How do the contributions of World Health Organization initiatives impact on infection control currently?

Within the World Health Organization (WHO) headquarters, many programs are either entirely dedicated to the prevention and control of healthcare-associated infection (HAI) or include some specific, related aspects. In general, all aim to develop guidelines and standardized approaches to infection control, support plans and actions to improve healthcare infrastructures and strengthen resources, engage with stakeholders and experts, and facilitate appropriate research and sharing of local experiences and data.

These activities are developed in close collaboration with regional offices where focal points for these programs usually exist with the role of linking to countries, ensuring continuous monitoring, and making these efforts coherent to the reality of each nation. In some cases, regional or country offices also launch autonomous initiatives that are more tailored to the needs of the region or a specific country.

For other activities/programs conducted at the regional level, the reader is recommended to contact the following:

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  • Regional Office for the Eastern Mediterranean.

  • Regional Office for Africa.

  • Regional Office for Europe.

  • Regional Office for Americas/ Pan-American Health Organization.

  • Regional Office for South-East Asia.

  • Regional Office for the Western Pacific.

The main programs dealing with HAI prevention and control at the WHO headquarters are listed in Table I with details on their aims and activities.

What elements of World Health Organization initiatives need to be adhered to for prevention and control?

Since June 2007, 194 United Nations’ member states have agreed to adhere to the International Health Regulations (IHR) that requires countries to report disease outbreaks and public health events to the WHO, according to specific criteria of risk for public health.

In many cases, events – mostly infectious diseases – that correspond to these criteria typically spread within healthcare facilities and then reach the community and cross borders. For this very reason, IHR, although originally focused on risks for public health, represent a political measure very instrumental to infection control internationally.

There are some major guidelines and documents issued by the WHO concerning some priority infection control topics. Some key recommendations and indications are:

Core components of infection prevention and control programs

As highlighted in a comprehensive document on the prevention of hospital-acquired infections issued in 2002, infection prevention and control (IPC) programs should be put in place both at the national and local levels of healthcare.

WHO internal and external experts subsequently identified core components within the following categories: appropriate organization of IPC programs; availability of technical guidelines; dedication of human resources; education; surveillance of HAI and IPC practices; microbiology laboratory support; consideration of issues related to the built environment (building and facility-related conditions); evaluation of IPC programs; and linkage to public health and other services/societal bodies.

Hand hygiene in healthcare

As the most effective single measure to prevent microbial spread and HAI occurrence, hand hygiene promotion in healthcare is highly recommended by the WHO (see also the chapter on Hand Hygiene Improvements).

Evidence-based guidelines were developed with the input of more than 100 international experts and underwent pilot testing to evaluate their effectiveness, feasibility, and adaptation. The WHO multimodal hand hygiene improvement strategy and related toolkit accompany these guidelines to facilitate their translation into practice and implementation at the point of care.

Prevention and control of acute respiratory diseases

Considering the frequent threats represented by airborne diseases easily spreading within healthcare settings and across international borders, the WHO produced two interim guideline documents for use in healthcare settings: one specifically focused on avian influenza in humans; and one on epidemic- and pandemic-prone acute respiratory diseases.

The former is currently under revision. In summary, the latter recommends:

  • early recognition, isolation, reporting, and surveillance of acute respiratory diseases of potential international public health concern;

  • the establishment or the strengthening of infection control committees and programs, and of support for the promotion of improved infection control practices;

  • the application of appropriate isolation precautions to patients affected by acute respiratory diseases;

  • cohorting of patients and suspected cases when isolation rooms are insufficient or unavailable;

  • the use of masks and other precautions by and for patients during their transportation within the healthcare setting, as well as for the collection/transport/handling of biological specimens;

  • the location of patients in airborne precaution or adequately ventilated rooms;

  • the protection of healthcare workers by offering effective vaccines, if available, and the use of adequate personal protective equipment;

  • the use of specific criteria and precautions in the care of the deceased.

An interim guidance document focusing on H1N1 prevention and control, including adaptation of these recommendations, was made available during the pandemic in 2009.

Most interestingly, and again related to the prevention of airborne disease spread, WHO carefully evaluated the option of natural ventilation as an asset to overcome the lack of airborne precaution rooms in many healthcare settings worldwide.

