When people suffer from serious injury or illness, they go to hospitals for treatment. Ironically, however, hospitals and nursing homes are increasingly becoming a source of disease. Across Canada medical experts are sounding the alarm about hospital-acquired infections (HAIs), which strike over 200,000 Canadians each year, and cause at least 8,000 deaths. Especially troublesome are the so-called "superbugs" - diseases that have developed partial or complete immunity to antibiotics.

The fight against these HAIs is conducted through the infection- control programs in hospitals and other health care facilities. What many people, and most politicians, fail to realize is that the foundation of any effective infection-control program is housekeeping - cleaning and disinfecting equipment, rooms and fixtures.

Last September, the Scottish government ordered health boards across that country to stop the contracting out of housekeeping services in health-care facilities. The health minister, Nicola Sturgeon, announced the move as part of a campaign against HAIs. Speaking to a conference of the Scottish National Party, Sturgeon said:

"On Monday morning, a letter will issue from my department to all health boards advising them that from now on, there will be no further privatization of hospital cleaning and catering services anywhere in Scotland... The public must have confidence in their NHS (National Health Service) and know that they're going to get the best possible care whenever they need to go into hospital. That's why tackling the problem of healthcare associated infections (HAI) is a key priority for this government."

These hospital-acquired infections pose a real and growing threat to patients and health care workers. Elderly Albertans  living in seniors' care facilities are especially vulnerable, because they may have weaker immune systems, and because infection-control procedures may be less vigorous than in hospitals, especially in the case of private for-profit nursing homes.

The link between hospital cleanliness and HAI incidence is well established, as is the conclusion that investment in housekeeping is one of the most cost-effective ways to prevent HAIs. A 2001 study concluded "a high standard of hygiene should be an absolute requirement in hospitals. In the long term, cost-cutting on cleaning services is neither cost-effective nor common sense."

THE HAI "BIG THREE" MRSA - Methicillin-resistant Staphylococcus aureus. These bacteria live on the skin and on equipment, fixtures and other surfaces in health-care facilities. When they infects the body, the resulting symptoms can include boils, abscesses and, in extreme cases, pneumonia or necrotizing fasciitis ("flesh-eating disease"). Since it was first reported in 1995, MRSA infection rates have increased tenfold. Intensive cleaning procedures are required to kill this "bug." C. Difficile - a bacterium spread by contamination from fecal matter. According to Health Canada: "The use of antibiotics increases the chances of developing C. difficile diarrhea because antibiotics alter the normal levels of good bacteria found in the intestines and colon. When there are fewer good bacteria, C. difficile can thrive and produce toxins that can cause an infection. In hospital and long-term care settings, the combination of a number of people receiving antibiotics and the presence of C. difficile can lead to frequent outbreaks." Symptoms include diarrhea and potential dehydration which can pose a significant threat to seniors in nursing homes or to hospital patients with weakened immune systems. VRE - Vancomycin-resistant enterococci. Infections can occur in wounds, the bloodstream or the urinary tract, but it can also exist in a "carrier state" in the bodies of people who exhibit no symptoms. Extremely drug-resistant, VRE poses a threat mainly to those who are already weak or ill.

Of course, cost-cutting on cleaning services is exactly what happened to Alberta hospitals in the Ralph Klein era, and the results have been predictable. Jane Sustrik, 2nd Vice President of the United Nurses of Alberta (UNA) says:

"The real problem with hospital-based infections did not start appearing until after the staffing cuts in the 90s. We need to ensure full  complements of nurses in order to cut back on cross infections. The same applies for the support staff, who do the cleaning and everything else. Good staffing, not cutting corners, makes for clean and safer facilities."

There are a number of diseases that are easily spread through health-care facilities in the absence of effective cleaning standards and infection control procedures. The Norwalk virus, for example, causes gastro-enteritis. For most healthy adults this is an unpleasant experience but hardly life-threatening. For patients who are already ill, however, or for elderly residents in a seniors' care facility, the virus can pose a very serious health risk.

Of greater concern, however, are new strains of drug-resistant diseases. Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium Difficile, and Vancomycin-resistant enterococci (VRE). Because these "superbugs" have developed and continue to develop immunity to antibiotics, they are a serious threat to patients and to health care workers. The UNA's Jane Sustrik puts it this way:

"HAIs are a real concern to nurses... both for their patients/clients/residents and for themselves... Cutting corners and reducing staffing levels only increases the risks... We have seen the impact MRSA and VRE can have on a hospital population and health care workers. It's the 21st century - we should be working to reduce risks and infections."

WHEN SUPERBUGS ESCAPE The risks associated with "superbugs" aren't just limited to hospitals and nursing homes - these diseases are capable of escaping into the community. In January of 2007, the Canadian Medical Association Journal warned of the dangers of community-associated MRSA, or CA-MRSA. In February of last year the Calgary Herald reported that the incidence of MRSA in that city had almost doubled in the previous year, and had struck "marginalized populations in the city: homeless people, drug users and prisoners." The Herald report went on to say that "The superbug has gained an even stronger foothold in the United States, where the Journal of the American Medical Association estimated last fall that severe infections from the bacteria killed about 19,000 people in 2005, taking more lives than AIDS." Source: http://www.canada.com/globaltv/natio...8- aa24063e95f5

The problem is that when health care budgets get cut, housekeeping often seems like an easy target for administrators. Doctors and nurses are high-profile professionals. MRI and CAT scan machines are high-tech and glamorous. Housekeepers are, by comparison, the invisible component of health care. Poorly paid and often ignored, they are often the first to experience cutbacks and/or see their jobs contracted out. Contracting out, however, is a recipe for disaster. When Britain's National Health Service conducted an audit of cleaning in selected hospitals, it found that:

"...where services are contracted out they are more likely to have failed (the audit). 20 out of 23 of these hospitals which did not pass the cleaning audit are contracted out compared to an estimated 50 per cent of contracts contracted out overall."

Over the last 13 years, in hospitals and nursing homes across Alberta, housekeeping budgets have been pared back and, in some regions, housekeeping services have been contracted out. One legacy of the Ralph Klein's war on deficits has been, to put it bluntly, dirtier hospitals.

The fight against superbugs begins with cleaning and disinfecting our health-care facilities. The government and the owners of nursing homes should make investments in housekeeping a major priority, and the contracting out of housekeeping services should be eliminated.

This argument is especially important in the current economic climate. With the province's energy revenues dwindling, and the possibility of budget deficits looming on the horizon, Ed Stelmach's Tories may be tempted to fall back on more cuts to health care. If we've learned anything from our experiences since 1993, it's that such a move would be a terrible mistake.

REFERENCES

• Prevention and Control of Hospital-acquired Infections, Special Report of the Office of the Auditor General of Ontario, September, 2008.
• Rampling, A., Wiseman, S. Davis, L., Hyett, P., Walbridge, A.N., Payne, G.C., and Conaby, A.J. (2001) Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus aureus. Journal of Hospital Infection, 49: 109-116.
• The United Kingdom Parliament. 2002. Supplementary memorandum by UNISON (PS 33A). http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmse