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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2013
Infectious Disease—The Never-ending Threat

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Healthcare-Associated Infections—Due Diligence

Highlights

  • More than 200,000 patients get infections every year while receiving healthcare in Canada; more than 8,000 of these patients die as a result.
  • Mortality rates attributable to Clostridium difficile infection have more than tripled in Canada since 1997.
  • The healthcare-associated methicillin-resistant Staphylococcus aureus infection rate increased more than 1,000% from 1995 to 2009.
  • About 80% of common infections are spread by healthcare workers, patients and visitors.
  • Proper hand hygiene can significantly reduce the spread of infection.
  • Best practices in preventing infection can reduce the risk of some infections to close to zero.

Contracting an infection while in a healthcare setting challenges the basic idea that healthcare is meant to make people well. Hospitals, long-term care facilities, clinics and home care services are meant to help people get better. Yet it is estimated that more than 200,000 Canadians acquire a healthcare-associated infection (HAI) each year and that 8,000 of them die as a result.Footnote 1 Although definitive numbers are not available, it appears that these numbers are rising.Footnote 2

The World Health Organization (WHO) suggests that HAIs (also known as nosocomial infections) are universal, affecting healthcare systems in every country.Footnote 3 However, noting that Canada is not alone does not make it less of a problem or any more acceptable. More must be done to keep Canadians safe while they seek treatment and care.

A healthcare-associated infection (HAI) is an infection that a patient contracts (or acquires) in a setting where healthcare is delivered (e.g. a hospital) or in an institution (e.g. a long-term care facility) or in a home care arrangement. The infection was neither present nor developing at the time the individual was admitted (or started treatment).Footnote 4, Footnote 5

Some of the HAIs monitored by the Canadian Nosocomial Infection Surveillance Program (CNISP) include:

  • Methicillin-resistant Staphylococcus aureus (MRSA) infections;
  • Vancomycin-resistant enterococci (VRE) infections;
  • Clostridium difficile (C. difficile);
  • Surgical site infections (SSI); and
  • Central venous catheter-associated bloodstream infections (CVC-BSI).Footnote 6

Preventing HAIs involves the right engineering and the right equipment; attention to hygiene; training of healthcare providers and staff; and the cooperation and help of patients and their families and friends. Washing hands, cleaning environments and sterilizing instruments are the best ways to prevent HAIs.Footnote 7-Footnote 9 However, following best practices is not always simple. It involves many people and increasing awareness in a complex environment. Educating and encouraging healthcare workers, patients and visitors to wash their hands at the right time and consistently perform other hygiene practices is one challenge. Others include the ever-changing characteristics of infectious agents and the increasing risk of infection associated with advances in medical care and increasingly vulnerable patients.

Becoming infected

People become infected with bacteria, viruses, fungi and parasites when these micro-organisms spread through the air, through direct or indirect contact or when infected blood or body fluids enter the body (e.g. the bloodstream).Footnote 10-Footnote 12 The risk of infection is higher in places where people gather, and the impact is magnified in hospitals and long-term care facilities because patients are already ill and at particular risk of infection due to medical interventions and “hands-on” care.Footnote 5

About 8% of children and 10% of adults in Canadian hospitals have an HAI at any given time.Footnote 13, Footnote 14 The severity is greatest among those who are elderly, very young, have weakened immune systems or have one or more chronic conditions.Footnote 15 Of greatest concern are the bacteria that are resistant to multiple types of antibiotics (see “Antimicrobial Resistance—A Shared Responsibility”).Footnote 8 More than 50% of HAIs are caused by bacteria that are resistant to at least one type of antibiotic.Footnote 16

Some infectious agents can spread easily from people who are infected to those who are not. They can also spread from healthy individuals who may carry the agent but do not develop clinical infections or know they are sick (see the textbox “Infected, colonized and the iceberg effect”). Infection can easily spread from patient to patient through the hands of healthcare workers during treatment or personal care or by touching contaminated shared surfaces, such as bathrooms, toilets or equipment. Even the simple act of holding a loved one’s hand can risk spreading infection if hands haven’t been correctly washed.Footnote 17

