The Scottish Parliament and Scottish Parliament Infor mation C entre l ogos .

SPICe Briefing

Healthcare Associated Infections 16 November 2011

11/80

Sobia Raza

Healthcare associated infections (HAIs) are infections acquired in a hospital or other healthcare settings. HAIs can arise as a result of a range of medical procedures and are caused by a number of micro-organisms. This briefing outlines the prevalence and burden of HAIs, and examines the trends in levels of key HAIs in Scotland over the past years. An overview of the strategies in place for tackling these infections is provided. Finally research progress and priorities in this area are explored.

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CONTENTS

EXECUTIVE SUMMARY .............................................................................................................................................. 3

ACCRONYMS AND ABBREVIATIONS ...................................................................................................................... 4

INTRODUCTION .......................................................................................................................................................... 6

WHAT ARE HEALTHCARE ASSOCIATED INFECTIONS (HAIS) .......................................................................... 6 THE MOST COMMON HAIS AND CAUSATIVE MICRO-ORGANISMS ................................................................. 6

THE BURDEN OF HEALTHCARE ASSOCIATED INFECTIONS ............................................................................... 9

RISK AND INCONVENIENCE TO PATIENT ........................................................................................................... 9 BURDEN ON THE HEALTH SERVICE.................................................................................................................. 10 ECONOMIC BURDEN OF HAIS ............................................................................................................................ 11

TRENDS IN HEALTHCARE ASSOCIATED INFECTIONS ....................................................................................... 12

RATES OF INFECTION – SCOTTISH NHS BOARDS .......................................................................................... 12 STAPHYLOCOCCUS AUREUS BLOOD INFECTIONS .................................................................................... 12 CLOSTRIDIUM DIFFICILE INFECTIONS ......................................................................................................... 14 SURGICAL SITE INFECTIONS ......................................................................................................................... 15

HAI PREVELANCE – REST OF THE UK AND EUROPE ..................................................................................... 17

PREVENTION............................................................................................................................................................. 18

EFFECTIVENESS OF HAI PREVENTION MEASURES ....................................................................................... 19 BEHAVIOURAL FACTORS ............................................................................................................................... 19 ORGANISATIONAL FACTORS ......................................................................................................................... 20

CURRENT POLICY FOR TACKLING HEALTHCARE ASSOCIATED INFECTIONS .............................................. 22

GOVERNANCE – THE HEALTHCARE ASSOCIATED TASK FORCE ................................................................. 22 MAIN OUTCOMES OF THE HAI-TASK FORCES FIRST TWO WORK PROGRAMMES ............................... 22 THIRD PHASE OF THE HAI TASK FORCE’S WORK ...................................................................................... 25 OTHER DEVELOPMENTS – VALE OF LEVEN ................................................................................................ 27

CASE STUDY: DUTCH MRSA CONTROL STRATEGY ....................................................................................... 28

OTHER KEY ISSUES ................................................................................................................................................. 29

EMERGING HAI PATHOGENS ............................................................................................................................. 29 RESEARCH INITIATIVES AND PRIORITIES ........................................................................................................ 29

SOURCES .................................................................................................................................................................. 31

APPENDIX 1............................................................................................................................................................... 37

APPENDIX 2............................................................................................................................................................... 38

APPENDIX 3............................................................................................................................................................... 39

APPENDIX 4............................................................................................................................................................... 41

RELATED BRIEFINGS ................................................................................... ERROR! BOOKMARK NOT DEFINED.

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EXECUTIVE SUMMARY

Healthcare associated infections (HAIs) are infections acquired by patients in a hospital or as a result of healthcare intervention. In contrast, community acquired infection are those infections contracted in the community, outside and prior to hospital admission. Surveys have revealed 9.5% of patients in Scotland have an infection that was not present or incubating at the time of their acute hospital admission. Most HAIs are caused by bacteria. These bacteria are also found in the general population and mostly exist harmlessly in the general environment. However in a healthcare setting the chances of these micro-organisms causing an infection is increased considerably. The major reasons for this are that hospital patients already have poor health or an underlying condition and this can impair their natural immune defence. Furthermore, healthcare treatments and procedures such as surgery can expose entry routes for the infection causing micro-organisms (also known as pathogens).

The most common types of HAIs in Scotland are; lower respiratory tract infections (including pneumonia), urinary tract infections and surgical site infections. These infections are commonly related to healthcare procedures for example, use of mechanical ventilation, urinary catheterisation and surgery. The most common types of HAI causing pathogens are the bacteria Staphylococcus aureus (S. aureus), followed by Clostridium difficile (C. difficile) and a class of bacteria known as Coliforms. Staphylococcus aureus can be further classified based on its ability to be treated with the common antibiotic Methicillin. A strain of S. aureus that is resistant to treatment with Methicillin is known as Methicillin Resistant Staphylococcus Aureus (or MRSA). Data shows that C. difficile infections and bloodstream infections caused by MRSA have been decreasing since surveillance began in Scotland. Conversely trends in deaths where MRSA or C. difficile have been involved have generally been increasing at least up until the year 2008. This anomaly may be explained by increased professional awareness of these pathogens, resulting in better recording on death certificates.

Not all HAIs are preventable. Most estimates suggest around 20-30% of HAIs could be prevented. The annual cost of HAIs to NHSScotland is estimated to be £183 million. It has been suggested that cost savings of £36.6 million are possible if a 20% reduction in HAIs were to be achieved. The single most cost effective intervention to prevent the transmission of HAIs is good hand hygiene. The Scottish Government‟s Healthcare Associated Infection (HAI) Task Force is responsible for overseeing and co-ordinating the development and implementation of the national strategy on HAIs. The Task Force has published three delivery plans for tackling HAIs to date. Key strategies have included; HAI surveillance, development of educational programmes, hand hygiene policy, and more recently an MRSA patient screening programme. Pre-emptive screening for MRSA has been in place for many years in the Netherlands, a country with relatively low rates of MRSA infection. Prudent use of antibiotics is also recognised as a crucial factor in controlling HAIs. Increased exposure to antibiotics can allow HAI causing bacteria to adapt and become resistant to treatment. Novel antibiotics to tackle HAIs are needed, however the expense and risk involved in developing these is speculated to be a deterrent for pharmaceutical companies to invest.

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ACCRONYMS AND ABBREVIATIONS

BMA British Medical Association

C. difficile Clostridium difficile

CABG Coronary Artery By-pass Grafting

CDI C. difficile Infection

CDC Centre for Disease Control

CNS Coagulase-Negative Staphylococci

DoH Department of Health

EARS-Net European Antimicrobial Resistance Surveillance System

E.Coli Escherichia coli

ECDC European Centre for Disease Prevention and Control

GI Gastrointestinal

GROS General Register Office for Scotland

HAI /HCAI Healthcare Associated Infection

HAI-SCRIBE Healthcare Associated Infection - System for Controlling Risk In the Built Environment

HDL Health Department Letter

HEI Healthcare Environment Inspectorate

HFS Health Facilities Scotland

HPA Health Protection Agency

HPS Health Protection Scotland

ICU Intensive Care Unit

ISD Information Services Division

NDM-1 New Delhi metallo-beta-lactamase-1

NHS National Health Service

NHS NES NHS Education for Scotland

NHS QIS NHS Quality Improvement Scotland

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PDS Post Discharge Surveillance

PICT Public Involvement and Communications Team

MRSA Methicillin Resistant Staphylococcus Aureus

MSSA Methicillin Sensitive Staphylococcus Aureus

S. aureus Staphylococcus aureus

ScotMARAP Scottish Management of Antimicrobial Resistance Action Plan

SGHD Scottish Government Health Directorates

SIRN Scottish Infection Research Network

SPCC Statistical Process Control Charts

SSI Surgical Site Infection

SSHAIP Scottish Surveillance of Healthcare Associated Infection Programme

VRSA Vancomycin-Resistant Staphylococcus aureus

WHO World Health Organisation

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INTRODUCTION

WHAT ARE HEALTHCARE ASSOCIATED INFECTIONS (HAIs)

Healthcare Associated Infections (HAIs) are infections that develop as a direct result of any healthcare intervention or contact in a healthcare or hospital setting. A “healthcare” setting is inclusive of other medical locations in addition to hospitals, for example care homes, general practice and dental surgeries. “HAI” was originally used to abbreviate hospital acquired infection, which strictly speaking refers to an infection that develops 48 hours or later after patient admission to a hospital. In recognition of the increasingly complex procedures now undertaken outside hospitals, the term “healthcare associated infection”, was coined1. The acronyms HCAI and HAI are used interchangeably, to define healthcare associated infections. The term “nosocomial infection” is synonymous with hospital acquired infection. Community acquired infections are infections acquired by patients in a community setting, outside and prior to their hospital or healthcare admission. The distinction between community acquired and healthcare associated infections becomes significant where symptoms of an infection present during the early stages of hospital admission (first 48 hours). In this scenario it is generally considered that the infection was incubating prior to hospital admission and was contracted in the community. In 2006, a prevalence survey in England, Wales, Northern Ireland, and the Republic of Ireland found 7.6% of patients have an infection that was not present or incubating at the time of their acute hospital admission (those intended for short term medical care or surgical intervention) (Smyth et al., 2006). Using the same HAI definitions as the four country study, Health Protection Scotland (HPS) also performed a survey during 2005-2006. The national survey found the prevalence of HAIs was 9.5% in acute hospitals and 7.3% in non-acute hospitals in Scotland (Reilly et al., 2007).

