1

2020

International

HosCom stands for Hospital Communication.
We aim to provide useful information
to the healthcare professionals involved in Infection Prevention
and Control to promote the sharing of knowledge
and experience globally so that we can improve further together.

2020 vol.1

c o n t e n t s
01

Excellence in hand hygiene begins where strategy,
leadership, and culture come together
Alexandra Peters, MA, PhD candidate & Prof. Didier Pittet, MD, MS, CBE

In fection Cont r ol Pr ogr am and W HO C o l l a b o r a t i n g C e n t r e o n P a t i e n t S a f e t y ,The Univer s it y of G enev a Hos pit als an d F a c u l t y o f M e d i c i n e , G e n e v a , S w i t z e r l a n d

06

Why should my hospital use the Hand Hygiene
Self-Assessment Framework proposed by
the World Health Organization?
Chloé Guitart1, Camille Bleeker2, Alexandra Peters1, Didier Pittet1

1 Infe ctio n Cont r ol Pr ogr am m e and W H O C o l l a b o r a t i n g C e n t r e o nPatie nt Saf et y , Univ er s it y of G enev a H o s p i t a l s a n d F a c u l t y o f M e d i c i n e ,Gen ev a, Swit z er land
2 Univer s it y of G enev a Fac ult y of M ed i c i n e , G e n e v a , S w i t z e r l a n d

10Current situation and challenges of
nosocomial infection in Vietnam
Phung Manh Thang1, Nguyen Van Khoi2

1 Dep artm ent of I nf ec t ion Cont r ol, Cho R a y H o s p i t a l
2 Vice Dir ec t or of Cho Ray Hos pit alWorld Information
Excellence in hand hygiene begins where strategy,
leadership, and culture come together
Alexandra Peters, MA, PhD candidate & Prof. Didier Pittet, MD, MS, CBE
Infection Control Program and WHO Collaborating Centre on Patient Safety,
The University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland

Everyone knows that hand hygiene is vitally important inhealthcare, but to date, no one has figured out how to achieve
optimal compliance. How does one achieve excellence inhand hygiene? In order to analyze this question one must firstunderstand the nature of “excellence” and its components, aswell as the context that makes hand hygiene so deceptively
simple and intuitive as an intervention, but so complex anddifficult to implement successfully. This paper will look atavailable tools for improvement and implementation, as wellas key case studies and examples that help to illustrate thequalitative aspects of the field.
Healthcare-associated infection is known for being one of
the main causes of morbidity and mortality, and the mostfrequent adverse event in healthcare worldwide. 1 It has
been long recognized that improved compliance with handhygiene drastically reduces healthcare-associated infections.2
More recently, the pivotal role of preventing healthcareassociated infections in combating antimicrobial resistancehas also been receiving increased recognition.3 If healthcareassociated infections are reduced, then there is less needfor prescribing antibiotics to patients, thus lowering theirconsumption and reducing the spread of resistant organisms.
As it is generally recognized that 50-70% of healthcareassociated infections are transmitted by healthcare workers’
hands; hand hygiene with alcohol-based handrub is the

1a. System change –alcohol-based handrub at point of care
1b. System change – access to safe,
continuous water supply, soap and towels
2. Training and education
3. Evaluation and feedback
4. Reminders in the workplace
5. Institutional safety climate
Figure 2. The Five Components of the WHO multimodal
hand hygiene improvement strategy

primary line of defense against such transmission.
There are numerous components that need to be inplace for hand hygiene with alcohol-based handrub to be
successful within a hospital, and for healthcare workers to
be compliant with the World Health Organization (WHO)5 Moments for hand hygiene (see Figure 1). While someare relatively easy physical measures to implement, others
involve influencing the behavior of healthcare workers,
and are much more difficult to realize. The WHO developed
a guide for implementation as a tool to facilitate handhygiene adoption in healthcare settings around the world.
This guide is constructed around the WHO multimodal
strategy, which consists of system change, training andeducation, evaluation and feedback, reminders in theworkplace, and institutional safety climate (see Figure 2).4

The Multimodal Strategy
Figure 1. My five moments for Hand Hygiene in Health CareFirst and foremost, system change must be implemented bymaking sure that high quality alcohol-based handrubs are1

World Information
available. This means they must have optimal antimicrobial
efficacy, an optimal distribution system on hands, and be
optimally placed in the healthcare setting at the point ofpatient care. The second part of the strategy consists oftraining and educating healthcare workers so that they
understand the 5 Moments for when to use hand hygiene,
how much alcohol-based handrub to use and how tohandrub. In order to make the training part of everyday
practice, the WHO recommends evaluating and sharing
performance feedback with the healthcare workers on how
and when they performed hand hygiene - if the actions
were sufficient and if they were performed at the right timein order to foster a more complete understanding of theprocess. Reminders in the workplace are the fourth part,and involves using tools such as posters or screen savers tokeep the idea of performing hand hygiene in the healthcare
workers’ mind in everyday situations. The last part of the
WHO multimodal strategy -“institutional safety climate”- isa bit less precise, as it concerns purely qualitative aspectsof healthcare worker behavior and perception. According
to the guide, it “refers to creating an environment andthe perceptions that facilitate awareness-raising about
patient safety issues while guaranteeing consideration ofhand hygiene improvement as a high priority at all levels,
including active participation at both the institutional andindividual levels; awareness of individual and institutional
capacity to change and improve (self-efficacy); andpartnership with patients and patient organizations.”4
Unlike the other components that are comparatively
straightforward to realize in the sense that there are set
processes in place that can be adapted to any hospital, theinstitutional safety climate remains an intangible, albeit crucialcomponent to hand hygiene compliance.

The Quest for Excellence
We cannot improve the institutional safety climate without
talking about culture change. We cannot talk about culturechange without understanding the current culture andwithout talking about implementation science. We cannot talkabout implementation science if we do not take into accounthow people think and work, and what is important to them.
Institutional safety climate is inextricably linked to the notionof excellence, and to the idea that healthcare workers embody
their knowledge and feel that they have ownership of theculture of safety in a hospital. But what exactly is excellence,and how can we encourage it in practice?
Excellence in individuals, institutions, and companies is both acommitment and a process, and people need to make it theirs.
Beyond the behavior of healthcare workers, hospitals need tohelp nurture environments that support staff and put patient2

safety at the center of the care they provide. Companies can
excel by providing the best possible products that they can to
the market, and help support the United Nations’ sustainable
development goals as well as the WHO agenda towards
quality universal health coverage. Excellence is a journey, andcontinuous improvement, innovation, and sustainability are
key elements.
Of course the main framework is and will always be thescience, the evidence. Healthcare workers need access toquality alcohol-based handrub, and they need to know how
to use it. But practice is not theory, people are not rationaland hospitals are hectic and stressful places. A perfect onesize-fits-all solution does not exist because cultures, value
systems, resources, working conditions and education vary
greatly among healthcare workers populations. By connecting
leadership, strategy and culture in a way that makes sense
to each individual institution’s needs, we can move towards
excellence.

