Saturday, December 11, 2010

Do Sick People Attend Health Facilities or Do Health Facilities Spread Disease?

A systematic review by Didier Pittet and others finds that rates of health care associated infections (HAI) are far higher in developing countries than they are in Europe and the USA. This is no great surprise, but such findings by prominent academics in a prestigious journal may make UNAIDS and others in the AIDS industry sit up and take notice for a change.

The HAI prevalence rate in developing countries was found to be 15.5 per 100 patients, more than double the rate in Europe and nearly four times the rate in the USA. In some hospital areas, such as intensive care, the rates were far higher. The report also finds that surveillance is rare and HAI rates are seriously underestimated. Developing countries simply don't have the resources to carry out such work.

However, an example of a cheap and simple surveillance exercise was carried out in Northern Tanzania in 2003. This exercise found that HAI incidence was 14.8% on the day they collected data. It also found that rates were far higher in some hospital locations, such as intensive care, surgical and even general medical wards.

The main concern of this blog is the rate of non-sexually transmitted HIV, especially the rate of blood-borne infections, that may be related to unsafe health care. According to SafePoint Trust, as many as 260,000 HIV infections every year result from unsafe injections (which is only one area of unsafe health care practice).

To put the WHO estimated rate of nosocomial (medical procedure related) HIV infection of over 14% in perspective, it is far higher than the rate of infection found among sex workers, sex worker clients, sex worker client partners and even men having sex with men. People attending health facilities are one of the highest risk groups in developing countries.

In addition, an estimated 1 million hepatitis C (over 30% of all cases) and 21 million hepatitis B infections (40% of all cases) result from unsafe injections. Syringes, designed to be used only once, are reused, often without adequate sterilization. More people are killed every year by unsafe injections than by malaria.

It's not just syringes that are reused without sterilization. Catheters, ventilators, dental and other invasive equipment can all be involved in transmitting infections of various kinds.

A particular worry is HAI rates among infants and young children, which can be many times higher than those among adults. But whenever the issue of nosocomial HIV infection in children is raised, 'professional' health care commentators get in a flap about putting people in developing countries off using health facilities (this is just one small example).

However, if these facilities are as dangerous as the above report suggests, people are entitled to know the risks and take steps to avoid them. More importantly, governments in developing countries need to take action. They receive billions of dollars in donor funding to treat people for HIV. A small amount of this would ensure than hundreds of thousands of infections are avoided in the first place.

High rates of HIV transmission tend to be found in areas with health facilities. Low rates of HIV transmission tend to be found in areas where health facilities are inaccessible or non-existant. These tendencies are established by population based surveys.

The Lancet report identifies the potential determinants of HAIs as: "inadequate environmental hygienic conditions; poor infrastructure; insufficient equipment; understaffing; overcrowding; paucity of knowledge and application of basic infection-control measures; prolonged and inappropriate use of invasive devices and antibiotics; and scarcity of local and national guidelines and policies." It also notes reuse of scarce resources, such as needles and gloves.

The question is, are people flocking to health facilities because they are infected with HIV or are health facilities playing a part in transmitting HIV, and if so, to what extent? This question needs to be answered before another year passes and another 260,000 avoidable HIV infections occur.


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