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"You can learn a lot in many different areas from each other"
Doctor Inka Daniels-Haardt;
Dr. Inka Daniels-Haardt is the coordinator for the EurSafety Health-net project and Head of the National Institute of Health and Work of North Rhine-Westphalia, Germany. She explained to MEDICA.de how such an exchange of knowledge and experience can work best.
MEDICA.de: Dr. Daniels-Haardt, nosocomial infections, infections with multi-resistant bacteria like MRSA are a big risk and cost factor in hospitals all over the world. The EurSafety Health-net currently works on significantly reducing the number of diseases in health care. What job are you taking on in this project?
Inka Daniels-Haardt: In this project I work as a coordinator and participate for instance in the planning and controlling of the overall project and join discussions on what kind of activities we are untertaking and what investigations and scientific studies we conduct. However, it is also my main task to be in charge of a so-called work package “for the teamwork of Public Health Service (ÖGD) in Germany and the GGD equivalent on the Dutch side”. We are trying to bring the partners on both sides together, so they are able to work together on different projects. For all intents and purposes I am the manager of a work package, a cross-section work package, in collaboration with the public health services. We collaborate with all regional partners of the participating Euregio regions.
MEDICA.de: Which partners are participating in this project?
Daniels-Haardt: That varies. In my work package the primary contact is the public health service. We work together with all stakeholders that are involved in some way in public health care; these are hospitals, private medical practitioners, laboratories, nursing homes, outpatient nursing services and patient organizations.
MEDICA.de: EurSafety Health-net primarily works binationally. It is an exchange between different health care stakeholders in Germany and the Netherlands. How is this collaboration shaping up?
Daniels-Haardt: In the beginning phase we initially searched for contact persons, people on both sides of the border who are interested in collaborating on this project. Then we invite the stakeholders to so-called “round tables“, meaning meetings of the different regions, the regional networks or “EurQHealth“ regions, to corresponding topics and continuing education seminars or also to initiate joint projects. There are many different activities of the individual Euregio regions that we conduct. A complete overview can be found on our homepage EurSafety Health-net. For instance there is the project called “Schmuddelfritze“(“Mr. Grubby Pants”) in Germany and the Netherlands. It is about promoting the topic of hygiene already in schools and teaching children to wash their hands and to sensitize them. At the moment we also work on a Euregional report on sexually transmitted diseases, an important topic. Right now we analyze how these diseases are being dealt with in the border area and what kind of data is already available for this.
MEDICA.de: What acute hygiene problems are you currently dealing with?
Daniels-Haardt: Time and again there are many acute problems, one after another. Several months ago for example, our Dutch partners had big issues with Q-fever in goats and humans. For this we had many intense discussions with all participants, since so far we had very few problems with this in Germany. Consequently it was interesting for all stakeholders to look beyond their own country border and see how both countries deal with the situation. Recently we had a large number of cases of EHEC infections in Germany. This was an extremely big problem, especially for hospitals. During this time the Dutch partners questioned whether the measures that are implemented in Germany make sense. Throughout this time it was important to inform the Dutch participants on the individual measures that we especially took in hospitals – this also includes the exchange on concrete cases- and discuss the particulars. The Dutch side informed us for example about this case: One child tested positive for EHEC and indicated to have visited a petting zoo in Germany prior to this. We very specifically pursue such information and check whether this indeed is a cause of infection. Thanks to the collaboration in the scope of the EurSafety Health-net we are able to better trace back and clear up such concrete cases.
In the future patients may search for appropriate medical care options not only at national side, but across national boundaries; © panthermedia.net / David Wetzel
MEDICA.de: The European Union stands behind the EurSafety Health-net project and has made it its business to afford all EU nationals more mobility in public health care. What key priorities does the binational network undertake here?
Daniels-Haardt: The focus is on patient safety and improving the quality of public health care with regard to infection protection, especially in hospitals. This way we want to make sure that patient mobility is possible on both sides of the border and the quality, for example in hospitals in regards to infection protection is being adapted. It is one of the high priorities in EU health care policy to ensure mobility beyond the border. We would like to enable nationals to get a 360 view. This means in the future that patients will not just look for the appropriate medical care options on a national level, but perhaps also consider the specialized center that’s 20 km away in the neighboring country, which is able to optimally take care of them. The cross-border health care is supposed to proceed without any obstacles. MRSA, an infection with multi-resistant bacteria, is still an obstacle that most notably occurs in hospitals in Germany more often than in the Netherlands.
MEDICA.de: Why does the containment of MRSA require a European and international collaboration?
Daniels-Haardt: I think this is true for all problems in our ultra mobile world of today. The borders are blurred – and particularly bacteria don’t care about these borders. In that respect it’s clear that you cannot view this as an isolated issue, but that it can only be resolved in collaboration with the partners on the other side of the border. MRSA and multi-resistant bacteria are not just a problem in Germany, but all over the world. There is a lot of border traffic especially in border regions. People work in the other country and agricultural and other goods are transported over the border area, which is why it is important in the so-called Euregios (also called Euroregions), the areas close to the European border, to work hand in hand.
MEDICA.de: To what extent do Germany and the Netherlands benefit from the mutual exchange of experiences?
