1:21pm , Tuesday 19th January 2021

Tunisia's Silent Killer: Hospital-acquired Infections

6 December 2012

When patients visit hospitals, they are exposed to infections caused by life threatening germs that are highly resistant to antibiotics.Yet no one utters a word about the dangers of Hospital-Acquired Infections or HAI. It is clear that ignoring this problem will only aggravate it, especially with the overcrowding of hospitals, the lack of hygiene and sterilization as well as the government’s ineffectiveness in monitoring the hospitals.

End of April 2011 in Al Soukra Clinic, the floors are sparkling and the smell of antiseptic fills the place. Everything points to freshness and cleanliness, making it hard for anyone to imagine that only two weeks ago a woman had died here as a result of contracting a hospital infection.

The victim is Inass Bin Najema, a 33-year-old married woman. She had gone to the Clinic to undergo plastic surgery on her stomach that ended up killing her, leaving behind two children, one and 5 as well as a 37-year-old husband.

The Ministry of Health conducted an investigation into the incident after the husband filed a complaint.It turned out that Methicillin-resistant Staphylococcus aureus – a staph germ –caused the patient to go into septic shock, leading to her death a week after her plastic surgery. The coroner’s legal report – a copy of which is available – confirmed these findings. It is expected that a legal case will be filed soon.

February 2012, in one of the capital’s medical laboratories, biologist Sanda Al Masmoudy takes a look at the test results which one of her colleagues had handed to her. The report states that a patient who entered the clinic to treat a heart problem, caught a resistant form of germ called Klebsiella pneumonia which then lead to “sepsis” – known as blood poisoning.

The patient’s health is in danger now for he had contracted a hospital infection a week earlier. His life is still in danger because doctors have not taken the necessary measures to treat him, such as isolating him and giving him the necessary antibiotics.

As soon as Sanda looks at the biological analysis report, she tries to call the doctor in charge. But he doesn’t answer as he is working in the Intensive Care Unit. She therefore calls his colleague, explaining the situation and asking him to intervene rapidly before it is too late.

Such cases of HAI come Sanda’s way daily, whether in the clinics with which she works or through the samples her laboratory is asked to test in order to identify the germs causing HAI.

She is outraged to see people lying there close to death because of those germs with no effort made to inform them or their relatives of the particulars of their condition or even to swiftly take the necessary measures to save their lives.

To demonstrate this further, Sanda tells the story of a 21-year-old man who underwent surgery–a lumpectomy in the spinal chord – in France and was then sent to a clinic in Tunisia for recuperation. There he contracted an HAI from a urinary catheter after a medical exam. He had left the clinic but was readmitted soon after. Sanda recounts: “The medical exam revealed that he was suffering from sepsis and that his life was in danger unless action was taken immediately”. She continues: “I sent the results by fax, pointing out the danger the patient was in, with all the explanations concerning the antibiotics that should be used.  The doctors did not take into account any of this and they were not quick enough to react. shockingly, I later found my fax thrown in the garbage bin!”. The young man died; he died of septic shock.

But what are these infections which, in terms of the frequency of their recurrence and their strength, can be said to amount to an epidemic? And why isn’t anyone addressing the problem?

Patients contract these infections 48 hours after they are admitted to hospital (if less than 48 hours, they do not qualify as HAI). The infections are a result of the growing number of antibiotic-resistant bacteria in health care areas. The bacteria can cling to medical equipment, floors, air, on the clothes or hands of hospital staff or even the patients themselves. The infection is contagious, transmitted from one patient to another or through the medical staff who become germ carriers. Humans are always surrounded by microbes but admission to hospital weakens the immune system and certain germs become dangerous if contracted.

In an article entitled: “The Science of Epidemic Diseases Associated with Health Care” (January 2010), Dr. Ridha Hamza, the director of health care in the region of Bizzerte, shows that “Hospital-Acquired Infections primarily target urinary tracts, respiratory systems and post-operative complications”.

