Biofilms and Device-Associated Infections
Rodney M. Donlan, Author
From: Centers for Disease Control and Prevention Atlanta, Georgia, USA
Microorganisms commonly attach to living and nonliving surfaces, including those of indwelling medical devices, and form biofilms made up of extracellular polymers. In this state, microorganisms are highly resistant to antimicrobial treatment and are tenaciously bound to the surface. To better understand and control biofilms on indwelling medical devices, researchers should develop reliable sampling and measurement techniques, investigate the role of biofilms in antimicrobial drug resistance, and establish the link between biofilm contamination and patient infection.
Microbial biofilms develop when microorganisms irreversibly adhere to a submerged surface and produce extracellular polymers that facilitate adhesion and provide a structural matrix. This surface may be inert, nonliving material or living tissue. Biofilm-associated microorganisms behave differently from planktonic (freely suspended) organisms with respect to growth rates and ability to resist antimicrobial treatments and therefore pose a public health problem. This article describes the microbial biofilms that develop on or within indwelling medical devices (e.g., contact lenses, central venous catheters and needleless connectors, endotracheal tubes, intrauterine devices, mechanical heart valves, pacemakers, peritoneal dialysis catheters, prosthetic joints, tympanostomy tubes, urinary catheters, and voice prostheses).
Characteristics of Biofilms on Indwelling Medical Devices
Biofilms on indwelling medical devices may be composed of gram-positive or gram-negative bacteria or yeasts. Bacteria commonly isolated from these devices include the gram-positive Enterococcus faecalis, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus viridans; and the gram-negative Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. These organisms may originate from the skin of patients or health-care workers, tap water to which entry ports are exposed, or other sources in the environment. Biofilms may be composed of a single species or multiple species, depending on the device and its duration of use in the patient. Urinary catheter biofilms may initially be composed of single species, but longer exposures inevitably lead to multispecies biofilms (1).
A distinguishing characteristic of biofilms is the presence of extracellular polymeric substances, primarily polysaccharides, surrounding and encasing the cells. These polysaccharides, which have been visualized by scanning electron microscopy, appear either as thin strands connecting the cells to the surface and one another or as sheets of amorphous material on a surface. Most biofilm volume is actually composed of this extracellular polymeric substance rather than cells, a fact that has been confirmed by ruthenium red staining and transmission electron microscopy (2). This biofilm matrix may act as a filter, entrapping minerals (1) or host-produced serum components (3). Biofilms are both tenacious and highly resistant to antimicrobial treatment; Anwar et al. (4) showed that treatment with levels of tobramycin far in excess of the MIC reduced biofilm cell counts for P. aeruginosa by approximately 2 logs, while the same dosage provided a >8-log decrease in planktonic cells of this organism.
Factors Influencing Rate and Extent of Biofilm Formation
When an indwelling medical device is contaminated with microorganisms, several variables determine whether a biofilm develops. First the microorganisms must adhere to the exposed surfaces of the device long enough to become irreversibly attached. The rate of cell attachment depends on the number and types of cells in the liquid to which the device is exposed, the flow rate of liquid through the device, and the physicochemical characteristics of the surface. Components in the liquid may alter the surface properties and also affect rate of attachment. Once these cells irreversibly attach and produce extracellular polysaccharides to develop a biofilm, rate of growth is influenced by flow rate, nutrient composition of the medium, antimicrobial-drug concentration, and ambient temperature. These factors can be illustrated by examining what is known about biofilms on three types of indwelling medical devices: central venous catheters, mechanical heart valves, and urinary (Foley) catheters.
Central Venous Catheter Biofilms
Scanning and transmission electron microscopy has shown that virtually all indwelling central venous catheters are colonized by microorganisms embedded in a biofilm matrix (5). The organisms most commonly isolated from catheter biofilms are Staphylococcus epidermidis, S. aureus, Candida albicans, P. aeruginosa, K. pneumoniae, and Enterococcus faecalis (6,7).
These organisms originate from patient's skin microflora, exogenous microflora from health-care personnel, or contaminated infusates. They gain access to the catheter by migration externally from the skin along the exterior catheter surface or internally from the catheter hub or port (8). Colonization of these devices can occur rapidly (within 24 hours) and may be a function of host-produced conditioning films (platelets, plasma, and tissue proteins) (8). Raad et al. (9) found that biofilm formation on central venous catheters was universal, but the extent and location of biofilm formation depended on the duration of catheterization: short-term (<10 days) catheters had greater biofilm formation on the external surface; long-term catheters (30 days) had more biofilm formation on the catheter inner lumen. The nature of the fluid administered through central venous catheters may affect microbial growth: gram-positive organisms (S. epidermidis, S. aureus) did not grow well in intravenous fluids, whereas the gram-negative aquatic organisms (e.g., P. aeruginosa, Klebsiella spp., Enterobacter spp., Serratia spp., and Pantoea sp.) sustained growth (10-14). Because many of these solutions have limited nutrients, bacterial growth rarely produces turbidity, meaning that numbers are <107 organisms per milliliter. The number of organisms on the catheter tip is related to occurrence of bloodstream infection in the patient (7,15-17), supporting the concept of a critical level of biofilm development above which substantial cell detachment and embolism occur.
Several studies have examined the effect of various types of antimicrobial treatment in controlling biofilm formation on these devices. Freeman and Gould (18) found that addition of sodium metabisulfite to the dextrose-heparin flush of the left atrial catheter eliminated microbial colonization of these catheters. Darouiche et al. (19) found that catheters impregnated with minocycline and rifampin were less likely to be colonized than those impregnated with chlorhexidine and silver sulfadiazine. In a study by Kamal et al. (20), catheters coated with a cationic surfactant (tridodecylmethylammonium chloride), which was in turn used to bond cephalosporin to the surface, were less likely to become contaminated and develop biofilms than were untreated catheters. Flowers et al. (21) found that an attachable subcutaneous cuff containing silver ions inserted after local application of polyantibiotic ointment conferred a protective effect on catheters, resulting in lower rates of contamination. Maki (8) suggested several ways to control biofilms on central venous catheters, including using aseptic technique during implantation, using topical antibiotics, minimizing the duration of catheterization, using an in-line filter for intravenous fluids, creating a mechanical barrier to prevent influx of organisms by attaching the catheter to a surgically implanted cuff, coating the inner lumen of the catheter with an antimicrobial agent, and removing the contaminated device.