Daniels-Haardt: You can learn a lot in many different areas from each other. In regards to MRSA, the Dutch have already followed a very intensive strategy very early on. It is called "search and destroy". Already in the 80s, hospital patients were intensively screened for MRSA, rehabilitated and a consequent antibiotic policy was being pursued. The spread of MRSA therefore was never an acute problem in Dutch hospitals as it is in Germany. We can learn something from the Dutch in this case. We have renamed and adapted this strategy somewhat in Germany; it now goes by the name "search and follow". This means that we also attend to MRSA patients outside of the hospital after they have been discharged. But the Dutch can also learn from the German partners, for example as it pertains to the exchange of diagnostic methods. We have also intensely pursued this in our first MRSA-net project. Both sides benefit of course from an optimization of health care. Another criterion is hugely important to Dutch patients: They have a short supply of hospital treatment spaces. It is not a matter of course to be able to immediately perform hip or bypass surgery at a Dutch hospital. In fact, patients are waitlisted. In this case it would be nice if these patients could directly have surgery in Germany without a waiting time. This works especially due to the fact that we adjust hygiene and quality standards accordingly on both sides.
MEDICA.de: Aside from the Netherlands, Scandinavia is also known for a low infection rate in hospitals. Are similar strategies to the ones in Netherlands being pursued here?
Daniels-Haardt: The Scandinavian countries also have consequently pursued a restrictive antibiotic policy very early on. They have very closely checked what kinds of antibiotics are being prescribed, introduced a good surveillance system, built up monitoring of antibiotics misuse and also established training for physicians and nursing staff. In addition they have started a great collaboration with experts in veterinary medicine. This is a complete package of measures that these countries have implemented very early on and thus were able to control the infection rate with.
Continuing education and training of clinical staff are key priorities in order to raise awareness of the issue of antibiotic resistance;©panthermedia.net/Piotr Marcinski
MEDICA.de: In a first project, the MRSA-net, you have already gained first experiences on hygiene standards and now these have been integrated into the larger scale Euregio-Project – which goal is the EurSafetyHeath-net project now pursuing and how is it meant to be reached?
Daniels-Haardt: In the predecessor Euregio project we already gained a lot of experiences. Yet compared to the EurSafety-project it was clearly a smaller project. Now we are working on a large project, in which multiple Euregio regions are consolidated. In the first project we already learned a lot about networking, intersectoral collaboration and the implementation of hygiene recommendations in medical practices. Basically these experiences that we initiated in the MRSA-net are being continued. Many elements from the MRSA-net can be found again in the EurSafety project. For example we are following up on the subject of quality seals for hospitals. Lately we have awarded a consecutive quality seal for hospitals that already participated in the first project and have implemented corresponding hygiene regulations. This is a continuous process.
Another main focus area is the topic of continuing education and training which we intensively pursue and also broadened in regard to the topic of antibiotic resistance. In addition we offer different focal topics of experts which we incorporate into the project. This includes topics such as “burden of disease“, meaning how you handle a disease, economic questions, developing a telematics platform, data on antibiotics consumption and the expansion of databases. We are pursuing another goal by doing so: we want to not only reduce the MRSA rate in hospitals or other medical facilities, but also comprehensively protect the people in the Euregio regions through cross-border collaboration against infections.
MEDICA.de: Do the German hygiene guidelines already guarantee comprehensive protection or are they in dire need of reform?
Daniels-Haardt: We don’t have a guideline problem in Germany. We have ascertained this already during the first MRSA-net project. There are outstanding guidelines. Since 1999 the Robert Koch Institute has recommended measures to fight against MRSA, which are still valid with a few modifications. The question was simply: Why are these recommendations not being implemented? This was the starting point of the project and it also continues to apply. We have an implementation issue. DART, the German Antimicrobial Resistance Strategy, hit the nail on the head with this by initiating many campaigns to implement the guidelines that we already have. However, there can always be certain points that require law changes. Currently the change of the Infection Protection Act is being put in motion, which will regulate the hygiene guidelines bindingly in the future. But at the end of the day, it is all about how the regulations are being implemented in the individual hospitals and individual medical practices. This only works if all stakeholders internalize and share these measures.
MEDICA.de: What developments can be internationally detected in terms of MRSA infections?
Daniels-Haardt: If you take a look at the statistics, MRSA is still the most important multidrug-resistant bacteria, even though resistances in gram-negative bacteria have also recently severely increased. The last annual report of the European Center for Disease Prevention and Control (ECDC) quotes about 170,000 MRSA infections, around 5000 fatalities through MRSA and approximately one million extra days in the hospital for Europe. This is a considerable amount. We know from the U.S.A. and Australia that the so-called “community acquired“ or “non-hospital“ MRSA infections that are not transmitted at the hospital, but in communities cause major problems. Especially skin and soft tissue infections through these bacteria continue to increase. On an international level, there is no all-clear for MRSA and the other multi-resistant bacteria.
MEDICA.de: What kind of prospects are there actually to stop these developments all over the world in the long run?
Daniels-Haardt: The World Health Organization (WHO) put this topic at center stage at the recent World Health Day in April. For this day, the WHO prepared a six-point agenda which includes many topics that can also be found in the EurSafety Health-net project. At the very top spot is a rational and restrictive antibiotics therapy, that is to say to make sure that antibiotics are only used where it also makes sense –e.g. not for treating viral infections- and that the proper antibiotic is being used. Another point is intensive surveillance, meaning: to know the data on the consumption of antibiotics and to be informed about resistance rates. For this you need appropriate microbiological laboratory capacities. Then it’s important to really consistently implement the infection prevention measures. Antibiotics of course are the driving force behind the emergence, but in terms of further spread, hospital hygiene is also an important factor to prevent the bacteria from spreading from one patient to another. The intersectoral collaboration between the individual organizations is also very crucial. What’s more, the development of new antibiotics needs to be promoted, since research stagnates here and we have to face the fact that we are not able to use new drugs in the foreseeable future.
The interview was conducted by Diana Posth and translated by Elena O'Meara.