The HAI problem is not limited to Tunisia.  According to the World Health Organisation (WHO), “At any given time, there are more than 1.4 million people suffering from complications resulting from hospital infections”.  The WHO has therefore developed an entire plan to fight this across the globe.

On the global scale, it has been almost 30 years since we have become aware of the dangers of HAI. But the problem has spread over the last few years as a result of the excessive use of chemical substances and antibiotics in agriculture and livestock farming, “contributing to the mutation of germs and making them more resistant to these antibiotics” explained Dr. Ali Al Sharif, the director of the Anaesthesia and Intensive Care Department at Rabta Hospital in the capital, Tunis.

This drives “pharmaceutical companies in the world to supply markets with stronger antibiotics”. In addition, both the frequent prescription of these drugs and the facility with which Tunisians can obtain them at pharmacies lead to the excessive consumption of antibiotics and the increase in the resistance of the germs. General practitioner Dr. Sami Al Alaqi is critical of “the ease with which a person can obtain antibiotics because pharmacies sell them with no constraints”.  He adds, “You wouldn’t see something similar in France for example, because it is forbidden to sell them without a prescription!”

To assess the danger of HAI in Tunisia, a national study was conducted in 2005 involving 7065 patients from 66 hospital institutions, 54 of them public hospitals and the other 12 private clinics. The study showed that the average of HAI contamination is 6.9%, which means that one patient in 7 is at risk.  This percentage remains within the global average which ranges between 5% and 10%.

This was the only study conducted on the national scale.  Unfortunately, there are no recent statistics that enable us to understand how widespread this phenomenon has become. A similar study will be conducted this year but statistics such as these should be conducted by HAI prevention committees which should be found in all kinds of medical institutions. That is not the case, however, just as reporting on the presence of HAI in hospitals and in private clinics is, by law, not compulsory for doctors.

In addition, no information is available on the average number of deaths caused by HAI contamination, although doctors do confirm that they happen.  For example, in a Maternity and Infant Care Centre in the capital Tunis, a study was conducted in 2008 as part of a medical thesis written by Maher Bin La’aybeh entitled: “Infant Mortality in 2008 – The Reasons and Risk Factors”. Published in 2010, the study proved that of 322 deaths, 151 cases were caused by HAIs, 43% of the overall number of 14,914 births at this Centre.

Even if the main reason for infant mortality in Tunisia is not HAI, it still constitutes one of the factors contributing to death when health care conditions and terms are not met in hospitals.

What is even worse is that patients contract HAI and sometimes die without knowing – or any of their family members learning – of the cause because in most cases no one even bothers to inform them.

Durrah tells us the story of her father who underwent surgery for his broken thigh bone: “He suffered for weeks due to complications and he went frequently to the clinic but neither he nor the family knew what he had. We tried to move him to another clinic, hoping that his condition would improve, but without success. During this entire period, he was on very strong antibiotics. We found out that he had contracted HAI from the surgery when our cousin, who is a doctor, looked into his test result. Unfortunately, he didn’t make it”.

Why the silence? Is it a form of solidarity between doctors? Is it the fear of private clinics for their reputation, especially because the institution is the first to be held responsible in the case of someone contracting HAI?

Yes, that is true, but nothing justifies the lack of transparency, because it is the legitimate right of patients to be informed.

Not only do hospitals not inform their patients about their HAI contamination, they also oblige them to pay the extra fees resulting from the extended period of treatment in the health institution and from the use of highly expensive antibiotics.

Dr. Sami Al A’alaqi says: “I saw patients spend between 300 to 400 dinars in one day (between 184 and 245 dollars) in extra fees to the private clinics because of HAI. A patient in a private clinic in Sfaqs had to pay the sum of 7000 dinars (4288 dollars) for having contracted HAI!”

To admit the presence of HAI especially when there are dangerous complications or when it leads to death means compensation for the patients and this is exactly what executives at hospital institutions and private clinics try to avoid at any price. The national study showed that the average of HAI contamination in private clinics amounts to 10.1% while it doesn’t exceed 7.4% in government university hospitals.

