Lauren Hurley explores how a renewed awareness of the importance of infection prevention and control should be maintained to manage future challenges

HURLEY Lauren

Lauren Hurley

Read this article to learn more about

  • the impact of the pandemic on infection prevention and control (IPC)
  • the role of vaccination within an effective IPC strategy
  • appropriate antimicrobial prescribing, and avoiding the spread of resistant organisms
  • how to implement the new national standards on healthcare cleanliness.

Read this article online at: GinP.co.uk/456945.article

Reflect on your learning after reading this article with our reflective template at: GinP.co.uk/454221.article

Reflection recordcpd logo

Reflection is important for continuous learning and development, and a critical part of the revalidation process for healthcare professionals. Reflect on what you have learned after reading this article with our interactive record.

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

Box 1: Key facts on measles

  • Before measles cases increased in 2018, the WHO had declared measles eliminated in the UK9
  • Patients who are at a higher risk of more severe measles complications include those who are immunosuppressed, young infants, and pregnant women10
  • Measles is transmitted through airborne routes, by droplet spread, by direct contact with nasal or throat secretions and, in rare circumstances, by contact with contaminated items8
  • Individuals are contagious from 4 days before the rash appears until 4 days after rash onset8
  • Cold-like symptoms usually appear 10–12 days after exposure, and include cough, fever, runny nose, and inflamed eyes—these can last for 7–21 days8,11
  • The distinctive maculopapular rash usually begins on the face and spreads to the rest of the body in the first 2–3 days8
  • Koplik spots—small white spots that form inside the mouth—may appear around the time of the rash, and last for 2–3 days8
  • Common complications caused by measles include temporary immunosuppression, diarrhoea, middle ear infection, and pneumonia8
  • Serious complications can include seizures, blindness, and inflammation of the brain8,11
  • Measles is a notifiable disease—laboratory verification is recommended and available through the UKHSA Virus Referencing Department12
  • Breakthrough measles in patients that have either completed a vaccination course or from previously contracted measles, is rare and usually mild, with fewer symptoms.8

WHO=World Health Organization; UKHSA=UK Health Security Agency

Table 1: Risk assessment of measles cases8
Laboratory/epidemiological features   Clinical features
Typical Mild Atypical
Laboratory confirmed Red Red Red
Epidemiologically confirmed Red Red Amber
Factors that favour measles Red Amber Amber
None of the above Amber Green Green

Public Health England. National measles guidelines: November 2019. London: PHE, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/849538/PHE_Measles_Guidelines.pdf

Contains public sector information licensed under the Open Government Licence v3.0.

Table 2: Management of measles cases and vulnerable contacts8
Risk assessmentManagement

Green

  • Post oral fluid kit—sample returned to VRD

Amber

  • Urgent testing of case
  • Assess susceptibility of vulnerable contacts[A] and arrange PEP if appropriate
  • Post oral fluid kit—sample returned to VRD

Red

  • Do not await further testing of case
  • Assess susceptibility of vulnerable contacts[A] and arrange PEP if appropriate
  • Post oral fluid kit—sample returned to VRD

[A] Vulnerable contacts include immunocompromised contacts, infants, and pregnant women for cases where primary measles is suspected, and immunocompromised contacts where breakthrough measles (reinfection) is suspected. This is discussed further in section 2.2. of the PHE National measles guidelines: November 2019, and the PHE Measles post-exposure prophylaxis guidelines.

VRD=Virus Referencing Department; PEP=post-exposure prophylaxis; PHE=Public Health England

Public Health England. National measles guidelines: November 2019. London: PHE, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/849538/PHE_Measles_Guidelines.pdf

Contains public sector information licensed under the Open Government Licence v3.0.

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

Figure 1 The UKs nine ambitions for change

Figure 1: The UK’s nine ambitions for change22

AMR=antimicrobial resistance

HM Government. Contained and controlled: the UK’s 20-year vision for antimicrobial resistance. London: HM Government, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/773065/uk-20-year-vision-for-antimicrobial-resistance.pdf

Contains public sector information licensed under the Open Government Licence v3.0.

