What is public health, and how does it impact infection control?

Public health is a discipline dedicated to improving the health of populations by preventing diseases and injuries before they occur through education, research, and promotion of healthy lifestyles.

Both infection control and public health are focused on preventing the spread of disease. Prevention strategies and interventions from both fields can be aimed at the environment, human behavior, or medical care practices. Both also participate in collaborative relationships with partners on local, state, national, and global levels.

Infection control is a relatively new area for public health surveillance, education, and research efforts. In 1968, the Centers for Disease Control and Prevention (CDC) began national-level surveillance for healthcare-associated infections (HAIs). State health department involvement in infection control was expanded greatly with the American Recovery & Reinvestment Act (ARRA) of 2009 and the legislation’s foci of building public health infrastructure to create HAI programs, enhancing HAI surveillance in acute and non-acute healthcare settings, and forming prevention collaboratives. The prevention and reduction of HAIs is a top priority for the U.S. Department of Health and Human Services (HHS) and HAIs have been identified as one of the ten “winnable” public health battles by CDC. In recent years, public health has also been increasingly involved with initiatives to reduce antibiotic resistance and promote antibiotic stewardship efforts, as evidenced by creation of both a national strategy and a national action plan for combating antibiotic-resistant bacteria.

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Internationally, the World Health Organization (WHO) has an infection prevention campaign entitled “Clean Care is Safer Care” that aims to ensure that infection control is recognized as a critical element of patient safety. One of the key components of this project is the “Save Lives: Clean Your Hands” campaign that emphasizes the role of healthcare worker hand hygiene in preventing the spread of infections in healthcare facilities.

What elements of public health are necessary for infection prevention and control?

  • Surveillance

  • Data validation

  • Public reporting

  • Goal setting

  • Communicable disease reporting

  • Outbreak investigation

  • Provide education to healthcare providers and the general public

  • Develop guidelines and policies

  • Serve as licensing/regulatory authority

  • Conduct infection prevention and control research

  • Provide governmental incentives to report HAI data and improve performance on HAI process and outcome measures

  • Ensure safety and effectiveness of medical devices, vaccines, and drugs

  • Liaise during disasters, major events, and bioterrorism attacks to conduct active surveillance and provide situational awareness

What are the consequences of ignoring key concepts related to public health and infection control?

Consequences of ignoring key concepts related to public health may include:

  • Higher incidence of HAIs

  • Outbreaks of disease and ongoing transmission of infection

  • Increased healthcare costs due to the treatment of HAIs

  • Spread of antibiotic-resistant organisms, resulting in more costly, difficult to treat infections

  • Distrust from the public

  • Citations and/or fines from licensing or accrediting bodies

  • Decreased healthcare reimbursements

Summary of current controversies.

One of the major controversies or areas of confusion regarding public health and infection control is the difference between public health surveillance definitions and clinical definitions of healthcare-associated infections. Surveillance definitions are standardized to be consistent across populations and jurisdictions and are used to measure disease occurrence or prevalence on a population level. Clinical definitions are used to treat illness in an individual and may not be the same as surveillance definitions.

To minimize the discordance between clinical and surveillance definitions, input from both public health and the clinical communities is sought when developing and revising HAI surveillance definitions. The National Healthcare Safety Network (NHSN) has a workgroup to review surveillance definitions for various HAIs periodically to assure that surveillance definitions are able to be applied feasibly in practice and align as much as possible with clinical definitions. When selecting a measure for public reporting, endorsement from organizations representing clinicians is obtained to demonstrate that the surveillance definition is considered valid, although it may still differ from the clinical definition.

What functions does public health serve with respect to infection control?

  • Surveillance

    CDC maintains the National Healthcare Safety Network (NHSN), the national surveillance system used to track healthcare-associated infections. Data collected include HAI outcomes such as surgical site infections and central line-associated bloodstream infections as well as process measures such as compliance with central line insertion practices and hand hygiene.

    Sets standardized definitions for HAIs under surveillance to ensure consistency and comparability of data across jurisdictions.

    Sets national benchmarks.

    As of July 2016, 34 states and the District of Columbia mandate the use of NHSN for public reporting in the United States.

    Publishes annual surveillance reports.

    Pilot projects or prevention collaboratives run by public health entities and/or state reporting requirements may influence which HAIs are under surveillance in healthcare facilities or aid in the prioritization of HAI surveillance efforts.