Despite all the ambiguity, some of the patients’ families succeed in finding out –by their own means – the presence of HAI and they then oblige the private clinic administrations to admit to their shortcomings in taking care of hygiene in their establishments.

Dr. Sami Al Alaqi tells us the story of a 56 year old patient who underwent an appendicitis procedure. Immediately afterwards, she contracted a staph germ, which lead her to go into a coma for more than two months. Her sister, a doctor, had the wit to take samples of the equipment used in the operating theatre (gloves, syringes, rubbish, etc.) and then to send them to a laboratory for analysis to identify the nature of the germ. She then took the evidence to the clinic’s administration officers and threatened to file a lawsuit. The administration agreed to pay her damages to avoid this kind of scenario. As for the patient, her condition improved gradually.

What explains the frequent recurrence of HAI in health institutions in Tunisia? And why isn’t the problem addressed effectively?.

According to employees in the health care field, the main reason is the lack of financial means and human resources. In order to fight these infections, a special quality control system should be put in place to maintain hygienic conditions at health institutions. This can be achieved at different levels, as Dr. Lamine Deheidah, Chief of Hospital Hygiene at the Sahloul University Health Centre in Sousse, states.  He is one of the first people to work on HAI in Tunisia.

This includes choosing the right hospital location and architecture whereby the pathways used for transporting food and those for moving garbage are separated. It also involves the very strict and regular cleansing of air, water, food and flooring as well as appropriate handling of waste materials and the continuous monitoring of medical staff to ensure adherence to the hygienic standards set by the institution.

All this requires a lot of money. While some hospitals do not have the resources and are unable to make these provisions, other hospitals are simply unwilling to do so.

The first problem standing in the way of this kind of quality control system is putting together a hygiene department in hospital institutions. While an internal document published by the Ministry of Health on January 25th 1990 listed the different elements of assembling this team -which includes ten people from different areas of expertise; heads of surgical departments, paediatrics, gynaecology, nutrition, hygiene, etc. – in most hospitals these teams are in fact mostly comprised of 3 to 4 people and sometimes one person only, especially in private clinics where you might find a hygiene specialist and you sometimes might not find one at all.

On top of that, the frequency of the supervisory and monitoring operations of the inspectors of the Administration of Health for the Immediate and External Environment at the Ministry of Health, remain below the standard required to create an effective quality control system. The chief of the Administration, Mr. Mohamad Al Rabhi, reveals that there is a “serious lack of human resources which we need to overcome”.  Since 2010, a total of 31,524 monitoring operations have been conducted at hospitals by 584 inspectors nationally, while the number of operations fell to 24,482 in 2011. The frequency of these operations ranges from once a week to once a month visits – as needed – to a total of 172 public hospitals and 118 private clinics.

This lack of human resources and financial means is confirmed by the lack of water faucets allowing doctors and quasi-medical staff to wash their hands regularly. Studies have shown that hands are the foremost means of transmitting germs so making sure they are clean is one of the most important recommendations that appear consistently in all prevention strategies.

“It is difficult to instill a culture of hand-washing in the medical staff.  I struggle to do that every day in the Intensive Care Unit in Rabta Hospital” says Dr. Ali Al Sharif, adding that this may be explained by the lack of means but it is also due to the lack of awareness.

A survey conducted at the University Hospital of Farhat Hached in Sousse in the second half of January 2009 on the compliance of the medical staff in four different departments classified as being dangerously infectious, showed that the average compliance by medical staff to the standards governing the washing of hands in these departments did not exceed 16.1%.

There is no doubt that efforts must be made to raise awareness amongst staff in the medical field and to train them – as there is a need for training courses concerning HAI prevention –as decisions regarding the number of such training courses and the frequency with which they are organised remain in the hands of the Administrations of the health institutions.