LeadershipWithout the involvement of the WHO, hand hygiene could
have never become a standard worldwide practice inhospitals this quickly. The story began in the mid-1990s,
when researchers at the University of Geneva Hospitals
were able to demonstrate that using alcohol-based handrub
for hand hygiene was revolutionary in terms of its efficacy
and the time that it saved. After being published in The
Lancet in 2000, 2 the “Geneva Model” for hand hygiene
garnered worldwide attention and began to be implemented
in institutions around the world.5,6,7,8
The WHO launched the World Alliance for Patient Safety
in 2004,9 and soon after incorporated hand hygiene as thecentral part of its Clean Care is Safer Care campaign. They
tested the implementation of the multimodal strategy in aquasi-experimental study in six countries with vastly different
cultures and resources (Costa Rica, Italy, Mali, Pakistan andSaudi Arabia).10 The study proved successful worldwide acrossgeographic regions, healthcare worker categories, and levelsof development (see Figure 3). This study highlighted theimportance of adaptation of the multimodal strategy to local
resources and access to alcohol-based handrub, including thefeasibility of producing alcohol-based handrub locally.10,11,12
In 2009, the updated version of the guidelines for the WHO
Guidelines on Hand Hygiene in Health Care was published,with particular focus given to the implementation of themultimodal improvement strategy. That same year, WHOstarted the SAVE LIVES: Clean Your Hands campaign,choosing the 5th of May as the international day for handhygiene (in reference to the 5 moments for hand hygiene andthe 5 components of the multimodal strategy).13,14

2020 vol.1(%)

Compliance with hand hygiene

100

(a)

80

60

WHO and the ongoing commitment of healthcare facilities
worldwide, hand hygiene is now a key indicator of quality ofhealthcare systems around the world.

71.5%

67.1%

65.7%
60.1%

54.9%

59.9%

51.3%
43.7%

36.6%
40

20

0

(%)

100

NursesMD

NS
Auxiliary
Health profession

MS

Others(b)
86.9%Compliance with hand hygiene

54.9%

47.8%

46.7%

74.9%

80

51.6%

60

Strategy: Adapt to Adopt

81.3%

76.1%
68.6%

58.6%

54.4%
40.0%

40

28.7%

20

0

1

2

Beyond the global leadership of the WHO, it is important
to note that leadership is also crucial on national, local, andinstitutional levels. Wards with a head nurse who is strong
in infection prevention and control and champions of handhygiene in the staff have a very different culture of compliancethan those that do not. Each individual, no matter what
their function, can be a champion of hand hygiene in their
institution, and can make a real difference in patient safety.

3
Moment

Before intervention

4

5

After intervention

Figure 3. Effect of the implementation of the World HealthOrganization multi-modal strategy across (a) healthcare
worker categories and (b) moments (indications) for
hand hygiene; quasi-experimental study.
MD : medical doctor, NS : nursing student, MS : medical student
Reprinted with permission from Allegranzi B et al. Lancet Infect Dis 2013;13:843-51.

In 2010, the WHO issued the Hand Hygiene Self-Assessment
Framework (HHSAF) as a tool for healthcare facilities toassess their level of success at implementing hand hygiene
measures in their institutions.15,16 This tool looks at specificindicators within each of the components of the multimodal
strategy, and allows institutions to score themselves by
the number of points obtained. The Hand Hygiene SelfAssessment Framework then directs healthcare facilities
to the appropriate WHO tools for improving their scoresin specific areas.15 The institutions with the highest scores
globally then have the possibility to apply for the Hand
Hygiene Excellence Award (HHEA; www.hhea.info).
To date, over 21,000 healthcare facilities have joined the
WHO campaign for hand hygiene, and it is endorsed bynational agencies as well as professional societies and privatecompanies around the world.13,17,18 The global implementationof hand hygiene has become the most successful WHO
initiative ever undertaken, and currently most of the world(over 140 countries) have signed the WHO pledge, officiallycommitting to implementing hand hygiene and the WHO
Guidelines at a national level. 19,20 Because of the work of

The WHO multimodal strategy, 5 Moments for hand hygiene
and their associated tools are all part of the prerequisite
strategy that was used for implementing the use of alcoholbased handrub in healthcare facilities worldwide. The tools
promoted by the WHO can be adapted to different languages,
cultural contexts and available resources. The principlethat ministries of health and hospitals can make thesetools adapted to their needs is essential to their successful
implementation.21 In Japan, Hello Kitty has been used to teachhand hygiene; in other places, the color, order, language andway of teaching were changed as well in order to adapt tolocal needs.21 Some have tested interventions such as useable
reminders when the healthcare worker enters or exits anarea.22 What remains most important is that institutions figureout what works for them, and that they do that.
Private companies have become an instrumental ally inhelping countries and health facilities “adapt to adopt”. In2012, the WHO launched the Private Organizations forPatient Safety (POPS), in an effort to encourage corporatesocial responsibility and harness the strengths of industry to
improve the implementation of the WHO guidelines aroundthe world. 18 These companies have the distinct advantage
of being in the field on a daily basis and have a unique
opportunity to drive excellence at the facility level.

CultureThe term “culture” is rather broad, yet relevant to each level ofanalysis. It can refer to a culture of excellence (or carelessness)within a specific institution, societal norms that impact alcoholbased handrub adoption in certain regions of the world, or theway that one can create change on a global scale.
One example of this is the work done in the area of social
innovation, by enabling local production of alcohol-based3World Information

Country with one or more survey sites
Countries and territories with no survey sites
Not applicable

One company
One health facility
Two health facilities
Six health facilities

Figure 4. Map showing the locations of sites that responded to survey on the local production of the WHOrecommended alcohol-based handrub formulations, 201112

handrub. This initiative is especially important for lowresource settings, where there is either not enough money or
not enough of a robust infrastructure to buy and ship readymade alcohol-based handrub internationally. Alcohol is easily
produced from the byproducts of many of the already existing
industries in the developing world such as sugar cane, manioc,
rice, potato, wood, or beets (see Figure 4). With the WHO
guide to local production, individual companies and healthcare
facilities can commit to producing high-quality, effective
alcohol-based handrub themselves. 23
One particular example of a successful local production
initiative is the work of Saraya at the Kakira Sugar Worksin Jinja, Uganda, which employs over 7,500 people. Thissocial business was founded by Saraya in 2011 and it
locally produces highest quality alcohol-based handrub anddistributes it to healthcare facilities. The project also aims tosolve social issues by creating local jobs and developing itself
as a sustainable business. At the beginning of the project there
were five Japanese employees from Saraya, and now there is
only one Japanese manager left and 15 employees that are of
local origin. Currently, the factory can produce up to 1,400Lof ethanol per day (See Figure 5). Although the factory is not
generating a profit, it is making a huge difference in the lives

Figure 5. Saraya alcohol-based handrub production site in Uganda

4of the people living there. Importantly, this model remains
quite unique today and deserves to be considered as a model
to be reproduced wherever needed.
Ultimately, if our common goal is to save lives by reducing
healthcare-associated infections, companies in this field
are well-placed to have a high level of social awareness andresponsibility. Saving and improving lives extends further thatthe hospitals that buy their products, and championing social
innovation is a way for companies to be more than purely
financially-motivated entities. Ultimately, they can be justas successful or even more successful at improving lives by
expanding their activities to the communities that need themthe most.