Infected, colonized and the iceberg effect

An infected individual is one in whom infectious agents have developed to the point where the person gets ill and shows symptoms such as fever and high white blood cell count.Footnote 18, Footnote 19 An infected person may transmit infectious agents to another person through touch (direct to another person or indirect touching of the same object). However, not all individuals exposed to the infectious agent become infected and sick. Instead, they may become colonized.Footnote 18 Since most colonized individuals have no symptoms, they are unaware they are carrying the infectious agents. As a result, everyone—not just those who are sick—must be vigilant about hygiene and handwashing to protect others.Footnote 18

For some bacteria and viruses the number of colonized people is much higher than the number of infected people (i.e. who are sick). The relationship between the number colonized and the number infected is often referred to as the iceberg effect. The smallest part of the iceberg—the tip visible above the water—represents those who are infected and have symptoms. The largest portion of the iceberg—underwater and mostly invisible—represents the number of colonized people with no symptoms.Footnote 18 The key message here is, that which is visible is not representative of all that is present and we need to be concerned with what is not always visible.

While direct person-to-person touch is the primary pathway, the healthcare environment itself can be a route of transmission. Bacteria can exist on many objects in the patient environment (e.g. bedrails, telephones, call buttons, taps, door handles, mattresses, chairs).Footnote 17 Some of those bacteria can survive for a long time—in some cases for many weeks and even months.Footnote 17

Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) are two of the most well-known bacteria that are able to adapt and survive in the healthcare environment long enough to cause infection.Footnote 17

Clostridium difficile

C. difficile is not a new bacterium. First identified in the 1930s, it was recognized as a cause of human illness in 1978.Footnote 20 Within the last five years, C. difficile has earned much public attention as a difficult-to-control superbug that attacks vulnerable patients, particularly the elderly, and undermines the safety of healthcare institutions.Footnote 20, Footnote 21

The bacteria are found in feces and causes mild to severe diarrhea as well as other serious intestinal conditions, including life-threatening pseudomembranous colitis, bowel perforation and sepsis.Footnote 22, Footnote 23 C. difficile infection (CDI) is the most frequent cause of infectious diarrhea in hospitals and long-term care facilities in Canada.Footnote 20

In hospitals reporting to the Canadian Nosocomial Infection Surveillance Program (CNISP), the incidence of CDI in the first nine months of 2011 was 4.5 cases per 1,000 patient hospital admissions.Footnote 24 Although the incidence of CDI has remained fairly steady in recent years, the severity seems to be increasing. The mortality rate attributable to CDI in Canadian hospitals more than tripled over the last decade and a half, from 1.5% of deaths among CDI patients in 1997 to 5.4% in 2010.Footnote 24, Footnote 25

The bacteria can be spread by touching contaminated feces and then a surface object and/or an individual. Eventually, the bacteria can reach the mouth or nose as a result of touching one’s face or eating.Footnote 21 Some populations, particularly seniors and those who are immune-compromised, are more vulnerable to infection.Footnote 21 C. difficile is not a significant risk for healthy people; however, they can still be colonized, potentially passing on the bacteria to others who may become infected.Footnote 26

Research on object contamination shows that as levels of environmental contamination increase, so does the prevalence of C. difficile transmitted between healthcare workers and from them to patients.Footnote 26 This specialized bacterium is very difficult to remove.Footnote 26 It creates spores that are resistant to many of the usual cleaning and disinfection practices.Footnote 26 The spores can survive for up to 5 months on surfaces such as tables, medical equipment and other objects, making hygiene critically important in hospitals and healthcare institutions.Footnote 20, Footnote 26 C. difficile is a particular problem for people already on antibiotics. Antibiotics kill many of the normal ‘good’ bowel bacteria, allowing C. difficile to multiply and produce the toxins that damage the bowel and cause diarrhea.Footnote 20

Simple acts can help reduce the risks of CDI. For example, proper hand hygiene can make a big difference (see “Preventing infection in healthcare settings”). Since the spores are resistant to alcohol, washing hands with soap and water is recommended over alcohol hand rubs in a healthcare facilities experiencing outbreaks of C. difficile.Footnote 26

