Saudi Ministry of Health Strategy for Infection Control - Essay Example

? Saudi ministry of health strategy for infection control and Introduction According to anarticle written by Memish (2002) infection control strategies in Saudi Arabia are still at their infancy. Mermish (2002) further observes that the infection control strategies are built around the concerns about the annual pilgrimage to Mecca. The infection control strategies in the country seek to prevent conditions such as meningitis, respiratory tract infections, bloodbone diseases and the zoonotic ailments. To increase the prevention levels and to promote the need for a nationwide strategy, the ministry of health has adopted the western models which seek not only to address particular health concerns, but suggests proactive measures that can be adopted throughout the country. This paper examines the Saudi’s Ministry of Health Strategy for infection control. 2. Background The hajj celebrations are one of the pillars of the Islam and each Muslim is mandated to take at-least one trip to Mecca in his or her lifetime. Muslim pilgrimage to Mecca is characterized by huge gatherings which retrace the footsteps of the Prophet Mohammed and undertake identical rituals. The attendants dress in Ihram clothing and travel to several spots including the Zamzam well, the plains of Arafat, Mount Safa and Mount Marwah (Pollard & Shlim, 2002). According to the available records, in 2008, 1.7 million pilgrims from 140 different countries attended the ceremony. The foreign pilgrims, most of who arrive by air, increase the imminent danger for international spread of infections during Hajj (Koch & Steffen 1994). The hajj celebrations are performed within different time periods, hence posing untold challenges to the organizers and the ministry of health (Memish & Ahmed, 2002). According to an article titled public health management of mass gatherings: the Saudi Arabian experience with MERS-CoV, the huge congregation that is experienced during hajj could lead to good and bad long-term effects on the health sectors in Saudi Arabia ( Memish & Al-Rabeeah 2013). During the pilgrimage, Saudi Arabia hosts close to 3 million visitors from more than 180 countries (Rashid et al., 2008). The need for a comprehensive disease control strategy is supported by the available statistics which show that during the 2013 hajj season, accidents of cardiovascular diseases are quite common (Arbon, 2007). In addition, most recently, the country recorded the highest number of confirmed cases of Middle East respiratory syndrome coronavirus. To address these situations, the country has adopted a surveillance system to reduce the number of viral transmission incidences among the pilgrims, and Memish, Venkatesh, Ahmed (2003) recommend that such an initiative should be replicated in the country to serve a wider population. Furthermore, the company established the Global Center for Mass Gathering Medicine to address health challenges and promote cooperation between the international organizations and scientific centers. The strategy brings in the stakeholders such as the media whose main role is promote responsible reporting and prevent non-alarmist coverage. One of the key contributors involved in the infection control strategies, is the ministry of health which establishes the relevant policies each year based on the knowledge of current global outbreaks and epidemiology of infectious diseases. The next section analyzes some of the potential threats and the strategies that have been adopted by the ministry of health to contain them. The sections below discuss the targeted diseases and the control mechanisms that have been initiated for infections prevention. 3. Target diseases and control mechanisms 3.1 Meningococcal diseases During the hajj celebrations the risk of the Menigococcal diseases are quite high due to the over-crowded conditions, the high humidity and the dense air pollution (Wilder-Smith & Freeman, 2003). Meningococcal outbreak was once experienced in 1987 and at the time the government took a number of measures (Dye & Gay, 2003). One such measure was mass vaccination of the pilgrims arriving for Hajj and launching aggressive campaigns targeted at the high-risk areas such as Mecca and the surrounding holy sites (Drazen, 2003). Incidences of the meningococcal outbreaks were also experienced in 1990s and early 2000s. Of particular concern is the 2001 outbreak, which led to 35 deaths and to avoid such an event from happening in future, the ministry of health adopted the quadrivalent polysaccharide vaccination to all the pilgrims arriving in Mecca and its environs (Hsu & Paten, 2003). Only visitors with documented proof of vaccination are allowed to visit the holy sites. 3.2 Respiratory infections Overcrowding, and sharing of sleeping accommodations during the hajj celebrations no doubt increases the chances of contracting respiratory infections. In the past, incidences of influenza were recorded especially in 2002 and 2003 hajj seasons (Zimmer & Stephens, 2004). To prevent the spread of respiratory in the country, the ministry of health mandates all the pilgrims older than 65 years to be vaccinated. Another common condition common during the Hajj celebrations is tuberculosis. According to Memish (2002) the prevalence of the resistant tuberculosis are very high in Mecca and other holy sites and cities. This could be attributed to the influx of pilgrims originating from developing countries where there is high TB- endemicity (Broker, 2002). The high number of visitors that arrive in the country has made it difficult for the ministry of health to initiate an effective infection control strategy (Regan, 2003). 