Infection Prevention And Control - History, Politics And Ethics

Abstract

The publications included in this thesis were selected on the basis that they describe research relating to prevention and control of either healthcare-associated infections (HAIs) and/or communicable diseases that are usually community-acquired, but often require hospital admission and/or pose a risk of nosocomial transmission. The overarching aim of this research has been to improve surveillance, prevention and/or control of HAIs and infections with epidemic or pandemic potential.

The papers are grouped into 11 chapters, according to theme and are not necessarily sequential. I have described the background to the research, its rationale, source of funding (if any), my role in it and those of the many graduate students and colleagues with whom I have collaborated and whose work is included. Some related publications, of which I was a co-author but a relatively minor contributor, have been noted where appropriate and cited as footnotes. A full list of publications included in the thesis appears in the Appendix. The thesis is divided into three nonsequential and sometime overlapping sections grouped by topic:

Part A. Infection Prevention and Control (IPC) in healthcare. Part B. A Global Approach to IPC. Part C. A Culmination and a Reckoning. Part A. Infection Prevention and Control (IPC) in Healthcare.

Chapter 1. Introduction

This historical overview sketched the trajectory of hospital IPC in the UK and Australia since the late 19th century, particularly the last 50 years. It includes a personal reflection on my own experience of hospital IPC and a book chapter on the history of healthcare-associated infections and IPC in Australia.

Chapter 2: Staphylococcus aureus: a persistent, adaptable nosocomial pathogen.

S. aureus, particularly MRSA, has played a critical and prolonged role in hospital IPC. This chapter describes and my research group’s research and development, and use of a novel sequence-based strain typing system suitable for routine MRSA surveillance, and described informatics-enhanced modelling and monitoring of MRSA transmission.

Chapter 3: Antimicrobial stewardship (AMS) - an integral component of hospital IPC.

Antimicrobial stewardship (AMS) is an essential tool in the ongoing struggle to limit the continuing spread of antimicrobial resistance (AMR), but it is difficult to implement effectively. This chapter describes the development of a decision support system, which was designed to improve antibiotic prescribing and user-friendly for clinicians. The chapter ends with a book chapter on the synergistic role of IPC and AMS.

Chapter 4: Visualising IPC improvement using video-reflexive ethnography (VRE).

VRE is an innovative practice improvement method, in which participants can visualise their work in new ways and devise strategies to enhance it. The chapter describes a VRE project in settings where MRSA was endemic, to raise clinicians’ awareness of their own and other’s roles in IPC and its intersection with routine clinical practice.

Chapter 5: Clinicians use of PPE; adaptation of VR methods (VRM) to IPC/PPE training.

Clinicians’ use of PPE in the Emergency Department, and training of HCWs in the use of PPE nationally, were identified as issues in need of urgent improvement before the COVID-19 pandemic began. This chapter describes the use of VRM in HCW training, to enhance learning and retention of skills required for the safe use of PPE.

Chapter 6: IPC ethics and politics: differences in HCWs’ approaches to IPC.

The source of data for this chapter was a series of interviews with senior medical and nursing clinician/managers at a large Sydney hospital. The aim was to gain insight into the reasons for differences in approach and attitudes to IPC, between doctors and nurses, and what, if any, adverse effect this has on patient care and staff morale.

Chapter 7: Ebola virus disease (EVD): an unrealised threat and a missed opportunity.

The international community was slow to respond to the devastating EVD outbreak in west Africa in 2014-15, until a small number of imported and hospital-acquired cases in western countries sparked fears of a pandemic. The outbreak drew attention to many ethical issues raised by the outbreak some of which are discussed in this chapter.

Part B. A Global Approach to IPC

Chapter 8. Interdisciplinary One Health research to tackle AMR and EIDs.

One Health recognises the interdependence of human, animal and environmental health. This chapter describes research, which explored professional and public attitudes to interdisciplinary One Health approaches to prevention and control of emerging infectious diseases (EIDs) and AMR, and its ethical implications.

Chapter 9. Communicable disease surveillance: ethical implications of new technology.

The integration of microbial genomics and health informatics into communicable disease surveillance systems has the potential to improve outbreak control and save lives, but public concerns about privacy and misuse of data have prevented their widespread use. This chapter explores the ethical issues and public values entailed in the use of technology-enhanced surveillance for infectious disease control.

Part C. A Culmination and a Reckoning

Chapter 10. COVID-19 - did Australia’s IPC practices live up to the challenge?

The COVID-19 pandemic challenged aspects of health governance, infrastructure, IPC policies and practices, and pandemic preparedness. No sector was more severely challenged than aged care. This chapter includes reports of three major reviews of some of the worst outbreaks in residential aged care facilities (RACFs) and the factors that contributed to better outcomes in the majority of outbreaks that were rapidly controlled.

Chapter 11. Healthcare workers’ (HCWs) experience of hospital IPC during the pandemic.

HCWs were at the frontline of the pandemic in hospitals and community settings. Interviews with HCWs, described in this chapter, revealed their increased awareness of personal risk and the limitations of IPC. Frequently changing IPC rules, disagreement among experts, staff shortages and high patient load contributed to their fear, uncertainty and increasing mistrust of hospital management. Inadequate government or expert guidance for general practices, forced them to use their own initiative to develop their own, often innovative, IPC strategies.