Addressing CDI requires understanding many aspects of the bacteria: who is at risk and why; how it spreads; and how to most effectively clean the environment in healthcare settings.Footnote 9 As noted in “Antimicrobial Resistance—A Shared Responsibility”, it also requires making sure that antibiotics are used as wisely as possible. Surveillance to monitor cases of CDI and to evaluate hospital programs to protect patients is critical to reducing infection.Footnote 26

Staphylococcus aureus and methicillin-resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) is a drug-resistant form of Staphylococcus aureus (S. aureus)—the most common cause of serious hospital-acquired infections.Footnote 27 S. aureus spreads primarily through direct skin-to-skin contact as well as indirectly, as when people share personal items such as towels, razors and needles. If this bacterium enters the body it can cause infections in many areas including the skin, bones, blood and vital organs such as the lungs and the heart.Footnote 28 Many people have S. aureus on their skin at any given time and approximately 30% of people are colonized with S. aureus in their nose.Footnote 29, Footnote 30 For healthy individuals, this does not pose a threat; however, they could spread the bacteria by touch to other people. This is particularly difficult to control in healthcare settings where healthcare workers need to touch patients to assess, treat and help them. In addition, visitors often touch a patient to greet or comfort them.Footnote 17

Of particular concern in healthcare situations are MRSA infections as these are generally multidrug-resistant.Footnote 31 In the early 1940s, penicillin was completely effective in treating S. aureus. However, after this antibiotic became widely used, the micro-organism quickly adapted and became penicillin-resistant.Footnote 31 In the early 1960s, the antibiotic methicillin was introduced and shortly after that MRSA emerged.Footnote 31

Figure 1 Healthcare-associated MRSA rates per 1,000 patient admissions from 1995 to 2009, CanadaFootnote 32

Figure 1

Text Equivalent - Figure 1

Rates of healthcare-associated MRSA infection and colonization have been steadily increasing for more than a decade (see Figure 1).Footnote 32 The combined, overall rate went from less than 1 case per 1,000 patient admissions in 1995 to more than 6 cases in 2009. The infection rate increased by more than 1,000%, from 0.17 cases per 1,000 patient admissions in 1995 to 1.96 cases in 2009. The increase in the colonization rate was even larger, with the number of colonized cases per 1,000 patient admissions climbing from 0.15 in 1995 to 4.21 in 2009.Footnote 32 While more common in healthcare settings, MRSA infections have been found among patients who had never been in a healthcare facility, indicating that MRSA was spreading in the community.Footnote 31 These strains of MRSA are called community-associated as opposed to healthcare-associated.

Preventing infection in healthcare settings

Everyone—patients, visitors and healthcare workers—is responsible for preventing infection in healthcare settings. While prolonged hospitalization and being immune-compromised can increase a person’s risk of infection, research shows that applying infection control practices can reduce those risks by significantly decreasing overall rates of infection, thereby reducing exposure.Footnote 33 Those practices range from individual behaviours to institution-wide policies.Footnote 33, Footnote 34

Addressing infection prevention in healthcare settings involves multiple tactics. Some of those are:

  • educating everyone about how infections occur and how to prevent them;Footnote 34
  • reminding everyone, including visitors, to carefully clean their hands with soap and water or alcohol-based hand rubs before and after interacting with patients;Footnote 34
  • making hand hygiene options easily available (e.g. by having alcohol-based hand rubs and handwashing stations/washrooms accessible in key locations);Footnote 35
  • limiting touching of patients by visitors, especially areas that may be more prone to transmitting infection such as open wounds or sores;Footnote 36
  • working with infection control specialists, and following advice for additional precautions where necessary (e.g. wearing gowns, gloves, limiting number of visitors, need for isolation rooms);Footnote 34
  • monitoring rates of infection, and evaluating and improving preventive programs;Footnote 37
  • using checklists to ensure best practices in infection prevention are followed;Footnote 38 and
  • detecting and identifying outbreaks of infection with careful and continuous monitoring and surveillance.Footnote 34, Footnote 37

During infectious disease outbreaks such as SARS and H1N1 healthcare facilities became much more diligent in enforcing infection prevention and control practices for staff, patients and visitors. A study of the effect of those stepped-up efforts in an Ontario hospital showed that intensive care patients were more than twice as likely to develop an HAI in the pre-SARS period as in the SARS period.Footnote 39

