Health care–associated infections (HAIs) are infections acquired while receiving treatment or care for another condition occurring in any health care setting. While preventable, about one of every 31 hospital patients has an HAI, and in 2015, the last year for which data are available, this resulted in 72 000 HAI-related deaths.1 In addition, antibiotic resistance (AR) is a major public health threat that compounds the challenge of HAIs. Antibiotic-resistant infections cause more than 35 000 deaths each year, and 9 of the top 18 infections considered to be the highest AR threats are often associated with health care settings.2
Local health departments (LHDs) are the chief health strategists in their communities and can play a vital and diverse role in HAI/AR prevention and response. To date, however, an understanding of the scale of LHD involvement in this work does not exist. As a result, in 2019, the National Association of County and City Health Officials (NACCHO) conducted, for the first time, a survey to assess the extent to which LHDs engage in HAI/AR activities, explore existing LHD partner engagement, examine the role that LHDs play in outbreak response, and evaluate LHD capacity and infrastructure in HAI/AR prevention and control.
The study employed a cross-sectional survey design using a randomly selected sample drawn from a population of 2461 LHDs, stratified by region and by size of population served (small, <50 000; medium, 50 000-499 999; and large, >500 000). Since LHDs with large population sizes represent a relatively small proportion of all LHDs, those LHDs were oversampled to ensure a sufficient number of responses from large LHDs for the analysis. NACCHO developed the survey instrument by updating, modifying, and expanding upon a 2011 survey tool developed to conduct case study interviews to assess the landscape of LHD engagement in HAIs. The process to develop the instrument for the present study was informed by more than 5 years of working with LHDs on an HAI demonstration site project. Questions were piloted in early January, and minor adjustments were made.
NACCHO distributed the survey to 485 LHDs from January to February 2019 through Qualtrics and received 146 responses (response rate of 30.1%). Respondent characteristics are detailed in the Table. Statistical analyses were conducted using Stata version 15.1. Sampling weights were computed for each stratum, and analyses were weighted to account for the stratified survey design. Descriptive statistics and weighted proportions were calculated for all LHDs responding to the survey. Chi-square tests were used to assess differences in responses by LHD characteristics, where appropriate.
|Small (<50 000)
|Medium (50 000-499 999)
|Large (500 000+)
Findings and Discussion
LHD HAI and AR activities and barriers
LHDs reported conducting a wide variety of HAI/AR activities (Figure 1). The most frequently selected activities included providing general public education and outreach (61.5%), conducting surveillance for outbreak detection (60.1%), conducting surveillance for situational awareness (54.1%), and maintaining situational awareness (50.4%). Small health departments were more likely to indicate no role, and medium and large health departments selected more activities overall than small health departments.
During infectious disease outbreaks or exposure events within health care facilities, 53.8% of LHDs reported providing on-site or consultative assistance within the past year. Of those who reported this, most indicated that these outbreaks or exposure events took place in nursing homes (92.1%) and short-stay acute care hospitals (48.6%). Health departments most frequently recommended control measures (85.1%), connected the facility to resources (63.9%), and led the investigation once an outbreak had been detected (61.6%). Containment of an emerging or novel multidrug-resistant organism (MDRO) is still a relatively infrequent activity for LHDs, in part, due to the relatively rare occurrence of these events. While many LHDs (72.5%) reported no involvement in an MDRO containment response in the past 2 years, a quarter had engaged in an MDRO containment response.
Lack of funding, selected by 72.9% of respondents, was the most cited barrier to LHD involvement in HAI/AR prevention and control, followed by a lack of staff training (49.8%), and competing LHD priorities (44.3%). Additional barriers can be seen in Figure 2.
A coordinated approach is needed to control the spread of MDROs, making public health and health care partnerships vital.3 Nearly half (45%) of LHDs indicated that they did not engage with any partners on HAI/AR work and only 47% reported engaging with their state HAI program/coordinator, indicating an opportunity for increased engagement between state HAI programs and LHDs. Of those who did report engaging with the state HAI/AR program, most reported engaging with them on outbreak investigation and control (88.4%), informally sharing information for situational awareness (63.8%), or sharing data (56.1%). Other partners engaged can be seen in Figure 3.