Conclusion
Achieving success and striving for excellence is never alinear exercise. The story of implementing hand hygienewith alcohol-based handrub across the globe is oneof immense importance, as well as one of dedication,
passion, resilience and adaptability. Although the scienceand technology is at its core, bringing that science to ahuman element is incredibly complex, and there is not one
universal right answer when it comes to implementation.
In order for your own facility to achieve excellence inhand hygiene, it must incorporate elements of leadership,
strategy, and culture. These three components encourage
innovation and others can benefit from that innovation
anywhere in the world, whatever the available resources
happen to be. Ultimately, excellence in hand hygiene isdeveloping solutions that are scientifically sound, andimplementing them in a way that makes people care.

2020 vol.1

References
1 World Health Organization. "Health care-associated infections FACT SHEET."(NA). Available at: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_
sheet_en.pdf (Accessed: 18th December 2018)
2 P ittet, D. et al. "Effectiveness of a hospital-wide programme to improve
compliance with hand hygiene. Infection Control Programme." Lancet 356,
1307–1312 (2000).
3 World Health Organization. "Hand hygiene a key defence in Europe’s fightagainst antibiotic resistance." (2017). Available at: http://www.euro.who.int/en/
health-topics/disease-prevention/antimicrobial-resistance/news/news/2017/05/
hand-hygiene-a-key-defence-in-europes-fight-against-antibiotic-resistance.
(Accessed: 15th December 2018)
4 W orld Health Organization. "Guide to Implementation: A Guide to the
Implementation of the WHO Multimodal Hand Hygiene Improvement
Strategy." (2009). Available at: https://www.who.int/gpsc/5may/Guide_to_
Implementation.pdf (Accessed: 18th December 2018)
5 Grayson, M. L. et al. "Outcomes from the first 2 years of the Australian National
Hand Hygiene Initiative." The Medical Journal of Australia 195, 615–619 (2011).
6 S. Fonguh, A. Uwineza, B. Catry, A. Simon & the national hand hygiene working
group. "National campaigns to promote hand hygiene in Belgian hospitals: A
continuous project." (NA) Available at: https://slideplayer.com/slide/12851324/(Accessed: 18th December 2018)
7 Magiorakos, A. P. et al. "Pathways to clean hands: highlights of successful handhygiene implementation strategies in Europe." Eurosurveillance 15, 19560 (2010).
8 Sheldon Stone et al. "Report to the Patient Safety Research Programme: on“The National Observational Study to Evaluate the Cleanyourhands Campaign(NOSEC)” and “The Feedback Intervention Trial (FIT)”." (2010).
9 World Health Organization. "World Alliance for Patient Safety: The Launch of
the World Alliance for Patient Safety, Washington DC, USA — 27 October 2004."(2018). Available at: http://www.who.int/patientsafety/worldalliance/en/.
(Accessed: 15th October 2018)10 Allegranzi, B. et al. "Global implementation of WHO’s multimodal strategy for
improvement of hand hygiene: a quasi-experimental study." Lancet Infectious
Diseases 13, 843–851 (2013).
11 Allegranzi, B. et al. "Successful implementation of the World Health Organization
hand hygiene improvement strategy in a referral hospital in Mali, Africa."
Infection Control & Hospital Epidemiology 31, 133–141 (2010).
12 World Health Organization. "Local production of WHO-recommended alcoholbased handrubs: feasibility, advantages, barriers and costs." (2013). Available at:
http://www.who.int/bulletin/volumes/91/12/12-117085/en/. (Accessed: 30th
August 2018)13 World Health Organization. "Web sites promoting WHO SAVE LIVES: Clean
Your Hands." (2018). Available at: http://www.who.int/infection-prevention/
campaigns/clean-hands/SLCYH_support/en/. (Accessed: 31st August 2018)14 World Health Organization. "About SAVE LIVES: Clean Your Hands." (2018).
Available at: http://www.who.int/gpsc/5may/background/5moments/en/.
(Accessed: 15th October 2018)15 World Health Organization. "WHO Hand Hygiene Self-Assessment Framework."(2018). Available at: http://www.who.int/gpsc/5may/hhsa_framework/en/.
(Accessed: 15th October 2018)16 Stewardson, A. J., Allegranzi, B., Perneger, T. V., Attar, H. and Pittet, D.
"Testing the WHO Hand Hygiene Self-Assessment Framework for usability andreliability." Journal of Hospital Infection 83, 30–35 (2013).
17 World Health Organization. "Support from WHO Member States and autonomous
areas: Infection Prevention and Control." (2018). Available at: http://www.who.
int/infection-prevention/countries/hand-hygiene/statements/en/. (Accessed:
15th October 2018)18 World Health Organization. "Private Organizations for Patient Safety (POPS)."(2018). Available at: http://www.who.int/gpsc/pops/en/. (Accessed: 16th
December 2018)19 World Health Organization. "The First Global Patient Safety Challenge: ‘Clean
Care is Safer Care’." (2018). Available at: http://www.who.int/gpsc/clean_care_is_safer_care/en/. (Accessed: 28th August 2018)20 Stewardson, A. J. & Pittet, D. "Historical Perspectives." in Hand Hygiene:
A Handbook for Medical Professionals 8–11 (Wiley-Blackwell, 2017).
doi:10.1002/9781118846810.ch2
21 TEDx Talks. Adapt to adopt | Didier Pittet | TEDxPlaceDesNations. (2016).
22 Fakhry, M., Hanna, G. B., Anderson, O., Holmes, A. & Nathwani, D.
"Effectiveness of an audible reminder on hand hygiene adherence." American
Journal of Infection Control 40, 320–323 (2012).
23 World Health Organization. "Guide to Local Production: WHO-recommended
Handrub Formulations." Available at: https://www.who.int/gpsc/5may/Guide_
to_Local_Production.pdf (Accessed: 18th December 2018)

