When controlling infections, some things never change

When controlling infections, some things never change

Source of Article:  http://www.publicservice.co.uk/feature_story.asp?id=11236


Public Service Review: Health Issue 18 -  Thursday, February 05, 2009

Professor Hugh Pennington, an emeritus professor of bacteriology, looks back at the treatment of infectious diseases at the turn of the 20th century and says that the 100 year old recommendations would still help to prevent infections today

"History is bunk," said Henry Ford. How wrong. For microbes, providers of healthcare ignore its lessons, not so much at their peril but for that of their patients. For some infections, we have developed effective controls, like vaccines against diphtheria, whooping cough and tetanus. But so far, only smallpox rests in the dustbin of history, and remedies like antibiotics, while still lifesavers, are becoming less effective for many conditions because their causative microbes evolve in real-time, making resistance common. Some antibiotics even have side effects that facilitate second infections, like Clostridium difficile associated disease.

A century ago, most of the major pathogenic bacteria that we are familiar with today had been discovered. For many of them, laboratory diagnostic methods like the agar plate haven't changed much. But effective treatments for the majority of their diseases lay far in the future. The emphasis had to be on prevention. Good things were done. Lessons were learned.

Nevertheless, very important ones have been forgotten. That rediscovering them has been slow is unfortunate. But the real scandal is that memory of them faded in the first place.

Take asylum dysentery. Historically, we think of Shigella infections in adults in terms of prisons and military campaigns. It killed many more soldiers in the Crimea than the Russians. But one of its natural homes used to be the mental hospital. In most of them, it was continually present. It was normal for a few patients at any one time to have diarrhoea. They attracted little interest. However, from time to time, it broke out in epidemics with high mortality. The interest of pathologists and bacteriologists was aroused. A particularly important outcome was the 'Report of Drs Mott and Durham on Colitis or Asylum Dysentery' presented to the Asylums Committee of the London County Council in May 1900. Mott and Durham recommended, among other things, that patients with a suspicious diarrhoea should be isolated, that the accommodation provided for isolation should not be used for other purposes, that all cases of diarrhoea should be notified, that 'while recognising the desirability and necessity of the transference of patients from ward to ward for purposes of treatment and administration, great discretion is necessary when diarrhoea, however slight, exists', and that much attention be paid to staff training, disinfection and handwashing.

Sadly, there is a very familiar ring to these recommend-ations. If they had been followed more than a century later at Stoke Mandeville and Maidstone, the enormous Clostridium difficile outbreaks there would never had happened. And even more recently, in Scotland, at the Vale of Leven Hospital, where an outbreak festered away for several months without being recognised as such, it could have been the same.

At this point, I am obliged to declare an interest. My grandmother was a nurse in the first isolation hospital to be established in an English mental hospital, purpose built in Lancaster out of bunter sandstone at the end of the 19th Century.

Another personal interest is in food-borne infections, particularly those caused by E. coli O157. From time to time, it reminds us of Shigella. The asylums are gone, but the residents of institutions providing care for the elderly are now subject to attack. Like Shigella, E. coli O157 provides a stern test for control of infection procedures because of the ease with which it spreads from person to person. Both have very low infectious doses.

In 1996-7, I chaired an investigation into Britain's largest E. coli O157 outbreak in Scotland. Now I am chairing a Public Inquiry into Britain's second largest outbreak, in Wales. Both had very similar features. So it is not surprising that a food safety blogger from Kansas has said that I have 'become unstuck in time...like Bill Murray in Groundhog Day'. Why don't we learn from history? Everyone has heard of Semmelweis, but many fail to follow his example. I only wish I knew why.



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