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

Key points

  • Primary care has been deeply disrupted by the COVID-19 pandemic, with ramifications that are far-reaching and not yet completely understood
  • Reinvigorated relationships between primary care and IPC teams should be maintained and nurtured, to put us in the best position to tackle future complications together
  • Conversations with primary care patients about vaccine hesitancy are extremely important, especially within the context of well-established and important programmes such as MMR vaccination
  • Engaging with AMR programmes and keeping up to date with local and national updates will be important in primary care in the aftermath of COVID-19
  • The National standards of healthcare cleanliness 2021 will aid us in reassuring our patients that healthcare environments remain as clean as they have come to expect during the pandemic
  • Primary care will undoubtedly be at the forefront of future health emergencies, and we must make the most of the lessons learnt during the pandemic, in order to protect our patients from future threats.

IPC=infection prevention and control; MMR=measles, mumps, and rubella; AMR=antimicrobial resistance

Reflection recordcpd logo

Reflection is important for continuous learning and development, and a critical part of the revalidation process for healthcare professionals. Reflect on what you have learned after reading this article with our interactive record.

References

  1. Guerra F, Bolotin S, Lim G et al. The basic reproduction number (R0) of measles: a systematic review. Lancet Infect Dis 2017; 17 (12): e420–e428.
  2. World Health Organization website. More than 140,000 die from measles as cases surge worldwide. www.who.int/news/item/05-12-2019-more-than-140-000-die-from-measles-as-cases-surge-worldwide (accessed 9 May 2022).
  3. Oxford Vaccine Group website. Measles. vk.ovg.ox.ac.uk/vk/measles (accessed 9 May 2022).
  4. Plans-Rubió P. Are the objectives proposed by the WHO for routine measles vaccination coverage and population measles immunity sufficient to achieve measles elimination from Europe? Vaccines 2020; 8 (2): 218.
  5. UK Health Security Agency. Laboratory confirmed cases of measles, rubella and mumps, England: July to September 2021—Health Protection Report, Volume 16 Number 1. London: UKHSA, 2021. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1049177/hpr0122-MMR_final.pdf
  6. UK Health Security Agency website. Around 1 in 10 children starting school at risk of measles. www.gov.uk/government/news/around-1-in-10-children-starting-school-at-risk-of-measles (accessed 9 May 2022).
  7. Wilkinson E. Is anti-vaccine sentiment affecting routine childhood immunisations? BMJ 2022; 376: o360.
  8. Public Health England. National measles guidelines: November 2019. London: PHE, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/849538/PHE_Measles_Guidelines.pdf
  9. UK Health Security Agency website. Measles in England. ukhsa.blog.gov.uk/2019/08/19/measles-in-england/ (accessed 9 May 2022).
  10. NICE. Measles: what are the complications? NICE Clinical Knowledge Summary. NICE, 2018. cks.nice.org.uk/topics/measles/background-information/complications/ (accessed 9 May 2022)
  11. NHS England website. Measles. www.nhs.uk/conditions/measles/ (accessed 9 May 2022).
  12. Public Health England. Immunisation and diagnosis unit (IDU): diagnostic and reference services. PHE, 2021. www.gov.uk/guidance/immunisation-and-diagnosis-unit-idu-diagnostic-and-reference-services (accessed 9 May 2022).
  13. World Health Organization website. Urgent health challenges for the next decade. www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade (accessed 9 May 2022).
  14. DH. UK antimicrobial resistance strategy and action plan. London: DH, 2000. Available at: webarchive.nationalarchives.gov.uk/ukgwa/20101105203430mp_/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4078448.pdf
  15. HM Government. Tackling antimicrobial resistance 2019–2024: the UK’s five-year national action plan. London: HM Government, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/784894/UK_AMR_5_year_national_action_plan.pdf (accessed 9 May 2022).
