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Early treatment of infections is essential in reducingtransmission of infection. This may be achieved throughhealth promotion and promotion of good health seekingbehaviour. Most individuals with infections are identifiedthrough screening and not as a result of havingsymptoms, hence screening of susceptible personsneeds to be continued and opportunistic screeningshould be encouraged.In order to make a difference a coordinated multisectoralapproach addressing many different factorsis necessary. There is an urgent need to coordinateeducational activities with the Department of Educationand to liaise with those working in the field of alcoholand other drugs to address the issue of substancemisuse and STI transmission.There is a great void in our knowledge concerningsexual behaviour and sexual networking in CentralAustralian indigenous communities. In order to developand disseminate appropriate safer sexual behaviourmessages there is a need to understand current normsin the area. Social and behavioural research needs to beconducted in this area.Finally, condoms should be accessible and freelyavailable in communities and there is a need to explorethe acceptability of female condoms to give women anopportunity to exercise greater control of their sexualhealth.References1. National Centre in HIV Epidemiology and ClinicalResearch. HIV/AIDS, viral hepatitis and sexuallytransmissible infections in Australia AnnualSurveillance Report 2005. National Centre in HIVEpidemiology and Clinical Research, The Universityof New South Wales, Sydney, NSW. Canberra, ACT:Australian Institute of Health and Welfare; 2005.2. World Health Organization Global Programme on AIDSmanagement of Sexually Transmitted Diseases.WHO/GPA/TEM/94.1. Geneva; 1994.3. Latif AS, Smith KS. STI screening conducted in NTDepartment of Health and Community Services andCommunity Controlled Health Services in CentralAustralia in 2004. NT Disease Control Bulletin. Centrefor Disease Control, NT Department of Health andCommunity Services. 2004;11:18-20.4. Miller PJ, Law M, Torzillo PJ, Kaldor J. Incident sexuallytransmitted infections and their risk factors in anAboriginal community in Australia: a population basedcohort study. Sex Transm Inf. 2001;77:21–25.5. Warchivker I, Japangati T, Wakerman J. The turmoilof Aboriginal enumeration: mobility and servicepopulation analysis in a central Australian community.Aust NZ J Public Health. 2000;4:444-449.6. Tangey A. Report on STI Screen. Sexual andreproductive health program. Ngaanyatjarra HealthService; 2004.7. Nganampa Health Council. Annual Report 2005.Alice Springs; 2005. Available from: http://www.nganampahealth.com.au34The Impact of HealthCare AssociatedInfectionIrene WilkinsonManager, Infection Control Service,Communicable Disease Control Branch.Healthcare associated infections (HAI) have long beenrecognised as a critical problem affecting the quality ofhealth care and are a principal source of adverse healthcare outcomes in Australian hospitals. 1 In overseasstudies, they have been shown to lead to increasedpatient morbidity and mortality, resulting in increasedlength of hospital stay, and additional diagnostictesting and treatment, with consequent increasedcosts to the health system. 2 In 1992 it was estimatedthat in the United States HAI affected over 2 millionpatients annually, at a cost in excess of $4.5 billion andhave been reported to account for 50% of all majorcomplications of hospitalisation. 3In 1999 the USA National Institutes of Health publisheda report entitled “To Err is Human” which addressed theincidence and impact of adverse events in healthcare, ofwhich HAI were a major contributor. 4 During the sameyear, the Department of Health in Britain published areport entitled “The Socio-Economic Burden of HospitalAcquired Infection”. 5 The aim of this study was to assessthe burden of HAI in terms of the costs to the publicsector, patients, informal carers and society as a whole.The researchers found that 7.8% of patients experienceda healthcare associated infection whilst still an in-patient,and a further 19.1% of surveyed patients experienceda possible HAI after discharge from hospital. Byextrapolation, HAI were estimated to cost the NHS £986million annually, of which £930 million was incurredduring the patients’ hospital stay and £56 million (or 6%of the total cost) was incurred post-discharge.There are little data on the cost of HAI in Australia,but recent estimates are provided in a report fromthe Expert Working Group of the Australian InfectionControl Association to the Commonwealth Departmentof Health and Ageing. 6 It is estimated that surgical siteinfections could be costing as much as $268 million peryear and that the total costs to the health care systemfor bloodstream infection may be as high as $686million. However, these figures should be viewed withcaution, since the lack of comprehensive surveillancedata in Australia make the estimation of the total burdenproblematic. There is little known about the relativecontribution of out-of-hospital expenses and societalcosts to the overall costs of nosocomial infection in