日本語要約
医療サービスにおいて、手指衛生が非常に重要であることは既知の事実である。
しかし、どうすれば最適な手指衛生遵守率を達成できるかについては、
まだ詳しくわかっていない。
「優れた手指衛生の実践をどうしたら達成できるのか」を考えるためには、
まず、優れた手指衛生の実践とは何か、実践する上での困難は何かといった背景を知る必要がある。
医療施設における手指衛生を推進するため、WHO（世界保健機構）
はその実践ガイドを作成した。
このガイドは、
システム変更、研修と教育、
評価とフィードバック、
職場での注意喚起、そして組織の安全文化を含めた「WHO複合的手指衛生改善戦略」
をもとに作成されている。
優れた手指衛生の実践を進めるにあたり、科学的根拠に基づいた実践方法は当然重要である。
しかし、人々がどのように考え、何を大切と考えているのかを理解し、それを変えない限り、習慣を改善することは難しい。
そのためには、個人だけでなく、施設がスタッフをサポートする環境を整えたり、企業が最適な製品を提供したりといったサポートも必要になってくる。
各施設の組織文化は異なっているため、唯一の手指衛生実践の改善方法はない。そこで必要になってくるのがリーダーシップである。医療施設における手指衛生の世界的な広まりは、WHOの働きなくしては決してなしえなかった。1990年代にジュネーブ大学の研究者たちがアルコール手指消毒剤の効果と時間短縮について研究し、その成果をラン
セットに発表して以来、このジュネーブモデルが世界中の注目を集め、実践され始めた。WHOは2009年に「医療施設における手指衛生のWHOガイドライン」
を発行すると、SAVE LIVES : Clean Your Hands
キャンペーンを開始し、5月5日を手指衛生の日と定めた。
これまでに世界の21,000の医療施設がWHOのキャンペーンに参加し、様々な国際的組織、学会、企業からもこれらのキャンペーンは推奨されている。
このようなWHOの働きと各医療施設の継続したコミットメントにより、手指衛生は世界の医療システムにおける質の指標とされるまでに至っている。
WHOの複合的戦略、手指衛生の5つのタイミング、
またそれらの関連
ツールはすべて医療施設におけるアルコール手指消毒剤の使用を推進するために必要な戦略に含まれている。これらを各国の保健省や病院がニーズに合わせて取り入れていくことが、手指衛生の実践には重要である。一般企業もサポートを始めており、WHOにより立ち上げられたPOPS（※）に属する企業は、WHOのガイドライン実践を世界中に広めていくために貢献する努力をしている。
「Culture（ 文化）」とは広義の意味があり、ある施設における組織
文化、世界のある地域でアルコール手指消毒剤を取り入れることに影響を与える社会的規範、または世界的規模で変化を生みだすことができる方法と解釈できる。
これに関連した例として挙げられるのが、資金やインフラの面でアルコール手指消毒剤を輸入することが難しい資源の乏しい施設において特に重要な、アルコール手指消毒剤の現地製造である。サラヤがウガンダのKakira Sugar Worksで2011年から製造しているアルコール手指消毒剤は、
その成功例である。現在では
毎日1,400Lのアルコール手指消毒剤を製造し、利益は大きくはないかもしれないが、ウガンダにおける人々の健康に貢献している。
優れた手指衛生の実践とそのための努力は、決して単一のものではない。世界のアルコール手指消毒剤を用いた手指衛生の実践の歴史はとても重要であり、関わった人々の献身、情熱、失敗を跳ね返す強さの賜物である。
※ Private Organizations for Patient Safety : WHOの呼びかけで結成された企業による協働組織。WHOと連携し、WHOの推奨を普及する教育・啓蒙活動を積極的に行い、
世界中で医療関連感染の減少に貢献することを目的としている。

5

World Information
Why should my hospital use the Hand Hygiene
Self-Assessment Framework proposed by
the World Health Organization?
Chloé Guitart 1, Camille Bleeker 2, Alexandra Peters 1, Didier Pittet 1
1 Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
2 University of Geneva Faculty of Medicine, Geneva, Switzerland

Healthcare-associated infections are the gravest
threat to patient safety in hospitals worldwide. 1 By
establishing infection prevention and control(IPC)
teams and programs, hospitals can decrease
healthcare-associated infections by at least 30%, 2 andimproving staff hand hygiene compliance can reducethem by half.3 When it was launched in 2005,4 the main
objective of the World Health Organization(WHO)First Global Patient Safety Challenge : Clean Care is
Safer Care was to make IPC a global priority in healthcare, with hand hygiene assessment and improvement
as the central component.
In 2019, healthcare facilities and IPC leaders areinvited to take part in the WHO 2019 Global Survey
and to use validated assessment instruments : theInfection Prevention and Control Assessment
Framework(IPCAF) and the Hand Hygiene SelfAssessment Framework(HHSAF). 5 These two simple
and systematic diagnostic tools allow healthcare
facilities to obtain a situational analysis of IPC andhand hygiene activities, and help identify key issues
that require attention in their respective institutions.
The IPCAF survey supports the implementation of
the WHO Guidelines on core components of IPC
programs at the acute healthcare facility level. 6 The
HHSAF is divided into five components that reflect
the five elements of the WHO Multimodal Hand
Hygiene Improvement Strategy. 7 The understandingthat hand hygiene practices are a central part of
IPC has become recognized globally over the pastfew decades, but this change cannot be taken
for granted. Even the idea of defining an array of
diseases as healthcare-associated infections, andaddressing healthcare-associated infection as apreventable condition, required a paradigm shift anda new way of thinking.

6

A shift in thinking
This shift had its origins in the mid-19 th century.
Ignaz Semmelweis was one of the main pioneersof improved IPC practices and is regarded as thefather of hand hygiene. As an obstetrician at the
Vienna General Hospital, he proved that scrubbing
hands with a chlorinated lime solution before contact
with a patient drastically decreased mortality due
to puerperal fever among women giving birth in thehospital. 8 He published his discovery, but his ideas
unfortunately remained unpopular.9 A few years later,
the French chemist and microbiologist, Louis Pasteur,showed that microorganisms were the cause of some
infectious diseases. He also helped confirm that acontaminated environment could be responsible for germtransmission. 10,11 Subsequently, the health community
had to wait for more than a century for any new
breakthroughs in the fight against healthcare-associatedinfections. In the 1970s and the 1980s, the United States
Centers for Disease Control and Prevention(CDC)
recognized handwashing as “the most important
procedure in preventing nosocomial infections”, and thefirst national hand hygiene guidelines were subsequently
published in 1983.12

One hospital model disseminatedworldwide
In the mid-1990s, researchers at the University of Geneva
Hospitals and Faculty of Medicine demonstrated that
promoting hand hygiene through the use of alcoholbased handrub at the point of patient care, insteadof soap and water handwashing, was revolutionary
for decreasing healthcare-associated infections and2020 vol.1

reducing methicillin-resistant Staphylococcus aureus
cross-transmission rates. 3 The ‘Geneva model’ for
hand hygiene promotion, published in The Lancet in
2000,3 drew the attention of the entire IPC community,and began to be implemented in healthcare facilities
worldwide.13 This model was the precursor of the WHO
Multimodal Hand Hygiene Improvement Strategy, which
was published in its current format in 2009. 13 In 2005,
in order to create a global momentum for the adoptionof hand hygiene worldwide, the WHO integrated handhygiene as the central part of its Clean Care is Safer Carecampaign.14 Since then, many tools and initiatives havebeen developed by WHO to facilitate the implementationof this patient safety intervention at local and national
levels, regardless of IPC expertise or resource setting.

