Stay Focused on Infection Control to Anticipate the Next Crisis

Lauren Hurley Explores how a Renewed Awareness of the Importance of Infection Prevention and Control Should be Maintained to Manage Future Challenges

Primary care may not be the focus of the many COVID-19-inspired books and television dramas that will inevitably grace our shelves and screens in the coming years, but the challenges of the pandemic have been felt as much here as within acute trusts and care homes.

For most patients affected by COVID-19, their GP has been the first port of call. Surgeries have had to adapt quickly to seeing more patients within different access streams, and have had to maintain patient-centred care while dealing with ever-changing guidelines, staffing shortages, outbreaks, and unprecedented demand for appointments.

Our response will undoubtedly be scrutinised in years to come, but one positive outcome must be the renewed engagement with infection prevention and control (IPC) measures.

A Changed Perception of IPC

IPC has often been seen by the wider workforce as an authoritarian process, designed to create extra work and criticism. The COVID-19 pandemic has brought IPC teams into much closer working relationships within their organisations, and has strengthened the connections between primary care and local IPC support systems, which can include the local authority, CCG, and UK Health Security Agency (UKHSA) health protection teams. Within the Hertfordshire and West Essex (HWE) CCGs (soon to be the HWE Integrated Care System), we have held monthly primary care webinars to discuss topics such as vaccinations, new COVID-19 variants, updates to guidelines, and new national cleaning standards. The excellent attendance at these webinars provides reassurance that IPC will remain a priority. This article discusses some of the challenges we face as we move on from the pandemic.

The Declining Uptake of Childhood Measles Vaccination

Measles is caused by Measles morbillivirus (MeV), a single-stranded, negative-sense RNA virus. Although it varies depending on local factors, measles has an estimated reproduction rate of 12–18, making it one of the most contagious human infections and a major cause of childhood morbidity and mortality.¹ In a global surge of measles cases in 2018, more than 140,000 people died from the infection, mostly children aged less than 5 years.²

Vaccination for measles has been hugely successful; since 1990 (when measles killed 872,000 people), it is estimated that more than one in five of all child deaths that have been averted have been due to the vaccine.³ Despite this, MeV continues to cause outbreaks, especially when vaccination coverage falls below 95% of the population.⁴ Although the primary symptoms of measles, such as fever and rash, may seem innocent enough, measles causes immunosuppression that can last for up to 3 years and that results in susceptibility to opportunistic infection, which can be much more serious.³

Since the beginning of the COVID-19 pandemic in 2020, there have been fewer cases of measles—this is likely due to enhanced IPC precautions, national lockdowns, reduced international travel, and a reduction in healthcare-seeking behaviour.⁵ However, there has also been a worrying drop in the numbers of children getting their vaccinations at the correct time, including the measles, mumps, and rubella (MMR) vaccine.⁶ It is estimated that coverage of the first dose of the MMR vaccine in England has dropped below 90% in 2-year-olds, and uptake of the second dose has dropped to 85.5% in 5-year-olds.^6,7 This reduced uptake may be due to confusion about access to primary care during the pandemic, worries about attending healthcare settings, or a wider vaccine hesitancy that may have been exacerbated by the roll-out of the COVID-19 vaccination programme.⁷

Primary care plays an important role in supporting patients to protect themselves and their children against infections such as measles. One of the simplest ways to do this is to raise awareness about the impact of the infection and the efficacy of the MMR vaccine; recent UKHSA research shows that almost half of parents surveyed whose children were aged 5 years or younger were not aware that measles can lead to serious complications; only 38% were aware that it can be fatal, and 56% were not aware that two doses of the MMR vaccine provides 99% protection against both measles and rubella.⁶ Box 1 includes some key facts about measles that can be shared with patients.^8–12

Full public health guidance on the risk assessment, diagnosis, and management of measles can be found in the National measles guidelines, published by Public Health England in 2019, and summarised in Table 1 and Table 2.⁸

Table 1: Risk Assessment of Measles Cases⁸

Table 2: Management of Measles Cases and Vulnerable Contacts⁸

Antimicrobial Resistance

Antimicrobial resistance (AMR) has been highlighted by the World Health Organization (WHO) as one of the most urgent global health challenges of the next decade, alongside climate change.¹³

The UK has made good progress in raising awareness of AMR since publication of the DH’s UK antimicrobial resistance strategy and action plan in 2000,¹⁴ increasing its AMR surveillance and implementing quality-improvement programmes to tackle the issue. However, as highlighted in the 5-year action plan for AMR, Tackling antimicrobial resistance 2019–2024, there is still more work to be done to decrease the UK’s antimicrobial prescribing rate, which is around double that of parts of Scandinavia and the Netherlands.¹⁵

From 2013–2015, it is estimated that 8.8–23.1% of antibiotics in primary care were inappropriately prescribed,¹⁶ but more recently, we have seen a decrease in the number of antibiotics prescribed in the GP setting, with a 23.2% reduction between 2016 and 2020.¹⁷