Australia, but there is no reason to suppose this wouldbe substantially different to the UK experience. Thusthe economic impact of HAI, a largely preventableconsequence of medical care, is not insubstantial.In an era when rising costs of healthcare are causingconcern, it is understandable that attention is beingfocussed on the potential resource savings that canbe made by the prevention of these adverse events.Healthcare associated infection impacts economicallyboth on the healthcare system and the community.From the perspective of a healthcare system operatingwithin a (more or less) fixed budget, the resources usedin treating healthcare associated infection are thereforeunavailable to provide valued health outcomes for otherpatients, the so-called “opportunity cost” of infection. 7From a societal perspective there are the indirect costssuch as lost productivity and litigation costs, as well asthe direct costs to patients and their carers in the formof out-of-pocket expenses for treatment and visits to theoutpatient department or general practitioner for followup,and possibly loss of income.The principal types of healthcare associated infectionare: bloodstream infection, surgical site infection,medical device-related infection such as intravenouscatheter insertion site infection or urinary catheterrelatedinfection, and ventilator-associated pneumonia.The most severe healthcare associated infectionin terms of patient morbidity and mortality isbloodstream infection (BSI), which is often acquired as aconsequence of medical device use, such as intravenousor urinary catheters, or mechanical ventilation or theymay occur secondary to surgical site or burn woundinfection. Of all the different types of healthcareassociated infection, BSIs are responsible for themost deaths and the greatest number of extra days inintensive care, and therefore incur the greatest costto the hospital and to society as a whole. 8 BSI alsocarries a substantial risk of further complications such asosteomyelitis or endocarditis, which can have long-termadverse consequences for the patient.Another significant problem for healthcare facilities ishow to control the emergence and spread of antibioticresistantbacteria. Several studies have linked theemergence of new antibiotic resistant strains to theoveruse, or inappropriate use of antibiotics. 9 Once thesestrains have emerged in a healthcare setting, strictadherence to infection control practices, especially handhygiene, becomes critical in preventing their spreadamongst other patients. Although most healthcareworkers are now well educated in the principles ofinfection control, lack of compliance with recommendedpractices remains a problem. The reasons mostcommonly cited for this situation include lack of time,and lack of properly designed and convenient facilities.It is often observed by infection control staff thathospitals these days appear to be designed for aesthetic35appeal over function, and when resources are scarce, itis often the hand washing and patient isolation facilitiesthat are cut.So how can these infections be prevented? The oftenquoted SENIC project in the United States demonstratedthat up to a third of all nosocomial infections could beprevented by the adoption of infection control programsthat had certain minimum requirements. 10 Theseincluded: routine surveillance, a full-time infectioncontrol practitioner per 250 beds, a trained hospitalepidemiologist, written infection control procedures, andfeedback of surgical wound infection rates to appropriatepersonnel. These elements have been incorporated intorecommended guidelines by the Society for HealthcareEpidemiology of America for the essential components ofan effective infection control program. 11For example, with appropriate infection controlmeasures the rate of BSI associated with medicaldevices can be significantly reduced. For intravenouscatheters, these measures include the use of: maximalsterile barrier on catheter insertion, a well-trained anddedicated intravenous catheter team, an alcoholic skindisinfectant preparation, and, most recently, the use ofantimicrobial catheters. 12 Adequate staffing may alsoimpact positively on the incidence of catheter-relatedBSI. The Centres for Disease Control and Preventionhave recently produced a set of guidelines for themanagement of intravenous catheters that include mostof the above interventions as recommendations for bestpractice. 13Routine targeted surveillance of HAI with regular andtimely feedback of results to clinicians has been shownto be an effective way of focussing attention on theseadverse events, and is useful for both illustrating themagnitude of the problem and for monitoring the effectof specific interventions. 14 This philosophy underpinsthe surveillance work of the Infection Control Service,which was established in 2001 with the aim of reducingthe incidence of HAI in South Australian healthcarefacilities. In this edition of the Public Health Bulletin, anarticle by Cope and Marwood summarises cumulativesurveillance data from the statewide healthcareassociated infection and antibiotic utilisation surveillancesystems. The HAI surveillance data illustrate theachievements obtained by South Australian infectioncontrol professionals, particularly in the area of infectionwith multi-resistant organisms, and bloodstreaminfection related to intravenous devices. Interpretationof antibiotic usage data is more complex, with usereflecting not only treatment of HAIs but also hospitaltreatment of community acquired infections, empiricuse for high risk patients and surgical prophylaxis.Using overseas published data on the cost of HAI, it iseasy to calculate that infection prevention programs canbe highly cost-effective. However, for administrators in
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