Mechanical Heart Valve Biofilms
Microorganisms may attach and develop biofilms on components of mechanical heart valves and surrounding tissues of the heart, leading to a condition known as prosthetic valve endocarditis. The primary organisms responsible for this condition are S. epidermidis, S. aureus, Streptococcus spp., gram-negative bacilli, diphtheroids, enterococci, and Candida spp. These organisms may originate from the skin, other indwelling devices such as central venous catheters, or dental work (3). The identity of the causative microorganism is related to its source: whether the contaminating organism originated at the time of surgery (early endocarditis, usually caused by S. epidermidis), from an invasive procedure such as dental work (Streptococcus spp.), or from an indwelling device (a variety of organisms). Implantation of the mechanical heart valve causes tissue damage, and circulating platelets and fibrin tend to accumulate where the valve has been attached.
Microorganisms also have a greater tendency to colonize these locations (3). The resulting biofilms more commonly develop on the tissue surrounding the prosthesis or the sewing cuff fabric used to attach the device to the tissue (22,23) than on the valve itself (24). Antimicrobial agents are usually administered during valve replacement and whenever the patient has dental work to prevent initial attachment by killing all microorganisms introduced into the bloodstream. As with biofilms on other indwelling devices, relatively few patients can be cured of a biofilm infection by antibiotic therapy alone (25). Illingworth et al. (22) found that a silver-coated sewing cuff on a St. Jude mechanical heart valve (St. Jude Medical Inc., St. Paul, MN) implanted into a guinea pig artificially infected with S. epidermidis produced less inflammation than did uncoated fabric. Although the number of attached organisms was not determined, the authors concluded that the degree of inflammation was proportional to the number of viable organisms. Carrel et al. (23) also found this approach was effective in in vitro studies with different organisms.
Urinary Catheter Biofilms
Urinary catheters are tubular latex or silicone devices, which when inserted may readily acquire biofilms on the inner or outer surfaces. The organisms commonly contaminating these devices and developing biofilms are S. epidermidis, Enterococcus faecalis, E. coli, Proteus mirabilis, P. aeruginosa, K. pneumoniae, and other gram-negative organisms (1). The longer the urinary catheter remains in place, the greater the tendency of these organisms to develop biofilms and result in urinary tract infections. For example, 10% to 50% of patients undergoing short-term urinary catheterization (7 days) but virtually all patients undergoing long-term catheterization (>28 days) become infected (1). Brisset et al. (26) found that adhesion to catheter materials was dependent on the hydrophobicity of both the organisms and the surfaces; catheters displaying both hydrophobic and hydrophilic regions allowed colonization of the widest variety of organisms. Divalent cations (calcium and magnesium) and increase in urinary pH and ionic strength all resulted in an increase in bacterial attachment. Tunney et al. (27) stated that no single material is more effective in preventing colonization, including silicone, polyurethane, composite biomaterials, or hydrogel-coated materials. Certain component organisms of these biofilms produce urease, which hydrolyzes the urea in the patient's urine to ammonium hydroxide.
The elevated pH that results at the biofilm-urine interface results in precipitation of minerals such as struvite and hydroxyapatite. These mineral-containing biofilms form encrustations that may completely block the inner lumen of the catheter (27). Bacteria may ascend the inner lumen into the patient's bladder in 1 to 3 days (28); this rate may be influenced by the presence of swarming organisms such as Proteus spp. (D. Stickler, pers. comm.). Several strategies have been attempted to control urinary catheter biofilms: antimicrobial ointments and lubricants, bladder instillation or irrigation, antimicrobial agents in collection bags, impregnation of the catheter with antimicrobial agents such as silver oxide, or use of systemic antibiotics (29). Most such strategies have been ineffective, although silver-impregnated catheters delayed onset of bacteriuria for up to 4 days. In a rabbit model, biofilms on Foley catheter surfaces were highly resistant to high levels of amdinocillin, a beta-lactam antibiotic (30). However, Stickler et al. (31) found that treatment of a patient with a polymicrobial biofilm-infected catheter with ciprofloxacin allowed the catheter to clear and provide uninterrupted drainage for 10 weeks. Morris et al. (32) found that time to blockage of catheters in a laboratory model system was shortest for hydrogel- or silver-coated latex catheters and longest for an Eschmann Folatex S All Silicone catheter (Portex Ltd., Hythe, Kent, England). Biofilms of several gram-negative organisms were reduced by exposure to mandelic acid plus lactic acid (33). In a study in which ciprofloxacin-containing liposomes were coated onto a hydrogel-containing Foley catheter and exposed in a rabbit model, the time to development of bacteriuria was double that with untreated catheters, although infection ultimately occurred in the rabbits with treated catheters (34).
Directions for Future Research
To better understand and control biofilms on indwelling medical devices, research must progress in several key areas. More reliable techniques for collecting and measuring biofilms should be developed. For central venous catheters, the reference method for quantification of biofilms on catheter tips is the roll-plate technique, in which the tip of the catheter is removed and rolled over the surface of a nonselective medium. Quantification of the biofilm depends on the number of organisms recovered by contact with the agar surface. Biofilm-associated cells on the inner lumen of the device are not detected with this method, which has low diagnostic sensitivity and low predictive value for catheter-related bacteremia (7). In addition, this method cannot detect more than 1,000 colony-forming units (CFU) per tip. A method that used sonication plus vortexing as a means of quantifying biofilms on catheter tips showed that a level of 104 CFU per tip is predictive of catheter-related septicemia. Although this method is an improvement over the semi-quantitative roll-plate technique, the recovery efficiency of the method needs to be determined (i.e., the percentage of cells that are not recovered and quantified). Zufferey et al. (35) described a method for rapidly detecting biofilm cells on catheters by direct staining of the catheter with acridine orange. Although they found good agreement with culture techniques and noted that this technique provided more rapid results, they did not quantify cells; instead, they recorded a simple positive or negative result. Techniques that allow counting of biofilm cells directly on the catheter surface would be an improvement over established methods.