From scientific evidence to daily
practice
To bridge the gap between scientific evidence and dailycare practice, WHO and the WHO Collaborating Centre
on Patient Safety at the University of Geneva Hospitals
and Faculty of Medicine developed My Five Moments
for Hand Hygiene.15 This tool designates key moments
when hand hygiene is required to avoid pathogen crosstransmission. The concept, described as a time-spaceframework, provides a solid basis to understand, teach,monitor and report hand hygiene practices. However,
the task of cleaning hands at the right times and in theright way is deceptively simple, and remains difficult toimplement successfully.15,16
The WHO Multimodal Hand Hygiene Improvement
Strategy promotes and facilitates optimal hand hygiene
implementation. It includes five key components : (1)system change (i.e. the systematic recourse to alcoholbased handrubbing instead of handwashing withsoap and water), (2) staff training and education, (3)evaluation and feedback, (4) reminders in the workplace,and (5) promotion of an institutional safety climate. 17
To facilitate system change and make access to alcoholbased handrub universal, the WHO Collaborating Centre
for Patient Safety in Geneva developed and tested two
alcohol-based handrub formulations suitable for local
production in low resource settings.18 WHO studied theimplementation of the multimodal strategy in a quasiexperimental study in six countries worldwide, andproved its feasibility and sustainability across a range ofsettings with different cultures and economic resources.13
Based on scientific evidence, an updated version of

the WHO Guidelines on Hand Hygiene in Health Carewas published in 2009, with a strong focus on the handhygiene multimodal promotion strategy. That same year,
WHO launched the annual SAVE LIVES : Clean Your
Hands campaign that culminates on World Hand Hygiene
Day, on and around May 5th of each year. This worldwide
initiative promotes a large series of activities and tools,
and is currently providing coordination and support tomore than 21,000 facilities in 182 countries.19,20

The Hand Hygiene Self-Assessment
Framework : a practical tool to leadthe fight
The momentum to combat healthcare-associatedinfections through improved hand hygiene continues in auniversal perspective with the WHO 2019 Global Survey 5
and with the third worldwide launch of the HHSAF
survey. The major benefit of using such a tool is that it
facilitates comparison between facilities and regions,and, when used sequentially over years, allows facilities
to assess progress made over time.21 The framework is
aimed at tracking the level of progress of health facilities
in the context of implementation, as well as continued
improvement. It is divided into five parts related to
the five components of the WHO multimodal strategy,
and it includes a set of 27 indicators to assess the stateof facilities’ hand hygiene promotion programs. 7 The
HHSAF has been made available to health facilities since2010. It quickly proved to be easy to use and useful forassessing the facility level with regard to hand hygiene
promotion.22
Recent studies have demonstrated the usefulness of the
HHSAF in developing a regional or national action plan
to improve hand hygiene practices within healthcare
facilities. In the USA, a national survey allowed hospitals
to assess the level of implementation of the WHO
strategy across the country for the first time.23 In Greece,
using a cross-sectional national survey, researchers wereable to quantify the impact of IPC nurse staffing levels
on the HHSAF score per key element. It also helped
facilities benchmark their results against comparable
international data. 24 In Italy, regional surveillance inPiedmont revealed critical issues concerning the lack ofactive involvement in hand hygiene activities by patients,
family members and caregivers. 25 Two hand hygiene
global surveys were conducted by WHO in 2011 and2015, showing a snapshot of the current position of handhygiene implementation and significant improvements

7World Informationin participating facilities across all WHO regions.21 Still,
the analysis of regular monitoring and reporting of the
WHO multimodal improvement strategy through the useof the HHSAF remains scarce in the literature. The more
hospitals take part in completing this self-assessment
tool, the more data will be available to compare results,
performances and attitudes in different regions. The
data provided by this questionnaire is an ideal source todesign a regional strategy for hand hygiene promotion ;the tool is freely available at : https://www.who.int/
gpsc/5may/hhsa_framework/en/.7

Table 1. M ay 5, 2019, World Health Organization SAVE LIVES: Clean
Your Hands campaign calls to action
Campaign participants

Call to action

Health workers“Champion clean care – it’s in your hands.”

IPC* leaders“Monitor infection prevention and control standards –take action and improve practices.”

Health facility leaders“Is your facility up to WHO infection control and handhygiene standards? Take part in the WHO survey 2019
and take action!”

Ministries of health“Does your country meet infection prevention andcontrol standards? Monitor and act to achieve quality
universal health coverage.”

Patient advocacy groups“Ask for clean care – it’s your right.”*IPC, infection prevention and control

2019 WHO calls to actions
The WHO 2019 theme for hand hygiene reflects astrong focus on providing clean care equally protecting
all patients and healthcare workers from infection
and antimicrobial resistance transmission, across all
countries, including in low-resource settings : Clean Carefor All - It’s In Our Hands! (Figure 1).
WHO urges ministries of health (Figure 2A), healthfacility leaders (Figure 2B), IPC leaders (Figure 2C),
health workers (Figure 2D), and patient advocacy groups(Figure 2E) to contribute to effective IPC action including
hand hygiene as a cornerstone of quality in healthcare(Table 1). WHO invites all healthcare facilities andcountries to ask their own representatives and leaders
to prepare their own posters using the pre-preparedposters to facilitate implementation (Figure 2F, see also
instructions at http://www.CleanHandsSaveLives.org/).
WHO invites everyone to pledge for “Clean Care for All ;it’s in your hands”. You can participate by sending yourphotos and selfies made together with your colleagues,
collaborators, patients, relatives and friends from all over
the world. The 2019 board is shown in Figure 3. Sign
your name and ask your friends and colleagues, as wellas patients and their relatives to do the same. Please notethat the hashtags are : #HandHygiene, #HealthForAll and#InfectionPrevention. You can submit your photos of theboard at http://www.CleanHandsSaveLives.org/.
IPC, including hand hygiene, is critical to achieve
universal health coverage, as it is a practical and evidencebased approach with demonstrated impact on quality ofcare and patient safety across all levels of resources andhealth systems. Let’s all monitor the capacity of promoting
hand hygiene in our institution and participate in the
global momentum to improve patient safety.
“Clean Care For All – It's In Your Hands” !

8Figure 1

Figure 2A

Figure 2B

Figure 2C

Figure 2D

Figure 2E

Figure 3
Figure 2F

Acknowledgement
This work is supported by the World Health Organization (WHO), Geneva,
Switzerland, and the Infection Control Programme and WHO Collaborating Centre on
Patient Safety (SPCI/WCC), University of Geneva Hospitals and Faculty of Medicine,
Geneva, Switzerland; hand hygiene research activities at the SPCI/WCC are also
supported by the Swiss National Science Foundation (grant no. 32003B_163262).
Didier Pittet works with WHO in the context of the WHO initiative Private
Organizations for Patient Safety – Hand Hygiene. The aim of this WHO initiative
is to harness industry strengths to align and improve implementation of WHO
recommendations for hand hygiene in healthcare in different parts of the world,
including in least developed countries. In this instance, companies/industry with afocus on hand hygiene and infection control-related advancement have the specific aimof improving access to affordable hand hygiene products as well as through education
and research. All listed authors declare no financial support, grants, financial interests
or consultancy that could lead to conflicts of interest.
The authors alone are responsible for the views expressed in this article and they do
not necessarily represent the views, decisions or policies of the institutions with which
they are affiliated. WHO takes no responsibility for the information provided or theviews expressed in this paper.

