Luke S. P. Moore, Infectious Diseases Physician and Clinical Microbiologist on behalf of the Healthcare Infection Society, directs our thoughts to optimising our control of infections and looks forward to the post-pandemic period
The months since January 2020 have demonstrated many things among our global community, including how citizens can and do respond to emphatic public health advice, the importance of emergency preparedness, and how difficult it can be to follow the science. These factors can, and on occasion have graphically resulted in a maelstrom of mixed messaging. Advice on social distancing, personal protective equipment and safe working conditions have oscillated, sometimes about-turning as data evolves. As we move slowly through this pandemic (1), perhaps now heading towards COVID-19 becoming endemic (2) rather than disappearing altogether, reflecting on how NHS infection services operate may enable us to deliver more effective care in the mid-to-long-term.
Enhancing the prevention, management & control of infections
Infection prevention and control teams have evolved through the last several decades, from vertical teams generating guidelines and analysing metrics instead towards horizontal programmes with stakeholder-driven change emphasising universal hygiene principles. Throughout this, the tenant of enabling healthcare, but ensuring that this is safe care, has remained central. This has been brought into stark relief during the pandemic where the waves of patients requiring inpatient care for COVID-19 have instead given way to more moderate, but constant, admissions. These patients with COVID-19 must now be managed in parallel to those citizens with other healthcare needs, with all efforts made to mitigate the possibility of cross-transmission within our healthcare environment.
It is on this issue that infection prevention and control teams are now focussing, supporting teams across the spectrum of clinical activity to assess and improve patient pathways to minimise the risk of onwards transmission of COVID-19. To support the return to business as usual, infection prevention and control teams input on changes to infrastructure (ventilation, waiting area segregation, room sizes, choice and use of equipment, etc.) and processes (personal protective equipment, decontamination, patient journey, etc.) across inpatient and outpatient care. Whilst national and international advice on how to do this continuously evolves, the application of these guidelines to individual healthcare settings requires local expertise. The overarching problem with actually accomplishing this, however, is that the requirement for input is large, covering all aspects of healthcare delivery, yet the infection specialists providing the expertise are historically small.
Building robust infection specialist services
Whilst the answer to too-small teams may seem obvious, the reality is more nuanced. To safely guide our clinical services through the COVID-19 pandemic- into-endemic transition requires more infection specialists, yet when not facing a worldwide contagious infection, what do they (we) do?
First, the day-to-day work of infection specialists is geared towards rapid and efficient diagnosis of, and safe management for, the common infections which can affect us all – pneumonia, urine infections, gastrointestinal infections, skin infection, meningitis, to name but a few.
Second, among those in hospital for other reasons, healthcare-associated infections (with the personal and financial costs they incur) and, in particular, infections from antimicrobial-resistant bacteria, have been progressively inhibiting the way we deliver safe healthcare for years. We are five years on from Jim O’Neill’s reports (https://amr-review.org/) on the threat of antimicrobial resistance, and the forecast that by 2050 it will kill more citizens per year than cancer, yet making headway in addressing this remains slow.
Finally, whilst hesitant to raise this before we are even out of COVID-19, with ever-faster globalisation, a return to inter-continental travel, and variable concordance to basic public health interventions in many areas, COVID-19 will not be the last pandemic we face.
A significant, and rapid, strategic level response to support the infrastructure of NHS infection services may, therefore, reap mid-and long-term benefits. An increased cadre of infection specialists would bolster the safe return to healthcare business as usual, but also aid our whole-healthcare response to common communicable diseases. It is likely to decrease healthcare costs from secondary infections and slow the spread of antimicrobial-resistant infections (aiding continuation of safe surgery and chemotherapy), as well as providing a robust and rapidly deployable team as we return to communicable disease threats from our wider global society.
Operationalising change in infectious diseases
Infection specialists are a complimentary group of multi-disciplinary professionals, from infection prevention and control nurses, through to doctors, antimicrobial pharmacists, healthcare scientists, and public health practitioners. While postgraduate training for all these professional groups takes time (several years), data-driven workforce planning must be applied to forecast NHS needs for this decade and beyond. Unfortunately, while attempts at national benchmarking infection services have been undertaken in other European and North American countries, fine resolution UK data is yet to be analysed.
This must be cognizant not only of the different roles infection specialists undertake but also be contextualised among the wider retention pressures facing NHS personnel.
Separate to personnel, the UK has led the way in many aspects of rapid diagnostics and machine learning to support responses to both the COVID-19 pandemic and in the field of antimicrobial resistance. Continuing to leverage engineering and artificial intelligence expertise, applying it across the spectrum of infectious diseases, and efficiently integrating it into patient pathways is a UK strength the NHS should capitalise on.
Undertaking such workforce planning and recruitment may seem laborious, and integrating technological solutions may involve infrastructure development costs, but the alternative is a failure to address the progressive undermining of modern medicine through antimicrobial resistance, and a failure to bolster our defences against the next pandemic.
1. A pandemic disease is one that spreads over multiple countries or continents.
2. An endemic disease affects large numbers of people across a population or region.