1. Journal of Hospital Infection (2007) 65(S2) 151–154
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
Simple measures save lives: An approach
to infection control in countries with
limited resources
Nizam Damani*
Department of Medical Microbiology and Infection Prevention & Control, Northern Ireland, UK
KEYWORDS Nosocomial infection; Healthcare-associated infections; Countries with limited resources; Developing
countries
It has been estimated that in developed countries £1.06 billion (approximately US$1.8 billion) in the
up to 10% of hospitalized patients develop United Kingdom.6
infections every year. The risk of healthcare- Despite the publication of guidelines from CDC,
associated infections (HAI) in developing countries WHO,7,8 IFIC9 and various professional bodies
is 2 20 times higher than in developed countries1 and organisations, some aspects of the practice
and it has been estimated that more than 40% of of infection control, especially in developing
these infections are preventable.2 countries, are still ritualistic and wasteful.10,11
Reducing HAI infection is now considered to Amongst others, the key barrier in implementing
be an integral part of patient safety and quality good infection control practices is the lack
of care. Many healthcare facilities worldwide of trained infection control personnel and pro-
have recognised the importance of infection
grammes to help educate and increase awareness
control and have incorporated this as part of
of the importance of infection control amongst
their quality improvement programme. However,
healthcare workers.11
delivery of infection control services in most
In order to achieve these objectives, it is
developing countries is either non-existent or
ineffective. In addition to the barriers highlighted essential that the healthcare facilities initially
in Box I, most often the senior management of invest in setting up an effective infection control
healthcare facilities may not be entirely convinced programme. It can be argued that once the
that infection control is important, and one of infection control programme is fully established,
the main reasons is that there are no local resources will be released from the wasteful and
surveillance data available to assess the scale of unsafe practices by promoting and implementing
the problem and perform cost benefit analyses. good infection control practices that help reduce
Although the economic rationale for preventing HAI (Table 1) and thus help fund the programme.
HAI are published,3,4 most of the good-quality The first step in achieving these objectives is to
data available are from developed countries. For appoint appropriate infection control personnel,
example, it has been estimated that annual costs especially in healthcare facilities where there are
of HAI are US$6.5 billion per year in the USA5 and no infection control personnel and/or structures.
It is essential that the Infection Control Team
* Dr Nizam Damani. Craigavon Area Hospital Group Trust,
(ICT) be adequately trained and resourced and
68 Lurgan Road, Portadown, Co Armagh, BT63 5QQ,
Northern Ireland, UK. Tel: +44 028 3861 2654. have full support from the clinicians and senior
E-mail: drndamani@cahgt.n-i.nhs.uk (N. Damani). management.
0195-6701/$ - see front matter © 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

2. 152 N. Damani
Box I. Barriers to the setting up and implementation of effective infection control in countries
with limited resources.
(1) Lack of strategic direction and poor planning for delivery of healthcare at both the local and the
national level.
(2) Lack of awareness and commitment from clinicians and senior management.
(3) Absence or inadequate/ineffective infection control infrastructure.
(4) Shortage of trained infection control personnel to set up and deliver effective infection control
programme.
(5) Lack of availability of simple, practical and affordable infection control guidelines in local
language.
(6) Inadequacy/unavailability of supply chain/logistics of products, e.g., hand disinfectants,
Personal Protective Equipment (PPE), antimicrobials and immunization.
(7) Lack of basic diagnostic microbiology laboratory service, sterile supply department, pharmacy
and occupational health department.
(8) Shortage of trained staff to operate/maintain equipment to recommended standards.