However, although there has been a general reduction in antimicrobial use in the UK, prescribing of antibiotics commonly used for respiratory infections—including broad-spectrum, ‘watch group’ antibiotics (those that have high resistance potential)—increased in both hospital and community settings during the pandemic.¹⁸ This was to be expected to some extent, as the symptoms of severe acute respiratory syndrome coronavirus-2 infection are comparable to many bacterial infections of the respiratory tract.¹⁸

The impact of AMR on healthcare systems has also become more difficult to assess during the pandemic as a result of changes to healthcare delivery and healthcare-seeking behaviours. As we return to ‘business as usual’, it is unclear whether there will be a rise in antimicrobial use and antibiotic-resistant infections compared with pre-pandemic levels. However, a recent report published by the Global Research on Antimicrobial Resistance Project estimates that AMR has become a significant global cause of death, overtaking both HIV and malaria.¹⁹ There are some calls to treat the AMR crisis in a similar way to COVID-19, with increased funding for research and surveillance, acceleration of development of therapeutics, and international collaboration.^20,21 However, the slower nature of AMR as an issue and the lack of visible impact on people’s day-to-day lives and the economy mean that it would take a substantial effort for this to happen.

Alarmingly, we are seeing an increase in carbapenemase-producing Gram-negative organisms that have acquired resistance to key antibiotics.²² This is often because of poor prescribing practice, import from different regions of the world, and local spread.²² It is imperative that we observe good infection control and prescribing practice to avoid the spread of this type of resistance within the UK, as there are few remaining options for treatment.²²

In 2019, the Government published Contained and controlled: the UK’s 20-year vision for antimicrobial resistance, which details the challenges posed by AMR and outlines the Government’s aims to combat this over the next two decades.²² Figure 1 shows the UK’s nine ambitions for change.²²

An important part of the Government’s action plan will be to continue to reduce the overall number of antibiotics prescribed in the UK and the number of inappropriate antibiotic prescriptions within primary care.

Resources to support appropriate antibiotic prescription in primary care include:

• local apps available for download with local prescribing guidelines for individual infections
• Public Health England guidance, including Summary of antimicrobial prescribing guidance: managing common infections²³ and Antimicrobial resistance: resource handbook²⁴
• the World Antimicrobial Awareness Week and European Antibiotic Awareness Day resources toolkit²⁵
• the Royal College of General Practitioners TARGET antibiotics toolkit hub²⁶
• the NHS England and NHS Improvement antimicrobial stewardship (AMS) dashboard²⁷ and PrescQIPP AMS hub²⁸
• online learning platforms such as elearning for healthcare from Health Education England²⁹
• the WHO AWaRe classification of antibiotics³⁰
• NICE Guideline 15, Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use, and the NICE quick reference tools³¹
• support from community pharmacists.

Maintaining Cleanliness in Healthcare Settings

The first NHS National Cleaning Standards were published in 2001; since then, we have benefited from the opportunity to measure cleanliness in a uniform way, with benchmarks for different types of healthcare environment.

Robust and proportionate cleaning practices have been a necessity during the COVID-19 pandemic, and a renewed focus on these will be useful for protecting our patients in the future. The National standards of healthcare cleanliness 2021 emphasise the transparency required to reassure our patients that the expected levels of cleanliness have been met.³²

The new standards state that different spaces within healthcare environments must be assessed and assigned to functional risk areas (1–6), which require different standards and frequencies for cleaning.³² By using the functional risk categories, these standards are flexible enough to be applied to any healthcare environment.

With collaborative responsibility for cleanliness at the heart of the new standards, they will result in the use of star ratings for patient-facing areas to give patients, staff, and the public an easy-to-understand, visual indicator of the standard of cleanliness being met.³² The standards also introduce ‘commitment to cleanliness’ charters that highlight the importance of a collaborative approach and publicise the provider’s commitment to achieving an excellent level of cleanliness.³³

Although the standards are complex, they are also supported by an audit tool and a set of appendices.^32,33 The topic is frequently discussed at the HWE CCG’s monthly IPC webinar, which includes guest speakers on the subject—all of the webinars are recorded and available for viewing at (hwetraininghub.org.uk), along with a toolkit for general practice created by the HWE IPC team.

IPC teams across the country are working with local providers to achieve these standards within the required 18 months.³⁴ We must use the current spotlight on IPC, including new interest from the public, to help us to improve the quality of care for our patients as we move into a post-pandemic world, whenever that may be.

Summary

There is no way of knowing where the next threat to our healthcare systems will come from. Will issues emerge from renewed vaccine hesitancy, AMR, or as a result of a sudden return to worldwide travel and social mixing? The current increase in cases of tuberculosis³⁵ and ongoing investigations into paediatric hepatitis of unknown origin³⁶  only serve to highlight the unknowns that remain about the long-term consequences of the pandemic.

We are likely to feel ripples for years to come, meaning that the importance of good IPC measures, surveillance programmes, and addressing healthcare inequalities on a national and global scale must remain a focus of healthcare policy.

Lauren Hurley

IPC Practitioner, NHS Herts Valleys CCG