Infection Prevention and Control History

The invention of the microscope allowed visualisation of microbes for the first time. Anton van Leeuwenhoek built a simple microscope with only one lens to examine blood, yeast, insects and many other tiny objects. Leeuwenhoek had invented new methods for grinding and polishing microscope lenses that allowed for curvatures providing magnifications of up to 270 diameters, which were the best available lenses at that time. Compound microscopes had been invented in the 1590s, but with magnification of 20x or 30x, whereas van Leeuwenhoek's was able to achieve magnification of over 200x. Using handcrafted microscopes, Anton van Leeuwenhoek was the first person to observe and describe single celled organisms, which he originally referred to as animalcules (which we now refer to as microorganisms). He was also the first to record and observe muscle fibres, bacteria, spermatozoa and blood flow in capillaries (small blood vessels). This greatly increased our knowledge of micro-organisms and the human body.

Edward Jenner’s work represented the first scientific attempt to control an infectious disease by the deliberate use of vaccination. Jenner did not ‘discover’ vaccination but was the first person to confer scientific status on the procedure and to pursue its scientific investigation. For many years, he had heard the tales that dairymaids were protected from smallpox naturally after having suffered from cowpox. In May 1796, Edward Jenner found a young dairymaid who had fresh cowpox lesions on her hands and arms. On May 14, 1796, using matter from the dairymaids' lesions, he inoculated an 8-year-old boy. Subsequently, the boy developed mild symptoms but by day 10 day he was much better. In July 1796, Jenner inoculated the boy again, this time with matter from a fresh smallpox lesion. No disease developed, and Jenner concluded that protection was complete (Riedel, 2005). In the early 1950’s (100 years after the introduction of the vaccine) an estimate 50 million cases of smallpox occurred in the world each year, but by 1967 this figure fell to around 10-15 million because of Jenner’s smallpox vaccination (WHO, 2011). Vaccines have been an integral part of infection prevention and control as they not only protect the recipient from disease, disability, and death but they also protect the entire community. Vaccines have been developed for a range of illness such as Polio, Diphtheria, Influenza, Hepatitis A & B, Measles, Mumps, Rubella, Yellow fever and more recently Human Papillomavirus (HPV).

In 1840 the importance and influence of hand-washing was bought to the forefront of the medical arena after independent studies by Semmelweis established a link between the hands of healthcare workers and the spread of hospital-acquired infection. Dr. Ignaz Semmelweis demonstrated that routine hand washing could prevent the spread of puerperal fever (the death rate for mothers giving delivery in hospital was five times than at home with a midwife). Semmelweis analysis of the outbreaks of puerperal fever in his hospital revealed that medical students, who were responsible for deliveries in Division I, often performed autopsies before assisting in deliveries, while midwives, who worked in Division II did not. He theorized that disinfecting hands could prevent transmission of infection from a diseased cadaver to a pregnant patient. On May 15, 1847, he required all medical students to wash their hands with chlorinated lime before assisting in deliveries, which resulted in a dramatic outcome - deaths on the maternity ward fell fivefold.

Florence Nightingale was the first to suggest that environmental factors effected health (often called the environment theory). She linked health with five environmental factors: i. Pure fresh air ii. Pure water iii. Efficient drainage iv. Cleanliness v. Light This was during the Crimean War (1854-1856). During this war, wounded soldiers were treated in deplorable conditions. There were dirty linens, poor waste management facilities, bad food and overwhelming presence of death. She developed a floor plan utilising each inch of space to provide a better environment for each patient, in particular: i. Where to place the beds and how far apart ii. Windows opened to provide ventilation and light iii. Hospital cleaned and infested blankets and soiled supplies discarded by implementing the improved patient care measures such as cleanliness and ventilation, the mortality rate dropped from 42.7% in early 1855 to 2.2% in June 1855 (attributed to sanitary reforms). Nightingale showed through her research that most deaths were from infectious disease, and by improving sanitary conditions, the death rate decreased. Additionally, a clean, bright, and well-ventilated environment is important to the treatment of disease as well as to prevent other diseases.

