The 2014 Ebola virus disease outbreak in West Africa and subsequent cases in the United States highlighted the critical need to enhance coordination in health care and community settings to improve infection control preparedness and response efforts across the nation. Within health care settings, even daily infection control poses a major challenge as evidenced by the prevalence of health care–associated infections (HAIs). These infections, including those caused by antibiotic-resistant (AR) pathogens, are acquired while receiving treatment of other conditions. The Centers for Disease Control and Prevention (CDC) estimates that nearly 2 million people are infected with bacteria resistant to antibiotics1 and more than 700 000 HAIs occur each year in the United States.2 As the community chief health strategist, local health departments (LHDs) are uniquely positioned to engage health care providers, systems, and communities to enhance infection prevention and control, respond to HAIs and AR pathogens, and prepare for emerging infectious disease threats. To support this work, the National Association of County & City Health Officials (NACCHO), with support from CDC, launched a funding opportunity and demonstration site project, the Lessons in INfection Control (LINC) Initiative.
The initiative aimed to enhance coordination for preparing for and responding to Ebola virus disease, HAIs (including AR infections), and other emerging infectious diseases by strengthening LHDs' organizational and administrative capacity, expertise, and partnerships. In 2016, through a competitive process, NACCHO selected 11 LHDs for the project, awarded each with up to $25 000, and provided technical assistance, staff development, and opportunities for peer sharing. The LINC sites included the following:
- Barren River District Health Department (Kentucky)
- Clark County Public Health (Washington)
- Eau Claire City-County Health Department (Wisconsin)
- El Paso County Public Health (Colorado)
- Flathead City-County Health Department (Montana)
- Florida Department of Health in Pasco County
- Kent County Health Department (Michigan)
- Marion County Public Health Department (Indiana)
- Kanawha-Charleston Health Department (West Virginia)
- Public Health–Seattle & King County (Washington)
- St Louis City Department of Health (Missouri)
In 2017, NACCHO provided an additional $2000 to each site to support capacity building and the development of a toolkit featuring demonstration site-developed resources to support other LHDs with HAI/AR response. The toolkit is in the NACCHO online toolbox. The LINC demonstration sites also completed self-assessments before and after the project to analyze their role in HAI-related activities, capacity to engage in HAI prevention and response, and broader preparedness for emerging infectious disease threats.
All LINC demonstration sites created inventories of health care facilities in their jurisdiction, an effort that aligned with state-level HAI program activities. Beyond this, each of the sites developed innovative projects to address specific challenges and circumstances in their jurisdictions. Several demonstration sites conducted tabletop exercises, and many pursued Certification in Infection Prevention and Control (CIC) for their staff members. Other activities included the following:
- Surveying local health care facility HAI policies, programs, and staff and conducting internal capacity assessments;
- Developing regional communication strategies for health care facilities and increasing enrollment in an emergency notification network;
- Conducting trainings on infection control and creating educational materials for LHD and health care facility staff;
- Collaborating on state-wide Infection Control Assessment Response (ICAR) program activities3;
- Creating an emerging infectious diseases online learning portal for health care and public health that includes professional development courses and evidence-based resources for bioterrorism, HAIs, and infectious diseases; and
- Strengthening partnerships, collaboration, and response efforts by creating coalitions, developing interfacility transfer forms and standards, hosting regional meetings, and improving patient notification during nosocomial outbreaks.
Although LINC sites conducted a variety of activities, several consistent themes emerged.
Partnerships and Collaboration
Developing new partnerships and strengthening existing collaboration efforts are important components to the prevention and control of emerging infectious diseases (Figures 1 and 2). LINC sites coordinated with multiple partners, including health care facilities, preparedness colleagues, and state health departments. Tabletop exercises created a space for partners to identify shared priorities, test response capabilities, and establish necessary emergency systems. Similarly, HAI coalitions created relationships that could later be strengthened or leveraged and were cited as the most valuable component of this initiative. Engaging key community stakeholders, identifying common goals, and establishing LHD value as a coalition member were critical to project outcomes.