2020 vol.1

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tools/core-components/en/
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Mar 2]. Available from : https://www.who.int/gpsc/5may/hhsa_framework/en/
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25 Bert F, Giacomelli S, Ceresetti D, Zotti CM. World Health Organization Framework :Multimodal Hand Hygiene Strategy in Piedmont (Italy) Health Care Facilities.
J Patient Saf. 2017 Jan 10 ;日本語要約
医療関連感染は患者安全を脅かす重大な問題であるが、感染対策の推進により30%、手指衛生遵守率の改善で50%、減少することが可能と考えられている。その背景から、WHOが2005年に開始したClean Care is Safer Careプログラムでは、手指衛生を中心とした感染対策を世界の医療機関における優先事項にすることを主な目的としており、毎 年 5月5日には手 指 衛生を世界的に推進するキャンペーンも実施している。今年は、Infection
Prevention and Control Assessment Framework（ 感染対策評価フレームワーク）とHand Hygiene Self-Assessment
Framework（ 手指衛生自己評価フレームワーク、以下HHSAF）を用いたグローバルサーベイが実施されており、医療機関や感染対策
従事者への参加が呼びかけられている。
《 意識改革 》 感染対策に関する意識改革は、19世紀半ば、感 染 対 策 活 動の先 駆 者で手 指 衛 生の父と称されるI g n a z
Semmelweisから始まっている。オーストリアのウィーン総合病院の産婦人科医であった彼は、患者接触前にさらし粉の溶液で手を擦ることが、産褥熱による死亡率を劇的に減少させることを証明した。数年後、フランスの化学者であり微生物学者でもあるLouis
Pasteurは、微生物が感染性疾患の原因であることを示し、汚染された環境が微生物の伝播に関連していることも証明した。1970から1980年代にかけては、米国のCDCが手洗いを「感染予防における最も重要な方法」ととらえ、1983年に初めての手指衛生ガイ
ドラインを発行した。
《ある病院の事例が世界に発信される》 90年代半ば、スイスのジュネーブ大学の研究者等は、アルコール消毒剤を用いた手指衛生の推進が革新的に医療関連感染を減少させることを実証し、後のWHO複合的手指衛生改善戦略の礎となった「ジュネーブ
モデル」
を2000年にランセットにて発表した。2005年、WHOはClean Care is Safer Careキャンペーンの中心として手指衛生を取り入れ、それ以降多くのツール開発や取り組みを実施してきた。
《科学的根拠を日々の実践へ》 科学的根拠と日々の実践の乖離を埋めるため、
交差感染防止に必要な手指衛生のタイミングを示す「手指衛生の5つのタイミング」が開発された。このツールは手指衛生の実践を理解しやすく、教えやすく、観察しやすく、報告しやす
いものにしたが、その実践はまだ難しいままであった。
WHO複合的手指衛生改善戦略は 1）
システム変更（手洗いの代わりに手指消毒を推進）、2）
研修と教育、3）
評価とフィードバッ
ク、4）
職場での注意喚起、5）
組織の安全文化の改善の5つの項目を含んでいる。WHOはこの複合的戦略の実現可能性と実践の継続性を、6つの異なる文化や経済資源を持つ地域で実証し、2009年には、それに重きを置いた「医療における手指衛生WHO
ガイドライン」を発行した。同年、WHOは5月5日を世界手指衛生の日としたSAVE LIVES：Clean Your Handsキャンペーンを開始した。
この世界的取り組みは多くの活動やツールを生み出し、現在182カ国の21,000以上の施設で活用されている。
《HHSAF：実践ツール》 HHSAFを使用することで、施設間や地域間で現状を比較し、また継続使用することで自施設の進捗を確認することができる。近年の研究では、
HHSAFが手指衛生改善計画の作成に役立つことが複数の国で実証されているが、その定期的なモニタリング結果や報告などは今だ蓄積されていない。
《 2019年グローバルサーベイ参加の呼びかけ》 2019年のWHO世界手指衛生の日のテーマは、すべての国で清潔なケアを提供し、すべての患者と医療従事者が感染症や薬剤耐性菌の伝播から平等に守られることに焦点を当てており、行政機関、医療機関の経営層、感染対策者、医療従事者、患者会に行動が呼び掛けられている（図1、2）。
また、WHOのボード（図3）に名前を記載し、同僚や友人、
患者との写真を投稿することも促されている。
手指衛生を含めた感染対策は、医療の質と患者の安全に影響を与える、実践的且つ根拠に基づいたアプローチであり、ユニバーサ
ルヘルスカバレッジの達成に必要である。HHSAFグローバルサー
ベイといった世界的活動に参加し、医療における感染対策を実践
していきましょう！

9World Information
Current situation and challenges of
nosocomial infection in Vietnam
Phung Manh Thang 1, Nguyen Van Khoi 2
1 Department of Infection Control, Cho Ray Hospital 2 Vice Director of Cho Ray Hospital

the HAI incidence rates in developed countries were less than

Background

1% (NHSN). There are differences in geology, climate andmedical system service between Vietnam and other countries,

The current situation of nosocomial infection in Vietnam

so there are various etiologies causing nosocomial infection.

in general, and Cho Ray Hospital is alarming. Four main

For developed countries, such as Japan, the microorganism

healthcare-associated infections (HAIs), namely, ventilator-

is usually gram-positive, such as Staphyloccocus aureus.

associated pneumonia (VAP), catheter line-associatedWhile in Vietnam, the majority of HAI microorganisms arebloodstream infection (CLABSI), catheter-associated urinary

gram-negative, such as Acinetobacter spp., E.coli, Klebsiellatract infection (CAUTI) and surgical site infection (SSI),

and Pseudomonas spp. Many hospitals in Vietnam are facing

are higher in Vietnam than in other countries. Importantly,

considerable challenges in infection control and prevention,

four HAIs are dominant, but the VAP incidence rate is the

such as overcrowding of inpatients from referral hospitals, lackhighest in Vietnam and in Cho Ray Hospital. Nosocomialof personal protective equipment (PPE) and medical facilities

infection results in increasing medical fees, treatment timeused for the isolation of MDROs and emerging infectious

and mortality for inpatients. Moreover, HAIs related todiseases, decreasing quality of medical construction, lack ofmultidrug resistance organisms (MDROs) are increasing

human resources working in infection control, insufficientthe mortality burden for medical systems in Vietnam and in

funding for infection control and lack of awareness of medical

the world. Jim O’Neill et al.’s study revealed that the deaths

staff about infection control. In addition, increasing antibiotic

attributable to antimicrobial resistance (AMR) every year will

resistance, especially with the appearances of MDROs in

be more than the current number of those associated withventilated patients in intensive care units (ICUs), has createdcancer, by 2050 (1). In Vietnam, there are insufficient detailed

new challenges for healthcare workers in Vietnam and Cho

reports about the current situation and the infection control

Ray Hospital. Although there were plenty of initial benefits,challenges for nosocomial infection. Therefore, in this cross

such as decreasing VAP rates, medical fees and mortality rates

descriptive study, we present the current situation and theafter applying several interventions including antimicrobial

infection control challenges against HAIs in Cho Ray Hospitalstewardship (AMS) , and nosocomial surveillance, the effectand Vietnam. We also provide some orientation of infectionof MDROs on hospitalisation time and mortality rate still

control and prevention solutions.

remains in complicated progression. According to the Cho Ray
Hospital in 2017, the percentage of MDROs was still high at

Purpose62% of inpatients and particularly higher in ventilated patients.
Another report, which was from the University of Medicine