THE MOST COMMON HAIS AND CAUSATIVE MICRO-ORGANISMS

A range of organisms are associated with the pathogenesis of HAIs. Although their existence is prevalent in the general population and environment, the chances of these pathogens manifesting into an infection is increased considerably in a hospital setting for several reasons;

Patients already have a medical condition or underlying illness and this can impair their natural defence response against pathogens.

Patient wounds obtained through injury or surgery can provide a route of entry for certain pathogens, as can the use of invasive medical devices (such as catheters, drains and tubes).

Certain treatments can leave patients vulnerable to infections. Immunosuppressive drugs, antimicrobial treatments and recurrent blood transfusions are all risk factors.

The nature of a hospital environment itself is a major contributory factor. Turnover of patients and personnel, the concentration of people with poor health, and movement

1 This briefing will use the acronym “HAI” to refer to Healthcare Associated Infection, unless quoting sources that

use other abbreviations.

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of medical staff from patient to patient all provide a fast means for spreading pathogens.

The most common causative organisms identified in patients during the prevalence survey of HAIs in acute hospitals in Scotland were the bacteria Staphylococcus aureus (S. aureus), followed by Clostridium difficile (C. difficile) and a class of bacteria known as Coliforms

(Escherichia coli (E.coli) is the most well known member). Staphylococcus aureus can be further classified as Methicillin Resistant Staphylococcus aureus (MRSA) or Methicillin Sensitive Staphylococcus aureus (MSSA). MRSA is any strain of S. aureus that has developed resistance to treatment with the antibiotic Methicillin. MSSA infection on the other hand can be treated with Methicillin and has yet to become resistant to common antibiotic treatments. MRSA accounted for 66% of all reported S. aureus infections in acute hospitals in Scotland (Reilly et al., 2007). A full breakdown of the frequency at which different HAI causing pathogens were reported in patients diagnosed with HAIs is shown in Table 1. The data (Table 1) is based on only those infections where the type of pathogen was confirmed by laboratory analysis. Table 1: Number and percentage of ten most frequently occurring organisms reported for inpatients diagnosed with HAI in acute hospitals. Data extracted from the Health Protection Scotland report on HAI prevalence.

Organism Type of Pathogen

Reporting Frequency

Number %†

Clostridium difficile Bacteria 95 17.6

Staphylococcus aureus (MRSA) methicillin-resistant Bacteria 93 17.2

Staphylococcus aureus (MSSA) methicillin-sensitive Bacteria 48 8.9

Coliform (unspecified) Bacteria 46 8.5

Escherichia coli Bacteria 36 6.7

Coagulase-negative staphylococci (CNS) Bacteria 26 4.8

Enterococcus spp. Bacteria 21 3.9

Candida spp. Fungus 16 3.0

Enterococcus faecalis Bacteria 12 2.2

All Other organisms* 147 27.2

Total 540 100.0 † The percentage reported is: (Count of Organisms reported / Count of all organisms reported) x 100

* The remaining organisms were grouped as „All Other organisms‟

Source: Reilly et al., 2007 The most common types of HAIs occurring in acute hospitals in Scotland were of the urinary tract (17.9%), surgical sites (15.9%), gastro-intestinal (15.4%), followed by eye, ear, nose, throat and mouth infections (12.5%) (Reilly et al., 2007). Lower respiratory tract infections (including pneumonia) accounted for 20.0% of all HAIs. Pneumonia considered alone accounted for 8.8% of all HAIs. Table 2 outlines the different types of HAIs, risk factors for contracting them and their common causative micro-organisms.

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Table 2: Overview of different healthcare associated infections. Infection percentages are based on acute hospital inpatients in Scotland, extracted from the Health Protection Scotland report on HAI prevalence, and presented as a percentage of all HAIs recorded.

Infection Type and

(Percentage of all HAIs)

Description Risk Factors and Complications

Main Causative Pathogen

Lower

Respiratory Tract

Infections

including

Pneumonia

(20.0%)

Infections of the airways and the

lungs.

Pneumonia accounts for the

largest proportion of lower

respiratory tract infections in

Scotland (44.0%).

Mechanical ventilation.

Contraction of pneumonia is the

most severe respiratory tract

infection, with fatality rate

approaching 40%.

Bacteria, including

Acinetobacter

species and

Staphylococcus

aureus (S. aureus).

Urinary Tract

Infections

(17.9%)

Urinary tract infections arise when

pathogens enter the urinary tract

and bladder.

Urine catheters.

Antibiotic resistance may develop in

patients with long term catheters

Bacteria, in

particularly

Escherichia coli (E

coli).

Surgical Site

Infections

(15.9%)

Wound infections occurring after

an invasive surgical procedure.

Examples include hip arthroplasty/

caesarean section, open heart

surgery.

Duration of surgery, surgery

techniques, preparation, presence

of foreign material, and duration of

hospital stay.

S. aureus is the most

common.

Pseudomonas

aeruginosa.

Gastrointestinal

(GI) Infections

(15.4%)

Infections of the stomach, intestine

(digestive tract). An example of a

causative bacterium is C.difficile

which is released into the

environment as spores released

from faeces and can survive for

long periods outside the body.

Another causative pathogen

Norovirus, is also highly

contagious.

Antibiotics use can disrupt the

balance of naturally occurring

bacteria in the gut, allowing the

usually modest number of C. difficile

to become over-populated.

The elderly (age 65+) are a high risk

group for C. difficile infection.

Most healthcare

associated GI

infections are caused

by the bacterium

Clostridium difficile

(C. difficile).

Norovirus is also a

contagious virus

responsible for

stomach flu.

Ear, eye, nose,

throat, and

mouth infections

(12.5%)

Infections of the oral cavity, upper

respiratory tract, eyes, (including

conjunctivitis).

Risk factors are often site specific.

For example removal of tonsils is a

risk factor for healthcare associated

throat infections.

Range of pathogens,

although some are

specific to location.

Bacteria include:

MSSA, MRSA,

Pseudomanas,

Streptococcus and

E.coli. Virus:

Influenza. Fungus:

Candida.

Skin and soft

tissue Infections

(11.0%)

Infections can be at the skin

surface or deeper and even

necrotizing (flesh eating).

Management of open wounds and

sores. Peripheral catheters.

S. aureus.

Bloodstream

Infections

(4.4%)

Local infection can develop around

catheter entry site or / and

pathogens may enter the blood

stream and cause more serious

infection referred to as sepsis.

Invasive devices, including

intravenous access devices.

E.coli, S. aureus,

including MRSA

Others

(3.2%)

Other infection categories are;

Bone and joint, central nervous

systemic, cardiovascular system,

reproductive system, and systemic

infections.

Sources: Reilly et al., 2007; National Audit Office, 2009

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THE BURDEN OF HEALTHCARE ASSOCIATED INFECTIONS

RISK AND INCONVENIENCE TO PATIENT

In terms of burden to patients who contract a HAI, the infection may:

complicate an existing medical condition

extend the duration of their stay in hospital

lead to physical and/or emotional stress

lead to a loss of earnings

reduce the chance of a successful recovery

and in the worst scenario, result in death

The General Register Office for Scotland (GROS) records and publishes data on deaths in which C. difficile and MRSA have been involved (see Tables 3 and 4). Over the past decade or so there has been a general upwards trend in the number of deaths where MRSA and C.difficile have been mentioned, however the data for the last two years shows MRSA and C. difficile related deaths have fallen. Figures should be interpreted with caution as changes in the number of cases year on year may be influenced by increased professional awareness of MRSA and C. difficile and subsequent recording on death certificates. This suggestion may well be corroborated by the fact that surveillance data for these pathogens shows a downwards tread in infection rates over the years. Table 3 – MRSA related deaths in Scotland from 1996-2010. MRSA was: (a) recorded as the underlying cause of death; (b) described as a contributory factor; and (c) mentioned as either the underlying cause of death or a contributory factor.

Year

Deaths where MRSA is mentioned as:

(a) an underlying

cause

(b) a contributory

factor

(c) either the underlying

cause or a contributory

factor

1996 6 28 34

1997 13 56 69

1998 14 64 78

1999 22 72 94

2000 35 74 109

2001 36 100 136

2002 46 109 155

2003 39 130 169

2004 42 148 190

2005 38 174 212

2006 51 162 213

2007 56 174 230

2008 48 166 214

2009 24 137 161

2010 25 93 118

Source: The General Register Office for Scotland(a)

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Table 4 – C. difficile related deaths in Scotland from 2000-2010. C. difficile was: (a) recorded as the underlying cause of death; (b) described as a contributory factor; and (c) mentioned as either the underlying cause of death or a contributory factor.