Model systems should be developed and used to study biofilm processes on various indwelling medical devices. These systems should closely simulate the in vivo or in situ conditions for each device, while at the same time providing reproducible, accurate results. To investigate biofilm formation on needleless connectors, Donlan et al. (14) used a biofilm disk reactor system (Figure 2) that incorporated a medium (intravenous fluid), a material (teflon coupons or needleless connectors), an organism (Enterobacter cloacae), and a flow rate (1 mL/min) that closely simulated conditions of use for these devices. Results were both reproducible and precise, and the system was capable of developing a steady state biofilm (Figure 3). This system design could be used to investigate and compare various biofilm control treatments, device design modifications, or different media formulations. By performing a similar experiment in an animal model system, biofilm processes in vivo could be predicted.
Another area of great importance from a public health perspective is the role of biofilms in antimicrobial-drug resistance. Bacteria within biofilms are intrinsically more resistant to antimicrobial agents than planktonic cells because of the diminished rates of mass transport of antimicrobial molecules to the biofilm associated cells (36) or because biofilm cells differ physiologically from planktonic cells (37). Antimicrobial concentrations sufficient to inactivate planktonic organisms are generally inadequate to inactivate biofilm organisms, especially those deep within the biofilm, potentially selecting for resistant subpopulations. This selection may have implications for treatments that use controlled release of antimicrobial agents to prevent biofilm growth on indwelling devices. Bacteria can transfer extachromosomal genetic elements within biofilms; Roberts et al. (38) demonstrated transfer of a conjugative transposon in a model oral biofilm. Hausner and Wuertz (39) demonstrated conjugation in a lab-grown biofilm with rates one to three orders of magnitude higher than those obtained by classic plating techniques. Resistance-plasmids could also be transferred within biofilms on indwelling medical devices.
The link between biofilm contamination of an indwelling device and patient infection is often unclear. Raad et al. (9) noted that biofilm formation was universal on vascular catheters collected from patients, yet observed that this universal colonization rarely resulted in bloodstream infection. A better understanding of the factors that control cell detachment may help answer the questions: Is there a critical biofilm density threshold above which detachment occurs? What is the role of the exopolymers in this process? Davies et al. (40) demonstrated the role of acyl homoserine lactones (HSL) in biofilms of P. aeruginosa and showed that HSL-knockouts were deficient in biofilm architecture and much more readily detached than wild-type organisms. Stickler et al. (41) detected these quorum-sensing molecules in biofilms on urethral catheters. A greater understanding of cell-to-cell communication within biofilms may lead to better predictability of biofilm processes such as detachment, as well as more effective control strategies.
Microbial biofilms may pose a public health problem for persons requiring indwelling medical devices. The microorganisms in biofilms are difficult or impossible to treat with antimicrobial agents; detachment from the device may result in infection. Although medical devices may differ widely in design and use characteristics, specific factors determine susceptibility of a device to microbial contamination and biofilm formation. For example, duration of use, number and type of organisms to which the device is exposed, flow rate and composition of the medium in or on the device, device material construction, and conditioning films on the device all may influence biofilm formation. More effective biofilm control strategies should result as researchers develop more reliable techniques for measuring biofilms and better model systems for evaluating control strategies. A clearer picture of the importance of biofilms in public health should also result as the role of biofilms in antimicrobial-drug resistance is investigated and the link is established between biofilm contamination and patient infection.
Dr. Donlan is team leader for the Division of Healthcare Quality Promotion Biofilm Laboratory, National Center for Infectious Diseases, CDC. His research interests focus on biofilms on indwelling medical devices, the role of biofilms in antimicrobial-drug resistance, and survival and treatment of pathogenic organisms in potable water system biofilms.
Biofilms and Device-Associated Infections
From the Institute for Healthcare Improvement
Implement the Central Line Bundle
Central venous catheters (CVCs) are being increasingly used in the inpatient and outpatient settings to provide long-term venous access. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream (bacteremia) and hemodynamic changes and organ dysfunction (severe sepsis) may ensue possibly leading to death. Approximately 90 percent of the catheter-related bloodstream infections (BSIs) occur with CVCs.
Forty-eight percent of ICU patients have central venous catheters, accounting for 15 million central venous catheter-days per year in ICUs. Studies of catheter-related bloodstream infections that control for the underlying severity of illness suggest that attributable mortality for these infections is between 4 and 20 percent. Thus, it is estimated that between 500 and 4,000 US patients die annually due to bloodstream infections.
In addition, nosocomial bloodstream infections prolong hospitalization by a mean of 7 days. Estimates of attributable cost per bloodstream infection are estimated to be between $3,700 to $29,000.
Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The science supporting the bundle components is sufficiently established to be considered standard of care.
The Central Line Bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.
The key components of the Central Line Bundle are:
Maximal Barrier Precautions Upon Insertion
Chlorhexidine Skin Antisepsis
Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters
Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
From the Institute for Healthcare Improvement
Implement the Ventilator Bundle:
By definition, ventilator-associated pneumonia (VAP) is an airways infection that must have developed more than 48 hours after the patient was intubated. Preventing pneumonia of any variety seems at first blush to be a laudable goal. However, there are some reasons to be particularly concerned about the impact of pneumonia associated with ventilator use.
VAP is the leading cause of death amongst hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. Perhaps the most concerning aspect of VAP is the high associated mortality. Hospital mortality of ventilated patients who develop VAP is 46 percent compared to 32 percent for ventilated patients who do not develop VAP.
In addition, VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU.  Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission. 
Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence-based practices.
The Ventilator Bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually.
The key components of the Ventilator Bundle are:
Elevation of the Head of the Bed
Daily "Sedation Vacations" and Assessment of Readiness to Extubate
Peptic Ulcer Disease Prophylaxis
Deep Venous Thrombosis Prophylaxis
An article reprinted from the Institute for Healthcare Improvement website: www.ihi.org
If you are new to the science of health care quality improvement or perhaps implementing your first formal program in this area, it’s helpful to become familiar with some basic terms. One of these is “bundle.”
At least two of the six interventions at the heart of the 100,000 Lives Campaign depended on implementing bundles in critical care or surgical settings.
So, what is a “bundle?” It’s a term or concept developed by faculty at the Institute for Healthcare Improvement (IHI) as a way to describe a collection of processes needed to effectively care for patients undergoing particular treatments with inherent risks. The idea is to bundle together several scientifically grounded elements essential to improving clinical outcomes. A bundle should be relatively small and straightforward − a set of three to five practices or precautionary steps is ideal.
