Q&A: COVID-19 brings health surveillance efforts into sharp focus

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Devex speaks with the International Safety Center on global health surveillance, the use of data, and health care worker safety.

“We have a simple message for all countries: test, test, test.” That was the clarion call from World Health Organization Director-General Tedros Adhanom Ghebreyesus at a media briefing on March 16.

Warning of a rapid escalation of COVID-19 cases the previous week, Tedros called for a series of immediate steps to complement social distancing, school closures, and hand-washing.

“We have not seen an urgent enough escalation in testing, isolation and contact tracing — which is the backbone of the response,” he said.

“We can’t begin to address any global public health issue until we measure it.”

— Amber Mitchell, president and executive director, International Safety Center

Since the onset of the pandemic, never have public health surveillance efforts been paid such attention to by the world’s media. Indeed, systematic collection, reporting, tracing, analysis, and monitoring is considered the only way to inform an effective response and an eventual exit strategy for government authorities the world over.

One group hit particularly hard by the ongoing pandemic have been health care workers on the front lines, often working without adequate personal protective equipment and placing themselves at great risk of exposure and infection, distress, fatigue, burnout, stigma, and physical and psychological violence.

While such risks are exacerbated in the current crisis, they are by no means a unique phenomenon.

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Devex spoke to Amber Mitchell, president and executive director of the International Safety Center, an organization that advocates for safer health care workplaces through research, surveillance, and advocacy, to talk about the role of surveillance in helping to keep frontline health care workers safe from injury and infectious disease.

“We can’t begin to address any global public health issue until we measure it,” Mitchell said. “Standardizing surveillance and therefore data is the only way we can measure what to address, change, and improve. Without it, we live in a world of guessing.”

One tool that has helped accelerate this effort, she said, is the Exposure Prevention Information Network surveillance system, or EPINet, a computer application for Microsoft Access originally developed in 1992, which tracks employee injury and exposure incidents for needlesticks, sharps injuries, and blood and body fluid exposures — mucocutaneous splashes and splatters — that health care personnel are exposed to.

This conversation has been edited for length and clarity.

How does EPINet work in practice and how is it used by health care workers?

EPINet includes reporting forms and customized data entry screens, a pre-programmed report facility, and graphing capabilities. The “needlestick and sharp object injury” and “blood and body fluid exposure” reports track exposure events, rather than individuals.

The post-exposure follow-up report then tracks the health care worker as he or she progresses through the postexposure protocol. When a sharp-object injury or blood and body fluid exposure occurs, the injured health care worker completes the appropriate report form, or sits down with a colleague or occupational health nurse to go through it together.

Appropriate post-exposure protocols are then initiated depending on the circumstances surrounding the incident and if the source patient is identifiable. The data entry process takes three to four minutes per incident and could end up preventing future incidents and saving lives.

How do you ensure that confidentiality is maintained when health care workers report needlestick injuries through EPINet?

EPINet data that is collected by the safety center in aggregate is free of all personal identifiers such as employee ID number, social security number, phone number, or mailing address. Facility and personal identifiers never appear on any report or graph.

Amber Mitchell, president and executive director of the International Safety Center, on EPINet: "We don't know how to reduce incidents until we track them.”

Where is the EPINet system in operation?

EPINet has been distributed to thousands of United States hospitals and countless numbers of hospitals and health care facilities around the world. We have about 40 hospitals in our U.S. network, some of which have been contributing data to the national network since the mid-1990s. This network provides a snapshot of what is occurring in hospitals in the U.S. We report this data publicly every year and it serves as a model for national incidence.

EPINet data has informed policy and regulations at a national and state level, including the OSHA Bloodborne Pathogens Standard and the U.S. Needlestick Safety and Prevention Act. It has been distributed in over 95 countries and is programmed in 24 languages. It is the widest and most frequently used needlestick and sharps injury surveillance database in the world and it is the national surveillance system for several countries including Japan, Australia, and — soon — Cambodia.

What is your call to action to the global health community on surveillance?

We can’t begin to address any global public health issue until we measure it. This is true with obesity, famine, war, maternal and child health, occupational fatalities, and more. And today, it is absolutely critical during this global COVID-19 pandemic. Identifying and measuring risks is how we as public health advocates remain credible, so that we can put protections and preventive strategies in place to protect people.

Standardizing surveillance — and therefore data — is the only way we can measure what to address, change, and improve. Without it, we live in a world of guessing. Guessing doesn’t keep people safe at work and it definitely doesn’t improve public health or health care outcomes. We have a duty to protect those who care for others.

Using EPINet, we have the ability to see how injuries and exposures vary from facility to facility, procedure to procedure, department to department, and year to year. EPINet can also illustrate to a facility where improvements need to be made relative to sharps injury prevention, whether or not the safety features have been activated, whether they were immediately disposed of, and whether unsafe practices resulted in injuring an employee that wasn’t the original user of the device — someone downstream, for example, environmental services, waste haulers, or sterile processing personnel.

Unfortunately, EPINet shows that operating rooms and surgical departments are not yet adopting devices with [sharps injury protection] features and therefore their injury rates have not dropped — especially among physicians.

What is the next frontier for EPINet and how does it continue to change to incorporate learning?

We still have a ton of work to do to improve safety in acute care hospital settings, so we will remain focused there, always. That said, we would love to expand to less-resourced facilities and health care environments that do not typically have a dedicated occupational or employee health department or infection prevention and control, including outpatient surgery centers, dental facilities, physician practices, schools, emergency services, and more. We really have no idea what the incidence of injuries and exposures look like in these environments and given the shift of health care outside of traditional settings, it’s important to get a handle on this now.

During this COVID-19 pandemic, EPINet continues to be a tool with great benefit. In our blood and body fluid exposure reports, we know that mucocutaneous [eyes, nose, mouth] exposures continue to be high and subsequent PPE use is unacceptably low.

We must continue to advocate for the availability and use of respiratory protection, gloves, gowns, and eye protection to protect health workers during this unprecedented time. In addition, the global prevalence of bloodborne disease is still an ongoing risk, so we cannot lose sight of the importance of preventing exposures to bloodborne, as well as COVID-19 disease.

For more coverage on health worker and patient safety, visit the Safety First series. Join the conversation using the hashtags #HCWSafety and #PatientSafety.

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