Clean care – the everyday measure to prevent, prepare for, respond to and recover from health emergencies

Mitchell Schwaber

Hand Hygiene Day on 5 May is a chance to promote the “Clean hands save lives” campaign. Everyone has the right to expect clean care, whether that care is administered in a field hospital, a care home or a state-of-the-art operating theatre. The simple act of cleaning hands is part of a bigger picture that includes emergency preparedness, outbreak control and the fight against antimicrobial resistance.

As an infection control specialist, Professor Mitchell Schwaber was part of the taskforce that dealt with an outbreak of a deadly, drug-resistant form of Klebsiella bacteria in Israel in 2006. He has unique insight into how this outbreak was brought under control with measures based on the fundamentals of infection control, including proper hand hygiene. The lessons learned from this challenge changed Israel’s approach to infection prevention and control forever, helping to prevent future outbreaks.

Carbapenem-resistant Klebsiella (CRK) is believed to have arrived in Israel in late 2005, and it spread like wildfire throughout health-care institutions. The bacteria can cause dangerous infections in vulnerable patients, infecting wounds and blood and causing pneumonia.

Because this form of Klebsiella is resistant to most classes of antibiotics, it can be very hard to treat. At the time, no national body for infection control was in place in Israel, making it almost impossible to build a picture of the national situation. Then, in 2007, a meeting gathered various infection control specialists and led to a dramatic realization.

“Everybody brought the data from their institution and when we all got together in one room we saw what was going on. We realized this was threatening the entire inpatient infrastructure in the state of Israel,” Professor Schwaber explains.

Inpatient infrastructure under threat

The group informed the Ministry of Health immediately and made 2 recommendations: first, issue national orders on how to effectively isolate patients who were carriers of CRK; second, create a taskforce to oversee implementation of the orders and carry out additional measures necessary to confront the outbreak.

The Ministry carried out both of these recommendations, and the taskforce became the National Institute for Infection Control and Antimicrobial Resistance. Its mandate is to act as a permanent national infection control body, developing policy beyond CRK.

“The first circular we put out was about hand hygiene in 2009,” Professor Schwaber recalls. “We realized this represented the ABCs: you can’t do infection control without firmly establishing hand hygiene. Since that time, it has become the law of the land.”

The circular came out at the same time as the WHO guidelines on hand hygiene in health care. Both were based upon the 5 moments to ensure clean hands:

  • before touching a patient;
  • before clean/aseptic procedures;
  • after body fluid exposure/risk;
  • after touching a patient; and
  • after touching patient surroundings.

Lessons learned created lasting change

The CRK outbreak ultimately led to lasting change. The Institute performs site visits, conducts staff training and teaches principles of hand hygiene surveillance, underscoring its perception of hand hygiene as a pillar of infection prevention and control.

“Infection control begins with hand hygiene,” Professor Schwaber emphasizes. “There’s a lot more to it than that, but if you are not doing hand hygiene, you are not doing infection control. My greatest hope would be that one day our regulatory role becomes superfluous, that our Institute no longer has to be the enforcer because everyone knows what they need to do, and they are all doing it.”

“Good hand hygiene is the first tool we reach for in our toolbox for infection prevention and control,” says Dr Dorit Nitzan, Acting Regional Emergency Director at WHO/Europe. “The experience from Israel is a great example of an effective health emergency management cycle moving from the initial response to the recovery phase, during which health systems are strengthened for future response.”

“Clean care is an essential part of this cycle,” she emphasizes. “It protects the most vulnerable, saves lives, helps combat antimicrobial resistance – and it all starts with clean hands.”