  16. Smieszek T, Pouwels K, Dolk F et al. Potential for reducing inappropriate antibiotic prescribing in English primary care. J Antimicrob Chemother 2018; 73 (suppl 2): ii36–ii43.
  17. UK Health Security Agency. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR)—report 2020 to 2021. London: UKHSA, 2021. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1033851/espaur-report-2020-to-2021-16-Nov.pdf
  18. Andrews A, Budd E, Hendrick A et al. Surveillance of antibacterial usage during the COVID-19 pandemic in England, 2020. Antibiotics 2021; 10 (7): 841.
  19. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022; 399 (10325): 629–655.
  20. Parmar R. What the COVID19 UK response can teach us to combat antimicrobial resistance. www.imperial.ac.uk/news/234237/what-covid19-uk-response-teach-combat/ (accessed 9 May 2022).
  21. London School of Hygiene and Tropical Medicine. AMR centre seminar 14-07-21. London: LSHTM, 2021. Available at: lshtm.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=11922f04-f1fc-412c-8104-ad6500e88715
  22. HM Government. Contained and controlled: the UK’s 20-year vision for antimicrobial resistance. London: HM Government, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/773065/uk-20-year-vision-for-antimicrobial-resistance.pdf
  23. Public Health England. Summary of antimicrobial prescribing guidance: managing common infections. London: PHE, 2021. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/994444/Common_Infect_PHE_context_references_and_rationale_May_2021_Bites_and_Eczema__1_.pdf
  24. Public Health England. Antimicrobial resistance: resource handbook. London: PHE, 2017. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/768999/PHE_AMR_resource_handbook.pdf
  25. UK Health Security Agency. World Antimicrobial Awareness Week (WAAW) and European Antibiotic Awareness Day (EAAD).  London: UKHSA, 2021. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1025912/waaw-eaad-resources-toolkit-healthcare-professionals-england.pdf
  26. Royal College of General Practitioners website. TARGET antibiotics toolkit hub. elearning.rcgp.org.uk/course/view.php?id=553?gclid=Cj0KCQjwl7qSBhD-ARIsACvV1X2-Q0Rbq3zUhlheZobFp5tDE4IPbJh84wuzwL2l-C2z-jMdKKXbCXcaAqePEALw_wcB (accessed 9 May 2022).
  27. NHS England website. Antibiotic quality premium monitoring dashboard. www.england.nhs.uk/ccg-out-tool/anti-dash/ (accessed 9 May 2022).
  28. PrescQIPP Community Interest Company website. Antimicrobial stewardship. www.prescqipp.info/our-resources/webkits/antimicrobial-stewardship/ (accessed 9 May 2022).
  29. elearning for healthcare website. Antimicrobial resistance and infections. www.e-lfh.org.uk/programmes/antimicrobial-resistance-and-infections/ (accessed 9 May 2022).
  30. World Health Organization. WHO antibiotic categorization. aware.essentialmeds.org/groups (accessed 9 May 2022).
  31. NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE Guideline 15. NICE, 2015. Available at: www.nice.org.uk/guidance/ng15
  32. NHS England. National standards of healthcare cleanliness 2021. London: NHS England, 2021. Available at: www.england.nhs.uk/wp-content/uploads/2021/04/B0271-national-standards-of-healthcare-cleanliness-2021.pdf
  33. NHS England. National standards of healthcare cleanliness 2021: supporting documents.  London: NHS, 2021. Available at: www.england.nhs.uk/publication/national-standards-of-healthcare-cleanliness-2021-supporting-documents/
  34. NHS England. National standards of healthcare cleanliness compliance grid. London: NHS England, 2021. Available at: www.england.nhs.uk/wp-content/uploads/2021/04/nshc-21-compliance-grid.docx
  35. UK Health Security Agency. UKHSA calls for a renewed effort to tackle TB. London: UKHSA, 2022. Available at: www.gov.uk/government/news/ukhsa-calls-for-a-renewed-effort-to-tackle-tb (accessed 9 May 2022).
  36. UK Health Security Agency. Increase in hepatitis (liver inflammation) cases in children under investigation. London: UKHSA, 2022. Available at: www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-children-under-investigation (accessed 9 May 2022).

Credit:
Lead image: Maridav/stock.adobe.com