This guideline first defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, and describes the basic principles of design, construction, operation, and maintenance for an effective natural ventilation system to control infection in healthcare settings.

Tuberculosis infection control

Policy guidelines dedicated to the control of tuberculosis were recently issued by the WHO for the first time, including a focus on aspects related to healthcare settings. Core recommendations urge healthcare facilities to:

  • identify and strengthen coordinating bodies for tuberculosis control and develop implementation plans;

  • consider either facility renovation or construction according to engineering principles for tuberculosis control;

  • conduct local surveillance among healthcare workers;

  • advocate and communicate about the importance of tuberculosis control;

  • monitor indicators of control measures;

  • participate in research;

  • establish mechanisms for the prompt identification of affected patients, separate those who are infectious and implement respiratory hygiene/cough etiquette;

  • provide prevention and care packages for healthcare workers (e.g., isoniazid prevention therapy for human immunodeficiency virus (HIV)-positive healthcare workers);

  • establish environmental control by using appropriate ventilation systems and use ultraviolet germicidal irradiation fixtures, at least when adequate ventilation cannot be achieved;

  • recommend the use of particulate respirators in situations with an increased risk of transmission.

Injection safety

Unsafe injections can result in the transmission of a wide variety of pathogens, including viruses, bacteria, fungi, and parasites.

In particular, this has been well documented for the three primary blood borne pathogens, HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV). They can also cause non-infectious adverse events, such as abscesses and toxic reactions.

Reuse of syringes or needles is common in many settings. To prevent these major transmission risks, recommendations have been issued by the WHO on best practices for drawing, collecting blood, and transporting it to laboratories/blood banks.

Protecting the patient

In summary, principles aimed at protecting the patient include the following:

  • healthcare workers should be fully trained to perform phlebotomy;

  • healthcare workers should wear well-fitting, non-sterile gloves and should also practice hand hygiene before and after each patient procedure – before putting on gloves and after their removal;

  • blood should be taken in a dedicated location;

  • counters, work surfaces, and chair arms should be cleaned with disinfectant at the start of each shift and when visibly dirty.

Protecting healthcare workers

Recommended elements for healthcare workers’ safety during phlebotomy include the following:

  • the use of safety (i.e., engineered) devices, such as retractable lancets, syringes with needle covers or retractable needles and, when appropriate, plastic laboratory tubes;

  • the elimination of any two-handed needle recapping and manual device disassembly, and instead disposing of the sharps into a puncture-resistant container (i.e., a safety container) immediately after use. Best practice is to discard the needle and syringe, or needle and tube holder, as a single unit into a sharps’ container;

  • surveillance of sharps’ injuries and accidental exposure to blood and clear instructions for procedures to follow in the case of accidental exposure to blood and body fluids, including immunization with HBV before assuming duties, and post-exposure prophylaxis for HIV and HBV.

A toolkit on best practices for injections and related procedures has also been made available by the WHO to promote the implementation of safe practices associated with intradermal, subcutaneous, and intramuscular needle injections, intravenous infusions and injections, dental injections, phlebotomy, and lancet procedures.

Over the last decade, together with other partners, WHO and the Safe Injection Global Network (SIGN) have fostered strategies for reducing injections worldwide, including technology transfers to manufacture non reusable syringes. Many country examples have demonstrated that the proposed approach is feasible, effective to reduce injection devices reuse and prevent infection, and also represents a cost saving.

Environmental health standards

Essential environmental health standards required for healthcare settings in medium- and low-resource countries were established by the WHO and guidelines issued for the implementation of safety conditions to provide adequate healthcare.

These guidelines deal specifically with water supply (water quality, quantity, and access), excreta disposal, drainage, healthcare waste management, cleaning and laundry, food storage and preparation, control of vector-borne disease, building design (including ventilation), construction and management, and hygiene promotion.

All member states are urged to:

refer to these guidelines to develop specific national standards that are relevant to various healthcare settings in different contexts;

support the application of national standards and set specific targets in healthcare settings;

assess the situation regarding environmental health in existing healthcare settings;

ensure that the construction of new healthcare settings is of acceptable quality;

prepare and implement comprehensive and realistic action plans so that acceptable conditions are achieved and maintained.

