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

"The coordinated actions by the Greek health authorities but also the immediate adoption of basic measures of prevention that control the transmission of the new virus by the vast majority of citizens, show that we already have suitable defense mechanisms at hand. The ultimate goal and opportunity now is for prevention practices to become permanently integrated into our daily lives, even after the COVID-19 pandemic. This way we can stop losing lives every year from the flu and other infections that can otherwise be prevented " says Dr Theoklis Zaoutis, Professor of Pediatrics and Epidemiology and Scientific Director of CLEO.

o far, COVID-19 mortality appears to be relatively low, with those who are most severely affected suffering from existing health conditions. But, while most cases of COVID-19 may be mild, the virus is more threatening – in the epidemiological sense- than would a virus which caused more severe symptoms. Those with an asymptomatic infection may not be aware of having contracted the virus, they may not take additional precautions to minimize their role in transmission, nor seek to receive adequate medical care. Unnoticed the virus may continue spreading widely, so much as to see large increases in prevalence and a domino effect not only each health system but also on the national and global economy.

One of the most important factors in limiting the spread of COVID-19 is the uptake of personal protection and prevention measures by all citizens. Another is the systematic adoption of infection control procedures by healthcare workers, who more than any other group are at greater risk of infection through the close contact with infected cases and environments. Basic precautions, such as good hand hygiene and the safe disposal of clinical waste, and transmission precautions, such as the use of isolated, clearly marked isolation areas and suitable personal protective equipment (e.g. masks, robes, goggles and gloves), are essential.
Infected patients should be moved as little as possible into and within a healthcare unit and when such movement cannot be avoided, patients should be isolated from healthcare staff and other patients through the use of dividers, curtains and appropriate air filtration systems. All healthcare professionals should be trained in infection control precautions and hospitals should be in close contact and cooperation with public health authorities in order to share up-to-date and accurate information about the spread of the virus.

The most important of these precautions – e.g. hand washing, wearing robes and gloves, and disinfecting or disposing of contaminated equipment, are quick, simple and low-cost practices that should become "second nature" not only to those who work in a healthcare environment but also to the wider public.

COVID-19 can teach us an important lesson about the urgent need for increased awareness around infection prevention as well as highlight the unique opportunity we now have to prioritize prevention for infection control in Greece and to take action on a permanent basis. The Greek government has recently taken an important step in this direction, introducing a Program for the Prevention and Control of Infections Related to Health Services and Antimicrobial Resistance, by law at the end of January 2020. The program is supported by a generous grant from the Stavros Niarchos Foundation within the framework of the "Health Initiative" program.

The importance of prevention, both for the health of citizens and for an effective health care system, is particularly evident now that the world is facing a public health emergency. Maximizing the use of standard precautions and best practices is vital to preventing and limiting both common infections and new pandemic diseases such as COVID-19.

The program is supported by a generous grant from the Stavros Niarchos Foundation within the framework of the "Health Initiative" program (https://www.snf.org/el/protoboulies/stirizontas-tin-ygeia-stin-ellada/).

The importance of prevention, both for the health of citizens and for an effective health care system, is particularly evident now that the world is facing a public health emergency. Maximizing the use of standard precautions and best practices is vital to preventing and limiting both common infections and new pandemic diseases such as COVID-19.

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.

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/