For my Work the World elective I travelled to Pokhara, Nepal and spent four weeks in a General Government Hospital. I did two weeks on a paediatric ward and two weeks on a surgical ward. One of my focuses was on infection control.
Nepal not only has a Gross Domestic Product (GDP) significantly lower than that of the UK, but they also spend a lower percentage of this on health care. This results in a much lower amount being spent on people and their health needs (World Health Organisation, 2011).
In Paediatrics, the most commonly observed problems were Respiratory Tract Infection (RTI), Pneumothorax, Diarrhoea and Vomiting, Nephrotic Syndrome and pyrexia of unknown origin (PUO). In surgery the most commonly observed problems were appendicitis, burns (burns unit was part of surgical ward), diabetic feet, cholelithiasis, and stab injuries. About 70% of illnesses in Nepal are attributed to infectious diseases.
Infection control guidelines in the UK can be split into three categories: hand hygiene, personal protective equipment and safe use and disposal of sharps. The use of all three can help to prevent infection.
A recent study found that Basic Health Care workers in Nepal had a poor knowledge of universal infection precautions and were not interpreting the guidelines correctly. This fits with what I saw in the hospital - gloves were kept in the treatment room and they were cleaned and re-used after each use. There were no aprons available. Protective masks were used by some health care staff, but this was mainly due to the air pollution in Nepal caused by vehicles, industry, cooking fuels and the burning of litter rather than infection risk from inhalation. These masks are not disposable, and are also worn between patients.
A good part of the experience was showing the staff that the Western standard is to clean your hands regularly between each patient. The water in Nepal is highly polluted by domestic and industrial waste so I used alcohol hand gel. The staff in the hospital seemed fascinated by this strange solution that I kept applying to my hands and it was only after some time that I noticed that they also had some alcohol gel on the drug trolley.
I observed many examples of cross contamination. In paediatrics the doctors and nurses would often touch a child with suspected tuberculosis, and then go on to touch another child on the ward with no Personal Protective Equipment (PPE) or cleaning their hands. In surgery the consultant on ward round would check every patient’s surgical wound by lifting the dressing without washing their hands between. I felt disappointed because there were so many incidences where infection could have easily been avoided.
Another aspect of infection control that I found concerning was the prescription of antibiotics. In paediatrics particularly, antibiotics were prescribed to almost every child regardless of their condition. One bay was specifically for children with diarrhoea and vomiting caused by gastroenteritis. Guidelines in the UK suggest that antibiotics must not be given routinely for this problem, unless there are clear signs of further infection because of problems like Methicillin Resistant Staphylococcus aureus (MRSA).
A study in a hospital in Western Nepal showed the increasing prevalence of MRSA in clinical specimens from 29% in 1990 to 69.1% in 2009. Prevalence was lowest in Nepal in places where there was little access to antibiotics. A third of patients with MRSA colonies will not show signs of infection; however two thirds of patients with MRSA colonies will develop anything from a skin infection to septicaemia.
Work the World advise that “It’s important to remember that you’re not going to Nepal to change things, you’re going there to learn. You may never fully understand the complex cultural and economic reasons behind some of what you see – but if the experience you have on your elective makes you a better healthcare professional, it has been worthwhile". I respected this agreement during my time in Nepal. I tried to set a good example and discussed with the nurses and students how things were done differently in the UK. If I were to go back to Nepal I would try and take supplies of gloves and aprons and perhaps some printed copies of policies and guidelines on infection control, all though this could only help in the short term.
Spending time in Nepal has opened my eyes to the realities and importance of infection control. Hopefully my example highlighted that to the Nepalese nurses too.