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Today is World Hand Hygiene Day – clean healthcare is among the most urgent challenges identified by the United Nations to be addressed by the global community in the next 10 years, and is highly relevant in meeting the Sustainable Development Goals (SDGs), as well as fighting against infections, sepsis, and, most recently, SARS-CoV-2/COVID-19.

Since the World Health Assembly has dedicated 2020 as the International Year of the Nurse and the Midwife, this year’s World Hand Hygiene Day theme is ‘Nurses and Midwives, clean care is in your hands’.

Please join us in celebrating World Hand Hygiene Day today. Share the official song (embedded below) with your friends and colleagues, join the campaign on social media, participate in the free WHO webinar today at 14:00h CEST, or register your institution, if you have not done so already.

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Although 80% of sepsis cases are contracted outside of the hospital (see video below), hand hygiene plays a critical role in the prevention of infections, and therefore the prevention of sepsis.

Consequently, the WHO and the GSA urge all healthcare institutions, all health workers, as well as all policymakers and other stakeholders to address hand hygiene, infection prevention and control, and sepsis holistically as pillars of a coordinated strategy.

There are between 47 and 50 million cases of sepsis every year worldwide, with 11 million deaths per year. 20% of all worldwide deaths per year are associated with sepsis, including many from SARS-CoV-2 / COVID-19.

In May 2017, the World Health Assembly adopted a resolution on improving the prevention, diagnosis, and treatment of sepsis, spearheaded by the Global Sepsis Alliance.

On Tuesday, April 28th, the newest research from the Global Maternal Sepsis Study was published in The Lancet. On this important occasion, we were able to speak to Dr. Mercedes Bonet, Study Lead at the World Health Organization (WHO), exclusively.

Marvin Zick: Please introduce the Global Maternal Sepsis Study (GLOSS).

Mercedes Bonet: The Global Maternal Sepsis Study (GLOSS) was a massive research effort led by the World Health Organization to better understand and stop maternal sepsis.

If we can understand why maternal sepsis is still a leading cause of death for women and newborns we will be better equipped to combat it. GLOSS is the first study to provide data on the frequency of maternal infections across the pregnancy and post-pregnancy period, in over 700 health facilities across 52 countries. The data collection was also accompanied by a campaign for healthcare providers, which increased their awareness and understanding of maternal sepsis identification and management.

MZ: Please introduce yourself.

MB: My name is Dr. Mercedes Bonet and I am a medical officer working at the WHO Department of Sexual and Reproductive Health which also hosts HRP, the main instrument within the United Nations system for research in human reproduction.

While I oversaw the study from WHO headquarters in Geneva, it was really a concerted global effort that engaged over 100 researchers across the 52 participating countries who supported the development of the study protocol, led the data collection, and the implementation of the awareness campaign.

MZ: Can you Please summarize the findings from the recent publication?

MB: The WHO GLOSS Research Group, which published results in The Lancet Global Health on April 28th, shows that infection has a much larger impact on global maternal mortality and morbidity than previously thought.

This is mainly due to two factors.

First, the underlying contribution of maternal infection to adverse maternal outcomes. Women may have died or developed severe morbidity from other complications, such as postpartum haemorrhage, but infection was present. Second, unlike previous estimates, GLOSS reports not only on direct (obstetric) infections, but also on infections after abortion and indirect (non-obstetric) infections, in keeping with the WHO maternal sepsis definition across the continuum of pregnancy, childbirth, and post-pregnancy periods.

The study also highlights important gaps regarding the early identification and management of maternal infections in health facilities. For example, a third of women did not have a complete set of vital signs reported on the day of suspicion or diagnosis of the infection.

Finally, we found that the most common infections are highly preventable with good quality care across the pregnancy and post-pregnancy continuum.

MZ: What surprised you most about the results of the study?

MB: The true burden of maternal sepsis has been unknown, owing to a lack of data, in particular for low- and middle-income countries. It was not a surprise, so much as an urgent step forward for GLOSS to address the absence of standardized data from those countries and to see more clearly what is actually happening around the world.  

This is critical for prevention, early diagnosis, and prompt management of maternal and neonatal infection, which we know will save lives and directly contribute to the achievement of Sustainable Development Goal 3.

MZ: Can you explain the differences between low- and middle-income countries and high-income countries?

MB: Most maternal infections are preventable and treatable, but efforts to prevent, diagnose, and treat maternal infection are linked to broader health determinants and different country contexts.