Year

Deaths where C. difficile is mentioned as:

(a) an underlying

cause

(b) a contributory

factor

(c) either the underlying

cause or a contributory

factor

2000 38 78 116

2001 57 113 170

2002 70 94 164

2003 73 115 188

2004 98 141 239

2005 102 211 313

2006 164 253 417

2007 220 377 597

2008 248 517 765

2009 139 326 465

2010 65 205 270

Source: The General Register Office for Scotland(b)

BURDEN ON THE HEALTH SERVICE

HAIs can have a significant negative impact on the health service. The repercussions include the cost of diagnosis and treatment, increased length of stay of the patient and the consequential strain on the availability of hospital beds, as well as increased staff workload. Research commissioned by the Department of Health (England) into the socio-economic impact of infections acquired in a hospital setting found costs incurred by the hospital were three times more for infected patients than for uninfected (Plowman et al., 1999). In absolute terms this represented an increase of £3154 per case, although the study was conducted in 1994-1995. Nursing care accounted for the largest portion of the additional costs incurred, followed by hospital overheads, capital changes and cost of management (a full breakdown is shown in Figure 1). The study also found infected patients were 7.1 times more likely to die in hospital than uninfected patients and infected patients may spend on average an extra 11 days in hospital (Plowman et al., 1999). However the more recent Scottish HAI prevalence report calculates the average increased length of stay as 6.6 days (Reilly et al., 2007). The report also notes the length of stay and cost associated with HAIs can vary depending on the hospital speciality the patient is being treated in. Care of the elderly has the longest increase of additional acute hospital stay (13.7 days) at a cost of £187 per added day and therefore an average total cost of case treatment of £2562. Whereas obstetrics has the shortest increase in length of stay due to patient HAI contraction (3.2 days) but the highest cost per added day at £596, resulting in a total cost of £1907 per case. There is also the danger of the HAI causing pathogens to develop resistance to common antimicrobial treatments, especially where there is the need for regular use of antimicrobials as the pressure on the pathogens can cause them to adapt. Consequently infections become more difficult and costly to treat.

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Figure 1: Breakdown of the additional costs incurred for treating patients who have contracted a HAI during their hospital stay. Data extratced for Plowman et al., 1999.

ECONOMIC BURDEN OF HAIS

The Scottish prevalence survey report calculates the cost of HAIs to the NHS in Scotland at £183 million per annum. In England the most commonly quoted estimate is at least £1 billion annually (Plowman et al., 1999). However, these figures relate to health service costs only and a 2006 review concluded that the costs of HAIs are underestimated and that MRSA alone results in annual costs to the UK economy of between £3-11 billion (Gould, 2006). Wider economic costs arise from lost productivity, litigation and the cost of social support. The Scottish report also suggests NHS cost savings of £36.6 million are possible if a 20% reduction in HAIs were to be achieved. The savings rise to £54.9 million or £73.2 million with HAI reductions of 30% or 40% respectively. However, it is worth noting that it is generally accepted that not all HAIs are preventable (see „Prevention‟). As a result, there may always be an economic burden associated with HAIs. Even with a 30% reduction in HAIs (the higher end of the estimated possible reduction), the remaining 70% would account to a cost of £128.1 million per annum (based on the most recent annual calculated cost of £183 million).

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TRENDS IN HEALTHCARE ASSOCIATED INFECTIONS

RATES OF INFECTION – SCOTTISH NHS BOARDS

The predominant methods for HAI data collection are either incidence surveillance programmes or prevalence surveys. The key distinction between these being:

Incidence surveillance is the ongoing systematic and regular collection of data on a population over a period of time.

Prevalence surveys record numbers of specified events in a specific population at a point in time or over a specified period of time.

In 2001 the Scottish Executive released a Health Department Letter HDL(2001)57, requiring the mandatory implementation of incidence surveillance of both inpatient surgical site infections (SSIs) and MRSA blood infections (bacteraemias). In 2006 the surveillance requirements were revised to also include incidence of C. difficile infections, MSSA, and post discharge surveillance following orthopaedic surgery and caesarean sections (HDL(2006)38). Voluntary surveillance programmes were also introduced for catheter-associated urinary tract infections, ventilator associated pneumonia and HAI outbreaks.

Surveillance data is reported by NHS Boards to the Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP) a division of HPS. Key reports are then produced by HPS and include; quarterly rates of all S. aureus bacteraemias; quarterly rates of C. difficile infections and annual rates of SSIs.

The surveillance data is utilised for analysis and interpretation usually for the purpose of planning, implementation, and evaluation of public health practice. Summarised in the subsequent sections are incidence surveillance data collected over time for S. aureus blood infections, C. difficile infections, and SSIs.

STAPHYLOCOCCUS AUREUS BLOOD INFECTIONS

In Scotland, all NHS boards report all isolates of MSSA or of MRSA from patient blood cultures to HPS. These reports come from routine hospital laboratory data systems. The numbers and rates of bactereamias are reported in quarterly publications and annual reports. Figures 2 and 3 show the trend in numbers and rates of MSSA and MRSA bactereamias over time. Surveillance of MSSA commenced in 2005, and became mandatory in 2006 (HDL(2006)38). In their most recent annual report, HPS calculated for the period of April 2005 to December 2009 a significant year on year reduction of 6.1% in S. aureus rates. During the same period MRSA and MSSA bacteraemia rates reduced year on year by 14.5% and 1.7% respectively. The data set of quarterly rates is appended (appendix 1).

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Figure 2: Total quarterly numbers of Staphylococcus aureus bactereamias across NHSScotland for the period January 2003 to June 2011

Source: HPS, 2011

Figure 3: Quarterly rates of Staphylococcus aureus bactereamias per 1000 occupied bed days across NHSScotland for the period January 2003 to June 2011

Source: HPS, 2011

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CLOSTRIDIUM DIFFICILE INFECTIONS

Surveillance and monitoring of C. difficile infection (CDI) began in 2005, with mandatory surveillance being established in 2006 to monitor CDI in patients aged 65 and over. In April 2009 the surveillance programme was expanded to include the age group 15-64. Since the predominant symptom of C. difficile infection (CDI) is diarrhoea, the surveillance programme monitors the occurrence of CDI in all patients (aged 15 and over), with diarrhoea, and who have been in contact with the healthcare system, including acute and non-acute hospitals and primary care. According to HPS, compared to 2008, the number of CDI cases dropped by 43% in 2009, in patients aged 65 years and older (HPS, 2010a). On average the age group 15-64 accounts for 26% of the total number of CDI cases, and the majority of these are concentrated in the 40-64 year age group, reflecting the propensity for CDI to occur in older populations. Figures 4 and 5 illustrate the trends in quarterly reported cases and rates of CDI in NHSScotland. (Data set also available in appendix 2).

Figure 4: Total quarterly reported cases of Clostridium difficile infection across NHSScotland for the period October 2006 and June 2011.

Source: HPS online appendix

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Figure 5: Quarterly rates of Clostridium difficile infection per 1000 occupied bed days across NHSScotland for the period October 2006 to June 2011

Source: HPS online appendix

SURGICAL SITE INFECTIONS

Recording of SSIs following hip arthroplasty and caesarean section procedures is mandatory for NHS Boards where these procedures are performed. Each NHS Board is required to undertake surveillance on at least two operation categories. If caesarean section or hip arthroplasty are not carried out within an NHS Board then SSI surveillance is required for any of the following procedures: abdominal hysterectomy, breast surgery, cardiac surgery, coronary artery by-pass grafting (CABG), cranial surgery, knee arthroplasty, colorectal surgery, reduction of long bone fracture, repair of neck of femur, and vascular surgery (HPS, 2010b).

Scotland was the first country in the world to introduce surveillance of patients after discharge from hospital in 2006. This was done in recognition of a number of factors including; the differing duration of post operative stay of patients for the same procedure in different hospitals, and advances in surgery techniques over time which have been considered to reduce the length of stay following surgery. Post discharge surveillance (PDS) is undertaken using prospective readmission data and is mandatory for up to 30 days following a hip arthoplasty and for 10 days following a caesarean section. From April to December 2009, over 80% of all caesarean section SSIs were detected in the post discharge period (to day 10), underscoring the importance of PDS (HPS, 2010a). The trends in rates of SSI following caesarean section and hip arthroplasty procedures are shown in Figures 6 and 7 respectively. The data set of SSIs including actual numbers of infections following caesarean section or hip arthroplasty procedures is also available in appendix 3.

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Figure 6: Quarterly rates of SSI following caesarean section procedures across NHSScotland for the period April 2002 to June 2010. Rate is the number of reported infections (over a quarter) as a proportion of the total number of caesarean section operative procedures performed in that quarter. Rates are based on either inpatient surveillance only or inpatient and PDS to 10 days post operatively since the introduction of PDS.

Source: Obtained directly from HPS Figure 7: Quarterly rates of SSI following hip arthroplasty procedures across NHSScotland for the period April 2002 to June 2010. Rate is the number of reported infections (over a quarter) as proportion of the total number of hip arthroplasty operative procedures performed in that quarter. Rates are based on either inpatient surveillance only or inpatient and readmission surveillance to 30 days post operatively since the introduction of readmission surveillance.