To present an overview of the current situation, challenges

and Pharmacy in Ho Chi Minh City in 2017, revealed theand solutions for infection control and prevention of HAI inpercentage of MDRO as 58.6% (3). Magill SS et al. reported

Vietnam.

that MDROs associated with mechanical ventilators enhancehospitalisation time, medical expenses and mortality rates

Introduction

10(4). A research in a university affiliated hospital for 315
inpatients revealed the high mortality rate of 30.8% (97/315)

The current situation of nosocomial infection in Vietnam isamong CAUTI patients (5). Other studies showed thatalarming. In 2018, the HAI rate was 5%, but some hospitals had

MDRO patients with VAP were associated with gram-negative

higher HAI rates of nearly 10% (2). In Cho Ray Hospital, theinfections and high mortality rates (6–8). In Vietnam, surveys

incidence rate of HAI was approximately 3% in 2018. However,about the current situation and the challenges of infection

2020 vol.1
control and prevention and researches assessing the effect ofnamely, VAP, CLABSI, CAUTI and SSI. By contrast, theMDROs on HAI have not been conducted in detail. Therefore,

HAIs incidence rate in developed countries is less than 1%.

this study presents an overview of the current situation andA report on HAIs in the USA shows that the CLABSI rate is

the challenges for infection control and prevention of HAI

0.8/1,000 catheter-day, the VAP rate is 0.9/1,000 mechanicalin Vietnam through analysing recent and detailed infection

ventilators-day and the CAUTI rate is 1.7/1,000 catheter-day

control data from Vietnam and Cho Ray Hospital.

(9). In addition, our research reveals a very high percentage
of MDROs in Cho Ray Hospital. We conducted all samples

Materials and methods
A survey on current situation and challenges for infection

positive culture for the first six months of 2018. According to
the results, the percentage of MDROs in the 6,820 positive
specimens of the culture was 62%.

control and prevention of nosocomial infection in Vietnam inrecent years.
We used a cross descriptive study to search publications on

Poor hand hygiene compliancevarious websites about the infection control of HAI in 2018

Hand hygiene is a simple and efficient intervention to

and Cho Ray Hospital surveillance data.

reduce the HAI rate. However, recent hand hygiene
surveillance data from Vietnam reveals that hand hygiene

Overcrowding of patients in final referral
hospitals

compliance rate remains low at approximately 50–70% (10).

Because of a perceived distinction in specialty degree

is still low compared to the requirement of the Vietnamese

between referral and local hospitals caused by the belief

Ministry of Health (MOH).

In Cho Ray Hospital, the hand hygiene compliance rateincreased to 61% in 2018 from 49% in 2017, but this numberof patients that the specialty degree of referral hospitals ishigher than that of local hospitals, most patients who canreceive adequate treatment in local hospitals still wish to bereferred to top referral hospitals for diagnosis and therapy.
Therefore, referral hospitals, such as Cho Ray Hospital andLack of PPE and other facilities
for isolating MDROs and preventing
transmission of emerging infections

Bach Mai Hospital, are overcrowded with inpatients and

The management of isolating MDROs and emerging

outpatients. Overcrowded patients lead to major challenges

infectious diseases in Vietnam and Cho Ray Hospital has been

for infection control and prevention, such as cross infection

facing many difficulties. First, isolation rooms are insufficientof MDROs or other emerging infectious diseases. According

for regular isolation, and negative pressure isolation rooms

to Cho Ray Hospital data, the hospital has 1,800 planned

are likewise not enough for cases with airborne diseases, such

beds, but there are approximately 3,000 inpatients every

as tuberculosis, chicken pox, influenza, and Ebola. Second,day. The daily number of outpatients is about 5,000–6,000,

the supply of PPE, such as aprons and masks, is insufficientwith 150 cases needing operations. Therefore, the distancefor taking care of MDROs. Cho Ray Hospital supplied PPE for

between two beds is excessively narrow at less than 0.5

outbreak precaution, but for MDROs, the supply is still limited

m. Sometimes, two patients share one bed, thereby easily

and not equally distributed to departments in the hospital.

leading to cross infection in the hospital. To solve this

Therefore, the efficacy of MDRO isolation is still limited.

problem, hospitals have been cohorting the patients infectedwith MDROs or emerging infectious diseases and needing
isolation in the same areas, using PPE and applying standard
precautions or additional precautions based on the route oftransmission.

Decreasing quality of hospitalconstruction
Most of the public hospitals in Vietnam were built many
decades ago, such as Cho Ray Hospital, which is half aHigh rate of HAIs

century old. Therefore, the quality of hospital construction,
patient rooms, facilities and environment has been

Several reports in Vietnam show that the HAI rate isdeteriorating. Plenty of construction has been added onto theapproximately 5–10% (2). Cho Ray Hospital’s surveillance

hospitals, causing their environments to have narrow spaces

data from 2018 revealed that the HAI incidence rate wasand limited airflow. Therefore, current infection control

nearly 3%. There are four types of HAI that occur frequently,

and prevention of HAI have many challenges in improving

11World Information
hospital environments and HAI prevention in Vietnam and
Cho Ray Hospital.

Lack of human resources for
infection control

Insufficient funding for infection control
Circular 16/2018 of the Vietnamese MOH defines
payment for infection control and prevention. However,this document does not define in detail the amount that

During the past decade, the Vietnamese MOH has focusedpatients have to pay for infection control. Therefore, there

on HAIs by issuing some detailed national rules for infection

is no standard amount for all hospitals regarding infection

control and prevention at medical services, such as Circular

control payment, and each hospital has to calculate by itself.

18/2009 and Updated Circular 16/2018. The circular defines

Hence, funding for hospitals’ infection control is limited by

the detailed roles of the Infection Control Committee, Head ofinsufficient, incorrect calculations for each patient or lack

Infection Control and the Infection Control Team. Importantly,

of influence and interest from managements for infection

the document shows that each person in charge of HAIcontrol. Consequently, the operation of infection control

surveillance has to respond full time for 150 beds. However,systems has difficulties and reduced efficiency.

hospitals in Vietnam currently lack infection control humanresources for daily HAI monitoring. Cho Ray Hospital has
approximately 3,000 beds. Therefore, it needs about 20 staff

Discussion

working full time in HAI surveillance. According to WHO,HAI is considered as the biggest concern of all countries

each HAI surveillance staff needs to support only 100 beds

with regard to improving hospital quality, and an importantfull time. However, in practice, the Department of Infection

indicator for comparison and evaluation of different hospital

Control has only five persons serving all patients in theservices. Therefore, HAI surveillance has been known andhospital. All hospitals in Vietnam have insufficient infection

practised worldwide for the past couple of decades. This

control staff. This is one of the most severe problems forhas led to a decrease in the HAI rate of developed countries

the infection control team in Cho Ray Hospital and Vietnam,

to less than 1% (9); reductions in antibiotics consumption,

thereby affecting the quality of HAI surveillance.

number of MDROs and total medical fees; and enhanced

HAI surveillance in Vietnam, except that in Cho Ray

survival rates.