Pasteur founded the science of microbiology and proved that most infectious diseases are caused by micro-organisms. This became known as the "germ theory" of disease. In 1861 Pasteur published his germ theory of disease based on his experiments. Pasteur definitively demonstrated that microorganisms are present in air but not created by air. In that connection, he carefully studied and discovered various infectious diseases such as staphylococcus, streptococcus and pneumococcus. In 1864 he discredited the theory of spontaneous generation. He prescribed methods of attenuating microbe virulence (chicken cholera and sheep anthrax). He followed his discovery of germ theory with the utilization of vaccines to prevent diseased like cholera, anthrax and swine erysipelas. With his analysis and treatment methods for infectious diseases, Pasteur established the immunology branch of science. Immunology looks at the body's immune system, innate and acquired immunity, and antibodies.

Lister had an interest in wound healing and wound infection. At the time, wounds resulted in 90% amputation rate from compound fractures and 50% mortality rate. Lister was the first to see the connection between Pasteur's discoveries of the fermentation process and the suppuration of wounds. He is credited with the beginnings of sterilization in the Operating Room. Before surgery, he sprayed the operating rooms with carbolic acid, because he thought that the infections were caused by dust particles in the air. Later, he began applying carbolic acid to compound fracture wounds. The wounds healed, amputation was averted, and the mortality rate from amputation plummeted from 45% to 15%.

Robert Koch developed ‘Koch's Postulates’ which are a sequence of experimental steps for directly relating a specific micro-organism to a specific disease. This was a change in scientific method which outlined the four basic criteria an organism must meet in order to be identified as pathogenic (capable of causing disease). Koch’s Postulates are: 1. The micro-organism must be found in all organisms suffering from the disease, but should not be found in healthy organisms. 2. The micro-organism must be isolated from a diseased organism and grown in pure culture. 3. The cultured micro-organism should cause disease when introduced into a healthy organism. 4. The micro-organism must be reisolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent. This theory was important to the development of microbiology and the development of the germ theory (see 1877 Germ Theory). Koch postulates have been adjusted over time, but they are still seen as an important part of the study of microbiology. In addition, Robert Koch discovered: vi. Bacillus anthracis (Anthrax) vii. Mycobacterium tuberculosis (TB) viii. Vibrio cholera (Cholera)

Sir Alexander Fleming observed that colonies of the bacterium Staphylococcus aureus could be destroyed by the mould Penicillium notatum, demonstrating antibacterial properties, which led to its use in combating many infections. During the Second World War, penicillin was commonly used to treat infections, particularly wound related. The 1940's saw the development of other antibiotics including streptomycin, erythromycin, tetracycline, and amoxicillin. At the time, penicillin was heralded as a medical miracle curing infections and illnesses otherwise deadly to the human population. Antibiotics continue to be widely used today and have a positive impact on patient outcomes.

In Queensland, Infectious Disease Units were established at both the Princess Alexandra Hospital and the Royal Brisbane Hospital to provide isolated care for highly infectious patients. The Infectious Diseases Ward at Royal Brisbane hospital is known as Wattlebrae. Wattlebrae took many forms, from a small wooden house (1907), to four open air pavillions (1908). It looked after patients through the outbreak of Diptheria (1931) and Polio (1941) and by the 1960's included a respiratory section. In fact it was not until 1950 when a brick building was completed that it was formally given the name Wattlebrae. Today Wattlebrae has in-patient care, focused on the treatment and management of patients with complex infectious diseases. The Infectious Disease unit at the Princess Alexandra Hospital had a similar evolution with initially one ward for open air tents back in 1910, opening its official doors in 1948, to now Ward 5D (Infectious Diseases). Ward5B looks after general infectious diseases, including HIV/AIDS, haematology, oncology, intensive care, specialised surgery and other branches of internal medicine.