Overcrowding, limited access to water and sanitation, substandard infection prevention and control measures, limited resources, including staff, supplies and equipment, and constraints to safe births by skilled birth attendants can reduce the ability of healthcare providers to manage the frequency and outcome of maternal infections. These factors may explain why the highest ratios of maternal infection and severe maternal outcomes were observed in low and middle-income countries.

MZ: What do you think is the reason for maternal sepsis not getting the attention it deserves globally?

MB: For a long time, the focus has been on addressing the two main maternal killers: post-partum haemorrhage and pregnancy-induced hypertension. Although we knew sepsis deaths due to obstetric infections were just next on the list, data on maternal infections were less frequent and often of limited quality.

Alongside our GLOSS results, there has been other important work on sepsis this year. Incidence estimates and an evidence synthesis on the incidence of peripartum infections, commissioned by WHO, confirmed that maternal infections are a real problem, and deserve more attention. 

Prevention and management of maternal infections are complex challenges and require a comprehensive response. This must be at all levels, from addressing individual-level risk factors (such as anemia or obesity) to behavioral changes by staff to improve monitoring and use of preventive measures.

Finally, improvements in infrastructure and resources are key. Attention to maternal sepsis is growing, but health facilities need investment in clean water and sanitation, infection prevention and control measures, training, and equipment.

It is extremely encouraging that WHO will publish a global sepsis epidemiology report in May around the 73rd World Health Assembly (WHA). This is in response to the 2017 WHA Resolution on Improving the prevention, diagnosis, and clinical management of sepsis.

MZ: What are the next steps for GLOSS and the WHO? Did the study point out any opportunities or untapped potential?

GLOSS presents, for the first time, a more complete understanding of the frequency and impact of maternal infections in health facilities.

Our hope is that GLOSS has answered some important questions about the role of maternal infection and sepsis in global maternal mortality and morbidity. With these data, healthcare providers, policy-makers, and the public at large are better equipped to mobilize, improve evidence-based practice, and save lives.

WHO is committed to improving the prevention and management of maternal infections through its research and normative work. Under the umbrella of the Global Maternal and Newborn Sepsis Initiative we are working with healthcare workers, researchers, and policymakers so that together we can stop maternal sepsis.

The data collection was also accompanied by an awareness-raising campaign for healthcare providers, which could improve maternal sepsis identification and management.

MZ: Is there anything else our audience should take away from the Global Maternal Sepsis Study?

MB: Every pregnant or recently pregnant woman is at risk of an infection that could trigger sepsis, regardless of where she lives.

Significant efforts are needed to develop and implement comprehensive approaches for effective prevention, improved identification, monitoring, and management of maternal infections and sepsis in health facilities.

Please visit http://srhr.org/sepsis for more information and resources about GLOSS.

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Press Release

Please download the GSA press release below or use the press release template to issue one on behalf of your organization.

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The above interview was conducted by Marvin Zick via email on April 30th, 2020. A big thanks to Dr. Bonet and the WHO Communications Team for putting this together so quickly.

Photo Credit: Saudi Patient Safety Center, 2020

As a healthcare professional (hepatobiliary surgeon), and as the leader of our national patient safety organization (Saudi Patient Safety Center), you think that you have seen it all. Well, that perception had to be re-evaluated the moment I was told: “You tested positive for COVID-19…”

The story began on Friday, March 20, 2020, when I started complaining of flu-like symptoms. It was unusual for me to get the flu at this time of year, as I’ve been blessed with great health and very good immunity. Over the past couple of years, I hardly even got sick with a mild cold. So, when I got severe flu-like symptoms, I was concerned.

Out of precaution, I decided to stay in home isolation, just in case. Over the next 3 days, my symptoms didn’t get better – high fever, sweating, generalized ache, diarrhea, cough, chest pain, and loss of sense of smell. As healthcare professionals, we were always “cautioned not to play the role of our own doctors”, but I was pretty sure that I had community-acquired pneumonia, based on my symptoms. I managed to start myself on Azithromycin orally. 36 hours after starting the antibiotic, it became clear to me that the treatment was not helping as my symptoms persisted- they had actually gotten worse. It was at that time that I checked myself into one of the tertiary hospitals in Riyadh.

At the emergency department, my temperature was 39.5° with a heart rate of 91 (which was high for me as I usually run in the 60s). I didn’t need any oxygen support as my O2 saturation was 93-94 % on room air.

I was admitted to a negative pressure isolation room, and it was at that time that I realized I just made the transition from a “National Healthcare Leader” into a suspected COVID-19 patient. My chest x-ray showed signs of a left lower lung infiltrate consistent with acute community-acquired pneumonia. I ended up also having blood and sputum cultures taken, in addition to a nasopharyngeal swab for COVID-19. To cover all the bases, I was started on broad-spectrum IV antibiotics in addition to Hydroxychloroquine.

