key: cord-0937989-0xqfej85 authors: Peters, Alexandra; Lotfinejad, Nasim; Simniceanu, Alice; Pittet, Didier title: The economics of infection prevention: why it is crucial to invest in hand hygiene and nurses during the novel coronavirus pandemic date: 2020-04-23 journal: J Infect DOI: 10.1016/j.jinf.2020.04.029 sha: 6ac7db09c5fe45eab0a5c0e159ce03f672e9ae55 doc_id: 937989 cord_uid: 0xqfej85 nan It is a well-known fact that healthcare associated infections (HAIs) are a global problem that affect between around 7 and 10% of patients, depending on the country (1). The novel coronavirus pandemic (COVID-19) is exacerbating this already dire situation and is currently causing a significant increase in the rate of HAIs around the world (2, 3). The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus is mainly transmitted through droplets, close contact with infected individuals and contaminated surfaces (4) . This makes healthcare workers (HCWs) a highly susceptible population both for contracting as well as for spreading the virus. The infection prevention and control (IPC) measures to limit or prevent HAIs caused by the SARS-CoV-2 are crucial to combatting this pandemic. Hand hygiene is widely recognized as the most effective and economically viable measure in IPC (5). Even before COVID-19, HAIs were a pandemic in and of themselves. Annually, they are responsible for the death of millions of people per year-more than tuberculosis, malaria, and AIDS combined. In Europe, over 4 million patients are affected by approximately 4.5 million episodes of HAIs every year, leading to 16 million extra days of hospital stay, 37,000 attributable deaths and the contributing factor to an additional 110,000 deaths, resulting in € 7 billion of additional healthcare costs (1). In the USA, it is estimated that around 1.7 million patients are affected by HAIs each year, and that they account for 99,000 deaths, costing hospitals between US$35.7 to US$45 billion (1). Although the direct costs due to these types of infections are already very significant, the indirect costs to health systems and economies are both extremely high and almost impossible to measure. As seen in the last two major outbreaks of the coronavirus family (severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS)), coronavirus epidemics can have a severe effect on both countries' individual economies and the global economy as a whole. The COVID-19 pandemic is currently estimated to have cost 1-2% of global gross domestic product (GDP) (2) . This number is of course still evolving and will vary greatly across regions and countries. Recently, it has been estimated that COVID-19 could cost the global economy up to US$1.1 trillion in lost income (6) . Infectious disease outbreaks challenge healthcare systems in many different aspects, impacting everything from resource allocation and staffing, education, politics and governance, to the systems' culture and economics. The current pandemic has highlighted the need for every country to be better prepared to deal with the effects that an infectious disease outbreak could have on healthcare systems and society as a whole. Preventing nosocomial spread of COVID-19 is a top priority for healthcare systems around the world. Though all HCWs are exposed at various levels, nurses are evidently at the front lines with the most patient contact. They are the ones responsible for daily patient care, while simultaneously being responsible for protecting patients against HAIs. If their IPC practices, especially their hand hygiene, are suboptimal, nurses become a source of transmission of infections between patients and to themselves. Contaminated hands are one of the main vectors of spreading SARS-CoV-2 (7). It is crucial that nurses adhere to proper hand hygiene in order to reduce HAIs, save money and ultimately, save lives. To achieve acceptable levels of hand hygiene compliance, nursing teams need to be adequately staffed, well trained, and have access to good quality alcohol-based handrub (8) . Adequate hand hygiene would ensure prevention of nosocomial spread not only from patient to patient through contaminated HCW hands, but also from patients to HCWs. Globally, an increasing number of HCWs are also contracting nosocomial COVID-19 as a consequence of providing patient care. As of early March 2020, more than 3300 HCWs in China (9) and 10% of all physicians and nurses in Lombardy, Italy were infected with the virus (3). This emergency is worldwide of course, but the breadth and scope of COVID-19 infection in HCWs will only become apparent as the pandemic progresses. Following its designation of 2020 as the Year of the Nurse and the Midwife, the World Health Organization (WHO) identified that there is a shortage of 9 million nurses and midwives around the world (10). The emergence of the COVID-19 pandemic has only further highlighted the global need for HCWs. Adequate staffing is not the only challenge to the HCW population; IPC measures are crucial for keeping HCWs healthy and operational in hospitals. In addition to being a population that is not easily replaceable once taken out of the workforce, an increased strain on the staffing levels of HCWs also has a negative effect on patient outcomes. Hand hygiene with alcohol-based handrub is globally recommended as one of the most effective and low-cost procedures against SARS-CoV-2 cross-transmission (5) . It is well known that improving hand hygiene compliance among HCWs reduces HAIs in hospital settings (11, 12) . The economic implications of successful hand hygiene improvement have long been established. It has been demonstrated that these programs cost less than 1% of the HAI-related costs, making them relatively cheap and unequivocally worth investing in (13) . In another study, the net benefit of a hospital-wide hand hygiene program was reported as US$5,289,364, again proving the program's cost-effectiveness compared to the costs generated by HAIs (14) . According to the aforementioned study, every US$1 spent on the program could result in a US$23.7 return on investment-the highest return of any IPC measure (14) . Good hand hygiene programs are also dependent on systemic components of the healthcare facility, including access to supplies, how nurses are allocated, organized and trained, and the work culture. Constant exposure to patients with COVID-19, a lack of supplies such as adequate personal protective equipment in many hospitals, fatigue and stressful work environments put nurses at a higher risk of acquiring or transmitting the virus (15, 16) . Infected HCWs reduce the workforce of well-trained HCWs that are able to provide sufficient care for their patients, which in turn reduces the hospitals' ability to deal with an outbreak (17) . Since emergency situations are associated with increased HCW anxiety, some individuals may be less willing to work in such contexts, which can in turn create or exacerbate any already existing staffing shortages (18) . If societies want to make economically sound, lasting investments they must invest not only in the materials needed, but also in the people doing the actual work. According to the existing evidence, investing in health sectors such as education and job creation will improve health outcomes, global health security, and inclusive economic growth (10) . Ensuring adequate HCW staffing, training and support lead to a decreasing rate of HAIs, and is considered a core component of effective IPC programs by the WHO (1). Clean and safe care starts with investing in our nurses, and the message to policy makers should be clear: "increase nurse staffing levels to prevent infections and improve quality of care. Create the means to empower nurses and midwives." Doing any less wouldn't make human or economic sense. World Health Organization. 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First global patient safety challenge clean care is cafer care2009 COVID-19: protecting health-care workers World Health Organization. Nursing and midwifery. Fact sheets Compliance with hand disinfection and its impact on hospital-acquired infections Effectiveness of a hospital-wide programme to improve compliance with hand hygiene Cost implications of successful hand hygiene promotion Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health2020 COVID-19: what is next for public health? The Lancet Lessons from the severe acute respiratory syndrome outbreak in Hong Kong Protecting Healthcare Workers During the Coronavirus Disease 2019 (COVID-19) Outbreak: Lessons From Taiwan's Severe Acute Respiratory Syndrome Response This work is supported by the Infection Control Programme (SPCI), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; hand hygiene research activities at the SPCI 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 health care indifferent parts of the world, including in least developed countries. In this instance, companies/industry with a focus on hand hygiene and infection control related advancement have the specific aim of 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 the views expressed in this paper.