Healthcare waste management

Poor management of healthcare waste exposes healthcare workers, waste handlers, and the community to HAI, and toxic effects and injuries.

The WHO Healthcare Waste Management (HWM) Programme (http://www.healthcarewaste.org/) activities include developing technical guidance materials for assessing the quantities and types of waste produced in different facilities, creating national action plans, developing national HCWM guidelines and building capacity at national level to enhance the way HWM is dealt with in low-income countries.Guidance is provided on the basics of HWM, and on management, training, regulatory and financial issues as well as technologies for HWM both at country and healthcare facility levels. Several guidance documents, including national plans and specific policy statements for HWM at district level and in primary healthcare centers, have been developed by the WHO

Blood safety

Donated blood should always be screened for HIV, HBV, HCV, and syphilis prior to transfusion. However, in 31 of 133 countries reporting in 2006, not all donated blood was tested for one or more of these infections.

Guidelines on this important topic were recently issued by the WHO and give policy indications to member states about national programs for blood screening and technical recommendations to healthcare settings to ensure the safe screening, collection, and delivery of blood transfusions. Furthermore, safe transfusion at the bedside with appropriate hand hygiene and skin disinfection prevents the inoculation of pathogens causing healthcare-associated bloodstream infection

Occupational health

The International Labor Organization, Joint United Nations Programme on HIV/AIDS, and WHO are working together to find common solutions to HIV and tuberculosis challenges for healthcare workers.

Very detailed guidelines dealing with all key aspects on this topic have been recently issued: national programs and policies; transmission prevention; access to preventive and therapeutic drugs; healthcare workers’ counseling and education; compensation and arrangements in the event of occupationally-acquired disease; and monitoring of the implementation of recommendations.

Surgical site infection

WHO Patient Safety recommends healthcare settings to implement a 19-item checklist that has been demonstrated to reduce complications and mortality associated with a variety of surgical procedures by more than 30 percent. One item specifically refers to the administration of appropriate antibiotic prophylaxis. The attack rate of surgical site infection was shown to decrease from 6.2 percent to 3.4 percent following the use of this checklist. New international guidelines on the prevention of surgical site infections are being developed by the WHO Patient Safety programme

Viral haemorrhagic fever

WHO provides specific infection control recommendations to avoid viral transmission to healthcare workers and patients when providing direct and non-direct care to patients with suspected or confirmed viral haemorrhagic fever.

These essentially consist of the strict application of standard and isolation precautions, use of personal protective equipment, ensuring accurate and safe waste disposal, and limiting any contacts with the patient.

What are the key conclusions from available clinical trials or meta-analyses related to World Health Organization initiatives that guide infection control practice and policies?

By definition, any official WHO guidelines and documents are based on available scientific evidence that is evaluated through systematic reviews and graded according to quality criteria by international experts.

By scrutinizing the references of these documents, particularly recommendations, findings from studies and reports supporting the WHO-recommended practices and policies can be found. In some cases, the final recommendations are also based on their interim testing in selected pilot sites.

What are the consequences of ignoring key concepts related to World Health Organization initiatives?

WHO infection control programs and initiatives not only promote and support the implementation of key prevention measures, but also develop evidence-based guidelines and standards agreed upon by international experts.

Furthermore, the WHO invests significant efforts to develop national policies and to facilitate their adoption and implementation in healthcare settings in collaboration with regional and country offices and ministries of health.

Ignoring these actions and recommendations would mean ignoring the key priorities and widely-acknowledged measures for the prevention of HAI.

Summary of current controversies.

Current controversies regarding some key aspects of hand hygiene promotion that are also related to the WHO recommendations on hand hygiene in healthcare are discussed in the chapter on Hand Hygiene Improvements. No further controversy has been identified.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and World Health Organization initiatives.

The impact of the WHO guidelines on hand hygiene in healthcare and their implementation strategy and tools was demonstrated by testing in selected pilot sites and many additional facilities that volunteered to be part of the test phase.

The results were preliminarely reported within the WHO guidelines and will be published in The Lancet in 2013. These clearly indicated that a significant improvement occurred across all pilot sites following the implementation of the WHO strategy in healthcare workers’ compliance with best hand hygiene practices, of their knowledge and perception of the importance of hand hygiene and HAI, and in the infrastructure available for hand hygiene.