Source: Obtained directly from HPS

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

SS

I ra

te

Quarter

NHS Scotland: rate of SSI for caesarean section procedures

Caesarean section -Inpatient

only

Caesarean section -Inpatient &

PDS

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

SS

I ra

te

Quarter

NHS Scotland: rate of SSI for hip arthroplasty procedures

Hip arthroplasty -Inpatient only

Hip arthroplasty -Inpatient &

PDS

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HAI PREVELANCE – REST OF THE UK AND EUROPE

According to the World Health Organisation (WHO), in developed countries HAIs concern 5–15% of hospitalised patients and can affect 9–37% of those admitted to intensive care units (ICU) (WHO, 2009). In ICU settings, the use of invasive devices (e.g. catheters, mechanical ventilation) poses one of the most important risk factors in patients who are already in a fragile state of health. In developing countries reliable estimates of HAI burden are often difficult to obtain, for reasons ranging from limited diagnostic facilities, paucity of laboratory data, and poor medical record keeping (WHO, 2009).

In Europe, a number of countries have performed HAI prevalence surveys and on average the HAI prevalence rate across industrialised Europe is considered to be ~7% (BMA, 2009). The prevalence rates reported across Europe are shown in Figure 8 (and appendix 4), however comparison of rates is somewhat confounded by differences in dates (year) and duration of surveys, methodology, patient population sampling, and the selection of HAIs reported.

Figure 8: HAI prevalence across Europe. Prevalence data is based on reported prevalence rates where information has been extracted from the major prevalence surveys across a number of industrialised European countries (European Centre for Disease Prevention and Control, 2008; BMA, 2009). However comparison of rates should be done with a degree of caution since the prevalence surveys have been conducted at different times, may reflect differences in data collection, and there will be variability in the duration, sample size and methods of the survey.

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The most recent prevalence survey performed in the UK countries and the Republic of Ireland, was a four country wide survey of HAIs in acute hospitals in England, Wales, Northern Ireland, and the Republic of Ireland (Smyth et al., 2006). A separate HAI prevalence survey was performed in Scotland during 2005-2006 (Reilly et al., 2007). Table 5 shows the HAI prevalence results and key details of the two surveys.

Table 5: Comparison of HAI prevalence across the UK and Republic of Ireland. Based on HAI prevalence surveys conducted in acute hospitals the UK and Ireland (excluding Scotland) (Smyth et al. 2006) and Scotland (Reilly et al., 2007). For consistency acute hospital information is shown for Scotland, even if the survey also extended to non-acute facilities.

Country Number of

hospitals

Number of patients

Infection prevalence

rate

UK and Ireland (exc. Scotland) 273 75,763 7.6%

England 190 58,795 8.2%

Wales 23 5,825 6.3%

Northern Ireland 15 3,625 5.5%

Republic of Ireland 45 7,518 4.9%

Scotland 45 11608 9.5%

For reasons of consistency and rigour both surveys made use of strict definitions of „prevalent‟ infections known as the CDC (Centre for Disease Control) HAI case definitions. However, comparison across countries should still be done with a degree of caution and consideration for variability in factors including; differences in location, hospital size (an important factor known to affect prevalence rates), hospital specialties, and population demographics.

PREVENTION

Not all HAIs are preventable. Although the preventable proportion of HAIs is unknown, various estimates have been suggested. The more recent, relevant estimates include those from the Hospital Infection Working Group of the Department of Health (DoH) in England who in 1995 suggested a 30% reduction in HAIs might be achievable (Department of Health, 1995). The European Centre for Disease Prevention and Control (ECDC) in its First Report on Communicable Diseases also noted that up to 30% of HAIs are preventable (ECDC, 2007). This estimate is partly based on an evaluation of 30 relevant studies conducted in various patient populations and healthcare settings, which suggests the potential to reduce HAI ranges from 10% to 70% depending on the setting, study design, baseline infection rates and type of infection. On average the review estimates at least 20% of all HAIs to be preventable (Harbarth et al., 2003). The potential for preventing HAIs can be influenced by a variety of factors; ranging from patient risk factors, treatment, and behavioural and organisational factors in the healthcare setting. Patient risk factors include (but are not limited to); the patients age, underlying or chronic illness, and malnutrition. The use of certain drugs (for example immunosuppressants) and the nature of a medical procedure the patient is undergoing can also influence the chances of contracting a treatment-associated infection. For example SSIs have been reported to have a reduction potential of 24-34%. Whereas for catheter associated urinary tract infections the reduction potential is estimated at 46-60% (Harbarth et al., 2003). This may imply that reducing the chances of an infection during invasive surgical procedures is more difficult in comparison to reducing infections during urinary catheterisation.

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According to the HCAI research network, amongst the multiple causes of HAIs, the most common causes arise from:

contaminated hands of healthcare workers,

contaminated medical devices, and

failure to comply with local policies, procedures and guidelines. Inadequate hand decontamination in particularly is recognised as a significant factor in transmitting HAIs (WHO, 2009). A WHO review of best practise found that improved hand hygiene can reduce the risk of transmission of pathogens and the incidence of HAIs (WHO, 2005). In addition to hand hygiene, the other most effective interventions leading to a reduction of HAIs are reported to be surveillance, education and audit (Harbarth et al., 2003). Evidence suggests that actively feeding back (surveillance) data to clinicians contributes to reductions in rates of infection (Mangram et al., 1999). Education is another approach, for example training for using indwelling devices (such as catheters) both correctly and aseptically has been reported to decrease the incidence of associated HAIs by 30 - 35% (Conterno et al., 2007).

EFFECTIVENESS OF HAI PREVENTION MEASURES

In 2009 the British Medical Association (BMA) published a report on tackling HAIs through effective policy action (BMA, 2009). The report which is intended for policy makers with strategic or operational responsibility for public health in the UK, examines the evidence base for the range of infection control policies and identify areas for action. The authors felt the strategies in place to reduce the burden of HAIs, focused on identifying short-term solutions which have failed to address the underlying problems that adversely impact on infection control. The range of infection control policies in place generally focus on preventing the spread of micro-organisms between patients and the transmission during invasive procedures and other treatments. The policies relate to behavioural characteristics, organisational factors and wider policy initiatives, such as surveillance and research priorities. The authors of the BMA report also state that there has been a disproportionate focus on reducing MRSA and C. difficile infection rates, rather than tackling the range of HAI causing micro-organisms. The BMA‟s review of the effectiveness of key behavioural and organisational factors is discussed in more detail below.

BEHAVIOURAL FACTORS

Amongst the infection control policies relating to behaviour, the BMA examines the role of antimicrobial prescribing, hand hygiene, use of indwelling devices, and patients and visitors (BMA, 2009). The report acknowledges complacency, poor prescribing practice and the misuse of antimicrobials as major factors in the emergence of drug resistant infections. However the authors still feel there is the need to further develop and implement strategies for promoting optimal antimicrobial prescribing through local consultation. Furthermore optimal prescribing policy should also be facilitated by close collaboration between clinical pharmacists, medical microbiologists and infectious diseases physicians.

In concurrence with the WHO, the BMA also recognise good hand hygiene as a crucial factor in preventing the transmission of infections. They note hand hygiene compliance requires comprehensive training and commitment at the most senior levels through role modelling. To improve compliance, the authors suggest that consideration should be given to the accessibility

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and design of hand washing facilities, including the use of elbow operated or no touch activated taps, as well as rewards for good practice and/or sanctions for unacceptable behaviour.

Indwelling devices can breach the body‟s natural defence and provide an entry route for pathogens. The BMA review looked at the role of educational approaches and use of „care bundles‟ for reducing device related infections. Recent years have seen the advent of „care bundles,‟ an approach of combining a number of set practises (usually 3-5) to control a range of HAIs. The notion behind these bundles is to provide a cohesive set of standard practises that must be performed consistently in every case and thereby reduce the variability in care from patient to patient. Health Protection Scotland‟s (HPS) Infection Control Team provides descriptions of the care bundles in place for controlling HAIs. These range from infection specific care bundles to the more generic hand hygiene standard procedures and monitoring tools. Below (Table 6) is an example of a care bundle in place for controlling transmission of C. difficile. Table 6: Clostridium difficile Infection (CDI), cross-transmission minimisation bundle. CDI transmission minimisation bundle, version 2 (24 August 2009), extracted from Health Protection Scotland (2009a).

The Bundle 1. Isolating CDI patients in a single room with either en suite facilities, or an allocated

commode, until they are at least 48 hours symptom free.

2. Reviewing antibiotic regimens and stopping inappropriate antibiotics.

3. Checking all healthcare workers remove personal protective equipment (gloves and aprons) after each CDI patient care activity.

4. Checking that the CDI patient’s immediate environment has been cleaned today with chlorine based solution.

5. Ensuring healthcare workers perform hand hygiene with liquid soap and water after leaving a CDI patient’s room.

A study published this year examined the effectiveness of care bundles to reduce mortality in several diagnostic areas with high numbers of deaths in UK hospitals (Robb et al., 2010). The authors concluded that implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate. Finally, in terms of behavioural factors, the BMA state the role of patients and visitors has received little attention and there is little formal policy in place that is supported by robust clinical evidence.