3.3 Diarrhea The condition is prevalent among pilgrims originating from the developing countries, and documented evidence confirms that during Hajj celebrations, there is a high chance of cholera outbreaks (Ahmed, Arabi, & Memish, 2006). A typical cholera outbreak was once reported in 1984 and another one in 1989, but the improvement of the sanitary conditions seems to have addressed the problem (Alzeer, 2009). Beside diarrhea incidences, food poisoning is also quite prevalent during the hajj seasons. Pilgrims from the developing countries are also at high risk of Hepatitis A. To deal with the challenge of diarrhea during hajj celebrations, the government has launched education programs regarding hand hygiene, and choice of foods (Landry& Slama, 2004). In addition, the government has introduced guidelines for food importation besides ensuring these guidelines are observed, the ministry of health conducts constant surveillance of visitors arriving from the cholera-affected countries (El Bashir et al., 2007). While administering education programs is a key step in the prevention of diarrhea incidences, the government could consider providing them with self-administered antibiotics. According to Memish, Venkatesh, Ahmed (2003) this strategy has proved effective in many countries and is widely recommended for travelers from cholera-affected countries. 3.4 Blood-borne diseases In Saudi Arabia, the pilgrims share different facilities and equipment which could lead to the transmission of the hepatitis and HIV Aids. Indeed, a study by Al-Tawfiq and Memish (2012) found out that a significant number of the pilgrims who visit the country test positive for hepatitis and HIV and these hazards could easily be spread by the unlicensed barbers. To address the challenges of spreading the blood borne diseases, the government has initiated an appropriate legal framework to ensure only licensed barbers are allowed to operate in Mecca and other holy cities. In addition, the ministry of health encourages the visitors to receive vaccinations prior to visiting the country. While such measures could easily the problems faced, the country is under imminent threats posed by emerging infectious diseases such as the Rift Valley fever, Ebola and acute respiratory syndrome (Madani et al., 2013). Of course, the hajj celebrations provide perfect conditions through which these diseases could be transmitted and to address this problem, the Saudi Arabian government has initiated a number of measures: i) The government launched an education program aimed at sensitizing the abattoir workers about the need to observe good sanitary conditions (Cowling, Chan & Fang, 2009) ii) The government has introduced ban policies to restrict persons from countries where emerging infections have been reported iii) The government has invested in modern surveillance equipment to screen visitors traveling to the country. Use of surveillance equipment particularly proved helpful during the SARS outbreak during which thermal scanners were installed at major airports to screen the pilgrims and other visitors. Use of high-tech equipment should be matched with development of dedicated institutions aimed at educating the pilgrims about the dangers of overcrowding and need to observe respiratory etiquette. iv) The government constantly engages the pilgrims and other stakeholders to adopt friendly measures that will produce the best results possible. Such an instance occurred in 2009, when the Saudi Arabian government held wide consultations with international heal organizations to initiate the most effective measures the mitigation of the pandemic influenza. In addition, the government prevailed on the high-risk visitors to refrain from attending the 2009 Hajj celebrations of such measures that the government has been able to break the chain of potential infections. v) The importance of adopting drastic measures when dealing with emerging infections was affirmed during the avian influenza outbreak which occurred in 2008. The government in consultation with the relevant bodies, restricted bird importation into the country and initiated awareness campaigns. 4. Corona-Virus Infections Control A number of countries including Saudi Arabia, UAE, Jordan and Qatar have recorded nCoV incidences. Following the reported cases of infections, the ministry of health convened the National committee and engaged the help of the WHO, CDC and EMRO. Other key measures that were undertaken include: the ministry of health initiated case based surveillance in Makah and Medina during mass gatherings and random screening were conducted. 