Outbreaks of Staphylococcal infection in healthcare facilities in the United Kingdom, Europe, and the Unites States of America in the 1950's lead to an interest in infection control issues and resulted in the introduction of the infection control nurse (ICN). The first ICN in Australia was SR N Wernigk she was appointed in 1962 at the Princess Alexandra Hospital, Brisbane. This was the second infection control nurse established anywhere in the world. The role of the ICN was to work with surgeons to conduct surgical site infection surveillance, to supervise and instruct on aseptic technique and examine sterilisation procedures. In order to keep up with the changing demands of healthcare, the role and scope of an ICN has evolved dramatically. The modern ICN now referred to as an Infection Control Practitioner is responsible for:

· Managing the infection control program;

· Clinical advice relating to infection prevention and control;

· Undertaking surveillance of Healthcare Associated Infections (HAI);

· Education healthcare workers; and

· Undertaking research.

In 1974 the Centre for Disease Control (CDC) initiated a study to evaluate the efficacy of nosocomial infection control programs throughout the United States (SENIC). This was considered by some to be the cornerstone of the earliest infection control (IC) programs. The SENIC study demonstrated that hospitals with established IC programs, coordinated and implemented by an Infection Control Nurse (ICN) and physician with training in epidemiology, had nosocomial rates 32% lower overall than hospitals without such programs. The SENIC study identified four key elements of an effective program to reduce nosocomial infection rates which were:

1. Surveillance;

2. Control including policy development, education and review of clinical practice;

3. An ICN to collect and analyse surveillance data in addition to having overall responsibility for co-ordinating the control program; and

4. Active involvement of a physician or microbiologist in the program. These elements, remain core components of infection prevention and control programs today.

In the 1970's the largest proportion of healthcare associated bacterial infections was as a result of Staphylococcus aureus. To treat the already penicillin-resistant Staphylococcus aureus, methicillin was used as an alternative antibiotic in 1960. The first recorded isolate of methicillin-resistant Staphylococcus aureus (MRSA) in Australia was in Sydney Hospital in October 1965. By 1967 5.7% of Staphylococcus aureus strains at this facility were methicillin resistant. From 1975 MRSA isolates proliferated in tertiary institutions on the eastern mainland (Sydney, Melbourne, & Brisbane) and in 1976 gentamicin-resistant 'endemic' MRSA emerged (EMRSA) which in the following years was a significant healthcare associated pathogen in Australia. With the prevalence of highly resistant infections increasing, infection prevention and control interventions become imperative in minimising the spread of multi-drug resistant organisms throughout the population.

Human Immunodeficiency Virus, more commonly know as HIV, is a virus that slowly damages the body's immune system. Without a strong, healthy immune system, the body is susceptible to many infections and illnesses. If a person living with HIV becomes sick with one of the more serious types of 'opportunistic infections', they are said to have Acquired Immunodeficiency Syndrome or AIDS. While there is no cure for HIV or AIDS, some people are living long productive lives, due to HIV medicines and aggressive treatment programs. This disease has evolved from a few cases (less than 10) in 1981 to a worldwide pandemic. According to the World Health Organisation (WHO) in 2009, worldwide there were:

· 33.3 million people living with HIV

· 2.6 million new HIV infections

· 1.8 million AIDS related deaths.

The first recorded case of AIDS in Australia was in Sydney in November 1982 and the first death from AIDS occurred in Melbourne in July 1983. In Queensland AIDS/HIV has been a notifiable disease since 1984. This disease greatly increased public awareness of infection prevention and control in two major ways. Firstly, it initiated many infection prevention programs for the public, particularly sexual health messages. Secondly it has increased the controls on medical procedures, such as increased testing for blood transfusions, and personal protective equipment for healthcare workers.

The Australian Infection Control Association (AICA) was formed in 1985 bringing together the various State and Territory infection control associations to support and encourage collaboration at a national level. AICA is the peak national body representing the interests of the specialist practice of infection control within Australia. The Association provides a forum for individuals who are practicing, or have a working interest in the specialist field of infection control. AICA works with a variety of stakeholders to develop strategies aimed at minimising the risk of health care associated infections (HAI). The Infection Control Practitioners Association of Queensland (ICPAQ) is designed to improve health care by serving the needs and aims common to all Infection Control Practitioners and all other members of the health care industry.

Extended Spectrum Beta-Lactamase (ESBL) are enzymes that have developed a resistance to antibiotics like penicillin. ESBL enzymes are most commonly produced by two bacteria - Escherichia coli (E. coli) and Klebsiella pneumoniae. ESBL producing organisms not only have the ability to break down beta-lactam antibiotics but they are also able to transfer these resistance enzymes to other microorganisms via plasmids. Emerging resistance in common pathogenic members of the Enterobacteriaceae is a world-wide phenomenon, and presents therapeutic problems for practitioners in the community and in hospital practice. It was first described in Europe in the early 1980s, but has since become a widespread problem especially in western and southern Europe.

Universal precautions were developed in 1987 by the Centre for Disease Control (CDC). Universal precautions were designed to prevent the transmission of Hepatitis B, HIV, and Hepatitis C and other bloodborne infectious diseases when providing first aid or healthcare. Under universal precautions, all patients were considered to be infectious and possible carriers of bloodborne pathogens, thus precautions were required to minimise the risk to health care workers. Universal precautions involved the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, to reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infective materials. In 1996 the CDC published new guidelines (standard precautions) for isolation precautions in hospitals which took the place of Universal Precautions. Standard precautions reflected developments in the understanding of how certain infections (particularly HIV/AIDS) were transmitted. The Australian Infection Control Guidelines updated these to become Transmission-based precautions in 2010.

Enterococci are gram-positive bacteria that are naturally present in the intestinal tract of all people. Vancomycin is an antibiotic to which some strains of enterococci have become resistant. These resistant strains are referred to as VRE and are frequently resistant to other antibiotics generally used to treat enterococcal infections. The first case of VRE in Australia was in 1994 (Melbourne), with only one more case in 1995. Unfortunately since March 1996 there has been a steady increase in the number of VRE reports throughout Australia. The Australian isolates of Vancomycin-resistant enterococci (VRE) have been widely scattered geographically with outbreaks in many states. Vancomycin resistance, like other antibiotic resistance is creating not only a focus on infection prevention and control, but also appropriate use of antibiotics.

The liaison program was developed to engage nurses and gain cooperation from the ‘front line’ staff on infection prevention and control. The initial project provided some training and established some “link” nurses within the hospital, however stagnated due to lack of resources. Once an infection control dedicated person was established in 1997, a four-stage plan was implemented. The first stage was marketing, in which the staff that were involved (“link” nurses/ IMPACT members) received posters, pens, badges and other promotional material and a self learning activity package (SLAP). The second stage was to promote teamwork across the different departments and get the members to work not only across their ward, but see their role as part of a hospital-wide network. The third stage was problem solving. This assisted members in identification and assessment of issues, plus planning and implementation of possible solutions. The forth stage was education. This came initially in the form of the SLAP, but this was replaced with face to face seminars and training programs over time. Additionally some monitoring tools were developed. The program empowered and engaged the nursing staff to be proactive about infection prevention and control. It had such positive results, that a similar style program was rolled out to operational staff such as ward attendants and cleaners. Link nurse programs are now established in many Queensland Health hospitals.

The PA Infection Control course started in 1996. The course is a two week full time course that covers the basics and more of Infection Control practices, procedures and recommendations. Topics covered include; Basic Microbiology, Basic Immunology, Infection Control Guidelines, Blood Stream Infections, Infection Surveillance, and Statewide Infection Prevention Updates. Speakers are experts in their fields with a passion for Infection Control and hail from both private and public health sectors. The course is suitable for novices in Infection Control, or those with an interest in Infection Control.