ORGANISATIONAL FACTORS

The BMA assessed the role of key organisational, management and leadership factors that can impact on infection control and HAI rates. The factors include; dress code, cleaning and environmental hygiene, bed occupancy, screening and isolation, performance targets, leadership, and workforce management. Some of these factors are discussed below in further detail.

Dress Code

Although pathogens are frequently carried on clothes, the BMA cites studies where no conclusive evidence linking contaminated uniforms and the spread of infection is found. However the use of protective clothing (e.g. aprons and gloves) has been shown to significantly reduce contamination with micro-organisms. Therefore they recommend that emphasis should be placed on the use of appropriate protective clothing where healthcare staff are exposed to

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pathogens. Furthermore, they recommend that the development of dress code policies should be evidence based (BMA, 2009).

Cleaning and Environmental Hygiene

Regular cleaning is seen as an important component of effective infection control although there is little direct evidence demonstrating that cleaning has an effect on HAI rates (BMA, 2009). Attention in recent year has also focussed on the tendering of hospital cleaning contracts to the private sector, the reduction in the number of cleaners and the rapid turnover of cleaning personnel over time. During 2009 the Scottish Government announced the recruitment of 600 new hospital cleaning staff and no further privatisation of hospital cleaning across NHSScotland (Scottish Government, 2009). The BMA cites a 2007 review by Pratt et al which found that a hospital environment can become contaminated with HAI causing pathogens and these have been recovered from a number of hospital surfaces. However the review found no conclusive evidence that environmental contamination is responsible for HAI transmission (Pratt et al., 2007). Improved cleaning regimens are associated with the control of HAI outbreak, although given a number of interventions are used to control outbreaks it is difficult to attribute any improvement to a single factor such as cleaning. The BMA does acknowledge that risk of pathogen transmission via contact with the environment is the greatest at „near-patient hand-touch‟ sites. These include bed rails, bedside lockers, door handles and switches, and have generally not featured in domestic cleaning specifications. The effectiveness of hospital deep cleaning in reducing HAI rates has also been disputed (BMA, 2009). Although deep cleaning reduces the presence of pathogens it is not thought to significantly impact on infection rates. Based on these multiple cleaning factors the BMA suggest the following areas for action:

providing adequate resources for thorough everyday cleaning

cleaning of high-risk near-patient hand-touch sites

ward cleaners should be an integral part of the infection control team

deep cleaning regimens should consider the implication for resources and service delivery

With respect to other organisational factors the BMA stress the need for reducing bed occupancy rates since there is a significant positive correlation between bed occupancy levels and MRSA rates (BMA, 2009). It is suggested this could be addressed through taking action on the availability of beds, targets governing admissions, and bed management policies. Management and leadership are key in developing an appropriate organisational culture for tackling HAIs as is effective workforce management. A review of evidence shows the risk of HAIs is greater during periods of understaffing and varies according to staff workload (BMA, 2009). Furthermore compliance with hand hygiene is also adversely affected by understaffing and high workloads. The BMA therefore suggest effective work planning management is required as well as training for all temporary and permanent staff. Screening of patients to determine whether they are carriers of MRSA is now in place across NHSScotland. Where patients test positive for the pathogen they will undergo decontamination and potential isolation to prevent transmission to other patients as well as reducing the chances of developing a HAI themselves. An MRSA screening policy has proven to be effective in the Netherlands, a country with relatively low rates of HAIs. The BMA stress the need to assess the

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evidence of effectiveness of screening patients as well as consideration for a number of implications of a screening policy, in particularly:

the practical and cost implications in terms of the need to isolate and decontaminate all those found to be positive

the requirement of adequate isolation facilities, staff education and training, as well as procedures to manage screening, results, patient notification, isolation and follow-up

the impact on targets for admissions, bed occupancy and waiting times. Finally consideration should also be given to the design of clinical areas in new healthcare buildings, with a focus on single occupancy rooms as opposed to multi-bed wards (BMA, 2009).

CURRENT POLICY FOR TACKLING HEALTHCARE ASSOCIATED INFECTIONS

GOVERNANCE – THE HEALTHCARE ASSOCIATED TASK FORCE

The Scottish Government‟s Healthcare Associated Infection (HAI) Task Force was formed in January 2003 and is led by the Chief Nursing Officer. The Task Force which includes members from the NHS, professional backgrounds as well as members of the public is responsible for overseeing and co-ordinating the development and implementation of the national strategy on HAIs. Specific objectives and strategy plans are set out in the Governments healthcare associated work programmes, of which three have been published to date.

The most significant areas of work completed by the HAI taskforce during its first two work programmes (over the period of 2003 – 2008) are summarised below. The third HAI task force Delivery Plan for 2008 – 2011 was published in March 2007 with funding of £54 million. The third phase of work encompasses a range of measures to tackle HAI including the roll out of a national MRSA screening programme, a target to reduce C.difficile infections by 30% and a zero tolerance approach to healthcare staff that do not follow hand hygiene rules.

MAIN OUTCOMES OF THE HAI-TASK FORCES FIRST TWO WORK PROGRAMMES

Implementation and Performance

The first phase of the work programme saw the publication of the NHSScotland Code of Practice for the Management of HAI and Hygiene (Scottish Executive, 2004a). Arising from this was the development and funding to support the role of Infection Control Managers and Nurse Consultants in HAI. During the second phase of the work programme NHS Quality Improvement Scotland (NHS QIS) was tasked with a review of its HAI standards. The final standards were published in March 2008 (NHS QIS, 2008).

Antimicrobial Prescribing

Antibiotic resistance poses a threat and complication in controlling HAIs. The case for prudent prescribing of antibiotics is recognised and guidelines to improve prescribing practices were established; The Scottish Medicines Consortium drafted the Antimicrobial Prescribing Policy and Practice in Scotland (Scottish Executive, 2005a), for the HAI Task Force. Further review of the area led to the publication of a more detailed plan in February 2008; the Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) (Scottish Government 2008a). The document outlines a national programme for tackling antimicrobial resistance in Scotland over the next five years.

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Cleaning, Hygiene and the Environment

Ensuring micro-organisms are not allowed to accumulate in the healthcare environment through regular cleaning is considered an important component of effective infection control. Initiatives taken range from the training of domestic services staff on the contributions they can make in minimising HAIs, guidelines for developing or renovating healthcare buildings, and minimum standards for cleaning of NHSScotland buildings.

A National Education and Training Framework for Domestic Services (NHS Health Facilities Scotland, 2007a), was developed in recognition that domestic staff at all levels have a contribution to make (in terms of competence, capability, knowledge and behaviour) to the provision of a quality service. Guidance was also created on reducing HAI in the built environment. The HAI-SCRIBE (Healthcare Associated Infection - System for Controlling Risk In the Built Environment) programme is aimed at all personnel who may be involved in providing newly built, refurbished or extended healthcare establishments, with the purpose of minimising the risk of HAIs through prior assessment and planning of new build and renovation projects (NHS Health Facilities Scotland, 2007b). Guidance is also provided for the ongoing maintenance of existing buildings in the Scottish Health Facilities Note 30: Infection Control in the Built Environment (NHS Health Facilities Scotland, 2007c). Minimum standards for hospital cleaning were set in the NHSScotland National Cleaning Services Specification (Scottish Government, 2004b) followed by a framework for monitoring cleaning services across NHSScotland (NHS Health Facilities Scotland(a)).

Public Involvement

In order to improve public engagement, the Task Force established the Public Involvement and Communications Team (PICT) with membership drawn from the general public. PICT has contributed to a number of areas of the task forces work programme including, the NHSScotland Code of Practice for the Management of HAI and Hygiene and, the Public Information Strategy.

Education and Training

Education and training are seen as priority areas in tackling HAIs and educational resources have been developed by NHS Education for Scotland (NHS NES). A national framework for mandatory induction training on HAI (NHS NES(a)) was introduced, as was a Cleanliness Champions Programme (NHS NES(b)) to promote the prevention of infection amongst NHS staff. The purpose of the programme was to equip staff with the appropriate skills and knowledge required to prevent and reduce HAIs. The programme was developed for all NHSScotland staff and is now also encouraged in undergraduate nursing and medical courses.

Hand Hygiene

Good hand hygiene is considered to be one of the most cost effective and important interventions in preventing the transmission of HAI causing pathogens and consequently infections. Measures taken during the task forces first two work programmes include; educational resources developed by NHS NES (NHS NES(c)); provision of alcohol hand rubs near every acute front line bed; and the launch of a national hand hygiene campaign entitled “Germs – Wash Your Hands of Them” (HPS(a)). The hand hygiene campaign was aimed and promoted at the general public; NHS Staff, patients and visitors, and nursery and primary school children.

Surveillance and Prevalence Surveys

HPS were assigned with the task of conducting a national HAI prevalence study to provide baseline information on the total prevalence of HAI in Scottish hospitals. The study reported on

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the prevalence of HAIs in acute and non acute hospitals, the prevalence of different types of HAIs, and the estimated costs to NHSScotland (Reilly et al., 2007).

