know, any of us who are trained
in infection control can look --
go into a facility and just see
a million things that are wrong.
But it's not pointing out all the things
that are wrong, it's starting out --
it's starting to identify where we can make some
gains, and where we can make some things right,
and how that will impact the overall situation.
>> Thanks, Ben.
Our next question is, "Now that Ebola has
decreased, funds for basic PPE, such as gloves,
are now extremely limited
in low-income countries.
What is being done, or can be
done to assist in this area?"
>> Yes; and this is another
area that we talk about a lot.
And certainly during the
Ebola outbreak there was --
part of the problem was that there wasn't enough
PPE and -- but that wasn't the entire problem.
The other parts of the problem were
that not only was there not enough PPE,
people didn't know how to use PPE.
So I would go into -- you know,
when I went to West Africa,
we saw things like people would wear
gloves, and would wear gloves all day.
You know, they would wear the same set
of gloves all day, because they didn't --
there was a lack of understanding around
how gloves protected you from getting --
from getting and transmitting disease.
You know, things like gowns
would be worn all day.
And so not -- yes so part of
the issue was the lack of PPE.
But part of the issue was
also a lack of understanding.
And the corporate pools around, you know, risk
assessment, and around transmission dynamics,
and breaking the chain of infection,
are things that we're emphasizing
heavily right now in West Africa.
Because hopefully there will
continue to be good stocks of PPE.
But what's probably more important than
just having PPE is the knowledge of how
to use it correctly, and also the
knowledge on how to protect yourself if --
because I think we all understand that
there are things that you could do even
without the best PPE, when you don't
have it, because it is a reality in low
and middle income countries where PPE
at times could you could have stock
out, you could have short supply.
So we also not only have to provide the
PPE, which is important for donor countries
to understand, but we also have
to teach them how to use it,
and how to best prepare themselves in
case it doesn't -- in case it's not there.
Because there are things that people can do.
>> So we've received several
questions with regards
to antibiotics being available
over-the-counter in many other countries.
Are there any efforts underway to stop OTC
sales of antibiotics in partner countries,
and how does this play with regards
to antibiotic resistance issues?
>> These are great questions.
And it shows that people really have a
good understanding about what's going on.
I think, you know, you don't even have
to have worked in another country,
you just have had to travel to another
country to realize that you can get a lot
of different things over the counter.
And it's not -- and when I say "over the
counter," what that really means is going
to a pharmacist, or what they call a
"chemist" in certain areas of the world.
And you can really just ask for anything.
And in some countries, there is regulation
where they will limit what you can buy.
There are some classes of
antimicrobials that you're not able
to purchase without a prescription.
Sometimes you're not able to
purchase any without a prescription.
And this whole idea is kind of foreign to us.
Right; we're so used to not being able to buy
anything over the counter that the very idea
that you can buy some things over
the counter, or possibly buy anything
over the counter, is just kind of crazy.
But one thing to think about is that
healthcare resources in low-income --
especially low-income countries and to
some degree middle-income countries,
healthcare dollars are -- you know,
as a proportion of the GDP are small.
So what that means is that
there aren't that many doctors.
There aren't that many nurses.
There aren't that many, you know, healthcare
-- there isn't much healthcare access.
And this becomes a problem, especially
where there isn't healthcare access,
because we have to remember that while AR
is a problem, you know, dying from diarrhea,
and dying from pneumonia is also a huge problem.
And if you limit the number of -- if you limit
the access to antimicrobials across the board,
then people will die from pneumonia;
people will die from diarrhea.
And that is also -- would
be a terrible consequence.
So we have to understand these things,
and we have to understand the realities
around access -- what we call access to
antimicrobials, versus excess of antimicrobials
where certainly, there is an
overuse of antimicrobials,
but how can we better -- how
can we balance this problem.
Because it's -- unfortunately
it's not as easy a thing
that every antimicrobial needs a prescription,
because there are I think
untoward effects that could happen.
And it's actually more complicated than that.
>> So we have received several other
questions that we're not going to get to today.
We've also received questions
about where to contact CDC
in case you do have follow-up
questions in the future.
The best email box to use
is patientsafety@cdc.gov.
That's patientsafety@cdc.gov.
And before I remind our participants about
continuing education opportunities, Linda,
did you have any additional final comments
from the APIC perspective
that you would like to convey?
>> No -- well actually I think
Dr. Park has done a great job.
I just want to reinforce that certainly,
APIC does have an international presence,
and also all of the tools that are available,
because I think they're so very important.
So thank you so much.
>> So to receive continuing education, you must
complete and pass a posttest activity at 80%,
and also complete a webinar evaluation.
When you close out of the webinar,
a post-meeting webpage will appear
that will have detailed instructions
about completing continuing education.
The access code for the webinar
is W C as in "cat," 1018.
So if you go www.cdc.gov/tceonline
and use the access code WC1018,
you'll be able to access continuing
education for this particular webinar.
Additionally, a follow-up email will be sent
out this afternoon with detailed instructions,
and also with the slides, as promised.
We'd like to thank our speakers today,
and we also would like to thank APIC
for your tremendous partnership in
having this particular webinar available
on International Infection Prevention Week.
Thank you all for joining us today,
and thank you for your commitment
to keeping patients safe.