    The Council of State and Territorial Epidemiologists (CSTE) has established an HAI Standards Committee to assure that standard definitions of HAIs brought under surveillance maximize public health and clinical usefulness of collected data and can move toward electronic disease capture. This HAI Standards Committee has also written position statements to set standards for HAIs to be reported from healthcare facilities to public health agencies at various levels of government so that data can be aggregated and interpreted across jurisdictions and nationally.

  • Data validation

    Many state HAI programs began conducting data validation on publicly reported data with ARRA funding. Several states have continued to validate HAI data and reporting processes by conducting on-site chart reviews and interviewing staff responsible for conducting surveillance.

    Annually, CDC releases a standardized data validation toolkit to aid healthcare facilities and health departments in applying internal and external validation strategies.

  • Public reporting

    Some state public health entities share HAI measures with the public; as of July 2016, 38 states, the District of Columbia, and Puerto Rico have legislation mandating reporting of one or more HAI measures. Illinois was the first state to pass a HAI reporting law (2003).

    The Centers for Medicare and Medicaid Services (CMS) Hospital Compare website shares facility-level data with the public on a variety of quality and surveillance measures. Similar websites are available for nursing homes and dialysis facilities.

  • Goal setting

    The U.S. Department of Health and Human Services (HHS) National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination (2009) document set five-year prevention targets for HAI metrics in acute care hospitals. An updated version of the Action Plan was published in April 2013 and was expanded to include ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities, as well as a section on increasing influenza vaccination of health care personnel.

    Healthy People 2020 contains two HAI-related goals: to reduce central line-associated bloodstream infections (by 75%) and to reduce invasive methicillin-resistant Staphylococcus aureus infections (by 75%).

    The White House National Strategy for Combating Antibiotic-Resistant Bacteria (2014) set goals to slow the development of resistant bacteria and prevent the spread of resistant infections.

  • Communicable disease reporting

    Certain types of diseases/conditions are reportable to public health entities.

    Health departments provide information to CDC on the nationally notifiable conditions, which are revised on a periodic basis (usually annually). The list of these conditions specifies the manner and time frame in which the health department notifies CDC.

    Local requirements for reporting to public health by healthcare providers, laboratorians, facility administrators, and others generally include the nationally notifiable conditions but may also include other diseases or syndromes and may specify different time frames.

    Contact the city, county or state health department for more information on the reporting requirements in the local jurisdiction.

  • Outbreak investigation

    Generally, outbreaks from healthcare facilities are reportable to public health entities, although there may be variation between states regarding what types of facilities are required to report and how an outbreak is defined.

    Contact the city, county or state health department for more information on outbreak reporting requirements in the local jurisdiction.

    Public health professionals work with healthcare facility staff to identify an outbreak, control the spread of disease, and implement prevention measures.

  • Provide education to healthcare providers and the general public

    Consult and give guidance on how to prevent the spread of disease.

    Disseminate prevention messages tailored to specific audiences through websites, public awareness campaigns, fact sheets, and other communication methods.

    Local health department staff tend to be well-connected with facilities in their communities and may provide on-site trainings, technical assistance with surveillance, and other education as needed.

  • Develop guidelines and policies

    Public health representatives participate in the Healthcare Infection Control Practices Advisory Committee (HICPAC) to issue recommendations for the surveillance, prevention, and control of HAIs.

    Public health entities are also responsible for disseminating guidelines for the control of emerging pathogens (for example, appropriate personal protective equipment for healthcare workers evaluating a patient under investigation for Ebola virus disease or proper respiratory protection for healthcare workers caring for a patient with novel influenza virus).

  • Serve as licensing/regulatory authority

    Public health may be involved with facility licensure and certification, which involves conducting facility surveys or inspections to assure compliance with regulations, including the infection control regulations.

    The HHS HAI Action Plan of 2009 identified and explored policy options for regulatory oversight of recommended practices and provided critical compliance assistance to select hospitals.

  • Conduct infection control and prevention research

    The HHS National Action Plan to Prevent HAIs published in 2009 identified gaps in the current knowledge of HAIs and created an agenda for current and future research.

    The CDC Prevention Epicenters Program began in 1997 and is a collaboration of academic medical centers that perform laboratory research. Contributions of this program to the infection control science base include lines of research focused on preventing transmission of antibiotic resistant-organisms and other infectious threats, manipulating the microbiome to prevent spread of antibiotic-resistant organisms, role of the environment in transmission of healthcare-associated infections, and improving antibiotic use to reduce illness caused by antibiotic-resistant organisms.

    Public health entities at the state and national levels have published articles describing outbreak investigations as well as quantifying HAI morbidity, mortality, and cost.