National surveillance of HAIs is overseen by the SSHAIP division of HPS. During the first two phases of the HAI task forces work programmes, mandatory surveillance of MRSA bacteraemias continued, surveillance of certain SSI‟s became mandatory, as did surveillance of CDI. Voluntary surveillance programmes were also developed. Incidence surveillance programmes are discussed in the Rates of Infection across NHSScotland section of this briefing.

A HAI outbreak is any increase in the incidence of an infection or presumed infection in people associated with a healthcare setting. Outbreak surveillance is performed to:

identify potential outbreaks rapidly as they occur as a means of damage limitation collect information on HAI outbreaks in order to identify any trends that may need

addressing

There are a number of toolkits (HPS(b)) in place to assist with prevention and control of infection in the health setting. The toolkits are designed as part of a system to identify and manage potential HAI outbreaks and include:

Hospital Outbreak Toolkit - a hospital outbreak management process Local Surveillance Toolkit - data-driven local infection control system Clostridium difficile infection (CDI) Toolkit – triggers and action warning limits for CDI in

wards and clinical setting.

Computerized Statistical Process Control Charts (SPCC) are used for the purpose of infection surveillance at a ward and hospital level. SPCCs are the application of statistical theory to Quality Control and in the context of HAI monitoring they allow the identification of potential outbreaks. SPCCs show data chronologically and describes variation in infection levels as natural (expected) or unnatural. Unnatural variation would indicate the number of HAIs identified is outwith the expected range. When cases occur at a rate exceeding the normal number of cases for the unit, ward or facility during a specified period of time, or when disease occurs at increased severity, immediate actions and interventions are required.

NHS Boards are also required to complete a national reporting template to give the public access to local hospital level data on infection rates. Infection data should be reported on a monthly basis on NHS Board websites and discussed publically at bi-monthly Board meetings. The Scottish Government website also has a portal through which the public can access the information for each NHS board area. In England the UK coalition Government increased the required frequency of reporting of MRSA bacteraemias and C. difficile infections to every week. In 2010, Scottish Health Secretary Nicola Sturgeon commented on the infection reporting frequency across NHSScotland:

S3W-34752 - Richard Simpson (Mid Scotland and Fife) (Lab) (Date Lodged Wednesday, June 23, 2010): “To ask the Scottish Executive, in light of the UK Government‟s decision to require the NHS in England to report rates of MRSA bacteraemia and Clostridium difficile infections weekly, what steps it is taking to provide the same level of information in Scotland.” Answered by Nicola Sturgeon (Monday, July 05, 2010): “NHS boards in Scotland already provide information on MRSA, Clostridium difficile, hand hygiene and environmental cleaning compliance and the causes of adverse incidents. This is

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published on NHS board websites and discussed publicly at bi-monthly NHS board meetings.

A national HAI reporting template used to capture and report this data has recently been revised and issued to NHS boards with a six month review date. This places a requirement on boards to publish hospital level cases of Clostridium difficile, MSSA and MRSA bacteraemia on a monthly basis. We will consider the merits of increasing the frequency of reporting as part of our ongoing review process.”

Patient Safety and Research

Patient safety initiatives have included the introduction and development of HAI related care bundles (HPS(c)) by the Infection Control Team at HPS. The Risk Management of HAI: A Methodology for NHSScotland (Scottish Government, 2008b) was published as a guidance document for assessing and controlling patient risks. The Scottish Patient Safety Programme (NHS QIS(a)), co-ordinated by NHS QIS has the general objective of reducing adverse events in Scotland‟s hospitals, and this includes reducing HAIs.

In recognition of the importance of high quality research in the subject, a Scottish Infection Research Network (SIRN), based at the University of Glasgow was established with the aim of improving the quality of research into HAIs.

THIRD PHASE OF THE HAI TASK FORCE’S WORK

The HAI Task Forces third delivery plan (Scottish Government, 2008c) which came into effect on 1 April 2008, set out to improve or develop HAI strategy in the following areas (with examples of planned actions):

(1) Patient safety, practice and culture

Example(s): Continued development and implementation of care bundles

(2) Education

Example(s): Further development of the national hand hygiene programme Implementation of an Outbreak Management programme

(3) Surveillance, information and audit Example(s): Repeated targeted prevalence survey Surveillance of use of antimicrobial resistance drugs

(4) Guidance and standards

Example(s): Implementation of the MRSA control strategy Full implementation of an MRSA screening programme following the pilot if indicated

(5) Physical environment.

Example(s): Promote specification of new builds as fit for purpose for HAI prevention

The third work programme was set to run until March 2011, and some of the key strategies completed or underway include the roll out of a national MRSA screening programme, targets to reduce C. difficile by 30% (later increased to 50%) and a zero tolerance approach to healthcare

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staff that do not follow hand hygiene rules. The zero tolerance policy launched in early 2009 (Scottish Government, 2009a) underscores the professional accountability of all NHS staff for adherence to NHS Board policies and hand hygiene compliance. Staff are required to take personal responsibility to remind colleagues, patients, and visitors of their responsibility to adopt good hand hygiene practise at all times. NHS Boards are also responsible for ensuring adequate facilities are available to enable staff to fully comply. HPS publish bi-monthly audit reports on compliance with hand hygiene, amongst NHS staff, and present the information according to national compliance, by the different NHS Boards, and by different staff groups. The HPS Compliance with Hand Hygiene - Audit Report (HPS, 2011) reports national compliance as 95% (for the period July – August 2011). During this period the most compliant staff group were allied health professionals, with a 98% hand hygiene compliance rate. Medical staff were the least compliant staff group with a compliance rate of around 88%. According to the NHSScotland Chief Executive‟s Annual Report 2009/10 (Scottish Government, 2010) a 54% reduction in C. difficile infections had already been achieved in NHSScotland against the original set target of 30% by March 2011. Following a trial MRSA screening programme (Scottish Government, 2008d) in three NHS Boards, a national roll out (NHSScotland, 2009) of the scheme to be implemented by 31 January 2010 across NHSScotland was announced. Screening is undertaken for all patients undergoing elective admission to acute hospitals (excluding paediatrics, obstetrics and psychiatric admissions) and for all elective inpatient and emergency admissions as well as hospital transfers into the specialties of nephrology, care of the elderly, dermatology and vascular surgery. The screening process involves a swab being taken from patients nasal cavities which is then tested for the presence of MRSA. HPS and NHSScotland have produced a MRSA screening information leaflet for patients (HPS, 2009b).

A summary of some of the key HAI guidelines and policy now in place across NHSScotland are provided in Table 7.

Table 7: A summary of some of the key guidelines and strategy in place for tackling HAIs across NHSScotland

Intervention Policy or Guidance Source

Antimicrobial

Prescribing

Antibiotic prescriptions should be compliant with a hospitals local antimicrobial policy

and the rational for treatment should be recorded in the clinical case notes (with the target of recording for ≥95% of cases)

Antibiotic prescribing training for foundation year doctors

Surveillance of antimicrobial resistance (as part of the European Antimicrobial Resistance Surveillance System (EARS-Net)

NHSScotland, Hospital-based empirical prescribing. National Report, May 2010

NHS NES(d), antibiotic prescribing.

Health Protection Scotland(c), surveillance systems.

Hand hygiene

Zero tolerance policy towards healthcare workers with poor hand hygiene compliance

Hand hygiene compliance audit

Hand hygiene care bundles

Hand hygiene procedure based on the WHO recommendations of the five key moments for hand hygiene: o before patient contact o before aseptic task o after body fluid exposure risk

The Scottish Government CEL 5 (2009)

Health Protection Scotland(d), national hand hygiene campaign

Health Protection Scotland(e), Bundles

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o after patient contact o after contact with patient surroundings

Use of indwelling

devices

Training available for healthcare workers: preventing catheter related bloodstream infections.

Care bundle for central vascular catheter (CVC) maintenance: to encourage appropriate use of CVCs, including reviewing the need for a CVC.

Care bundle for preventing catheter associated urinary tract infections (CAUTI): to encourage appropriate use, hand hygiene and daily review of the need for catheterisation.

NHS NES(e), Preventing catheter related bloodstream infections

Health Protection Scotland(e), Bundles

Health Protection Scotland(f), Bundles

Patients / visitors

Advice for patients and visitors from the chief medical officer and chief nursing officer includes:

To not visit patients if feeling unwell

Practising hand hygiene

Consulting hospital staff before bringing food

Never touching dressing, drips, equipment

Alerting charge nurse if concerned about hospital cleanliness

Health Protection Scotland and the Scottish Government (2009); Healthcare associated infections, information for the public

Dress code Scottish Government Health Directorates (SGHD) have introduced guidance for all NHS staff:

avoid use of white coats, ties, and wristwatches when providing patient care, as well as the wearing of pens and scissors in outside pockets

prohibiting staff from leaving work in their uniforms, except where it is part of duties

Scottish Government Health Directorates (CEL 53) 2008(e) NHS Scotland Dress Code. Edinburgh: Scottish Government Health Directorates.

Cleaning The thoroughness of cleaning standards in NHS Boards is monitored by Health Facilities Scotland (HFS).