Most important, a bundle is a cohesive unit. The steps must all be completed to succeed; the “all or none” feature is the source of the bundle’s power. In his December 2004 IHI National Forum plenary launching the 100,000 Lives Campaign, Donald Berwick, IHI’s President and CEO, described the bundle as central to what he called a new scoring system for clinicians that would “up the stakes on reliability.” Rather than scoring ourselves, he said, for successfully completing individual steps in a list of proven interventions for a group of patients, what if we rate ourselves “on a pass-fail basis for the whole bundle of things?” So, he continued, “a patient gets a ‘yes’ if we actually did everything we planned to do, and a ‘no’ if anything, even one thing, was left out.” This bundled scoring system pushes us to raise the bar on health care performance.
For example, one intervention in the 100,000 Lives Campaign, Prevent Ventilator-Associated Pneumonia, recommends reliable use of the Ventilator Bundle. This bundle is designed to help clinicians in the Intensive Care Unit (ICU) better care for patients on ventilators or breathing machines. Patients on these machines are at risk of developing ventilator-associated pneumonia, which can be deadly. There are guidelines for preventing ventilator-associated pneumonia, but even the most rigorous institutions fall short in efforts to adhere to them. The Ventilator Bundle addresses this challenge. It includes these steps:
Elevating the head of the patient’s bed to 30-45 degrees
Daily "sedation vacations," or gradually lightening the use of sedatives each day
Daily assessment of the patient’s readiness to extubate or wean from the ventilator
Peptic ulcer prophylaxis
Deep venous thrombosis prophylaxis
Teams that have adopted the Ventilator Bundle report that having the steps joined provides a “forcing function.” And the rewards are significant; use of the Ventilator Bundle has resulted in dramatic reduction of ventilator-associated pneumonia in scores of hospitals. For example, a team in the ICU at St. Vincent’s Hospital in Birmingham, Alabama, reported no cases of ventilator-associated pneumonia over 255 days in 2004 after implementing the Ventilator Bundle. This enhancement in care means better outcomes, reduced hospital stays, lower costs, and improved staff morale.
It’s also important to understand what a bundle is not. It is not a list of absolutes or precise protocols. It is a set of steps that experts believe are critical, but in many cases the clinical values attached to each step are locally defined or may change over time based on evolving research and the experiences of users.
Think of a bundle as a starting point, a tool that your organization can shape and develop to your needs. Ideally, performing the steps in a bundle means simply answering ‘yes’ or ‘no,’ in Don Berwick’s exacting new scoring system. “Yes, we did this step, that step, and these two others.” The “how,” “when,” “what,” and “how much” that will trigger a task at your patients’ bedside with each step may involve decisions for your internal experts.
We encourage you to read more about the two bundles central to the 100,000 Lives Campaign. The bundle approach is quickly becoming a standard in quality improvement strategies embraced by large and small institutions, medical associations, and policy makers. And it’s likely to be important to your organization’s success in helping to drive the movement focused on saving lives.
Seven years ago, the Institute of Medicine (IOM) issued its landmark report on medical errors, To Err Is Human: Building a Safer Health System. The report's finding that as many as 98,000 people die each year due to medical errors ignited professional and public dialogue. Patient safety has since become a frequent topic for journalists, health care leaders, and consumers, but is health care any safer now? And if not, why not?
Two authors of the IOM report, Lucian Leape, M.D., of the Harvard School of Public Health, and Donald Berwick, M.D., of the Institute for Healthcare Improvement, endeavored to answer these questions in 2005 with "Five Years After To Err Is Human: What Have We Learned?" (JAMA May 18, 2005). Despite finding small improvements at the margins—fewer patients dying from accidental injection of potassium chloride, reduced infections in hospitals due to tightened infection control procedures—it is harder to see the overall, national impact, Leape and Berwick say. "The groundwork for improving safety has been laid in these past five years but progress is frustratingly slow," they write.
While To Err Is Human has not yet succeeded in creating comprehensive, nationwide improvements, it has made a profound impact on attitudes and organizations. First, it has changed the way health care professionals think and talk about medical errors and injury, with few left doubting that preventable medical injuries are a serious problem. "It truly changed the conversation," say Leape and Berwick. A central concept of the report - that bad systems and not bad people lead to most errors - has since become a mantra in health care.
The second major effect of the report was that it helped recruit a broad array of stake-holders to advance the cause of patient safety. In 2001, Congress responded to the IOM recommendations by allocating $50 million annually for patient safety research to the Agency for Healthcare Research and Quality (AHRQ), the lead federal agency for health care safety.
Other important players that have emerged include the Veteran's Health Administration, the Joint Commission, and the Centers for Medicare and Medicaid Services (CMS), as well as purchasers and payers. However, the most important stake-holders, say the authors, are the physicians, nurses, therapists, and pharmacists who have become much more alert to safety hazards and who are committed to making improvements on the front lines.
Clearly, the report has also produced real changes in the practice of health care. In 2003, the Joint Commission began requiring hospitals to implement 11 safety practices, including improving patient identification, communication, and "surgical site verification" (marking a body part to ensure surgery is performed on the correct part). More safe practices were added in 2005. In addition, teaching hospitals initiated new residency training hour limitations aimed at reducing errors due to fatigue.
With all this growing awareness and activity, why is health care not measurably safer? The answers, the authors say, lie in the very culture of medicine. Creating a culture of safety requires changes that physicians may perceive as threats to their autonomy and authority. Fear of malpractice liability, moreover, may create an unwillingness to discuss or even admit to errors. Other issues include the complexity of the health care industry, with its vast array of specialties, subspecialties, and allied health professionals; a lack of leadership at the hospital and health plan level; and a scarcity of measures with which to gauge progress.
The current reimbursement system can also work against safety improvement and, in some cases, may actually reward less-safe care, the authors say. For instance, some insurance companies will not pay for new practices to reduce errors, while physicians and hospitals can bill for additional services that are needed when patients are injured by mistakes.
Despite formidable barriers, the authors expect to see dramatic advances in the next five years in the following areas: implementation of electronic health records, wide diffusion of proven and safe practices, spread of training on teamwork and safety, and full disclosure to patients following injury. However, while these advances will have an impact on reducing errors, they represent only a small fraction of the work that needs to be done. To create comprehensive, nationwide change, pressure must be applied to the health care industry. Public outrage, reformed reimbursement policies, and regulation can create some of this needed pressure. In addition, the authors suggest payment incentives to accelerate widespread adoption. It may be equally important, they say, to create negative financial consequences for hospitals or organizations that continue to perform unsafe practices.