Recognizing the global need for infection control, WHO launched the first Global Patient Safety Challenge in 2005—an international campaign to encourage member states to reduce the risk of infection in healthcare settings. The “Clean Care is Safer Care” campaign includes several components: clean products, clean practices, clean equipment and clean environment, all within the overall goal of implementing WHO hand hygiene recommendations.Footnote 40, Footnote 41 Canada joined the Global Patient Safety Challenge in 2006 and later launched the Canadian Patient Safety Institute’s (CPSI) Stop! Clean Your Hands program.Footnote 42, Footnote 43 This program is part of Canada’s Hand Hygiene Challenge, which is meant to improve hand hygiene practices and compliance in healthcare settings.Footnote 44

Hand hygiene

It’s clear: clean, healthy hands equals better health. Proper hand hygiene—washing hands with soap and water or using alcohol-based hand rubs—is the single best way of preventing HAIs.Footnote 40, Footnote 45 Even small improvements in hand hygiene result in large benefits: an increase in adherence to hand hygiene by only 20% has been shown to reduce the rate of HAIs by 40%.Footnote 46, Footnote 47 Even though infection control today has new challenges, such as antibiotic resistance, the principles of hand hygiene remain key to preventing infection.Footnote 40 For example, the use of regular soap and water, rather than antimicrobial soaps, is sufficient. In fact, antimicrobial soaps may contribute to the development of antimicrobial resistance (see “Antimicrobial Resistance—A Shared Responsibility”).Footnote 48, Footnote 49 When hands are not visibly soiled or soap and water are not readily available, alcohol-based hand rubs should be used.Footnote 50

Despite public health messages about the importance of washing hands to reduce the spread of infection, handwashing is not always done effectively. This could be because people establish hand hygiene patterns in childhood. Old habits are hard to break—changes in practice can be difficult and slow even among some healthcare professionals.Footnote 47, Footnote 51 Everyone needs to learn and practice the correct technique (see the textbox “Proper hand hygiene tips”).

Proper hand hygiene tips

The Public Health Agency of Canada recommends that Canadians wash their hands often, with soap and warm water, for about 20 seconds or, if handwashing is not possible, use an alcohol-based hand rub. The proper handwashing practice is to:

  • Remove all jewellery and rinse hands with warm running water.
  • Use a small amount of liquid soap in the palm of your hands and rub your hands together for about 20 seconds to form a lather that covers your entire hands including the palms, the backs, the backs of the thumbs, the fingertips and between the fingers.
  • Rinse hands well for about 10 seconds and then dry completely. Try not to touch faucets and other items with clean hands.Footnote 50

It is never too early to learn the basics of washing hands. Parents, teachers and childcare workers can teach children the importance of handwashing as well as how to do it correctly. The amount of time it takes children to soap their hands thoroughly is the same as the amount of time it takes to sing a nursery rhyme such as “Twinkle, Twinkle Little Star.”Footnote 50

A vital part of ensuring effective hand hygiene is making sure that healthcare professionals know about the risks and prevalence of HAIs and about the benefits of having proper hand hygiene. For healthcare providers, following specific handwashing practices is critical to controlling infections and reducing transmission.Footnote 45, Footnote 46, Footnote 52

Patients can also make a difference and improve hand hygiene practices among healthcare workers and visitors by simply asking if they have cleaned their hands or requesting that they do so.Footnote 47 However, while most patients want to be involved in improving hygiene, many say that they are reluctant to ask questions in case they become a nuisance to their healthcare team.Footnote 47 Better efforts are needed to make patients and their advocates feel comfortable in speaking up for their own safety and to encourage them to be vigilant in healthcare settings.