HFS provides data on compliance with the requirements set out in the NHSScotland National Cleaning Services Specification.

Announcement in 2009 of 600 new hospital cleaners to be recruited and no further privatisation of hospital cleaning.

Scottish Executive, The NHS Scotland National Cleaning Services

Specification, (2005b)

Scottish Government, News release, 17 April

2009(b)

Screening Screening for MRSA presence in patients across all NHS boards (for the chosen admissions and specialties).

Health Protection Scotland(g), MRSA screening programme

Surveillance Mandatory surveillance of MSSA and MRSA blood infections, C. difficile infections, SSIs following hip arthroplasty and caesarean section procedures.

Health Protection Scotland(h), Scottish Surveillance of Healthcare Associated Infection Programme

OTHER DEVELOPMENTS – VALE OF LEVEN

Following a significant outbreak of C. difficile in the Vale of Leven Hospital (Scottish Government(a)) in early 2008, an independent review was commissioned (University of Aberdeen, 2008). The review found the facilities at the Vale of Leven Hospital were inadequate for effective patient isolation and infection control, and there were frequent patient transfers

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between wards and other hospitals during period of the outbreak. Furthermore a number of key facilities were found to be inadequate including:

hand washing facilities

single room accommodation

sufficient toilets

appropriate spacing between beds

clinical and storage space to facilitate effective infection control practices It was also noted that there was no active monitoring of the implementation of antibiotic policies or feedback on usage to clinical staff. Following the publication of the independent review in August 2008, the Scottish Government published a National Action Plan (Scottish Government, 2008f) to tackle C. difficile. This was in addition to and a supplement to the HAI Task Forces Delivery Plan (Scottish Government (a & b)). Amongst some of the actions outlined in the National Action Plan was the need for a clearer hand hygiene policy (indicating what agents to use for hand hygiene and when they are indicated), the introduction of an interim NHS dress code, and increased public engagement on HAIs. Currently a public inquiry (The Vale of Leven Hospital Enquiry) is underway to examine the circumstances surrounding the 2008 outbreak of Clostridium difficile in which 55 people developed C. difficile and 18 people died. Oral hearings proceeded on Monday 7 June 2010. The enquiry is required to report its findings and recommendations to the cabinet secretary for Health and Wellbeing by September 2012. Healthcare Environment Inspectorate

The Healthcare Environment Inspectorate (HEI) was established by the Cabinet Secretary for Health and Wellbeing following the 2008 Vale of Leven events. HEI‟s work feeds into the wider work of NHS QIS to support improvement. Operating independently of both the Scottish Government and NHS boards, HEI undertakes announced and unannounced inspections to acute hospitals across Scotland. During the inspections HEI assess a number of factors that contribute towards the quality of infection control, hygiene and cleanliness in hospitals. A recent report sets out findings from the inspections over the past year (HEI, 2010). The report finds most hospitals across NHSScotland are generally clean and improving. However it was also noted that attention to detail could be improved in many areas, for example cleaning hard to reach areas. The report also sets out other key recommendation and requirements to improve standards. These include:

ensuring all staff are implementing standard infection control precautions

ensuring infection control managers have clear roles and responsibilities

the need to develop and implement a national specification for equipment cleaning

CASE STUDY: DUTCH MRSA CONTROL STRATEGY The Netherlands has maintained low levels of MRSA infections over the past 30 years. Following several outbreaks in the early 1980s a “search and destroy” strategy was deployed. This approach includes systematically screening patients, and often staff, as well as isolating or decolonising (decontaminating) those found to be infected. Other key elements of the strategy include:

pre-emptive isolation and screening of patients coming from foreign hospitals

immediate isolation of every new case of MRSA

screening of contact patients and care-givers and decontamination of carriers

where more infections are observed, collective isolation of the entire ward and discontinuation of further admissions is required

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Similar strategies are also in place for other pathogens that are highly resistant to antimicrobial treatment. Specific attention is given to high risk departments where patients are admitted from foreign hospitals or Dutch hospitals with known problems with highly resistant pathogens. Furthermore the general HAI strategy is also supported by restrictive antibiotic prescribing policies (Marcel et al., 2008; Dekker et al., 2010).

OTHER KEY ISSUES

EMERGING HAI PATHOGENS

The most common HAI causing pathogens are outlined in Table 1. However over recent years there has been increasing concern and media attention on other potentially difficult to treat “hospital superbugs”. These include VRSA (vancomycin-resistant Staphylococcus aureus), a strain of S. aureus that is resistant to the antibiotic vancomycin. Vancomycin has to date been considered the most reliable therapeutic agent against infections caused by MRSA (Hiramatsu, 2001). During January 2010 HPS and Information Services Division (ISD) Scotland published a report on antimicrobial resistance and use in humans (HPS, 2010d). The report found for the observed period there were no MRSA resistant strains detected in Scotland. However 16.7% resistance to vancomycin was observed amongst another type of bacteria (Enterococcus faecium) isolated from blood infections. The report states this is of particular concern as these resistance mechanisms can be transferred to other pathogens (including MRSA). 2010 witnessed considerable press coverage of NDM-1 (New Delhi metallo-beta-lactamase-1) bacteria (BBC, 2010). NDM-1 is an enzyme found in some bacteria, and provides resistance to treatment with a powerful class of antibiotics known as carbapenems (HPA, 2009a). There are fears that the enzyme could transfer to resistant strains of bacteria, making them even more difficult to treat. At least one case of NDM-1 case was reported in Scotland although this was over a year ago (HPA, 2009b). NDM-1 bacteria are thought to be most prevalent in South East Asia and a number of NDM-1 positives patients in the UK had travelled to India or Pakistan within the past year (NHS UK news, 2010).

RESEARCH INITIATIVES AND PRIORITIES

Research into the mechanisms of antibiotic resistance is progressing although the scope for developing new antibiotics is more challenging. Discovering new classes of antibiotics has become increasingly difficult (Chopra et al., 2008). Moreover, there is some speculation of major pharmaceutical companies reducing their investment and interests in the antibiotics market as this is not necessarily as profitable as markets for treating chronic and lifestyle diseases (Norrby et al., 2005). There is a considerable expense involved in establishing the safety and efficacy of a new antibiotic with no guarantee of the drug being approved. If a new drug were to be approved and manufactured, pharmaceutical companies may face long delays in recouping costs since:

it would be expected that any new treatments would be used cautiously by clinicians

antibiotics are intended as short term medication.

Finally the inherent ability of pathogens to adapt and become resistant to antibiotics poses the risk of the drug becoming ineffective before costs of developing it are recouped.

There are however other innovations into combating HAI pathogens. Recently researchers from the University of Strathclyde developed a light based technology that can kill pathogens including MRSA and C. difficile (University of Strathclyde news release, 2010).

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Apart from research into therapeutics, there is also much to be understood about other HAI preventative interventions. During 2009 the British Medical Association (BMA) published a document examining the evidence base for the range of infection control policies (across the UK) (BMA, 2009). HAI research priorities were one of the identified areas for action. The BMA suggested further research is required into:

the effectiveness of educational and behavioural interventions in relation to compliance with hand hygiene protocols, prescribing behaviour and the use of indwelling devices

the role of organisational factors such as bed occupancy, workforce management, leadership, and resource allocation in relation to the implementation of infection control policies

the effectiveness of current and emerging approaches to environmental decontamination, including different cleaning regimens

the role and clinical effectiveness of different screening methods.

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Pratt, R.J. et al. (2007) National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65: s1-64.

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37

APPENDIX 1

Table 8: Staphylococcus aureus bloodstream infections across NHSScotland: total numbers and rates.

Number of bacteraemia Acute occupied bed days

Rate per 1000 acute occupied bed days

Quarter MRSA MSSA S.

aureus MRSA MSSA S.