Electronic Infection Control Assessment Technology (eICAT) is a data collection and analysis package developed by a team of infection control professionals to serve the needs of the infection control community. It collects information on palm handheld computers, organises the data in an access database and generates surveillance data, charts and reports. This system was developed at the Princess Alexandra Hospital in 1996, and was then rolled out to other facilities throughout Queensland Health in 1999.

In 1996, the National Health and Medical Research Council (NHMRC) and Australian National Council on AIDS (ANCA) released a joint publication, 'Infection Control in the Health Care Setting'. This document was based on a review of previous infection control guidelines, and the need for national guidelines. The report establishes nationally agreed minimum standards for infection control. In addition to current technical information or 'best practice' for infection control, the document addressed some ethical issues, including policy guidelines on health care workers (including students) who may be infected with blood borne viruses such as HIV, hepatitis B and hepatitis C.

Griffith University, Queensland, Australia began to offer post graduate courses in infection control in 1997. The courses offered included:

• Graduate Certificate in Infection Control

• Master of Advanced Practice (Infection Control)

• Master of Advanced Practice with Honours (Infection Control).

The program was designed to educate graduates in the modern day practice of Infection Control. Graduates acquire the relevant knowledge and skills to work within and/or establish an effective infection control program within a health care setting. Originally the course was offered on-campus, however was made available externally in 1998.

In 1997 the Queensland Health Capital Works Guidelines, Building and Refurbishment Infection Control and Sterilising guidelines were released. In 2002 they were superseded by the Capital Works Guidelines: Building and Refurbishment: Infection Control Guidelines. These guidelines aimed to provide minimum standards for the physical conditions of acute care, residential care and community-based health settings. The guidelines were provided for use by architects, engineers, project managers, health care workers and building contractors. The principles of infection control were outlined as they relate to construction and renovation projects. The guidelines included generic design recommendations to minimise the risk of preventable health care associated infection, as well as recommendations for the design of specific health care settings.

The Queensland Infection Control Guidelines were released in 1999 with a second edition released in 2001. The guidelines were developed to assist a range of health care services in the design and delivery of an infection control program that minimises infection risk through the application of generic infection control principles. Information on specific infectious diseases and relevant legislation was also included.

The Communicable Diseases Branch established Infection Control Steering and Reference Groups in 1996 that resulted in the creation of the first State-wide Infection Control Practitioner position. Dolly Olesen was appointed to the position in January 1997 and worked closely with Mr Doug Friend, the Adviser in Sterilizing. Funding provided by the 1998-2003 Australian Health Care Agreement enabled the creation of the Quality Improvement Enhancement Program (QIEP), led by Dr John Youngman then Deputy Director General Queensland Health and Ms Elizabeth Garrigan, Program Manager. The QIEP Program provided an opportunity for Dolly and Dr Michael Whitby, then Director Infection Management Services, Princess Alexandra Hospital, to submit a business case to establish CHRISP. Approval was granted in 1999 and CHRISP founded in 2000 at the Princess Alexandra Hospital. CHRISP's responsibilities included the surveillance of healthcare associated infections (HAI), socio-economics of HAI and behavioural research with focus on hand hygiene. Further QIEP funding was granted in 2004, the same year CHRISP moved to the Patient Safety Centre and Dolly was appointed Director of CHRISP. In December 2004 CHRISP gained the State-wide Infection Prevention Service and moved to the Southern Area Health Service. Due to ill health in 2007, Dr Michael Whitby relinquished his position in CHRISP to Professor David Paterson. Professor Paterson is a Brisbane trained Infectious Disease Physician who has held a number of senior medical positions internationally. He has studied bacterial infections resistant to multiple antibiotics occurring in a variety of settings, ranging from “high-tech” transplant units in the United States to rural regions of Africa and Asia. He recently received a Senior Clinical Research Fellowship and is based at the Royal Brisbane and Women's Hospital and the University of Queensland Centre for Clinical Research. Permanent funding of CHRISP was granted in 2008. The restructure of Queensland Health in 2009 resulted in the transfer of CHRISP to the Communicable Diseases Branch. CHRISP remains focused on the prevention of HAIs through the implementation of evidence-based, clinician-led practice change.