LHD Staff Capacity
LINC sites frequently reiterated the immense benefit of capacity building, a project priority. Initially, only one LHD reported having a staff member certified in infection control. This increased to 7 (64%) in the postassessment period. Obtaining CIC increased LHD credibility with partners, strengthened LHD staff confidence in infection prevention and control, and enhanced guidance provided to health care facilities. In one case, LHD project success resulted in the state health department designating funding to support up to 15 LHD staff members from around the state to take the certification examination and requesting that LINC demonstration site staff serve as mentors.
LHDs reported a better understanding of state health department priorities and gained opportunities to attend training sessions (such as geographic information system mapping and Epi Info 7 courses) and national conferences to learn new topics; build specific skills; engage in peer learning; and identify available resources such as the National Healthcare Safety Network (NHSN).
The LINC Initiative provided an opportunity to gain and expand access to HAI data, primarily through LHD partnerships. There was a notable increase, from 5 to 8, in the number of LHDs that collected HAI data from pre- to postassessment. Per reporting requirements, the data are often directly collected from health care facilities and some LHDs reported getting data from state health department laboratory reports. Partnering with the state health department can be a valuable way to expand surveillance activities; however, a partnership can be difficult to forge. As one participant noted, “Local health departments must be persistent and aggressive to be included in HAI surveillance and prevention initiatives run by their state health department.” The LINC Initiative also raised awareness around NHSN access; however, none of the LINC sites had access to these data. As one participant remarked, “Prior to starting this project, it would have been beneficial to know what relationship other health departments (state or local) have with the NHSN data entered by their hospitals and acute care facilities. Until this project, our program was unaware that health departments could have access to this data.”
Role in HAI Activities
Through this initiative, the number of LHDs working in HAI prevention and response and the scope of their role increased. In the postassessment period, respondents reported that LHDs should be in a leadership role conducting investigations and surveillance, facilitating coordination, guiding implementation of control measures, and providing education to facilities. This was a significant change from the preassessment results, where respondents identified LHDs in a supportive role.
The LINC Initiative reinforced that LHDs play a valuable role as chief health strategists in their community, particularly around issues such as emerging infectious diseases. These demonstration sites strengthened partnerships and conveyed important information to frontline providers. The project also reflected the broad spectrum of LHD involvement in HAI prevention and control. For some health departments, this was an introduction and opportunity to learn more, whereas others leveraged existing partnerships and activities to advance priority areas.
LHDs are on the front lines of public health and with sufficient funding and resources, they play a vital role when facing threats such as Ebola virus disease, HAIs, AR pathogens, and other emerging infectious diseases. LHDs serve as conveners and educators, identify risk factors for infection during outbreaks, make recommendations to reduce risk, and support health care facilities in improving infection prevention and control practices. There are key steps that can enhance the effectiveness of LHDs in these roles, including increasing access to data. Strengthening reporting requirements and processes will allow for more targeted and timely interventions for prevention and response to outbreaks. In addition, investing in expanding LHD staff capacity is critical to response efforts.
Employing lessons learned from the LINC Initiative, NACCHO continues to provide capacity-building assistance and advocate for HAI/AR programs. Advances in HAI/AR local programs were evident throughout the project, and the need for continued funding, capacity building, resources, and tools is vital for effective response to emerging infectious threats. LHDs are equipped to prevent, detect, contain, and respond to HAI/AR pathogens and are uniquely positioned to forge strong partnerships across public health, health care, and communities. NACCHO is committed to supporting LHDs to strengthen and improve their HAI/AR programs to ensure the safety of the public from emerging infectious disease.
1. Centers for Disease Control and Prevention. Antibiotic/Antimicrobial Resistance Web page. https://www.cdc.gov/drugresistance/index.html
. Published January 8, 2018. Accessed March 14, 2018.
2. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med. 2014;370(13):1198–1208.
3. Centers for Disease Control and Prevention. Infection Control Assessment Tools Web page. https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html
. Published November 13, 2015. Accessed March 14, 2018.