In particular, very encouraging results were shown in Mali and Armenia – settings with limited resources. The feasibility of local production of the WHO alcohol-based hand rub solutions and their low cost was demonstrated in a rural hospital in Kenya.

Based on this evidence, several surveys and reviews demonstrated that most countries with a national or sub-national hand hygiene campaign consider the WHO guidelines as the choice reference document.

Many other scientific publications issued by the Clean Care is Safer Care program highlight the evidence behind the WHO hand hygiene recommendations and improvement strategies. Findings from testing the safe surgery checklist and a report on successful country implementation of injection safety strategies are described above. No additional scientific publication documenting the impact of other WHO infection control initiatives has been retrieved.

Controversies in detail.

For controversies regarding some key aspects of hand hygiene promotion that are also related to the WHO recommendations on hand hygiene in healthcare, please see the chapter on Hand Hygiene Improvements.

No further controversy has been identified.

What national and international guidelines exist related to World Health Organization initiatives?

Other guidelines developed by scientific societies or by national and international infection control bodies exist in many countries and regions. In general, they usually refer to the WHO guidelines and recommendations.

Although these documents cannot be listed individually, it is worth mentioning that specific programs and documents related to infection control are promoted by the United States Centers for Disease Control and Prevention and the European Centre for Disease Prevention and Control.

Disclaimer

The WHO takes no responsibility for the information provided or the views expressed in this text.

References

Prevention of hospital-acquired infections. 2002.

Core components for infection prevention and control programmes. 2009.

WHO guidelines on hand hygiene in healthcare. 2009.

Avian influenza, including influenza A (H5N1), in humans: WHO interim infection control guideline for healthcare facilities. 2007.

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in healthcare. 2007.

Infection prevention and control in healthcare for confirmed or suspected cases of pandemic (H1N1) 2009 and influenza-like illnesses. 2009.

Natural ventilation for infection control in healthcare settings. 2009.

WHO policy on TB infection Control in healthcare facilities, congregate settings, and households. 2009.

WHO guidelines on drawing blood: best practices in phlebotomy. 2010.

WHO best practices for injections and related procedures toolkit. 2010.

Safe Injection Global Network. Summaries of Injection Safety Country Success Stories. 2011.

Essential environmental health standards in healthcare. 2008.

Screening donated blood for transfusion-transmissible infections. 2009.

Joint WHO-ILO-UNAIDS policy guidelines for improving health worker access to HIV and TB prevention, treatment, care and support services. 2010.

Surgical safety checklist. 2009.

Haynes, AB, Weiser, TG, Berry, WR. “A surgical safety checklist to reduce morbidity and mortality in a global population”. N Eng J Med. vol. 360. 2009. pp. 491-99.

Interim infection control recommendations for care of patients with suspected or confirmed filovirus (Ebola, Marburg) haemorrhagic fever. 2008.

Allegranzi, B, Sax, H, Bengaly, L. “Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa”. Infect Control Hosp Epidemiol. vol. 31. 2010. pp. 133-41.

Bédat, B, Mauler, F, Allegranzi, B. “Successful hand hygiene improvement strategy in a referral children’s hospital in Armenia”. J Hosp Infect. vol. 76. 2010. pp. 362-63.

Nthumba, PM, Poenaru, E-S, Poenaru, D. “Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based hand rub for surgical hand preparation in a rural hospital in Kenya”. Br J Surg. vol. 97. 2010. pp. 1621-28.

Mathai, E, Allegranzi, B, Kilpatrick, C, Bagheri Nejad, S, Graafmans, W, Pittet, D. “Promoting hand hygiene in healthcare through national/subnational campaigns”. J Hosp Infect. 2011.

Magiorakos, AP, Leens, E, Drouvot, V. “Pathways to clean hands: highlights of successful hand hygiene implementation strategies in Europe”. Euro Surveill. vol. 6. 2010. pp. 15

Magiorakos, AP, Suetens, C, Boyd, L. “National hand hygiene campaigns in Europe, 2000-2009”. Euro Surveill. vol. 14. 2009. pp. 17

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