In 2000 AICA launched a credentialing process to certify that practitioners have the prescribed competence of the relevant specialist nursing role. Credentialing does several important things including:

• outline advanced/specialist expertise within the field;
• establishes a national standard for infection control practitioners;
• identifies a community of experts; and
• enhances the quality of care for patients and staff.

Credentialing has provided a benchmark for infection control practitioners.

The scoping study was a report prepared by an expert working group of the Australian Infection Control Association (AICA) to provide the Commonwealth Department of Health & Aging with:

• An overview of current surveillance activities, policies and programs in Australia;
• Advice on options for development, including a review of current literature, an examination of gaps, and methods for facilitating linkages; and
• A series of scenarios concerning the cost of nosocomial infection in health care, including no surveillance, epidemics and individual infections.

This was one of the first documents to outline in detail the scope of current infection control. It also outlined the costs associated with implementing protocols, but more importantly, the costs of not implementing any changes. This allowed many to understand that infection control was not only beneficial to patients and staff, but is also cost effective.

In February 2001, CHRISP initiated a statewide Surveillance Program requesting voluntary submission of data from Queensland Hospitals. Hospitals participating in the surveillance program were required to submit data on key Healthcare Acquired Infection (HAI) indicators on a six month basis using electronic Infection Control Assessment Technology (eICAT). In addition, a Minimum Surveillance Data Set was developed by the National Advisory Board (NAB) of Australian Infection Control Association (AICA). Due to wide variation in surveillance practices in Australia the National Advisory Board (NAB) was established to develop standardised definitions and terminology for surveillance of surgical site and healthcare associated blood stream infection. These definitions provided Australian ICPs in all healthcare facilities with a standardised strategy for surveillance.

The Handbook provided accurate and appropriate advice and support for those involved with the task of redesigning or building a health care facility with particular emphasis on patient care. The Handbook was developed by a group of experts in infection control, hospital engineering and architecture, and provided essential data that should be considered in all aspects of the planning and design of health care facilities.

Severe acute respiratory syndrome (SARS) is a viral respiratory illness that was recognized as a global threat in March 2003, after first appearing in Southern China in November 2002. During November 2002 through July 2003, a total of 8,098 people worldwide became sick with severe acute respiratory syndrome that was accompanied by either pneumonia or respiratory distress syndrome (probable cases), according to the World Health Organization. Of these, 774 died. A unique feature of SARS was its ability to spread easily within healthcare settings. The rapid spread of SARS was unprecedented in modern infectious diseases and as such, resulted in urgent, intensive efforts to disseminate information, improve infection control, and carefully prepare unaffected countries. The 2003 SARS outbreak provided a rich opportunity for clinicians to test the practicalities of new approaches to infection control and to identify deficiencies of existing controls. Subsequent to the SARS outbreak, researchers have further investigated and reported on the most efficient strategies for reducing patient and healthcare worker transmission of respiratory viruses.

The Australian Council for Safety and Quality in Health Care was set up as a time-limited, expert advisory body in January 2000 by the Australian Government Health Minister, with the support of all Australian Health Ministers. The main role of the Council was to lead national efforts to improve the safety and quality in health care, with a particular focus on minimising the likelihood and effects of error. The Australian Council for Safety and Quality in Health Care helped shape the national agenda and worked collaboratively to address identified priorities. The National Strategy to address Health Care Associated infections was published in 2003 by the council. Five national priority areas were identified with associated national strategies needed to meet these priority areas. It was acknowledged that strong national leadership was critical to raise community awareness of the need to act, to support clinical practice improvements, to develop national data, to inform better surveillance and to make an impact on high target areas. In 2004 a national healthcare associated infection advisory committee was established under the auspice of the Australian council for safety and quality in healthcare to provide national leadership to progress the National Strategy. The technical advisory group enacted standardised definitions of minimum data set for surveillance to underpin surveillance activities.

