Public Health Highlights

Hospitals in Europe Link for Infection Control through Surveillance (HELICS)
Interventions
Meliodosis

Hospitals in Europe Link for Infection Control through Surveillance (HELICS)

Antimicrobial resistance and hospital infection are now amongst the highest priorities in the PHLS and the European Union. LHI has for several years been involved in European studies. In 1999 there was the completion of the DGV funded HELICS II project (‘Hospitals in Europe Link for Infection Control through Surveillance’). The steering group led by Professor Jacques Fabry from France also has members from Belgium, Denmark, England (Dr Barry Cookson) and Holland. The two objectives were to produce an inventory of infection and antimicrobial resistance control activities in the EU and to propose ways to harmonise these efforts. Extensive questionnaires were distributed to all EU member states and a consensus meeting was also held. In addition, all countries were invited to submit contact names and relevant details of infection control related activities for the inventory. All the raw data, inventory and initial report are available on the INTERNET (www.univ.lyon1.fr/iusi.nice). A fuller consensus on the report will be sought in early 2000 and some of the proposed aims are being explored further with the EU.

There are recommendations in five key areas. The first comprises the standardisation of surveillance methods, information and data exchange. Clearly, the more comparable the surveillance standards and data quality evaluation systems, the easier it will be to establish collaborative EU projects. Three other areas comprised: guideline and policy development, a European training programme in infection control and hospital epidemiology with educational fellowships and proposals for the review of mechanisms for the prioritisation and increased funding of research and development. The final area was the surveillance of antimicrobial resistance and antimicrobial use, which it was felt should take advantage of the extensive experience of nosocomial infection surveillance.

The actions outlined above are mindful of the essential role and involvement of the local infection control team and healthcare workers (“thinking globally and acting locally”). LHI staff considers themselves to be reflective practitioners in this process and will play key roles in the above actions.

The second EU activity is the DG-XII funded project “HARMONY” (Harmonisation of Antibiotic Resistance measurement, Methods of typing Organisms and ways of using these and other tools to increase the effectiveness of Nosocomial Infection control). This is led by LHI’s Dr Barry Cookson and will comprise a resource, facilitating centres, an international network of opinion leaders and centres of excellence. It will interact with the emerging hospital infection surveillance networks and target four areas: antibiotic susceptibility testing, microbial typing (initially of MRSA), infection control and antibiotic therapy policy and audit and the establishment of a "State of the Art" European interactive database on the INTERNET. The project is in its first year but has already established an EU epidemic MRSA collection and the first inter-country MRSA typing project is underway.

Interventions

LHI in their reflective practitioner role receive many requests for advice on the prevention and control of infection and outbreaks. These cover infection control in hospitals and other, wider aspects of healthcare. One example of this was recently generated in the Infection Control Unit and concerns the transmission of blood borne infectious agents by jet injectors. These injectors use a high-pressure focussed jet of fluid to provide a needleless mechanism for penetrating skin. They have great potential in mass immunisation campaigns in areas of limited resources and allow high immunisation delivery rates. They would eliminate many logistical problems such as the shipping of single-use syringes and needles, accidental contaminated needlestick injuries to immunisation staff, and the burden of safe disposal of sharps clinical waste. At the request of the World Health Organisation, we developed a laboratory model of jet injection safety that could test the capacity of jet injectors to transmit blood between injection recipients. Hepatitis B is thought transmissible in volumes of blood as low as 10 picolitres, so a novel immunoassay (developed in conjunction with Kings College, University of London) was used that could detect these extremely low levels. Results from the use of this model indicated jet injectors can regularly transmit relevant volumes of blood. Use of this model under field conditions in Brazil (in conjunction with WHO and the Brazilian Ministry of Health) confirmed the laboratory model as valid.

As a result of this work, WHO and other major users of jet injectors have reconsidered their use. A more positive outcome of this work has been an understanding of previously unsuspected contamination mechanisms, which is enabling design of new generations of jet injector whose safety can be assessed in our model.

Meliodosis

The extensive expertise of LHI staff is also drawn upon for Public Health activities other than Hospital Infection. One such example is melioidosis, is a life-threatening infectious disease prevalent in Southeast Asia and tropical Australia, but it has been reported in other tropical and occasionally subtropical regions worldwide. The disease is caused by the bacterium Burkholderia pseudomallei which is found in wet soil and water. Clinical manifestations range from acute overwhelming septicaemia to chronic infections with abscesses in many organs of the body. Most cases occur during the rainy season and major predisposing risk factors are occupation (rice farming) and diabetes. Indeed, in rural northeastern Thailand, B. pseudomallei is one of the most common organisms causing septicaemia during the wet season. Treatment with appropriate antibiotics reduces mortality significantly, but 30-40% of patients will still die. In the survivors prolonged maintenance treatment is necessary. Relapse of infection occurs in some patients.

About 400,000 UK residents visit Southeast Asia annually especially Thailand. The risk of infection is extremely low for ordinary tourists and melioidosis has most commonly occurred in UK resident Asian immigrants returning from visits to their homeland. There were 15 cases of melioidosis recorded in the UK in the period 1988-1998 (Dance et al. Lancet 1999;353:208).

The Public Health Laboratory Service provides a clinical and microbiological reference service for melioidosis to England and Wales and occasionally Europe. The Laboratory of Hospital Infection performs serodiagnostic tests and microbiological confirmation of B. pseudomallei (Dr T Pitt) and advice on diagnosis and treatment of melioidosis is provided by Dr D Dance (Plymouth PHL) and Dr M Smith (Taunton PHL) both of whom worked for some years in Thailand. We also conduct collaborative research studies into the epidemiology and pathogenesis of B. pseudomallei leading to a wide range of publications. This serves to heighten awareness and ensure the correct diagnosis is made and appropriate treatment is given to reduce patient mortality.