Healthcare systems the world over depend on three main pillars, drugs, medical professionals and hospitals for delivering the much needed services. The smooth and effective functioning of these three components are enabled through the pharmaceutical industry responsible for the discovery and development of new drugs, skilled and knowledgeable medical professionals for treating patients and state-of-the-art hospitals where in patient medical interventions are carried out. While all these are meant to benefit the patients who need them the most, in practice each one of them pose its own unique problems for its customers, leading to grave consequences, in some cases graver than the diseases themselves. Thus the incidence of adverse and toxic reactions to drugs, diseases caused by drug usage (iatrogenic diseases), medical negligence and frauds and hospital originated infections (Nosocomial Infections) can lead to high and unacceptable levels of morbidity and even mortality. It is estimated that adverse drug reactions kill over 10,000 patients every year and cause serious injuries to as many as 2 million people in the US alone. It is rated as the 6th major cause of death after cardiac diseases, cancer, lung diseases, strokes and accidents. Iatrogenic diseases have been reported to be responsible for around 5% of all hospital admissions in the US.
Nosocomial infections
Nosocomial infections acquired during treatment in hospitals are secondary infections not related to the original diseases for which the patient was admitted. They are classified as such if they occur 48 hours after hospital admission or within 30 days after discharge. Worldwide, 5-10% of hospital in-patients are affected by nosocomial infections. In the US, 2 million patients get infected in hospitals with fatal outcomes in as many as 100,000 per year. The economic loss due to these infections has been computed to be around $ 4.5 to 10 billion per year. In a study by WHO in 55 hospitals of 14 countries, it was reported that incidence was as high as 8.7% of admissions with the highest being in hospitals in South East Asia. Paradoxically 30% of these occur in the so-called cleaner and more sterile environment of ICUs. Of these infections, the predominant ones are blood infections, followed by urinary tract, respiratory tract, orthopaedic and surgical wounds infections. The specific cases are ventilator assisted pneumonia, antibiotic/drug resistant, including vancomycin and methicillin resistant staphylococcus aureus, pseudomonas aeruginosa, klebsiella pneumoniae and clostridium difficile, mycobacterium tuberculosis and various urinary and gastro-intestinal tract infections. Their incidence have their aetiology from lack of hospital hygiene and proper housekeeping, human transmissions, surgical and other invasive interventions and airborne, water borne and food borne infections. Treatment related infections include use of contaminated medicines, equipments, intubation devices, IV sets, syringes & needles, blood tranfusions, use of immuno suppressive drugs and radiation therapy. Transmission vectors including mosquitoes, leeches and flies are other common causes. While maternal transmissions of viral and bacterial infections are difficult to control in labour wards, all the other infections can be effectively controlled by appropriate measures of both preventive and curative nature. One of the major problems faced is that organisms present in the hospital environment are usually more virulent and even more importantly, resistant to most antibiotics including new generation cephalosporins, methicillin, amikacin or even vancomycin. The reasons for higher incidence in ICUs compared to general wards is due to the fact that surviving microbes in ICUs generally acquire higher levels of resistance than those in general wards. Management of large number of patients including many immuno-compromised ones, emergence of newer organisms and increased number of resistant mutants of organisms have all been quoted as additional impediments to reducing nosocomial infections. Both the WHO and CDC, Atlanta have developed practical guidelines for prevention of hospital acquired infections. However implementation in hospitals even in developed countries with modern and sophisticated infrastructure has been tardy.
Case of India
In recent times, in terms of numbers, type, nature and intensity, many healthcare issues such as the incidence and spread of infectious diseases such as dengue, chikungunia, leptospirosis, Japanese encephalitis, malaria etc, not to speak of TB and HIV/AIDS have surfaced in India, some of them reaching epidemic proportions. While many of these diseases are vector borne and hence can be controlled largely through sustained improvement in environment and public health, what has been alarming has been the spurt in hospital originated infections resulting in high levels of infant and adult mortality in some of the leading hospitals in the country.
While no estimates are readily available for India, a few studies carried out in Delhi and Mumbai point to incidence of nosocomial infections in the range of 15-30% of hospital admissions. In a study published in 1997 it was reported that of the 422 of cardiac surgeries conducted in a Delhi hospital, as much as 38% developed some infection or the other during the hospital stay. In yet another report from a Cancer hospital in Mumbai, it was found that the incidence of Nosocomial infections increased from 35% of Hospital admissions in 1988 to 64% in 1996.
Assuming that the national average for nosocomial infections in India is anywhere near the estimates based on limited reports of 30% of hospital admissions, Indian healthcare scene is facing an enormous challenge in terms of the need to prevent and control if not eradicate such infections. Considering that the around 1 million beds are available in Indian hospitals, the incidence of infections will be around 300,000 per year and at 10% mortality from these infections the number of deaths could be as high as 30,000 per year.
Apart from drastic improvements in hospital hygiene including better design of hospitals with particular attention to higher levels of hygiene and sanitation and better maintenance, awareness creation among all personnel in the hospital including patients is essential. Since the main causative organisms leading to hospital infections are of bacterial, viral and fungal origin including infections from gram positive, gram negative and anaerobic strains of Staphylococcus, E.coli, Proteus , Klebsiella, Pseudomonas and Clostridium, viral infections from hepatitis, A, B and C and HIV viruses, use of rapid diagnostic kits, surveillance programmes and reporting systems should be part of hospitals' routine activities.
India has not formally adopted or implemented the WHO or the CDC guidelines for prevention and control of nosocomial infections. The Govt of India had in the past set up Committees in 1968, 1976 and 1992 to address at least partially some of the concerned issues, but the recommendations have remained on paper even today. The preventive steps are largely straight forward and commonsensical and includes, maintenance of hygiene, sanitation, quality standards in food, water , environment, clothing, linen, sterilisation, medical check up of all personnel, medical waste management and bio-decontamination procedures using modern techniques, equipments and processes. The development and launch of a series of bio-decontaminant equipments based on plasma glow technology by Klenzaids provides a valuable array of products which can be gainfully installed and utilised for preventing nosocomial infections in hospitals. Proper documentation and monitoring systems to assure standards at all places and at all times is imperative. At present proper records, documentation and analysis of the issues and problems are not available at the Institution, district, state or national level.
Considering the seriousness of the problem and its impact on healthcare in the country, it is important to develop a strategy to address the concerned issues and develop a suitable action plan. For a start, it is important to create a data bank which will monitor and document hospital originated infections across the country. In other words, an audit system should be developed whereby it is possible to assess the prevalence, incidence and progression of such infections so that timely intervention is possible. Even though the problems are common to all hospitals, both public and private, they are more acute in the latter due to the very nature and volume of the services they offer. Health being the primary responsibility of the States, it is imperative that all States take up a pro-active approach to save the over 30,000 lives per year estimated to be lost per year in India due to preventable nosocomial infections across the country.
(The author is a senior research scientist and industry expert based in Chennai)