aureus

Jan 03 - Mar 03 255 1394657 0.18

Apr 03 - Jun 03 227 1360071 0.17

Jul 03 - Sep 03 176 1347919 0.13

Oct 03 - Dec 03 217 1366960 0.16

Jan 04 - Mar 04 267 1395310 0.19

Apr 04 - Jun 04 259 1325854 0.20

Jul 04 - Sep 04 201 1324792 0.15

Oct 04 - Dec 04 247 1340337 0.18

Jan 05 - Mar 05 253 1382156 0.18

Apr 05 - Jun 05 221 375 596 1327034 0.17 0.28 0.45

Jul 05 - Sep 05 247 511 758 1325690 0.19 0.39 0.57

Oct 05 - Dec 05 264 422 686 1342990 0.20 0.31 0.51

Jan 06 - Mar 06 274 464 738 1390111 0.20 0.33 0.53

Apr 06 - Jun 06 252 358 610 1362072 0.19 0.26 0.45

Jul 06 - Sep 06 212 389 601 1329262 0.16 0.29 0.45

Oct 06 - Dec 06 227 300 527 1339822 0.17 0.22 0.39

Jan 07 - Mar 07 249 364 613 1378926 0.18 0.26 0.45

Apr 07 - Jun 07 215 415 630 1344984 0.16 0.31 0.47

Jul 07 - Sep 07 210 459 669 1308607 0.16 0.35 0.51

Oct 07 - Dec 07 207 417 624 1321950 0.16 0.32 0.47

Jan 08 - Mar 08 198 386 584 1382550 0.14 0.28 0.42

Apr 08 - Jun 08 180 397 577 1335033 0.14 0.30 0.43

Jul 08 - Sep 08 150 382 532 1299840 0.12 0.29 0.41

Oct 08 - Dec 08 161 400 561 1334459 0.12 0.30 0.42

Jan 09 - Mar 09 170 386 556 1353145 0.13 0.29 0.41

Apr 09 - Jun 09 143 392 535 1319537 0.11 0.30 0.41

Jul 09 - Sep 09 101 384 485 1290589 0.08 0.30 0.38

Oct 09 - Dec 09 119 362 481 1314328 0.09 0.28 0.37

Jan 10 - Mar 10 117 391 508 1339454 0.09 0.29 0.38

Apr 10 - Jun 10 79 345 424 1299495 0.06 0.27 0.33

Jul 10-Sep 10 73 367 440 1264799 0.06 0.29 0.35

Oct 10-Dec10 82 389 471 1281429 0.06 0.30 0.37

Jan 11 – Mar 11 69 355 424 1301525 0.05 0.27 0.33

Apr 11 – Jun 11 52 345 397 1284412 0.04 0.27 0.31

Source: HPS, 2011

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APPENDIX 2

Table 9: Clostridium difficile infections across NHSScotland: total numbers and rates.

Clostridium difficile infections: total numbers

Clostridium difficile infections: rates per 1000 occupied bed days

Quarter Age 65 and

above Age 15-64 Age 65 and

above Age 15-64

Oct 06 - Dec 06 1213 0.96

Jan 07 - Mar 07 1775 1.47

Apr 07 - Jun 07 1588 1.47

Jul 07 - Sep 07 1459 1.16

Oct 07 - Dec 07 1608 1.26

Jan 08 - Mar 08 1861 1.41

Apr 08 - Jun 08 1729 1.33

Jul 08 - Sep 08 1435 1.15

Oct 08 - Dec 08 1300 1.02

Jan 09 - Mar 09 1157 0.88

Apr 09 - Jun 09 996 313 0.77 0.79

Jul 09 - Sep 09 808 327 0.66 0.86

Oct 09 - Dec 09 673 236 0.51 0.61

Jan 10 - Mar 10 640 194 0.49 0.50

Apr 10 - Jun 10 577 165 0.46 0.42

Jul 10 – Sep 10 575 204 0.47 0.52

Oct 10 – Dec 10 427 129 0.34 0.34

Jan 11 – Mar 11 355 127 0.28 0.34

Apr 11 – Jun 11 378 160 0.31 0.43

Source: HPS online appendix

39

APPENDIX 3

Table 10: Surgical site infection following caesarean section procedures across NHSScotland. Total infection numbers and rates of infection as a proportion of total caesarean section operative procedures. Infection numbers and rates are based on either inpatient surveillance only or inpatient and post discharge surveillance (PDS) to 10 days post operatively since the introduction of PDS.

Caesarean section

Inpatient surveillance

Inpatient and post-discharge surveillance to

day 10

Quarter Operations Infections Rate Infections Rate

Apr 02 - Jun 02 24 1 4.2%

Jul 02 - Sep 02 229 8 3.5%

Oct 02 - Dec 02 571 12 2.1%

Jan 03 - Mar 03 546 10 1.8%

Apr 03 - Jun 03 637 10 1.6%

Jul 03 - Sep 03 685 14 2.0%

Oct 03 - Dec 03 614 12 2.0%

Jan 04 - Mar 04 774 14 1.8%

Apr 04 - Jun 04 774 10 1.3%

Jul 04 - Sep 04 765 19 2.5%

Oct 04 - Dec 04 824 14 1.7%

Jan 05 - Mar 05 1001 20 2.0%

Apr 05 - Jun 05 1223 17 1.4%

Jul 05 - Sep 05 1460 18 1.2%

Oct 05 - Dec 05 1283 16 1.2%

Jan 06 - Mar 06 1441 23 1.6%

Apr 06 - Jun 06 1563 29 1.9%

Jul 06 - Sep 06 1562 31 2.0%

Oct 06 - Dec 06 1586 21 1.3%

Jan 07 - Mar 07 2842 37 1.3% 148 5.2%

Apr 07 - Jun 07 3269 27 0.8% 133 4.1%

Jul 07 - Sep 07 3478 23 0.7% 135 3.9%

Oct 07 - Dec 07 3559 21 0.6% 100 2.8%

Jan 08 - Mar 08 3430 21 0.6% 113 3.3%

Apr 08 - Jun 08 3354 16 0.5% 94 2.8%

Jul 08 - Sep 08 3744 15 0.4% 109 2.9%

Oct 08 - Dec 08 3507 16 0.5% 100 2.9%

Jan 09 - Mar 09 3348 11 0.3% 100 3.0%

Apr 09 - Jun 09 3659 14 0.4% 91 2.5%

Jul 09 - Sep 09 3706 20 0.5% 89 2.4%

Oct 09 - Dec 09 3784 16 0.4% 92 2.4%

Jan 10 - Mar 10 3579 8 0.2% 77 2.2%

Apr 10 - Jun 10 3799 14 0.4% 119 3.1%

Source: Obtained directly from HPS

40

Table 11: Surgical site infection following hip arthroplasty procedures across NHSScotland. Total infection numbers and rates of infection as a proportion of total hip arthroplasty operative procedures. Infection numbers and rates are based on either inpatient surveillance only or inpatient and readmission surveillance to 30 days post operatively since the introduction of readmission surveillance.

Hip arthroplasty

Inpatient surveillance

Inpatient and readmission

surveillance to day 30

Quarter Operations Infections Rate Infections Rate

Apr 02 - Jun 02 214 3 1.4%

Jul 02 - Sep 02 324 4 1.2%

Oct 02 - Dec 02 507 6 1.2%

Jan 03 - Mar 03 508 8 1.6%

Apr 03 - Jun 03 729 18 2.5%

Jul 03 - Sep 03 1182 25 2.1%

Oct 03 - Dec 03 1087 19 1.7%

Jan 04 - Mar 04 1355 25 1.8%

Apr 04 - Jun 04 1313 18 1.4%

Jul 04 - Sep 04 1339 22 1.6%

Oct 04 - Dec 04 1474 23 1.6%

Jan 05 - Mar 05 1500 18 1.2%

Apr 05 - Jun 05 1629 13 0.8%

Jul 05 - Sep 05 1575 23 1.5%

Oct 05 - Dec 05 1498 26 1.7%

Jan 06 - Mar 06 1383 13 0.9%

Apr 06 - Jun 06 1441 14 1.0%

Jul 06 - Sep 06 1325 14 1.1%

Oct 06 - Dec 06 1191 17 1.4%

Jan 07 - Mar 07 1937 16 0.8% 24 1.2%

Apr 07 - Jun 07 1962 22 1.1% 34 1.7%

Jul 07 - Sep 07 2101 16 0.8% 20 1.0%

Oct 07 - Dec 07 2141 17 0.8% 20 0.9%

Jan 08 - Mar 08 2308 15 0.6% 26 1.1%

Apr 08 - Jun 08 2303 21 0.9% 34 1.5%

Jul 08 - Sep 08 2247 22 1.0% 32 1.4%

Oct 08 - Dec 08 2336 13 0.6% 25 1.1%

Jan 09 - Mar 09 2423 14 0.6% 20 0.8%

Apr 09 - Jun 09 2374 28 1.2% 38 1.6%

Jul 09 - Sep 09 2347 9 0.4% 24 1.0%

Oct 09 - Dec 09 2357 24 1.0% 33 1.4%

Jan 10 - Mar 10 2418 15 0.6% 27 1.1%

Apr 10 - Jun 10 2113 10 0.5% 19 0.9%

Source: Obtained directly from HPS

41

APPENDIX 4

Table 12: Overview of recent prevalence surveys of HAI infections in industrialised European countries

Country Year (study/ publication)

Prevalence %

Hospitals (N)

Patients (N)

UK, 1996 9.00% 157 37,111

Germany 1997 3.50% 72 14,996

France 2001 (1996) 6.60% 1,533 162,220

Switzerland 2002 8.10% 160 7,540

Greece 2000 9.30% 14 3,925

Slovenia 2001 4.60% 19 6,695

Italy 2002 7.50% 15 2,165

Portugal 2003 8.40% 67 16,373

Denmark 2003 8.70% 38 4,226

Latvia 2003 3.90% 7 3,150

Finland 2005 8.50% 30 8,234

Sweden 2004–2006 9.50% 56 13,999

UK and Ireland 2006 7.60% 273 75,763

France 2006 5.00% 2,337 358,353

Norway 2002–2007 6.80% 53 11,359

Scotland 2007 9.50% 45 11,608

Spain (1990) 2004–2007 6.80% 259 58,892

Lithuania 2003, 2005, 2007 3.70% 35 8,000

Netherlands 2007 6.90% 30 8,424

Source: ECDC, 2008

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