5. Improving current strategy 5.1 Vaccination One of the core components of the infections control initiative is the use of quadrivalent polysaccharide vaccinations. Coupled with a strict domestic policy and public health education campaigns, this initiative seems to have worked well. However, the effectiveness of this strategy is highly undermined by the herd immunity and the persistence of meningococcal carriage even after vaccinations (Hifnawy& El-Said, 2007). With these challenges, the ministry of health sought an alternative- the conjugated meningococcal vaccine- which is more effective. Although the new strategy adopted by the government seems to be working well, it is too undermined by the lack of resources necessary for its successful implementation. Furthermore, the cost of receiving the vaccine is very high for the international pilgrims and so the strategy is likely to fail in the long term. The decision for adopting the conjugated vaccine becomes even more questionable considering that the etiology of the meningococcal changes all the time, and could end up being a very expensive affair. Vaccination is also carried out to deal with the respiratory tract infections in the country, but the strategy seemed not to be working as expected. The decisions of using vaccinations to reduce respiratory infections is challenged by a study conducted by Borrow (2009) which shows that there are no major differences of respiratory symptoms between vaccinated and non-vaccinated persons. In essence, the study seems to suggest that vaccinations are not working and it is a high time that the government adopted an alternative strategy. The other biggest challenge at the moment is for the government to initiate effective screening policies to prevent importation and dissemination of the disease. While vaccination has for long been used as an effective tool for disease prevention, the high number of visitors makes it impossible to ensure all the guidelines and protocols are observed (Balkhy et al., 2004). The use of vaccination in the infections control is likely to face heavy opposition from the pilgrims especially those originating from developing countries. As indicated earlier, attendance of the hajj celebrations cannot be restricted, as each Muslim is required to attend the ritual. So the success of the immunization programs is contingent on the willingness of the visitors to participate, and requires the cooperation of the individual governments. The vaccination strategy is also likely to face opposition from the pilgrim attendants due to the high costs involved. 5.2 Use of face masks Another alternative would be to encourage the use of face masks. The use of face masks in the containment of the TB and respiratory diseases is supported by a study conducted by Maclntyre et al (2009). The study by Maclntyre and high friends is one of the best non-pharmaceutical interventions in the control of virus transmission during an influenza epidemic. In this cluster-randomized trial, Maclntyre et al (2009) concluded that face masks are effective in controlling seasonal respiratory diseases and as such should be adopted during severe pandemics. These findings are replicated in a randomized intervention trial involving 1437 young adults. The study sought to examine whether the face masks are a viable solution to the influenza pandemic. The researchers found out that continue use of face masks during the influenza season is associated with low incidences of influenza in shared living settings. The results of the two studies support the use of face masks during Hajj seasons. Although the use of face masks is recommended by various studies that have been conducted it raises serious compliance issues. Typically, the government can only encourage the pilgrims to use the masks, but cannot enforce a strict compliance policy. As a result, the chance of reducing TB incidences is lost, as most pilgrims are unwilling to use the device. While a strict compliance policy may not achieve positive results, it has proved useful in some cases (Kaiser, 2006). A case in point was in a study conducted by Esolen (2011) in which unvaccinated individuals were forced to wear masks. Imposing a similar requirement on the pilgrims will increase vaccination rates against communicable diseases. 5.3 Education programs As described above the government has initiated education programs to raise the level of awareness, and improve the hygienic levels among the pilgrims. While such initiatives are considered effective in infection control, they could be used in the prevention of the non-communicable diseases and other ailments. According to Memish (2002) the Hajj Medical Group has already incorporated educational campaigns in its campaigns in the prevention of increasing mortality and morbidity among pilgrims. The institution target cardiac patients visiting holy sites, and such an intervention could also be necessary in protecting the participants from abnormal crowd behaviors. In this regard, the Ministry of health should initiate education programs to promote consumption of salty foods, drinking of water, and carrying of sufficient medical supplies. 