The overcrowding of health institutions opens the door for breaking the sanitation and hygiene rules such as those governing the washing of hands, the recurrent use of medical equipment intended to be used only once and the lack of sterilisation in the operation theatres. In this context Mr. Mohamad Al Rabhi, director of the Administration of Health for the Immediate and External Environment, confirms that “the control operations conducted by the Ministry of Health revealed that when hospital institutions are overcrowded, equipment is used without sterilisation.”

In overcrowded hospitals, there are fewer isolation rooms to separate HAI patients from other patients. When a patient’s temperature rises because of HAI, the doctor usually resorts to isolating the patient in order to limit the contamination risks, while he waits to discover the nature of the germ causing it.  This is impossible when there are not enough isolation rooms. The 2005 national study revealed that in a group of 66 health institutions included in the survey there were 76 isolation rooms — i.e. an average of one room per establishment which is a very small percentage.

The operation theatre is considered to be the likeliest place for HAI contamination and transmission, for two main reasons: the first is that different kinds of surgery are done in the same operation theatre, without differentiating between them. According to Dr. Khalil Abdul Aziz, an orthopaedic surgeon and specialist, “it is not possible to incorporate in one operation theatre the “clean” surgeries (such as cosmetic and orthopaedic surgery) and the “dirty” surgeries (such as the digestive system and ear, nose and throat surgery).  Unfortunately this occurs frequently, especially in private clinics, and the risk of contamination increases”.  Similarly, the excessive use of operation theatres, between 20 to 25 operations a day especially in certain private clinics, does not allow the sanitation and hygiene staff enough time to sterilise them thoroughly as should be required after every surgery. As a consequence, this helps transmit the germs. The reality is also that this is about the bottom line and such cuts are made in order to make a profit.

Parallel to that, the arrival of Libyans in large numbers to Tunisia during the revolution complicated the health situation in the country. The influx of the patients wounded during the war created extra pressure on Tunisian hospitals and private clinics. Sanda Al Masmoudy, a biologist says: “we discovered resistant and dangerous germs formerly unknown in Tunisia. They were brought in by the Libyan patients”. She adds: “private clinics were working day and night and they even had to put beds in the administration offices to accommodate the large number of patients. This in turn reflected on the sanitation and hygiene conditions and increased the frequency of HAI contraction”.

The war on HAI has become a pressing matter, especially because of the very high cost to human life, the society and the economy. According to the 2005 study, the average number of patients contracting HAI averages 6.7%on the national scale, which is the equivalent of around 33,500 patients per year.  Dr. Lamine Deheidah shows that the cost for every HAI patients is around 1,700 dinars, which amounts to more than 50 million dinars per year (around 30.7 million dollars) — equal to 5.6% of the Ministry of Health’s budget for 2007.

Today in Tunisia, awareness concerning the importance of taking the necessary measures to face this rising problem has increased.  A number of experts and specialists in hygiene control in hospitals have set up a national strategy headed by the HAI Prevention Unit, which was introduced into the Ministry of Health in 2011.  Dr. Nawal Al Faqih, who heads this Unit, has stated that the strategy will focus on five basic levels:

  • At the organisational level: A comprehensive law on combating HAI and texts governing its application
  • At the training level: Improving basic training and continuous education in the health sector
  • At the environmental level: Ensuring a safe and healthy environment in health institutions alongside improving the disposal system of hospital waste
  • At the supervision and monitoring level: Creation of a national system enabling the monitoring of HAI proliferation and helping the medical staff to improve their performance when it comes to prevention
  • At the level of hygiene standards: Hygiene standards will be standardised, to be incorporated in all health institutions.

This strategy was put into effect this year and a second national study on HAI is expected to be conducted this coming autumn.

It is hoped that this strategy will limit the frequency of HAI contamination in health institutions especially that it is no longer possible to continue ignoring the dangers it poses or avoiding its discussion, especially when it is taking so many lives.

(This investigation was completed with help from Arab Reporters for Investigative Journalism and coached by Dr. Mark Hunter)


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