Hospital, often uses short-term surveillance. In Cho Ray

On the contrary, medical systems in developing countries,

Hospital, HAI surveillance adopts longitudinal surveillancesuch as Vietnam, are undergoing gradual completionin all departments. Therefore, the result of HAI surveillancewith many difficulties. The development of specialty andis more accurate and thus valuable for finding solutions foradministration rules has not been synchronised between

HAI intervention.

referral and local hospitals. HAI surveillance systems are being
completed to serve the high-quality medical service needed

Poor cognition of infection
control of healthcare workers

12by patients. As shown by the current situation, challenges
include overcrowding of patients in referral hospitals dueto the belief of patients that referral hospitals have higher

Awareness about HAIs, infection control and prevention

specialty degrees than local hospitals. Hence, patients wish toand self-awareness regarding HAIs infection control intransfer to the best hospitals and this is leading overcrowding

hospitals are low due to healthcare workers’ poor cognitionof patients in these top hospitals. To solve this problem, weabout the importance and benefits of HAIs prevention andneed to develop the same infection control systems in bothcontrol. For example, the hand hygiene compliance rate ofreferral and local hospitals and enhance infection control

healthcare workers in Vietnam is lower than in developed

training for local hospital staff, thereby regaining the trust of

countries worldwide. The hand hygiene compliance ratepatients during their treatment in rural hospitals. The HAIof Cho Ray Hospital staff was approximately 61% in 2018,rate in Vietnam was as high as 5–10% in 2018, whereas that ofand the hand hygiene compliance rate of doctors was

Cho Ray Hospital was 3–5%. In particular, the MDRO rate islower than that of nurses. Therefore, infection control staff

also high at a warning point of 62% of positive cultures. Someneeds to train all staff in the hospital to adopt hand hygiene

microorganisms have developed resistance to the antibiotics

practices. In addition, maintaining a high hand hygiene

currently being used. To decrease the HAI and MDRO rates,

compliance rate is also essential and staff need to persist

we have been implementing several complete solutions,and have passion for infection control.

such as VAP, SSI and MDRO care bundles, in all related

2020 vol.1
departments. Additionally, medical staff have been training for
improved infection control knowledge, enhanced awarenessabout the benefits of increased hand hygiene compliance
rate. Moreover, we need to conduct additional research

日本語要約
ベトナムにおける医療関連感染の現状と課題
ベトナム全体、及びチョーライ病院における医療関連感染（HAI）の状 況は深 刻である。とりわけ、人 工 呼 吸 器 関 連 肺 炎（ V A P ）、

and evaluation to supply facilities for isolation patients and中 心 静 脈カテーテル感染（CLABSI）、尿道留置カテーテル感染

medical equipment, such as PPE at ICUs for the care of（CAUTI）、手術部位感染（SSI）の４つが諸外国に比べて高い状況

MDRO patients and to monitor isolation compliance whenで、中でもVAPの発生率がチョーライ病院及びベトナムにおいて最も

medical staff look after MDRO patients. Furthermore, eachhospital in Vietnam has to recruit sufficient infection control
staff following MOH’s guidelines and enhance the parallel
application of Internet technology to improve the efficiency
of HAI surveillance and decrease surveillance cost and time

高くなっている。HAIは、医療費や治療期間、死亡率の増加等に繋がり、さらに近年世界で問題となっている多剤耐性菌（MDROs）
により引き起こされる医療関連感染が、ベトナムの医療現場でも大きな課題となっている。ベトナムではこれまで詳細な調査や研究があまりなされていない為、
ここ数年のベトナムとチョーライ病院のデータから現状と課題を調査した。

consumption. Finally, each hospital has to correctly and2018年のベトナムのHAI発生率は5%となっており、チョーライ

sufficiently calculate their medical fees for infection control.

病院では約3%であった。病院によっては10%近い高い値も記録してThus, Vietnamese hospitals have to show annual cost for
infection control.
In conclusion, according to the discussed current situationand challenges, HAI infection control in Vietnam has many
advantages and disadvantages and all of the ministry and the
MOH’s full attention is required to support infection control
in the near future. With the MOH’s support for infection
control, especially for the targeted decrease in HAIs and
MDROs, we will definitely obtain good results.

おり、先進国における1%未満に比べると非常に高いことが分かる。
さらにチョーライ病院では、2018年上半期に収集したデータでは、陽性検体6,820サンプルのうち多剤耐性菌が約62％という高い値を示した。調査の結果、感染管理の観点から多くのベトナムの病院が直面している課題として、収容能力を超えた入院患者の過密状態、高いHAI発生率、低い手指衛生遵守率、PPEや隔離施設の不足、施設の老朽化、感染管理の専門人材の不足、感染管理に関する医療従事者の認識不足、感染対策に割く資金の不足等が明らかになった。抗菌薬の適正使用（AMS）や院内感染のサーベイランス
実施により、VAP発生率の低下や医療費の減少等の成果も一部見られるものの、多剤耐性菌感染による入院期間や死亡率への影響等については、依然として複雑な経過を辿っているところであり、明確

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and%20wealth%20of%20nations_1.pdf
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chuyende/benh-phoi/388-viem-phoi-benh-vien-dhac-dhiem-vi-khuan-va-de-khangkhang-sinh-in-vitro-tai-benh-vien-dhai-hoc-y-duoc-tphcm
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な成果は現在のところ不明である。
収容能力を超えた入院患者の過密状態については、特に各地域のトップに位置する基幹病院で深刻である。
というのも、患者の多くに、地方病院よりも基幹病院の方が医療の質が高いという思い込みがあり、地方病院で十分に対応可能な病状であっても、基幹病院への紹介を希望する患者が多いからである。チョーライ病院の例で言うと、1,800床で計画されているところに、3,000人近い入院患者が押し寄せている。
さらに、外来患者は1日あたり5,000～6,000人、外来手術件数は150件に上る。その結果として、ベッドの間隔は50cm以下等非常に狭くなり、時に2人の患者が1つのベッドを使用せざるをえないこともある。このような状況は交差感染を容易に引き起こし、感染対策を非常に困難にしている。
また、手指衛生の遵守率について、最近のデータでベトナムは約50-70%となっている。チョーライ病院では、2017年に49%、2018年が61％と増加を示しているものの、
ベトナム保健省の基準と比較すると、まだ低い値である。
また、人材の面でいうと、保健省は150床に1人のHAIサーベイランス担当者を定めており、WHOでは100床に1人となっている。チョーライ病院では3,000床あるので、少なくとも20人のスタッフが必要になるが、実際は感染管理部から対応できるのは5人しかいない。
このようなベトナムの課題を解決する為には、基幹病院と地方病院とで共通の感染管理システムを開発し、地方病院のスタッフへの教育を強化し、患者の信頼を取り戻すことが必要である。
さらに、保健省のガイドラインに準じた十分な人数のスタッフを各病院が確保することも重要で、同時に、サーベイランスの負担を減らせるような技術の導入の検討も有用である。
さらに、適切な感染対策に必要なPPE等の供給や施設・設備等を検証することも必要と考える。保健省をはじめ関連する
各省庁の支援は不可欠であり、ともに感染管理分野の強化に取り組む
ことで、深刻な多剤耐性菌問題についても成果をあげていきたい。

13

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