News

by Theoklis Zaoutis*

But to win the war against infectious disease – and to be ready for the next health crisis – we need a stronger, more accountable health system.

We should all be proud of our country’s successful response to the coronavirus crisis. It shows that with a concerted group effort from everyone in our society, we can achieve better health outcomes – better even than other countries with far more resources.

Having won this early battle, it’s tempting to pat ourselves on the back for a job well done and return to our normally scheduled programming. But now is not the time to pause our infection control efforts; it’s time to double down on them, and to use the momentum from our fight against COVID-19 to tackle the long-standing challenges of a health system weakened by years of austerity measures.

While the creation of the National Organization for the Provision of Health Services has streamlined a fragmented system devastated by the 2008 financial crisis, and in recent years healthcare resourcing has slowly increased towards pre-crisis levels, Greece still faces a variety of obstructions to the delivery of high-quality care to all of its citizens.

The most pressing challenge of them all is the overarching lack quality assurance and accountability for care provided across the country. Right now, there is no centralized authority overseeing the quality of health services, particularly those provided within public hospitals – and as a consequence, we’re not ensuring that citizens receive the care they deserve.

At best, health services provided without strong quality oversight disappoint patients; we see this manifested in the dismal Eurobarometer survey results that show nearly three out of every four Greeks think hospital care is worse here than in other EU member states. At worst, this lack of quality assurance leads to poorer health outcomes – and ultimately more deaths. The health system regularly encounters staff and equipment shortages, inadequate GP and paramedic training, and other indicators of low-quality service delivery.

These barriers to quality care end up creating an environment that allows infectious disease to spread. Greece tops EU rankings for rates of hospital-acquired infections (HAIs), some of the hardest to treat and therefore deadliest infections. For every COVID-19 case reported so far in 2020, there are at least ten HAIs reported worldwide. Unlike COVID-19 cases, however, we know how to prevent these infections: by providing better, safer care in the hospitals where they happen.

A critical step towards improving hospital care and reducing HAIs is to establish mechanisms for quality assurance and accountability across the entire network of care providers. A new bill proposed by the Ministry of Health in the Greek Parliament would establish a new Agency for Quality Assurance in Healthcare (AQAH) to do just that.

But recent political squabbling may be undermining the bill’s chances, putting again the issues of public health being public and the role of private sector supporting this effort – things that are not negotiable. These criticisms are well-intentioned – indeed the free exchange of opposing ideas is critical to sustaining our democracy – but without the establishment of strong quality assurance mechanisms, the health of the Greek population continues to be at risk.

Parliament must pass legislation establishing the new Agency for Quality Assurance in Healthcare. Without this new quality assurance mechanism, we will miss our chance to leverage our victories against COVID-19 to strengthen the Greek health system and ensure we are prepared for the next health crisis.

As part of its mission, the AQAH would also focus resources on promoting equal access and universal health coverage to the entirety of the Greek population. Universal health coverage for all humans on earth is a core tenant of the United Nations’ Sustainable Development Goals, and a global effort is underway to support this coverage worldwide by 2030.

*Written by Theoklis Zaoutis, MD, MSCE

Director of CLEO,
Professor of Pediatrics and Epidemiology
University of Pennsylvania School of Medicine
Division of Infectious Diseases
The Children's Hospital of Philadelphia

Antimicrobial resistance is a global public health challenge with serious implications to patient health outcomes and enormous added costs to national health systems. The development of antibiotic resistance is directly linked to the scale and manner of antibiotic consumption.

Recent data show that antibiotics are not only overly consumed in Greece but also that the rates of antibiotic resistance are consistently higher than other EU member states. Greece and Italy have the highest levels of morbidity and number of deaths associated with antibiotic-resistant infections. And while the judicious use of antibiotics is considered critical in halting the development of antibiotic resistance, Greece still ranks 1st in the consumption of antibiotics within primary healthcare settings, among other EU member states. Greece is also far ahead of Romania, which ranks 2nd.

The use of antibiotics without a doctor's prescription is forbidden in Greece for the last three decades, (since 1973, as per Law (ΦΕΚ) 172 / 8.8.1973). But the situation is rather different in practice. In a study conducted in 2010 which showcased the true magnitude of the availability of over-the-counter antibiotics, 21 researchers went to 174 pharmacies across Greece and asked for 2 antibiotics without providing neither a doctor's prescription or any other explanation to the pharmacist. Out of every visit to a pharmacy (100% of the time), researchers were sold at least one antibiotic. A second antibiotic, which in this case was ciprofloxacin and which has been labelled as prescription-only since 2003 in Greece, was sold to researchers just over half of the time (53% of instances). The latter finding, showed that though the 2003 law limiting the prescription of some antibiotics may have managed to reduce prescription at the pharmacy 5 years later, it had yet to completely eliminate the phenomenon.