  • Provide governmental incentives to report HAI data and improve performance on HAI process and outcome measures

    Examples include the CMS Hospital Inpatient Quality Program and the CMS End Stage Renal Disease (ESRD) Quality Incentive Program, which offer payment for reporting of HAI metrics and in the future will tie payment to performance on those metrics.

  • Ensure safety and effectiveness of medical devices, vaccines, and drugs

    The Food and Drug Administration (FDA) assures the safety, efficacy, and security of drugs, biological products (including vaccines), and medical devices to protect the public’s health.

    The FDA monitors reports of adverse events including serious drug side effects, product use errors, product quality problems, and therapeutic failures.

    To prevent the spread of infection that may be associated with contaminated or faulty products or equipment, the FDA issues safety alerts and recalls. Recent examples include liquid docusate sodium solution contaminated with Burkholderia cepacia and heater-cooler machines contaminated with Mycobacteria chimaera.

  • Liaise during disasters, major events, and bioterrorism attacks to conduct active surveillance and provide situational awareness

    Public health and infection control staff work together to collect data and identify risk factors for morbidity and mortality during disasters such as hurricanes, major events such as the Olympic Games or Presidential Inauguration, and bioterrorism attacks such as 9/11.

What national and international guidelines exist with respect to public health and infection control?

National guidelines:

  • The Healthcare Infection Control Practices Advisory Committee (HICPAC) gives guidance and advice to CDC and HHS regarding the practice of infection control, and HAI surveillance and prevention in US healthcare facilities. The membership is varied and contains experts in the fields of public health and epidemiology. Some national guidelines published by this committee include:

    Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings (2011)

    Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)

    Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities (2009)

    Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009)

    Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

    Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)

    Influenza Vaccination of Health-Care Personnel (2006)

    Management of Multidrug-Resistant Organisms in Healthcare Settings (2006)

    Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations (2005)

    Guidelines for Environmental Infection Control in Health-Care Facilities (2003)

    Guidelines for Preventing Ventilator-Associated Pneumonia (2003)

    Guidelines for Hand Hygiene in Healthcare Settings (2002)

    Guideline for the Prevention of Surgical Site Infection (1999)

    Guideline for Infection Control in Hospital Personnel (1998)

  • The nationally notifiable disease reporting guidelines outline which conditions/diseases are reportable to CDC. The list of these conditions specifies the manner and time frame in which the health department notifies CDC.

  • The Society for Healthcare Epidemiology of America (SHEA) is a membership organization of healthcare epidemiologists that publishes white papers and guidelines on HAIs. Some relevant guidelines include:

    Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (2016)

    Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update (2014)

    Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Update (2014)

    Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery (2013)

    Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures (2012)

    Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus (2011)

    Guideline for Disinfection and Sterilization of Prion-Contaminated Medical Instruments (2010)

    Clinical Practice Guidelines for Clostridium difficile Infection in Adults (2010)

International guidelines:

  • Infection Prevention and Control Guidance for Care of Patients in Health-Care Settings, With Focus on Ebola (2014)

  • Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care (2014)

  • WHO Guidelines for Hand Hygiene in Health Care Facilities (2009)

  • WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households (2009)

  • Core Components for Infection Prevention and Control Programmes (2008)

What other consensus group statements exist and what do key leaders advise?

In October 2010, a multidisciplinary group of organizations representing public health, infectious disease physicians, infection preventionists, state health officials, and other groups published a white paper embracing the goal of HAI elimination and outlining steps to achieve this goal, including promoting adherence to evidence-based practices, increasing sustainability by aligning financial incentives and reinvesting in successful strategies, filling knowledge gaps by strengthening the evidence base, and collecting data to target prevention efforts and monitor progress.

From 2008 to 2016, the Council of State and Territorial Epidemiologists (CSTE) issued 15 position statements related to HAI surveillance and reporting or HAI policy. The two statements from 2010 stipulated that CDC should establish and maintain a CSTE/CDC process for setting national standards for HAI case criteria and data requirements. Furthermore, CDC should “work with CSTE as well as state, local, tribal, and territorial health officials to refine surveillance definitions, standardize methods, and ensure complete and accurate reporting of HAIs in a manner similar to that currently employed for nationally notifiable diseases.”