The aim of the 2005 Public Health Act is to protect and promote the health of the Queensland public. The Act provides the basic safeguards necessary to protect public health through cooperation between the State and local governments, healthcare providers and the community. It also provides instruction on requirements for Infection Control in health care facilities and imposes a statutory duty on persons involved with the provision of declared health services to take reasonable precautions to minimise the risk of infection. The duty is reinforced by the requirement of healthcare facilities to have an Infection Control Management Plan. The Infection Control Management Plan (ICMP) must identify the infection risks at the facility and detail the measures to be taken to prevent or minimise the risks. The Public Health Regulation 2005 supports the Act. It also designates the childhood contagious conditions and notifiable conditions, and sets out details for perinatal statistics, health information, cancer notifications and the Pap smear register. One of the major changes between this Act and the previous Health Act 1937 was that it specifically addressed infection control in healthcare facilities. This made certain infection control practices were part of the law and no longer just guidelines.

The Staff Protect program started in 2006, with the computer application made available by 2008. The program included adopting a screening, education and immunisation policy that minimises the risk to healthcare workers against vaccine preventable illnesses that may occur in the workplace. The staff protect application enables the recording and reporting of healthcare workers vaccination status.

Avian influenza (AI) is an infectious viral disease of birds (especially wild water fowl such as ducks and geese), often causing no apparent signs of illness. AI viruses can sometimes spread to domestic poultry and cause large-scale outbreaks of serious disease. Some of these AI viruses have been reported to cross the species barrier and cause disease or subclinical infections in humans and other mammals. The H5N1 virus subtype (a highly pathogenic AI virus) first infected humans in 1997 during a poultry outbreak in Hong Kong. Since its widespread re-emergence starting in 2003 (peaking with 115 cases and 79 deaths in 2006), the avian virus has spread from Asia to Europe and Africa and has become entrenched in poultry in some countries, resulting in millions of poultry infections, several hundred human cases and many human deaths. The primary risk factor for human infection appears to be direct or indirect exposure to infected live or dead poultry or contaminated environments. Controlling circulation of the H5N1 virus in poultry is essential to reducing the risk of human infection. Past flu pandemics (such as the Spanish flu - 1918) had such devastating effects, that the avian flu pandemic was treated with great interest and caution from the worldwide community. This re-focused many back to infection control and prevention, as well as risk management and disaster continuity planning.

The Australian Commission on Safety and Quality in Health Care commenced on 1 January 2006 and is funded by the Australian, State and Territory Governments to develop a national strategic framework and an associated work program that will guide efforts to improve safety and quality across the health care system in Australia. The 5 initiatives of the Healthcare Associated Infections program of the Commission are:

• National Hand Hygiene Initiative,
• Antimicrobial Stewardship,
• National HAI Surveillance program,
• Building Clinician Capacity and
• National Infection Control guidelines.

Poor hand hygiene among Healthcare Workers (HCWs) is recognised as being the largest problem associated with healthcare-associated infections (HAIs) within hospital environments. CHRISP invested in research to gain a better understanding of why healthcare workers do not wash their hands, specifically looking at the behavioural factors. This research guided the development of Queensland Health's multimodal hand hygiene program. The "Clean Hands are Life Savers" program aimed to improve hand hygiene compliance of healthcare workers in acute care settings and change healthcare workers behaviour and Queensland Health culture to ensure hand hygiene was a high priority. The program achieved significant success evidenced by the improvement in hand hygiene compliance of healthcare workers. In 2010 Queensland health aligned its education, auditing and reporting methodologies to the National Hand Hygiene Initiative.