In addition, LHDs reported engaging with a variety of health care facility partners on a range of HAI/AR activities, including outbreak investigation and control activities (84%), informal information sharing (79%), and provider and patient education (73%). For outbreak investigation and control activities, the majority of LHDs reported working with nursing homes/skilled nursing facilities (75.2%), short-stay acute care hospitals (59.8%), long-term acute care hospitals (51.4%), and other outpatient facilities (50.4%). While small LHDs were less likely than medium or large LHDs to work with nursing homes on outbreak investigation and control activities, more than half of all small LHDs surveyed (60%) did engage with nursing homes more than with any other health facility type. LHDs that reported having no role or referring to the state for HAI/AR activities are still collaborating to some extent with health care facilities on outbreak investigation and control, informal information sharing/awareness, data sharing, prov-ider education, patient education, and communications with the public/media.
Infrastructure: Data and workforce
Understanding the existing infrastructure, including systems and programs, to support HAI/AR activities and programs is crucial. HAI/AR data can be used to implement effective infection prevention strategies. More than 50% of LHDs reported having access to HAI/AR data through 4 sources: access to a local or statewide surveillance system (73%); data received directly from the state health department (70%); other HAI/AR case-based or laboratory-based surveillance data (57%); or a direct report from providers or health care facilities (57%). However, further assessment is needed to determine the scope and utility of these data. Of note, only 20% of LHDs reported having access to AR Laboratory Network isolate testing results and only 4% reported having direct access to the National Healthcare Safety Network.
Exploring the HAI/AR workforce is also critical to understanding the current landscape of HAI/AR work at the local level. LHD staff engaged in HAI/AR work most frequently identified as a public health nurse (83.4%) or epidemiologist/data analyst (77.7). Other positions included educators/community outreach staff (33.6%) and infection control experts (28.4%). Most respondents (81.2%) reported that their staff are not Certified in Infection Control (CIC) through the Certification Board of Infection Control and Epidemiology. LHDs serving populations of 500 000 or more were significantly more likely to report having staff with CIC certifications. Only 10.2% of LHDs reported having a program or department specifically dedicated to addressing HAIs/AR. For jurisdictions that reported having a program or department specifically dedicated to addressing HAIs/AR, the median number of full-time equivalents (FTEs) working within those programs was 1 (IQR = 1-2). For LHDs without a dedicated HAI/AR department, the median number of FTEs doing HAI/AR work was 0.25 (IQR = 0-3).
The findings may be limited by the response rate of 30.1%, which may limit the ability to generalize findings to all LHDs; however, the survey completion rate was 98% and there were no differences in completion rate among individual survey items.
The results of the 2019 LHD HAI/AR assessment expanded previous insight and revealed key activities, roles, and partnerships as well as critical gaps and opportunities for LHDs engaging in HAI and AR work. LHDs have strong foundations to support this work including relationships with their health care facility partners, particularly nursing homes and long-term care facilities. The most commonly reported HAI/AR activities align with activities that LHDs conduct and excel at, including surveillance, outreach, and education. For example, LHDs most commonly reported providing on-site or consultative assistance for general infectious disease outbreaks in health care facilities, such as influenza and Norovirus infection. These may represent opportunities for LHDs to build upon to support future HAI investigations, after additional capacity building. The work can further be strengthened by expanding partnerships, particularly with the state health department to coordinate efforts. These existing strengths and capabilities can be leveraged to enhance prevention and control of HAIs and AR, but a culture shift must take place among LHDs, state health departments, health care facilities, and national partners that recognizes the valuable role that LHDs can play to strengthen HAI/AR prevention and increase the speed of response activities during an outbreak throughout the country. Support in funding, increased access to relevant HAI/AR data, and expanded local HAI- and AR-specific training and technical assistance should be prioritized. Continuing to understand and cultivate the expanding role that LHDs play is necessary to advance HAI/AR prevention and control.
1. Centers for Disease Control and Prevention. HAI data. https://www.cdc.gov/hai/data/index.html
. Published October 5, 2018. Accessed July 8, 2020.
2. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2019.
3. Centers for Disease Control and Prevention. Making health care safer: stop spread of antibiotic resistance. CDC Vital Signs. https://www.cdc.gov/vitalsigns/stop-spread/index.html
. Published August 2015. Accessed September 3, 2020.