Amongst other duties, one of the main re- resources are allocated to ‘process’ monitoring
sponsibilities of the ICT is to carry out basic (audit) with emphasis on early identification
surveillance of HAIs to help identify key issues and immediate intervention rather than counting
and areas of concern which can be communicated (‘outcome’ monitoring) preventable disasters.
to the senior management to help assess the Ayliffe12 has highlighted that even though
scale of the problem and set the priorities for infection rates can be drastically improved in
action. Although surveillance is considered one most hospitals in developing countries, they cannot
of the key components of effective infection be reduced below 5% unless excessive costs are
control, it is important to note that in developed incurred, and he described this as the ‘irreducible
countries a considerable amount of ICT resource minimum’. The SENIC Study13 has highlighted
is devoted to outcome surveillance. This is that 6% of infections can be prevented using
expensive and time consuming and requires trained minimal infection control efforts; 32% could be
infection control personnel, a good microbiology prevented by a well-organised and highly effective
laboratory and other support. These resources infection control programme. The main objective
are not usually available in developing countries. of the infection control programme in countries
Therefore, it is essential that the ICT in developing with limited resources is to reduce HAIs to
countries should carry out only basic surveillance the irreducible minimum by applying minimal
with the aim of identifying key issues and areas infection control measures. These measures must
of concern. Once this has been achieved, periodic be simple, affordable and cost effective, and
point prevalence surveillance can be used to should be designed to suit the local needs and
monitor the effectiveness of infection control circumstances. This approach is proven, affordable
measures. In addition to basic surveillance, the and achievable. In Pakistan, for example, a study
ICT must also devote time to regular audits in the neonatal unit showed that with active
(process surveillance). Audits are usually simple involvement of the mother in management of very
to perform, and are less resource intensive than low birthweight babies (encouragement of breast
outcome surveillance. They will help the ICT to feeding to reduce the need for parenteral feeding,
identify inappropriate and unsafe infection control co-bedding of mother and infant to reduce the
practices immediately. In addition, they will also need for incubator, etc.), introduction of strict
help them to identify wasteful practices and handwashing and training of healthcare workers
help divert resources to implement evidence-based in aseptic procedures resulted in a substantial
and cost-effective practices. This is the approach reduction in nosocomial infections and need for
taken by the Airline industry, which has a well nursing staff.14 In Bangladesh, topical emollient
established record on safety, and where the entire therapy was used to improve the function of skin as

3. Simple measures save lives: An approach to infection control in countries with limited resources 153
Table 1
Summary of measures for improving infection control
Cost saving measures: Wasteful No-cost measures: Using good Low-cost measures: cost-effective
practices that should be eliminated infection control practices practices
(1) Routine swabbing of the (1) Aseptic technique for all (1) Education and practical training in
environment to monitor standard of sterile procedures standard infection control, e.g.,
cleanliness (2) Remove indwelling devices hand hygiene, aseptic technique,
(2) Routine fumigation of isolation when no longer needed appropriate use of PPE, use and
rooms with formaldehyde (3) Isolation of patients with disposal of sharps
(3) Routine use of disinfectants for communicable diseases or (2) Provision of handwashing material,
environment cleaning, e.g. floors multi-resistant organism on e.g. soap and alcoholic hand
and walls admission disinfectants
(4) Inappropriate use of Personal (4) Avoid unnecessary vaginal (3) Single-use disposable sterile needles
Protective Equipment (PPE) in ICU, examination of women in and syringes
NNU and operating theatre labour (4) Sterile items for invasive procedures
(5) Use of overshoes, dust attracting (5) Minimise the number of (5) Avoid multi-dose vials and containers
mats in the operating theatre, people in operating theatres between patients
intensive care and neonatal unit (6) Place mechanically ventilated (6) Adequate decontamination of
(6) Unnecessary IM/IV injections patients in a semi-recumbent equipment between patients
(7) Unnecessary insertion of indwelling position (7) Hepatitis B immunization for
devices, e.g. IV lines, urinary healthcare workers
catheters, nasogastric tubes, etc. (8) Post exposure management
(8) Inappropriate use of antibiotics for arrangement for healthcare workers
prophylaxis and treatment (9) Disposal of sharps in robust
(9) Improper segregation and disposal containers
of clinical waste
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