Cleaning environments

While hand hygiene is a critically important way to fight HAIs, one strategy alone cannot win the battle; many other practices need to be in place.Footnote 53 Cleaning equipment and environments is also very important—and connected to hand hygiene since hands touch equipment and the environment in healthcare settings.Footnote 9

There are policies and guidelines which specify the way in which healthcare environments should be cleaned and disinfected, such as how often, with what types of products and in what way. These guidelines are best practices based on factors such as how often a surface is touched, the risk of infection with the type of activity in the area, the vulnerability of the patients and the probability of contamination from body fluids.Footnote 9 For the most part, items should be cleaned and disinfected shortly after use. Finishes on furniture and surfaces on equipment should be made of materials that can be cleaned, and items that have been damaged should be properly discarded.Footnote 9 Many healthcare settings now use external cleaning services. In these situations, it is also essential that proper policies and procedures are followed.Footnote 9

After cleaning and disinfection of the environments in healthcare settings is carried out, there are no national standards in Canada to measure how clean things are. Instead, the level of cleanliness is assessed by how clean things look.Footnote 9 But visual assessments are not enough. Researchers in the United Kingdom found that 90% of the wards that looked clean still contained unacceptable numbers of micro-organisms.Footnote 54 The researchers proposed bacteriological standards for assessing surface hygiene in healthcare facilities modified from the standards used for food preparation surfaces.Footnote 53

Monitoring infection

Most HAIs are preventable. As many as 70% of some types of HAIs could reasonably be prevented if infection prevention and control strategies are followed.Footnote 55 But this is just one estimate—not enough is known about infections and how many patients could have been affected had programs not been in place.

Monitoring, tracking and prevention activities together work towards reducing the number of HAIs.Footnote 37 Nearly all hospitals in Canada routinely monitor the incidence of HAIs through surveillance activities. Surveillance is either broad (assessing all care areas) or targeted to specific units (e.g. the intensive care unit) or for specific infections that are a priority for a particular hospital.Footnote 37

However, just because some type of monitoring occurs does not mean that it is effective in preventing and controlling HAIs. The Centers for Disease Control and Prevention in the United States carried out the Study on the Efficacy of Nosocomial Infection Control (SENIC) project to identify the most effective approaches to infection surveillance, prevention and control.Footnote 56 A survey of Canadian hospitals with more than 80 beds reported in 2008 that hospitals carried out, on average, only two-thirds (68%) of the recommended surveillance activities based on SENIC project findings and only 64% of the recommended infection control activities. In addition, only 23% had the recommended number of infection control professionals on staff.Footnote 2 Mandatory standards, monitoring and public reporting are necessary to understand and tackle HAIs. Some current practices are inconsistent and uncoordinated, and more could be done to improve monitoring, addressing and reporting of HAIs in Canada.

Standards and best practices

Daily prevention and control of infectious agents is important everywhere. However, it is particularly important in healthcare environments. Hospitals started to establish infection prevention and control programs in the late 1950s. Initial concerns were with staphylococcal bacteria, and addressing them focused on identifying the infection and isolating patients. During the 1980s, infection prevention and control programs expanded to long-term care facilities and the community.Footnote 57, Footnote 58 There are now aggressive efforts across various types of healthcare services in Canada to create networks and to uphold standards in infection prevention and control.

The Canadian Patient Safety Institute (CPSI) works with governments, health organizations, leaders, and healthcare providers to raise awareness and facilitate best practices to make healthcare safer.Footnote 59 Through their primary program, Safer Healthcare Now!, CPSI provides services, tools and resources for all levels of healthcare, including frontline workers, middle managers, senior leaders and boards.Footnote 60

Through a peer review process, Accreditation Canada’s standards assess governance, risk management, leadership and infection prevention and control in healthcare organizations. Accreditation Canada’s more than 600 peer reviewers (or surveyors) are healthcare professionals across many fields from different types of healthcare services (including physicians, nurses, scientists, therapists and social workers). Accreditation Canada currently has over 1,000 client organizations including regional health authorities, hospitals and community programs and services in Canada and internationally.Footnote 61

Patient safety is a priority for accreditation, which is implemented and monitored as part of Required Organizational Practices (ROPs) developed by Accreditation Canada. ROPs are put in place to mitigate risk, reduce the potential for adverse events and foster high-quality care.Footnote 62 The ROPs fall into six patient safety areas: safety culture; communication; medication use; worklife/workforce; infection control; and risk assessment.Footnote 63

Similarly, the Community and Hospital Infection Control Association-Canada (CHICA-Canada) is a national association that promotes best practices in infection prevention and control. Generally, the focus is to improve patient care and staff health in healthcare facilities and the community by developing united control efforts (involving multidisciplinary teams), standardizing practices, promoting research and facilitating educational programs for all those working in healthcare settings.Footnote 64

