Outbreak response: Infection Prevention Control specialist

In Week 1, we learned about the role of infection prevention and control professionals in outbreak response. In this step, Emilio Hornsey (PHE & UK-PHRST) will describe the specific activities and tools these professionals use in order to help control an outbreak.

1) What tools do Infection Prevention & Control Professionals (IPCPs) use in an outbreak response?

During an outbreak response, infection prevention and control (IPC) activities concentrate on risk mitigation measures to protect patients, staff and visitors in fixed health facilities and the families, carers and community health workers who provide health care in the community from communicable disease. These risk mitigation measures include¹:

• rapid case identification (using a mix of training materials, educational resources to raise awareness and diagnostic testing where relevant);
• source control (i.e. controlling cases or sources of infection, draining environmental reservoirs, rapid isolation or cohorting of patients, or provision of facemasks to patients who are suspected of an infectious respiratory disease);
• implementing administrative controls such as triage algorithms and training of health workers;
• engineering controls including altering patient flow through the facility to encourage patient separation; and
• the correct use of personal protective equipment (PPE).

Additional IPC measures for outbreak control are available and the evidence for each should be considered before they are employed. These measures may include: increasing staffing ratios; closing health facilities to new admissions; and/or limiting the movements of patients and staff around the facility (through quarantine, cohorting or isolation). In some health care facilities, individual features such as overcrowding and lots of movement of patients and staff between different areas present greater risks of direct and fomite transmission of disease.

Quarantine, cohorting or isolation are all terms to describe the separation of groups or individuals from others. The validity of measures such as quarantine and isolation have to be fully compatible with the incubation period, mode of transmission, symptoms and the capacity of local government structures or health facilities to ensure the needs of those kept separated are met.² In low- and middle-income countries (LMICs), the capacity to individually isolate patients in health facilities may be extremely limited and patients with communicable diseases will often be cohorted together away from the general patient population.

2) Who are the main counterparts and collaborators for IPC professionals in an outbreak response?

IPCPs will work closely with all other specialists to develop a response plan. Team work and collaboration are essential for an effective response. The specific collaboration will be tailored to the scale and nature of the outbreak but key partners include clinicians and microbiologists to characterise the disease clearly and identify the mode(s) of transmission. Working with epidemiologists helps IPCPs identify risk factors, hotspots and appropriate measures of the effectiveness of interventions. WASH expertise is required to identify engineering solutions and community hygiene measures. For diseases of zoonotic origin, input from vets and agricultural experts may be called upon as well.³ IPCPs also work closely with logisticians as providing timely and thorough feedback to logistics allows efficient supply of equipment and material during all phases of outbreak control.

IPC is as much, if not more, a behavioural practice than purely biomedical. For example, the simple passive presence of policies or facilities shows little impact on outcomes such as blood stream infection prevalence; whereas proactive programmes with multiple activities show a positive correlation with improved healthcare-acquired infection rates.⁴ Behaviour change is rarely achieved through a single measure, regardless of how well it is implemented. Challenging accepted norms and changing the safety culture within any working environment (including healthcare) is complex work⁵ and so IPC programmes and interventions may also benefit from social science input.

In preventing and responding to outbreaks, immediate IPC interventions should be aligned with longer term capacity building as far as possible. Longer-term and sustainable improvements will require structural support, commitment from stakeholders, and integrated programmes.

3) What are the main challenges for IPC professionals in outbreak response?

Challenges to implementing an effective IPC intervention may include a lack of specific resources, either human or material. IPC may not be well integrated in the management structure which facilitates the oversight and monitoring of interventions. There may be other practical issues such as supply chain management for resupply of bulky items such as PPE. Managing community expectations and allowing visits to patients in isolation may be culturally specific challenges. It is important to always keep in mind though, that in all the urgency to intervene in a vigorous and effective way, we should not override the dignity and human rights of those affected.

The principles of IPC are the same everywhere but they may have to be a significantly adapted depending on the human and financial resources available. In LMICs there is often a variety of health service providers and IPC standards may vary hugely. IPC may be well resourced in some facilities but almost non-existent in others close by.

Improving IPC, however, does not always require greater resources; rationalising expenditure and concentrating on evidence-based, cost-effective strategies (for example limiting the use of intravenous antibiotics and use of inappropriate PPE) are also valuable IPC interventions.