CSTE position statements related to standardization of HAI surveillance and reporting have addressed central line-associated bloodstream infections (2012), C. difficile laboratory-identified events (2013), methicillin-resistant Staphylococcus aureus laboratory-identified events (2013), outpatient dialysis events (2014), and carbapenem-resistant Enterobacteriaceae (2015). The first policy position statement in 2008 proposed that CDC allocate sufficient resources to the National Healthcare Safety Network. Subsequent policy position statements have addressed creation of a CSTE HAI Standards Committee to provide joint state and national oversight of NHSN reporting methods and surveillance definitions (2011), prioritizing electronic reporting of healthcare-associated infection data (2011), interfacility communication (2013 and 2016), data analysis and presentation standardization (2013), strengthening antimicrobial stewardship (2014), and enhancing surveillance and reporting in long-term care facilities (2015).

What are some public health agencies or organizations that are involved in infection control and prevention initiatives?

In addition to state and local health departments, in the United States, several federal agencies and organizations have engaged in infection control activities including:

  • U.S. Department of Health and Human Services (HHS), which is comprised of several agencies including:

    Agency for Healthcare Research & Quality (AHRQ)

    Agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare.

    Engaged in research on the effectiveness of public reporting.

    Centers for Disease Control and Prevention (CDC)

    Foremost agency on public health, providing disease surveillance, reference laboratory, field investigation, and educational service expertise.

    Produces publications of HAI data reported to NHSN.

    Issues guidance and prevention recommendations.

    Centers for Medicare and Medicaid Services (CMS)

    Runs the national health insurance programs Medicare and Medicaid.

    Incentivizes reporting of and performance on HAI metrics.

    Publicly reports HAI and quality data online through Hospital Compare, Nursing Home Compare, Dialysis Facility Compare, and Home Health Compare websites.

    Food and Drug Administration (FDA)

    Agency responsible for ensuring that drugs, vaccines, other biological products, and medical devices intended for human use are safe and effective.

  • Occupational Safety & Health Administration (OSHA)

    Agency within the Department of Labor that ensures safe and healthful working conditions by setting and enforcing standards and by providing training, outreach, education, and assistance.

  • Council of State and Territorial Epidemiologists (CSTE)

    An organization of member states and territories representing public health epidemiologists.

    Holds the responsibility for defining and recommending which diseases and conditions are reportable within states and which of the diseases and conditions will be voluntarily reported to CDC.

    CSTE also has a HAI Subcommittee that is responsible for supporting the use of effective public health surveillance for HAIs, developing standards for practice, and advocating for resources and scientifically based policy.

  • Society for Healthcare Epidemiology of America (SHEA)

    Membership organization of healthcare epidemiologists (professionals within healthcare settings [usually hospitals] who are responsible for tracking and reporting infections).

    Collaborates with other organizations to prepare evidence-based guidelines, resources, and white papers on infection prevention and control across the continuum of care.

    Active in developing public policy on HAIs and educating regulatory bodies and policymakers about HAI prevention and patient safety issues.

What is the American Recovery and Reinvestment Act (ARRA) of 2009 and how did it affect the relationship between public health and infection control?

The American Recovery and Reinvestment Act (ARRA) was signed into law on February 17, 2009 and was designed to stimulate economic recovery in various areas including healthcare. The HAI portion of ARRA supported state efforts to reduce and prevent HAIs by building infrastructure within state health departments, enhancing surveillance efforts, and implementing prevention collaboratives within healthcare facilities. Over $50 million was dispersed across the United States and its territories in August 2009; many of these funds were used to support activities outlined in the HHS National Action Plan to Prevent HAI: Roadmap to Elimination.

Each state or territory was required to write its own state action plan discussing the individual goals of its HAI program and targets for infection reduction. Collaboration and partnership with others engaged in infection control initiatives, including healthcare facilities, professional organizations, hospital associations, quality improvement organizations, and other groups were strengthened. Each ARRA grantee hired a state HAI Coordinator to build public health infrastructure and support the group’s activities. Multidisciplinary Advisory Committees were established or expanded to leverage resources, improve coordination of HAI surveillance and prevention efforts, and enhance communication about HAIs among key stakeholders.

Initiatives to enhance surveillance included surveillance pilot projects, validation of publicly reported HAI data such as central line-associated bloodstream infections (CLABSIs) or surgical site infections, education on the use of the National Healthcare Safety Network (NHSN), facilitation of compliance with state reporting mandates, and provision of technical assistance to facilities using NHSN. In the 29 states funded to enhance surveillance, 55 validation studies were conducted.

Some state health departments also used ARRA funds to expand or establish prevention collaboratives. Prior to ARRA, only two states had existing health department-led prevention collaboratives. In July 2011, the 27 states with prevention collaborative funding reported engaging in 53 prevention collaboratives that targeted 75 infections. Nearly half of the collaboratives targeted CLABSI or Clostridium difficile infection.