Intravascular Devices (IVD) are important devices for administering fluids, medications and sometimes emergency vascular access. Unfortunately they provide potential routes for infectious agents to cause local infection or to enter the bloodstream. There are approximately 5,000 cases of IVD-related bloodstream infection (BSI) a year in Australia. A large number of interventions have been developed to prevent healthcare associated intravascular device-related bloodstream infections. The CHRISP I-Care Program consolidated these interventions into one document called Recommended Practices, for the six main types of intravascular devices (IVD). The recommended practices were specifically tailored for the Queensland Health environment and are broad statements used to guide policy and procedure development in specific work environments. The purpose of the Recommended Practices is to provide evidence-based support to healthcare professionals related to the insertion and management of six intravascular devices. The use of the acronym I-Care is to reinforcing the key steps healthcare professionals need to take to prevent intravascular device-related bloodstream infections, that is - cleaning their hands, using alcoholic chlorhexidine to prepare the insertion site, using sterile alcohol swabs to clean injection ports before accessing, reviewing the need for the IVD on a daily basis and removing it when no longer required, and educating everyone about I-Care.

MedTRx is an application CHRISP developed in 2008 to help better understand antimicrobial usage across Queensland Health facilities. Through MedTRx it is possible to extract dispensing and distribution data from the Queensland Health iPharmacy database, calculate defined daily doses and utilisation rates to provide antimicrobial usage reports through the Queensland Health Enterprise Reporting System (QHERS).

Occupational exposures to blood borne pathogens from needle stick and other sharps (percutaneous) injuries as well as blood and body fluid (non-percutaneous) exposures, carry the greatest risk of transmission of a blood borne virus - Hepatitis B virus, Hepatitis C virus and Human Immunodeficiency Virus (HIV). Due to high transmission risk, CHRISP developed a Hollow-bore needle sharps safety program. The program consisted of work practice controls (e.g. care in handling sharp devices), personal protective equipment, educational programs, avoidance of recapping and sharps disposal systems, as well as needles and other sharp devices with an integrated engineered sharps injury prevention feature. This program has resulted in a significant reduction in related injuries across participating Queensland hospitals over the last five years.

In April 2009, a novel virus termed HINI was identified in the United States and Mexico. The situation evolved rapidly and on 11th of June 2009, the World Health Organisation declared it be a pandemic. The Queensland Health influenza pandemic plan was activated on 28th April which involved the establishment of a state health emergency coordination centre. Five hundred and ninety-three laboratory-confirmed cases were notified in Queensland with onset of illness between 26 April and 22 June, 2009. Sixteen patients were hospitalised, but no deaths were reported. The true incidence of infection was probably considerably higher than reported as not all of those infected would have been tested because of the often mild nature of the illness. As the pandemic progressed, the response shifted from predominantly public health to a clinical domain, with focus on preparing for the expected surge in admissions. The use of personal protective equipment among health practitioners in the pandemic was not always ideal. Population health units reported several clinicians requiring prophylaxis and quarantine because of inadequate infection-control precautions. A cluster of six cases was also reported in a Queensland public hospital, linked to a health care worker. The rollout of the pandemic vaccine, prioritised according to risk group, commenced nationally on 30 September 2009. The pandemic (H1N1) 2009 virus did not cause the severe pandemic that was feared.

The National Health and Medical Research Council have developed guidelines, with the best available evidence and consensus methods that outline the critical aspects of infection prevention and control. These guidelines also outline key areas of focus for Infection Control Practitioners (ICPs) and other healthcare facility staff.

In 2010 Cathryn Louise Murphy, RN, PhD, CIC, was the first Australian elected as President of the Association for Professionals in Infection Control and Epidemiology (APIC). Cath began a career in infection prevention after a back injury limited her ability to work as a hands-on nurse, and after relieving in an infection prevention position, she was inspired to continue in the field. Since then she has practiced clinically in Australia, been employed by the U.S. Centres for Disease Control and Prevention (CDC), and consulted to governments in Australia and South East Asia. Cath is an active member of both APIC and the Australian Infection Control Association (AICA) and has sought ways to introduce APIC and North American trends to infection prevention and control in Australia.

OrgTrx was developed by CHRISP to provide easy access to information about antimicrobial susceptibility and resistance trends in Queensland Health facilities. Susceptibility data is extracted from the AUSLAB database and a data cube is built and accessed via the Queensland Health Decision Support System (DSS).