The single most important step, however, is to set and adhere to "strict, ambitious, quantitative, and well-tracked national goals," say Leape and Berwick. They urge AHRQ to bring together organizations, including the Joint Commission, CMS, and the AMA, to agree to a set of patient safety goals to be reached by 2010. The most important lesson of the past five years, the authors argue, is that "we will not become safe until we choose to become safe."
Following surgery in 2005, ISPIS executive director Ron Stoker contracted a nosocomial staph infection. This occured several weeks after surgery and nearly took his life. Four surgeries and eight weeks of IV antibiotics later, he has recovered, with only a few permanent side effects. He believes that the infection could have been prevented if proper hospital procedures had been followed, including proper hand hygiene and gloving techniques.
Clean hands are the most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Proper hand hygiene reduces the incidence of healthcare-associated infections because the hands of healthcare workers can transmit pathogens that cause nosocomial infections.
While I feel blessed to be alive and am responding well, many other patients have not been so fortunate; the Centers for Disease Control in Atlanta, Georgia, USA, estimate 2 million patients in the USA catch a nosocomial infection in hospital each year. Between 90,000 and 105,000 patients die each year from these infections.
"The unfortunate truth is that most people simply do not wash their hands as often as they should."
While most healthcare workers are no different from any other group of people, the unfortunate truth is that most people simply do not wash their hands as often as they should, or even as often as they say they do.
The American Society for Microbiology conducted a survey to find out how often people told the truth about their handwashing habits. Of over a 1,000 people surveyed across the USA, 95% said they always washed after using a public restroom. However, when observing people in public restrooms almost one third of the people did not wash their hands.
So, with the general public struggling to wash their hands after going to the bathroom, it is easy to see that some healthcare professionals carry the same attitudes and behaviour into their professional lives. "Physicians and nurses have been documented repeatedly to not wash their hands properly," says Dr. William Jarvis, chief of the CDC hospital infections programme's investigation and prevention unit. "At best, it is 40% of the time that we recommend that they should wash their hands that they really do."
If clinicians would only make more widespread use of hand hygiene products, they would be able to promote patient safety and prevent infections, because there is substantial evidence that hand hygiene reduces infections.
What is particularly frustrating is that handwashing and proper hand hygiene are not new concepts – they have been common knowledge since the mid-19th century. The experiences of two physicians, Dr. Ignaz Semmelweiss and Dr. Joseph Lister, helped to establish the importance of proper hand hygiene.
Semmelweiss noticed that deaths were more numerous among women attended by doctors and medical students than among women attended by midwives. At the time it was common for a doctor to move from one patient to the next without washing their hands. They would also move from performing an autopsy on a diseased body to examining a living person without washing their hands.
"Physicians and nurses have been documented repeatedly to not wash their hands properly." Semmelweiss ordered that hands be washed in a chlorine solution before each examination. Mortality rates among women attended by doctors and medical students dropped from almost 20% to just over 1%.
Influenced by Semmelweiss's work, Lister went a step further. He found that spraying instruments, surgical incisions and dressings with a solution of carbolic acid made a difference in infection rates. He also required surgeons in his employment to wear clean gloves and wash their hands before and after operations with a 5% carbolic acid solution. His work changed the face of infection control.
All healthcare workers must be brought together and motivated to make a change. They need to be encouraged to wash their hands to prevent infections in the healthcare setting.
One way of doing this is for institutions to formalise a nosocomial infection prevention training programme. In a recent article, Dr. Dennis G. Maki and Dr. Christopher J. Crnich indicated that: "Healthcare workers need to receive more effective training in nosocomial infection control."
To provide more effective nosocomial infection control training, it must be recognized that many healthcare workers are generally not compliant with recommended hand hygiene practices.
One study found that healthcare workers that were placed in an alcohol gel hand-rubbing group were more compliant than the ones required to wash with soap and water. Compliance with hand rubbing was markedly lower among the nurses who had more than three years' experience of hospital practice.
Both hand rubbing and hand washing compliance were poorer among nurses working in intensive care units than among nurses working in the other hospital wards. Generally, after taking off their gloves, nurses preferred handwashing to hand rubbing.
Healthcare institutions need to be able to effect a transformational change in behaviour, but before this can occur, a fundamental change has to occur in beliefs and attitudes. This resistance to change may explain why in 2005 a large percentage of healthcare providers still do not practise acceptable hand hygiene, and the pain of childbirth continues to be extolled by some as a necessary part of womanhood, just as pharmacologic pain relief is discouraged.
"2 million patients in the USA catch a nosocomial infection in hospital each year." In one study, one researcher recorded 1,400 potential opportunities for handwashing during 15-minute observation periods. The average duration of handwashing was ten seconds. Most healthcare workers (99.%) used liquid soap during handwashing, but 79.8% did not dry their hands.
For all indications, compliance with handwashing was 31.9% and compliance with glove use was 58.8%. Compliance with handwashing varied inversely with both the number of indications for hand hygiene and the number of patient beds in the hospital room. Compliance with handwashing was better in dirty, high-risk situations. The conclusion of this study was that compliance with handwashing was low, and that there was a need for new motivational strategies.
Some institutions are mandating that healthcare workers wear badges with: "Ask me if I washed my hands". Some nurses have expressed outrage that they are requested to wear these badges – they don't like being looked on as being dirty by their patients. However, these types of programmes create many opportunities for feedback from patients that can reinforce good hand hygiene.
Safe Care Campaign, a hand hygiene advocacy in Atlanta Georgia takes a more positive approach with their "EVERY SINGLE TIME" program. In addition to other stepped-up practices and procedures focusing on hand hygiene and the prevention of the spread of infections, staffer buttons proactively tell patients how dedicated caregivers who wear them are to the highest level of care. The buttons say, "Committed to providing you with safe care - I will sanitize my hands before touching you EVERY SINGLE TIME".
Current theory suggests that the most effective messages for health promotion behaviour should be framed in terms of gains rather than losses for the individual. However, as clinical hand hygiene is largely for the benefit of patients, messages should also invoke a sense of personal responsibility and appeal to altruistic behaviour. The uses of repeated minimal fear appeals have their place. Posters that simply convey training messages have been found to be ineffective.
Why don't healthcare workers wash more often? Many healthcare workers report the following reasons for poor adherence with proper hand hygiene:
Belief that handwashing agents, particularly alcohol gels, cause irritation and dryness
Sinks are inconveniently located
Lack of soap and paper towels
Not enough time
Understaffing or overcrowding
Patient needs taking priority
Lack of knowledge of guidelines
"Healthcare workers need to receive more effective training in nosocomial infection control."
Disagreements with the recommendations were also self-reported factors for poor adherence with hand hygiene.
Many nurses believe that the time required to leave a patient's bedside, go to a sink, and wash and dry their hands before attending to the next patient is a deterrent to frequent handwashing or hand antisepsis. Somehow we need to be able to change this mindset.
The following are some suggestions for improving compliance:
Select an alcohol-based hand rub that has a good skin tolerance and is acceptable to healthcare workers.
Alcohol gel needs to be easily available - wall dispensers near the patient and pocket bottles may help - pocket bottles can be kept in a pocket or clipped to a belt.
The teaching and promotion of hand hygiene is the most effective tool, but costs time and money.
Create a hospital budget that covers all the costs involved with preventable nosocomial infection and combine it with the budget for hand hygiene products - even a small number of prevented nosocomial infections will outweigh the cost of effective hand hygiene products.
Choose senior staff to be product champions, they need to set a good example to motivate junior staff - negligence in hand hygiene correlates with years in the profession.
Make sure that the patient-staff ratio is well balanced, staff shortages lead to decreased hand hygiene compliance.
Constant exposure to hand hygiene promotions in a hospital will help healthcare workers remember the importance of good hand hygiene and develop the mindset to always be compliant with the guidelines for one of the first lessons taught during medical training: "First, do no harm".
Hospital acquired infection maims and kills patients, prolongs hospital stays, consumes scarce hospital resources, and thus presents a major challenge for clinical governance.
In a seminal intervention study 150 years ago Semmelweis insisted that doctors performing necropsies washed their hands before delivering babies, so reducing mortality due to streptococcal puerperal sepsis from 22% to 3%.
Many studies since have confirmed that doctors decontaminating their hands between seeing patients can reduce hospital infection rates.
Nevertheless, healthcare workers still fail to wash their hands and fail to appreciate the importance of doing so. The Department of Health has had another attempt at reminding them by sending a document and health circular to all NHS chief executives, public health directors, and microbiologists in England.
Many observational studies, mainly conducted in intensive care units, show low rates of hand washing, especially among doctors. Bartzokas et al observed that, despite frequent patient contacts, senior doctors washed their hands only twice during 21 hours of ward rounds. Though doctors spend less time than nurses in direct patient contact and may think that they need to decontaminate their hands less often, they have many transient contacts and move from ward to ward. The same is true for phlebotomists, physiotherapists, radiographers, and various technicians.
Self reporting overestimates compliance. After unobtrusive observation of doctors to obtain a baseline hand washing rate, Tibballs asked a sample to estimate their own hand washing rates before patient contact. Their perceived rate of 73% (range 50%-95%) contrasted sharply with the observed frequency of just 9%. Pritchard and Raper were astonished that “doctors can be so extraordinarily self-delusional about their behaviour.”
Why is compliance so poor? Even when taught the theoretical basis of hand washing, healthcare workers do not seem to understand the risks associated with non-compliance. Hospital acquired infections usually present as sporadic cases, perceived as insignificant or unrelated to non-compliance. Staff horrified by lice on a patient fail to consider the potentially far more serious consequences of bacteria present on their hands.
The failure of healthcare workers to decontaminate their hands reflects fundamentals of attitudes, beliefs, and behaviour, and there are no simple solutions. Many attempts have been made to improve hand washing compliance through education, and indeed elementary hygiene practice should be taught explicitly in medical schools. Principles taught in the lecture theatre can be reinforced by experiential learning, such as demonstrating the need for proper hand washing technique by showing microbial growth from unwashed hands and by using fluorescent oil-based dyes to illustrate the effectiveness of hand washing. Such methods increase personal impact, but, though they may be temporarily improve compliance, behavioural changes tend not to be maintained.
Role models are important in hospital practice. Junior doctors washed their hands more often when consultants set an example (although they were not perfect, washing their hands on fewer than half the indicated occasions) (Larson and Larson, conference of Association of Practitioners in Infection Control, San Diego, 1983). Unfortunately, poor practice can also be learnt at the bedside. Junior staff and students taught to wash their hands abandoned the habit when others, especially more senior ward staff, did not bother.
Senior staff should take the lead to achieve lasting behavioural change. To increase compliance, medical staff could police each other, and it suggested that patients should be encouraged to ask their caregivers to wash their hands.
It is clear that healthcare workers fail to understand the importance of hand washing. This issue is so crucial that we need a greater commitment from management to influence their behaviour. It is now time for an explicit standard to be set, that hands should be decontaminated before each patient contact. If such a policy is not in place or being followed, the trust concerned may be liable in the event of litigation.
The culture change required for this new practice may be forbidding, but similar challenges such as the safe disposal of sharps and, in another setting, the use of seat belts in cars, have been faced and overcome. Hand decontamination should have similar status to other health and safety policies, where individuals are accountable for day to day operational practices. Hand washing should be regarded as part of the normal duty of care.
REFERENCES: Bartzokas, CA.;Williams, EE.; Slade, PD. Studies in health and human sciences. London: Edward Mellen; 1995. A psychological approach to hospital-acquired infections.
Tibballs J. Teaching hospital medical staff to handwash. Med J Austral. 1996;164:395–398. [PubMed]
Pritchard RC, Raper RF. Doctors and handwashing: instilling Semmelweis’ message. Med J Austral 1996;164:389-90.
Pritchard V, Hathaway C. Patient handwashing practice. Nursing Times. 1988;84:68–72.
Emmerson AM, Ridgway GL. Teaching asepsis to medical students. J Hosp Infection. 1980;1:289–292. [PubMed]
Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible sinks. Infection Control. 1986;7:408–410. [PubMed]
Jarvis WR. Handwashing: the Semmelweis lesson forgotten? Lancet. 1994;344:1311–1312. [PubMed]
Experts Call for Improvements to Control Global Hospital Infection Epidemic of C-Difficile-Associated Disease
Leading experts called for immediate improvements in the diagnosis and treatment of Clostridium difficile-associated disease (CDAD) to contain the spread of this serious hospital-acquired diarrhea. CDAD is increasing in incidence and severity in the United States, Canada and certain European countries, according to presentations made during a symposium at the 17th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Munich, Germany.
CDAD, the most common form of hospital-acquired diarrhea, affects more than 500,000 people in the United States and one out of every 1,000 patients hospitalized in Europe as of 2005. The increased incidence and severity of the disease, coupled with an increase in treatment failures with standard therapies, is a growing concern among public health officials, infectious diseases physicians, gastroenterologists, microbiologists and epidemiologists.
Data from the symposium entitled, "Clostridium Difficile-Associated Disease: Underdiagnosed, Underreported, Undertreated; How to Overcome the Challenges," confirmed the emergence and spread of a new virulent epidemic strain of CDAD known as North American Phenotype 1/027 (NAP1/027).
"Today's growing CDAD epidemic is characterized by the emergence of a highly virulent and resistant strain, increases in incidence and severity of infection, increases in failed responses to existing therapies, and a growing number of recurrences following treatment. These problems all contribute to a rise in healthcare costs associated with treating CDAD," said Ed Kuijper, M.D., Ph.D., Vice President, European Society of Clinical Microbiology and Infectious Diseases, Professor of Medical Microbiology, Leiden University Medical Center and co-chair of the ECCMID symposium sponsored by Optimer Pharmaceuticals (Nasdaq: OPTR). "Increased surveillance in hospitals and healthcare facilities, along with new approaches for diagnosing and treating patients, is urgently needed to combat this rapidly emerging infectious disease."
According to a presentation by Dr. Kuijper, 13 hospitals were monitored for CDAD in the Netherlands. An average of 17 per 10,000 patients (87 patients) admitted acquired CDAD, and two patients died as a result of CDAD. Early and rapid diagnosis, strict hand hygiene with soap and water, the use of gloves and aprons, grouping patients with CDAD, effective environmental cleaning with chlorine containing disinfectants, banning the use of fluoroquinolones and restricting the use of cephalosporins, were shown to help mitigate the further spread of the disease.
Frédéric Barbut, Pharm.D, Ph.D., an Infection Control Practitioner at the Infection Control Unit at Hôpital Saint-Antoine in Paris, France, and his colleagues, in collaboration with the Institut de Veille Sanitaire and regional coordinating centers, strengthened the surveillance of CDAD and built a network of regional laboratories for C. difficile characterization to promptly detect and control CDAD outbreaks in France. These investigators also confirmed the emergence and spread of the new epidemic strain North America Phenotype 1/027 (NAP1/027) in France. A national surveillance of CDAD will be launched in France in 2007 to complete the targeted surveillance of outbreak and severe CDAD.
The emergence and spread of the hypervirulent North America Phenotype 1/027 (NAP1/027) strain of CDAD in the United States, Canada and in some European countries call for improved rapid diagnosis, including the determination of C. difficile antibiotic resistance. Elisabeth Nagy, M.D., Ph.D., DSc, Professor from The Institute of Clinical Microbiology, Faculty of Medicine at the University of Szeged in Hungary, presented how molecular typing methods help track the spread of C. difficile in hospitals and the community, including real-time PCR, which is a rapid method used to detect the gene directly from feces in symptomatic patients and asymptomatic carriers.
According to Dale N. Gerding, M.D., Professor from the Department of Medicine at Loyola University Stritch School of Medicine and Associate Chief of Staff for Research & Development, Hines VA Hospital in Illinois, United States, patients prescribed metronidazole experienced poor response to therapy and high rates of recurrence following treatment. He further presented that patients prescribed vancomycin, the only FDA approved product to treat CDAD, also experienced high rates of recurrence following treatment. New agents, such as antimicrobials and monoclonal antibodies, are under development and show promise for the treatment and prevention of CDAD. Among the promising therapies under evaluation are gastrointestinal flora-sparing antibiotics, Difimicin and Rifaximin, and a toxin binder, Tolevamer.
Finally, C. difficile results in significant economic consequences for hospitals, healthcare providers and patients, including increased costs and prolonged hospital stays. Peter G. Davey, M.D., Professor from the Health Informatics Centre at the University of Dundee in Dundee, Scotland, presented data showing that patients in the intensive care unit (ICU) who contracted CDAD stayed in ICU for 6.1 days as compared to 3 days for patients with no CDAD. ICU costs increased to $11,353 versus $6,028 for patients with no CDAD.
Excerpted from an article in Townsend Letter for Doctors and Patients 2002 by Jule Klotter
Using data collected from 315 hospitals, the Centers for Disease Control and Prevention (CDC) estimated that 90,000 deaths in 2000, were caused by infections acquired at a hospital.
According to the CDC, about 2,000,000 of the 35 million annual hospital admissions will acquire an infection during their stay. The Chicago Tribune places the estimate for hospital-infection deaths at 103,000 and says that about 75,000 were preventable, "the result of unsanitary facilities, germ-laden instruments and unwashed hands." They derived their figures by analyzing records from 75 federal and state agencies, patient databases, internal hospital files, and court cases that were tied to 5,810 hospitals.
According to Michael J. Berens of the Chicago Tribune, hospital cleaning and janitorial staffs have been cut across the nation by 25% in order to save money, since 1995. Understaffing and inadequate training mean that germ-contaminated bedrails, telephones, and other fixtures often do not get cleaned. When serious sanitary problems arise, administrators, who are trying to cut costs, can be slow to react. Berens cites an operating room at a Connecticut medical center, known to have a faulty air ventilation system; administrators refused to spend $20,000 to replace it in 1995. Instead, they continued to use the room with its dusty air and flies for surgery. Court records report that "up to one in five patients" operated on in that room during 1997 ended up with an infection. The costs in human suffering, further medical costs to treat infection, not to mention litigation, make such 'cost-cutting measures' extremely short-sighted.
Health-care workers who forget or claim a lack of time to wash their hands between patients are another major contributor to the spread of hospital infections. According to Mr. Berens, "in a Detroit hospital, as doctors and nurses moved about the pediatric intensive care unit without washing hands, infections killed four babies in the same row of bassinets, according to court records and interviews." When health-care workers become careless about washing their hands and some of their colleagues come to work sick, a full-blown epidemic can occur.
Article by Paula Carlson - Associate Editor of the Surrey Leader
Apr 06 2007
Results from a recent audit that examined hygiene in Fraser Health Authority hospitals in Canada is shocking at best and life-threatening at worst. The 2005 survey had nurses in emergency departments, intensive care wards and surgical units observe whether hospital staff and visitors properly washed their hands before contact with a patient. Two-thirds did not.
While visitors and family members of patients could plead ignorance (although the benefits of hand hygiene are widely known and are shared with the great unwashed starting as early as kindergarten), health professionals have no excuse.
It was after all, a physician – Dr. Ignaz Semmelweis – who in the late 1840s first demonstrated the connection between dirty hands and disease. He wondered if the high rate of maternal death in childbirth (up to 25 per cent) was linked to medical students delivering babies directly after leaving the autopsy table. Semmelweis insisted the students wash their hands before assisting women in labour, and the mortality rate dropped dramatically – to less than one per cent.
Today, centres for disease control around the world view hand washing as the single most important means of preventing the spread of infection. Not expensive antibiotics or vaccines, just a simple bar of soap and warm water.
So surely, the low rate of hand washing in hospitals can be attributed to uneducated lay people? Unfortunately, survey results rinse that notion down the drain. Three-quarters of health professionals did not properly wash before performing an invasive procedure, such as drawing blood, intubating a patient or inserting a catheter. And after? Nearly half didn’t clean up.
This is disturbing, and dangerous. With so-called “superbugs” on the rise and highly contagious illnesses such as Norwalk and C. difficile circulating more frequently, proper personal hygiene in health care facilities is crucial.
The elderly, children, pregnant women and those with weakened immune systems are especially vulnerable to infections that could be stopped in their tracks by a trip to the tap. Yet approximately one in nine patients contract infections during their stay in hospital, and about 8,000 Canadians die of hospital infections each year.
By extension, one wonders: how many other industries with cleanliness as a priority are equally remiss?
For example, inadequate hand washing is blamed for up to 40 per cent of all food poisoning cases.
The poor performance in hospitals, however, remains the most troubling.
The B.C. government agrees, saying the $130,000 spent on an education campaign to teach front-line health workers in the Vancouver Island Health Authority how to wash their hands properly is money well spent. The announcement in February appeared ludicrously obvious, but now, seems suddenly imperative.
FHA spokesman Stephen Harris recently suggested patients also have a role to play, saying before submitting to treatment they shouldn’t be afraid to ask nurses and doctors if they have properly washed up.
Perhaps the principal and ancient tenet of medicine still imparted to modern medical students – primum non nocere, or first, do no harm – should be updated. How about: Physician – first, wash your hands.
The Mayo Clinic advises proper hand-washing techniques; they say that good hand-washing techniques include washing your hands with soap and water or using an alcohol-based hand sanitizer. Antimicrobial wipes aren't as good as alcohol-based sanitizers.
Antibacterial soaps have become increasingly popular in recent years. However, these soaps are no more effective at killing germs than are regular soap and water. Using these soaps may lead to the development of bacteria that are resistant to the products' antimicrobial agents making it even harder to kill these germs in the future. In general, regular soap is fine. The combination of scrubbing your hands with soap, antibacterial or not, and rinsing them with water loosens and removes bacteria from your hands.
Follow these instructions for washing with soap and water:
Wet your hands with warm, running water and apply liquid or clean bar soap. Lather well.
Rub your hands vigorously together for at least 15 seconds.
Scrub all surfaces, including the backs of your hands, wrists, between your fingers and under your fingernails.
Dry your hands with a clean or disposable towel.
Use a towel to turn off the faucet.
To use hand sanitizers:
Alcohol-based hand sanitizers, which don't require water are an excellent alternative to hand washing, particularly when soap and water aren't available. They're actually more effective than soap and water in killing bacteria and viruses that cause disease. Commercially prepared hand sanitizers contain ingredients that help prevent skin dryness. Using these products can result in less skin dryness and irritation than hand washing. Not all hand sanitizers are created equal, though. Some "waterless" hand sanitizers don't contain alcohol. Use only the alcohol-based products.
Apply about 1/2 tsp of the product to the palm of your hand.
Rub your hands together, covering all surfaces of your hands, until they're dry.
If your hands are visibly dirty, however, wash with soap and water rather than a sanitizer.
(March 22, 2007 )
Cases of bird flu are cases of children dying because of bird flu, hence it is of utmost importance that all efforts are done in keeping Philippine bird flu free. Thus says Mr. Nilo A. Yacat, Senior Programme Monitoring Assistant of UNICEF during the March 19-21 Seminar-Workshop on Stay Bird Flu Free Philippines at the Richville Hotel in Mandaluyong City.
About one-half of the total number of bird flu victims all over the world, are children. Of the total number of deaths caused by bird flu, one-third is composed of children. These blatant facts make the advocacy of UNICEF unilateral with the Stay Bird Flu Free Philippines.
This is the very reason why UNICEF is now involved in the IWAS BIRD FLU advocacy campaign, Mr. Yacat informed the PIA Regional Directors and Provincial Information Managers who were the participants in the seminar-workshop. The children are most vulnerable to bird flu and so the PIA information experts are requested to focus their advocacy programs in communicating bird flu to the children of the country.
Believing that everything is communication, UNICEF received a grant from the Government of Japan specifically for communication campaign on keeping the Philippines bird flu free. It is worth noting that Japan is one of the biggest importer of poultry products. Considering that Southeast Asia is the hardest hit with only the Philippines , Brunei and Singapore not affected with bird flu, Japan deemed it important to help keep the Philippines bird flu free. Japan has already assisted the bird flu stricken countries of Southeast Asia.
UNICEF is particularly focused on the communications side, particularly for children, in the prevention of bird flu in the country. It is important to inform and educate the Filipino children and other people not to touch sick or dying chicken or any other birds.
Observing proper hygiene, specifically hand hygiene plays a vital role in the prevention of bird flu. It is important that children and other people make it a habit to wash their hands.