In terms of surveillance, the CNISP was established in 1994. It is a collaboration between the Canadian Hospital Epidemiology Committee, a subcommittee of the Association of Medical Microbiology and Infectious Disease Canada, and the Public Health Agency of Canada. The CNISP gathers data from participating locations across the country to provide rates and trends on HAIs at Canadian health care facilities. These evidence-based data can be used in the development of national guidelines on clinical issues related to HAIs.Footnote 65

Actions for success

HAIs complicate the lives of Canadians when they are at their most vulnerable, resulting in longer illnesses and greater risk of death. They can impact people even after they are discharged from healthcare facilities.Footnote 57, Footnote 66, Footnote 67 What’s more, the longer patients remain infectious, the longer they can spread infectious agents to others.Footnote 66 Continued vigilance is necessary to reduce the numbers of those affected by HAIs. The nature of healthcare continues to evolve. To be current and ahead of emerging and re-emerging threats, infection prevention and control must also evolve as the nature of infection evolves. Canada can do more to reduce and try to eliminate risk of infection within healthcare settings. All Canadians can be involved in minimizing the spread of infection by taking actions within their control.

  • Clean and safe healthcare environments are everyone’s responsibility.
  • Public awareness and education for healthcare providers are necessary to prevent HAIs.
  • Proper handwashing and hygiene practices in healthcare environments are essential in preventing HAIs.
  • National and targeted surveillance beyond the current range of coverage is needed to develop guidelines and responses to emerging HAI issues and trends.

References

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Footnote 2
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Footnote 3
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Footnote 5
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Footnote 8
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Footnote 9
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Footnote 10
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Footnote 44
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Footnote 45
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Footnote 46
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Footnote 47
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Footnote 48
Aiello, A. E., Marshall, B. M., Levy, S. B., Della-Latta, P. et al. (2005). Antibacterial Cleaning Products and Drug Resistance. Emerging Infectious Diseases, 11(10), 1565-1570.
Footnote 49
Aiello, A. E. & Larson, E. (2003). Antibacterial cleaning and hygiene products as an emerging risk factor for antibiotic resistance in the community. The Lancet Infectious Diseases, 3(8), 501-506.
Footnote 50
Public Health Agency of Canada. (2009-10-08). Get the dirt on clean hands! Your top questions answered. Retrieved on January 29, 2013, from http://www.phac-aspc.gc.ca/im/iif-vcg/wh-lm-eng.php
Footnote 51
Whitby, M., McLaws, M.-L. & Ross, M. W. (2006). Why Healthcare Workers Don't Wash Their Hands: A Behavioral Explanation. Infection Control and Hospital Epidemiology, 27(5), 484-492.
Footnote 52
Government of Ontario. (n.d.). Your 4 Moments for Hand Hygiene. Retrieved on December 31, 2012, from http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/JustCleanYourHands/Pages/JCYH-Hospitals-Education-and-training.aspx
Footnote 53
Dancer, S. J. (2004). How do we assess hospital cleaning? A proposal for microbiological standards for surface hygiene in hospitals. Journal of Hospital Infection, 56(1), 10-15.
Footnote 54
Malik, R. E., Cooper, R. A. & Griffith, C. J. (2003). Use of audit tools to evaluate the efficacy of cleaning systems in hospitals. American Journal of Infection Control, 31(3), 181-187.
Footnote 55
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Footnote 56
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Footnote 57
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Footnote 58
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Footnote 59
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Footnote 60
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Footnote 61
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Footnote 62
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Footnote 63
Accreditation Canada. (2013). Required Organizational Practices Handbook 2013.
Footnote 64
Community and Hospital Infection Control Association - Canada. (2011-08-02). About Us - Overview. Retrieved on June 11, 2013, from http://www.chica.org/about_overview.php
Footnote 65
Public Health Agency of Canada. (2012-04-16). The Canadian Nosocomial Infection Surveillance Program. Retrieved on November 14, 2012, from http://www.phac-aspc.gc.ca/nois-sinp/survprog-eng.php
Footnote 66
World Health Organization. (2013-05). Antimicrobial resistance. Retrieved on October 24, 2012, from http://www.who.int/mediacentre/factsheets/fs194/en/index.html
Footnote 67
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