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Prevent infection  –  Inspirational examples

Prevention of HAIs in Ethiopia

In Ethiopia, an intervention study on the prevention of healthcare-associated infections (HAIs) and antibiotic resistance was conducted during 2011-2014. This was done by competence building and knowledge improvement among healthcare professionals.

Healthcare-associated infections (HAIs) are a global threat towards patient safety. Treatment is complex and problematic due to high prevalence of multi-resistant bacteria. The risk of acquiring HAIs is higher in low-resource settings on account of limited resources, healthcare infrastructure and irrational use of antimicrobials. An international research collaboration project was formed involving researchers from the Karolinska Institute, the Public Health Agency of Sweden and Addis Ababa University and a study was conducted at Tikur Anbessa Hospital, the largest teaching University hospital in Addis Ababa, Ethiopia to prevent healthcare-associated infections and the spread of antibiotic resistance.

Two people looking at samples in a lab
Jens Odlander from the Swedish embassy in Ethiopia visiting the study site.

Competence and capacity building

The overall aim of the project was to prevent healthcare-associated infections and antibiotic resistance. This was done by increasing awareness through capacity building and competence development within infection control of healthcare professionals working at the Ethiopian hospital. The project was a three-phase prospective intervention.

  1. During the first phase, the team evaluated the prevalence, severity and etiology of resistant bacteria at the hospital. The Knowledge-Attitudes-Behaviors-Perceptions (KABP) with regards to healthcare-associated infections, antimicrobial resistance and hand hygiene among healthcare professionals was assessed using a standard questionnaire translated into Amharic, the local language.
  2. In the second phase, an educational intervention was introduced based on the gaps identified from the KABP study and observations made during the first phase. The identified gaps and problems were given as feedback to the Tikur Anbessa Hospital administrators and healthcare professionals through several small-group discussions with nurses, midwives and doctors. Research collaborators from Sweden went to Ethiopia and participated actively in the group discussions and experience sharing.
  3. Evaluation of the overall impact of the project was assessed in the third phase by repeating the KABP assessment. Evaluation included comparing data before and after the intervention as well as point prevalence surveillance.

Further objectives of the project included:

  • Promoting rational use of antimicrobials
  • Provide evidence-based recommendations for prudent use
  • Establish proper infection control routines and an infection control network
Photo of Eleni Aklillu
Eleni Aklillu, Karolinska Institute.

When asking one of the project managers about initial thoughts of the healthcare personnel regarding the project, Eleni Aklillu of the Department of Laboratory Medicine at Karolinska Institute says

“At first there were hesitations among some healthcare workers regarding what this project will achieve and the impact it would have. But afterward the same people who had doubts during the initiation of the project came to me and acknowledged the great work that we had done.”

How did you handle healthcare workers concerns about the project?

– We told the healthcare workers that resistant bacteria do not stay at this hospital, with your contaminated hands and cloths, you can possibly take it home to your families. That was something everyone could relate to, says Eleni Aklillu.

Nurses sitting around a table
During the intervention phase, nurses were invited for a group discussion.

High prevalence of HAIs

The results from the first phase showed high prevalence of healthcare-associated infections mainly in the pediatric, medicine, neonatal and obstetric wards and in the intensive care unit. These wards were crowded and had the highest use of antimicrobials at the hospital. Extended Spectrum Beta-Lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumonia occurrence was higher among neonates and children compared to adults. All data from phase two and phase three have not yet been published, though following are some results that are available.

Local production of hand rub

One of the major issues identified during the intervention was hand hygiene practice among healthcare staff. The main factor preventing the staff from proper hand hygiene was the unavailability of alcohol-based hand rub in the hospital. The project team started a local production of alcohol-based hand rub to lower the costs and make it available for all wards. They were in charge of this during the first three months until an infection control team from the hospital, including health professionals and health management personnel, was set up to take over to keep the hand hygiene practice in place, including the hand rub production. The World Health Organization has developed tools and resources for this purpose, which can be found here.

Knowledge improvement

A yellow certificate the research team received
Certificate of Appreciation.
When comparing the baseline KABP with the endline, the overall knowledge among healthcare staff improved. In recognition of the great impact of the project, the Tikur Anbessa Hospital gave certificates of appreciation to the project team. The hospital wanted to express their appreciation for the project team’s contribution in raising awareness and establishing infection prevention practices, hand hygiene in particular. The team was also invited to participate during the celebration of hand hygiene promotion week at the hospital 17 January 2014.

 “I would not have done anything different if I would have done the project again today. But even though we had a great impact, more intervention studies are needed in African hospitals. There is still much to be done to solve the issue of AMR and the problem is not an African problem, but a global one”
– Eleni Aklillu

It is clear that the research team made a great impact during this project and had a great experience, they hope to continue similar work in the future.

Selected Resources

Resource Description
Tools and Resources. WHO tools and resources on hand hygiene, including a hand hygiene self-assessment framework and a guide to local production of hand rub formulations.
High Gastrointestinal Colonization Rate with Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Hospitalized Patients: Emergence of Carbapenemase-Producing K. pneumoniae in Ethiopia Article related to the first phase when the research team studied prevalence of healthcare-associated infections.

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World Health Organization - WHO. Clean Care is Safer Care: Tools and resources [Internet]. Clean Care is Safer Care. 2009 [cited 2016 Mar 22]. Available from:
Desta K, Woldeamanuel Y, Azazh A, Mohammod H, Desalegn D, Shimelis D, et al. High Gastrointestinal Colonization Rate with Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Hospitalized Patients: Emergence of Carbapenemase-Producing K. pneumoniae in Ethiopia. PLoS ONE [Internet]. 2016;11(8):e0161685. Available from:
Kompetensutveckling i u-länder för att förebygga vårdrelaterade infektioner och antibiotikaresistens [Internet]. [cited 2017 Mar 15]. Available from:
World Health Organization - WHO. The burden of health care-associated infection worldwide [Internet]. WHO. [cited 2017 Mar 15]. Available from: