Thursday,25 April, 2019
Current issue | Issue 1323, (8 - 14 December 2016)
Thursday,25 April, 2019
Issue 1323, (8 - 14 December 2016)

Ahram Weekly

Infections in injections?

Rumours about the reuse of syringes and other instruments in Egypt’s hospitals have led to renewed concerns about hospital-acquired infections, writes Rasha Geddah

Al-Ahram Weekly

“I didn’t have Hepatitis C before I underwent hernia repair surgery in a university-affiliated hospital in Cairo,” grumbles Magda, a 50-something Hepatitis C (HCV) patient, whose tired, heavily wrinkled face expresses an inner sense of bitterness. Magda’s battle with the virus started a year ago when she was admitted to a university-affiliated hospital in the capital to have an operation for a hernia.

“My blood tests were clear of any disease before the surgery,” Magda maintains. She was asked to keep a cannula fitted for a month in her hernia following the operation until the wound was totally dry, but to her shock the wound did not heal properly and her legs swelled up. She went for a check-up at the same hospital where she had had the surgery, but was sent back twice with the message that it was just a matter of time until the wound healed up and her swollen feet would soon be back to normal.

“I decided to go to a private clinic, where the doctor suspected I had an infection. He asked for a blood test that showed I had contracted the Hepatitis C virus,” Magda added. “He said I had contracted the disease in the hospital.”

Magda is one of thousands of victims of hospital-acquired infections in Egypt caused in many cases by negligence or inadequate sterilisation. Former minister of health Adel Adawi conceded in press statements that hospital-acquired infections could be spread by the inadequate sterilisation of instruments used during surgery. He also said that data from the Ministry of Health has shown that Egypt had some eight to ten million HCV patients and 150,000 new ones every year.

He attributed the spread of HCV to negligence or inadequate sterilisation in hospitals as well as in dentistry clinics and blood transfusion and kidney-dialysis centres, as well as to the malpractice of hairdressers or barbers.

These alarming figures have prompted the Ministry of Health to adopt a national programme to combat hospital-acquired infections. The programme comes on the heels of a tragic incident in the Fakous Hospital in Zagaziq, where HCV was spread among patients with kidney failure due to the absence of sterilisation and other infection-control measures, including the breakdown of filtration equipment in the hospital’s dialysis unit.

Eight doctors and 36 nurses were questioned on allegations of negligence last year, but the question of whether other hospitals have sufficient infection-control measures remains open.

A few weeks ago a rumour on social media went viral, saying that some hospitals in Egypt had ordered the reuse of syringes and other medical instruments in order to make up for a shortage of such material because of the dollar shortage and inflation following the floatation of the pound.

The rumour spread after the deputy head of the Doctors Syndicate told a popular TV talk show via telephone that she had received a message on her mobile from a doctor, telling her that he and other colleagues had received oral directions from the management of the hospital where they worked asking them to cut the amount of medical equipment used by half, including syringes and intravenous fluids.

“This would mean that a patient could receive one instead of two bags of intravenous fluids and that syringes might not be disposed of after use, but might be used again in a total breach of infection-control procedures,” she said.

The comments then went viral on Facebook, provoking public panic, especially since they were widely misinterpreted to mean that syringes were shared among patients, whereas in fact the same syringe would be used again with the same patient and not with another one.

Health Ministry spokesman Khaled Megahed was quick to refute the claims, accusing the doctor of spreading rumors likely to cause public panic.

However, the doctor made it clear in press statements and on her Facebook account that the Ministry of Health had needed to take action to meet a shortage of pharmaceuticals and equipment due to soaring prices and that it had chosen these methods to do so. “The SMS on my mobile was only an alarm bell,” she wrote.

That alarm soon echoed among the public, which, already suffering from a deteriorating healthcare system, now faces new challenges in the light of current economic constraints. In particular, the rumours have raised concerns that Egypt’s already fragile infection-control system may be turning hospitals into hot spots for the contraction of disease.

ABSENCE OF FIGURES: Hospital-acquired diseases, or diseases that patients acquire while in medical facilities, are a global issue today. In developed countries it is estimated that some five to ten per cent of patients admitted to hospital contract some disease during their stay in healthcare facilities, according to the World Health Organisation (WHO).

Egypt, however, does not have adequate data on the issue. Whereas many patients, doctors and nurses claim infections are widespread in hospitals, officials refute such claims, saying Egypt has strong infection-control programmes. But in the absence of documentation, there is an absence of accountability in many cases of hospital-transmitted diseases.

The former minister of health said that the ministry had been monitoring infections in hospitals on a weekly basis and that the surveys had revealed that Egypt had a low rate of only three to five per cent of patients acquiring infectious diseases in health facilities. He said that these infections mostly occurred in public hospitals and were sometimes even caused by the low immunity of the patients themselves.

But many doctors remain sceptical. Maha Talaat, head of the infection-control department at the US Medical Research Unit (NAMRU) in Cairo, stated at a recent medical conference on the issue of infection-control in medical facilities that the US had an annual mortality rate of 100,000 out of every 2.5 million patients suffering from contracted diseases from healthcare facilities every year.

Talaat did not give figures regarding the number of people contracting infections in Egypt’s healthcare facilities, but said that a recent study assessing the volume of hospital-acquired infections had shown that the infections were mostly acquired through blood (29 per cent), followed by pneumonia cases (28 per cent), and in intensive-care units (ICU).

Many of those interviewed by Al-Ahram Weekly said that accurate statistics for the number of hospital-contracted diseases remained unavailable, largely due to the absence of proper documentation. Many patients and doctors told the Weekly that many hospitals refused to provide patients with the check-up reports they had had before and after operations in order to avoid any issues of liability arising.

The fact that diseases like Hepatitis C have a fairly lengthy incubation period further complicates the matter, and many patients, especially unmarried girls, feel reluctant to report their diseases for fear of the social stigma that could delay or hinder marriage.

Figures aside, a visit to Cairo’s National Institute for Liver and Endemic Diseases, affiliated to Cairo University’s Al-Qasr Al-Aini Hospital, reveals that Egypt has a serious problem with its infection-control systems.

It was early in the morning at the time of the visit, and hundreds of Hepatitis C and Hepatitis B patients had already filled every corner of the institute. They sat on plastic chairs, stairs and even floors or in corridors, either waiting for their turn to get a two-month stock of free medicine or to obtain a prescription that would allow them to claim free medication.

The majority of those interviewed by the Weekly said they were not sure when and how they had contracted the disease, but many insisted they had contracted it after surgery or in healthcare facilities.

PERSONAL TESTIMONY: Eman, a Hepatitis C patient in her early thirties, was sitting with her three-year-old son on the institute’s stairs waiting for her turn to get her medication.

“I discovered I had Hepatitis C seven months after I gave birth to my son,” Eman said, her face looking ten years older than her real age and bathed in sadness as she started to tell her story. “I had a Caesarean section operation in a big public hospital, and all my blood checks were clear prior to the operation. I started to get tired seven months later and went to a doctor who asked for a blood analysis. The analysis revealed I had Hepatitis C, which the doctor told me had probably been contracted due to the blood transfusion I had had during the delivery.”

Other patients similarly blamed certain hospitals or doctors for their diseases, but said they had not been able to report their complaints to the authorities owing to a lack of documentation. One Hepatitis C patient said she had wanted to file a complaint against the hospital where she said she had contracted the infection, but the hospital had refused to give her the blood test reports that would have showed she did not have the virus before the operation.

Hisham Al-Khayyat, a professor of gastroenterology and hepatology at the Theodor Bilharz Research Institute (TBRI) in Giza, said he had seen cases of HCV in patients who had contracted the virus during surgery or in healthcare facilities. He said that such infections did not occur only in small facilities in impoverished areas, as some people may think. Instead, they “can happen anywhere, in large public, university and private hospitals, especially in Cairo, and even in facilities known by name.”