It is important to remember that the use of antibiotics is not without consequences for patients. Antibiotics should only be administered upon specific indications and upon a doctor’s prescriptions. Today, should new laws be developed against over the counter prescribing and these are also imposed, then Greece can stand a chance to limit resistance and stop being the champion in a race where the winner should come last.

Recognizing the scientific work of the Center for Clinical Epidemiology and Outbreaks - CLEO and its contribution to the reduction and prevention of infections in Greece, the American Hellenic Educational Progressive Association – AHEPA has announced its decision to support the work of CLEO.

AHEPA has donated the amount of $30,000 for the training of health professionals in primary health care centres and in specialized COVID-19 reference centers that were established in Greece from early April for the prompt diagnosis and treatment of COVID-19. In addition, the donation will support novel research that CLEO is about to undertake aiming at assessing the knowledge, perceptions, and practices of health professionals regarding transmission, prevention and measures taken to address the pandemic in Greece.

The President of AHEPA, George G. Horiates, made a special mention to the work of the Scientific Director of CLEO, Dr. Theokli Zaoutis who has also been serving in the Expert Committee of the Ministry of Health for the control of COVID-19 in Greece, emphasizing that "AHEPA and the people of Greece are fortunate to have Dr. Zaoutis serving the medical and public health profession during this time of crisis” and added that “AHEPA is proud to back his research".

See also: https://ahepa.org/ahepa-donates-30000-to-support-public-health-research-training-in-greece/

The rapid spread of the coronavirus pandemic, which has infected over 3 million people and causing more than 200,000 deaths to date, has shed light on existing weaknesses and structural problems in healthcare systems worldwide, from poor compliance with infection control procedures to insufficient supplies of medical equipment.1,2

One of the most serious such problems is the threat of antibiotic resistance, which occurs when bacteria adapt in response to medications used to treat infections such as pneumonia, tuberculosis, sexually transmitted infections, urinary tract infections, and wound and skin infections, among other conditions. As the bacteria evolve, they become resistant to these medications, which makes these infectious diseases increasingly difficult to treat.3 For years, the World Health Organization (WHO) and other leading public health organizations have warned that antibiotic resistance, which is caused primarily by the misuse and overuse of antibiotics, is one of the most serious threats facing public health and development worldwide.4 At least 700,000 people die each year from drug-resistant diseases, and the United Nations has warned that this number could increase to up to 10 million deaths per year by 2050.5.6

Now, in the midst of a global pandemic, the threat of antibiotic resistance has become even more serious, according to the Center for Clinical Epidemiology and Outbreaks. Bacterial infections are often major drivers of high fatality rates during viral pandemics due to their increased spread in crowded healthcare facilities, where they afflict already weakened and immunocompromised patients.7,8 Writing in Scientific American, Oxford historian Claas Kirchhelle and his colleagues noted that a large proportion of deaths during the 1918-20 flu pandemic were due not to influenza itself, but to bacterial infections that spread in the hospital wards; similarly, it’s estimated that between 29-55% of deaths associated with the 2009 H1N1 influenza pandemic were actually caused by secondary bacterial pneumonia.7,8 In a study of 191 patients in Wuhan, China, half the patients who died from COVID-19 tested positive for a secondary infection, compared to only one such infection among the patients who survived.9 Furthermore, antibiotic resistance not only decreases the effectiveness of the medications that are urgently needed to fight bacterial infections during a pandemic; resistance itself may increase due to the large quantities of antibiotics prescribed to COVID-19 patients, which jeopardizes effective treatment for a variety of diseases and populations beyond the scope of any one pandemic.9,10

This is an especially serious threat in Greece, due to the country’s already exorbitant rates of antibiotic resistance. Greece has historically had among the highest rates of antibiotic use and resistance in Europe; in a recent survey of antibiotic use of acute-care hospitals in the EU from 2016-2017, the prevalence of antibiotic use in Greece was 55.6%, compared with 30.5% in Europe overall.11,12,13 Greece also has among the highest rates of hospital-acquired infections (HAIs) in Europe, many of which are caused by organisms — known colloquially as “super bugs” — that are resistant to many different drugs.12 The result is that although Greece may have relatively low rates of illness and death due to the coronavirus itself, the country is at an elevated risk of experiencing significant illness and death due to bacterial infections during this pandemic.

Fortunately, the best weapon we have to fight antimicrobial resistance is simple, affordable, and supported by robust evidence: antimicrobial stewardship (AMS), which aims to optimize the use of antibiotics in order to simultaneously prevent the development of resistance and improve patient outcomes.14

Since 2011, the nonprofit Center for Clinical Epidemiology and Outcomes Research (CLEO) has been working to foster the development of AMS in healthcare settings throughout Greece and to reduce both the misuse and overuse of antibiotics as well as rates of hospital-acquired infections.