6. Other key components of the infections control The sections above have highlighted the importance of vaccination and education programs in the infections control. These strategies have proved effective in dealing with communicable infections at the sites where pilgrims frequent. Another key component of the infections control strategy is the provision of free medical services to all the pilgrims. Following the increased cases of emerging infections, the Saudi Arabian government appreciates the need to set up critical care beds, where pilgrims can be treated as fast as possible. Such healthcare centers are located in the major holy cities and are equipped with the emergency management medical systems and qualified personnel to provide quality services to the patients. By setting up major medical centers in all pilgrimage routes, the government has show commitment to provision of quality healthcare to the pilgrim patients. Moreover, by providing pilgrims with free services the government is promoting the use of the available facilities and increasing the chances of disease detection and containment. 6.1 Establishment of supervisory committees The ministry of health has set up committees, whose mandate is to oversee all the activities aimed at controlling infections while assisting with planning and coordination. The committees work with personnel operating in ports of entry, and that way any potential infections can easily be detected and contained. The committee is also mandated with the role of ensuring all health requirements are adhered to during Hajj celebrations and enough health personnel are deployed to the pilgrim camps. The effectiveness of public teams in the infections control is supported by Memish (2002). Through collection, analysis and data dissemination, teams are able to warn the relevant departments about any emerging infections and how they can be contained. However, for the public health teams to fulfill their responsibilities, they need adequate resources. The role of the public health teams can well be understood using the example at King Abdulaziz International Airport, a key port of entry for the majority of pilgrims. At the airport, public helath teams perform vital activities such as checking the immunization status of the pilgrims and administering prophylactic medicine. The members of the teams are also in constant communication with key healthcare installations where pilgrim patients are referred to and treated at no cost. In 2012, the infections control activities were planned and coordinated by 24 supervisory committees. There are also mobile teams who are deployed on a need basis to the many ports of entry in the area. The importance of committees is supported by the available literature on this topic. According to Memish (2002) early detection of the communicable infections facilitates the decision-making process. Early detection of the communicable infections can be fast-tracked using public health teams. In the past, information obtained from such team has helped government to initiate drastic measures including cancellation of large public gatherings to contain disease transmission. Another measure that has proved effective in the infections control is the restriction of the visitors’ movements. Such a measure has proved important in slowing the importation of infection cases to high-risk countries like Saudi Arabia. While the use of public health teams may prove effective, they utilize huge resources. Their workload also increased tremendously during the hajj celebrations, an event that could lead to lower performance. 6.2 Recommended surveillance indicators While public teams play an important role in the infections control, they could be overwhelmed by the huge workload. For this reason, the government’s strategic plan should consider maintaining the right efficiency by introducing the necessary indicators. Firstly, the plan should introduce the process surveillance indicators to ensure screening protocols are adhered to. Practice audits should as well constantly be conducted to ensure team members adhere to basic hygiene practices such as washing hands, and conform to the established immunization protocols. 7. Conclusion The Saudi Arabian government infections control plan has several components: use of vaccinations, initiation of education programs, constant surveillance, import restrictions, erection of healthcare facilities, and establishment of the public health teams. While these components can be used to reduce incidences of communicable diseases in the country, their effectiveness could be impaired by the unwillingness of the pilgrims to participate. In addition, some of the planned interventions such as the use of conjugated vaccines are unaffordable to the ordinary pilgrims. The success of the government’s plan also relies heavily on the cooperation of other partners especially those from the developing countries. From the above literature it is also apparent that the success of the strategic plan could negatively be impacted on by lack enough resources. Already, the number of the pilgrims visiting Saudi Arabia is growing and emerging infections are increasing. As a result, in future the government could be forced to turn to outside development partners to seek the necessary funding, and qualified personnel. Most importantly, for effective infections control the government needs to invest on enhancing international collaboration through integrated vaccination campaigns, developing visa quotas and arranging rapid repatriation. References Ahmed, Q.A., Arabi,Y.M., & Memish, Z.A.(2006). Health risks at the Hajj. 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