The Hepatitis C virus usually has an incubation period of up to six weeks before its symptoms manifest themselves, according to Al-Khayyat. “About five to ten per cent of all HCV cases in Egypt occur due to hospital infections,” he said.

Bacteria may also lurk in intensive-care units, and these can cause severe pneumonia, Al-Khayat added. “Infection may happen through more than one medium. It could be acquired through medical instruments that should have been disposed of after use, but can be reused in hospitals, including endotracheal tubes for ventilation and nasogastric tubes for feeding. Sterilisation can be inadequate and not done according to international standards.”

Aliaa Abdel-Fattah, head of the Intensive Care Unit at the Al-Qasr Al-Aini Hospital, concurred, saying that pneumonia and bronchitis were the most common infections that could be contracted in hospitals. “It is internationally recognised that various kinds of bacteria live in intensive-care units and that these can cause infection. Pneumonia patients in hospitals can themselves be a source of infection, and the fact that we often do not have enough nurses to designate a special nurse to each case can lead to a higher rate of infection in hospitals,” Abdel-Fattah said.

In 2009, the Ministry of Health issued a survey showing that infections occurred in some 80 per cent of intensive-care units in Egypt and that many did not properly apply international standards. The former minister of health said five years later in a statement that only a small percentage of the country’s hospitals had received the relevant ISO certificate.

SHARED ACCOUNTABILITY: It was visiting time, and the Ain Shams University Demerdash Hospital in Cairo was like a park open to the public. Some patients’ family members were dotted around the hospital corridors, while others were sharing seats with patients in crammed units away from any direct supervision by the hospital.

The smell of detergent and pharmaceuticals mingled with that of the meals that the families had brought in metal and plastic vessels, all in the presence of nurses who jokingly asked them to abide by hospital rules. Leftovers and plastic bags soon filled the corridors where the families were sitting, and everybody’s features — patients, nurses and family members — seemed to reflect a similar state of concern.

“Infections do happen in hospitals, of course,” noted one nurse, who spoke on condition of anonymity. “A friend of mine contracted Hepatitis C during a delivery in another university-affiliated hospital. In this hospital, one patient contracted a serious bacterial infection that meant he had to be kept in and on antibiotics for a month,” she said.

The nurse explained that the infection was caused while fitting a device to regulate the heart. “The nurses always try to follow correct procedures, but too often we are treated as scapegoats,” she added.

However, Al-Khayat insisted that nursing staff in charge of sterilisation were often to blame for the spread of diseases in healthcare facilities. “Doctors have nothing to do with sterilisation,” he explained. “This is the responsibility of infection-control units in hospitals, and these are also supposed to keep every corner of the hospital clean, even ordering its closure if there are concerns that it is not sterile and bacteria-free. Keeping the hospital clean is essential. Negligence is a significant concern,” he said.

But Abdel-Fattah said that everybody should share responsibility for hospital-acquired infections: doctors and surgeons, those in charge of the intensive-care units, those in infection-control units and nurses. She said that the infection-control units in most university-affiliated hospitals, particularly the Al-Qasr Al-Aini Hospital, were very effective in combating the spread of infection.

Doctors, too, may contract hospital-transmitted infections, and after years of battling to increase their allowances in such cases to LE1,000 a month, the Administrative Court finally ruled in their favour last November. Previously, they only received LE19 despite being at risk of contracting an infection in their line of work.

According to the Doctors Syndicate, six doctors have died over the past three years and dozens had been left with long-lasting problems after contracting an infection at work. Doctor Ahmed Abdel-Latif, who died last year of a respiratory infection he contracted in a public hospital in Al-Qalyoubiya, is a case in point.

Finally, Abdel-Fattah insists that hospital-transmitted infections are decreasing today in Egypt, thanks to greater public awareness of the problem. That said, she added that more attention should be paid to issues of sterilisation in Egypt’s healthcare facilities and the application of international standards of disease-control if hospital-acquired infections are to be to eliminated.

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