Within 24 hours, my results came back positive for COVID-19. I have to admit that, even though I couldn’t remember being exposed to any suspected or confirmed COVID-19 patients, I wasn’t surprised to be positive for two reasons:

1. My symptoms were so severe, which was very unusual for someone like me who hardly gets a mild cold.

2. My body’s response to Hydroxychloroquine was so pronounced. With the first 2 doses of it, I had shaking and chills for 30 minutes every time I took it.

36 hours after I was started on the Hydroxychloroquine, my fever subsided, and my other symptoms started to improve. The pleuritic chest pain continued for about 7 days. but eventually receded.

My overall hospitalization was for 4 days after which I was transferred to quarantine. In my country, the government in collaboration with several hotels have transformed a large number of hotels into “Quarantine Centers”. These centers deal with the following conditions:

1. Citizens coming back to the country from abroad.

2. Asymptomatic COVID-19 patients that didn’t need to be admitted to hospitals.

3. Symptomatic COVID-19 patients who just finished treatment and no longer require to be in the hospital.

I belonged to the third category. The protocol is that you must have two consecutive negative swabs 24 hours apart before you are deemed ‘cured’ and be allowed to go back home. It took me 7 days after I got discharged from the hospital to have my first negative swab (the first two swabs were positive). After a total of 15 days in quarantine, I was given a clean bill of health (after 2 consecutive negative swabs) and was discharged home.

Here’s some reflection on my experience with COVID-19:

1. I am still unclear on how I contracted COVID-19 (most likely from an asymptomatic carrier as I was very careful with any suspected and/or confirmed COVID-19 individuals).

2. I had 4 days of severe flu-like symptoms where I isolated at home. Throughout my entire life (43 years), this qualifies to be the worst flu I had.

3. My hospitalization in a negative pressure isolation room was for 4 days. Even though I developed COVID-19 pneumonia, I never required oxygen or any other respiratory support.

4. I strongly believe that Hydroxychloroquine was effective and very instrumental in my speedy recovery.

5. My experience in isolation has highlighted a couple of potential safety risks:

• Responsiveness to COVID-19 patients is poor due to a number of factors, one of which is the health workforce’s concern about contracting the virus from patients.

• Identification of caring health workers (nurses, physicians, allied health), while they are wearing full PPE attire becomes very difficult. I suggest that health workers either put their photos or at least their names on their gowns so patients would be familiar with who’s looking after them.

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The article above was written by Abdulelah Alhawsawi, and is shared here with his explicit consent. The views in the article do not necessarily represent those of the Global Sepsis Alliance. They are not intended or implied to be a substitute for professional medical advice. The whole team here at the GSA and the World Sepsis Day Movement wishes to thank Abdulelah for sharing his experience and for fighting to raise awareness for sepsis and patient safety.

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Today, we are releasing our new 2020 WSD Infographics in Spanish and Italian, following the initial release of the English ones back in January. These include a brand-new design that is more mature, easier to read and comprehend, and, most importantly, include the staggering findings from the Global Burden of Disease Study released in The Lancet in January.

As always, the new infographics are a quick and free download in our World Sepsis Day Toolkit Section – please download them and use them as you see fit, on your social media channels, printed at your events, and everywhere in between.

There is a total of 21 infographics, nine on sepsis itself, ranging from symptoms, sources, prevention, risk groups, to physiology, post-sepsis symptoms, and more. Additionally, there are two on hand-washing (very important nowadays), and ten more highlighting the relationship to other World Health Days, such as World AIDS Day, World Immunization Week, and more. The infographics are available as images (.jpg), as well as optimized for print (.pdf).

We put a lot of thought and time into the new infographics – please contact us to give feedback so we can improve them even further. Lastly, please consider donating to support the ongoing development of our free sepsis awareness resources – thanks!

The Global Sepsis Alliance is the largest professional network on sepsis worldwide, with over 100 member organizations from all parts of the world. After two articles explaining how COVID-19 can cause sepsis, we want to put our network and resources to further good use.

That is why over the last two weeks, we have assembled an international task force consisting of medical professionals, communications experts, and sepsis survivors from all over the world, standing by to answer your most burning questions on COVID-19, especially focused on the relationship between COVID-19 and sepsis.

Please send us your questions via social media (Twitter / Instagram / Facebook), either as a private message or publicly, or submit them via the form below. If you send them publicly via social media, please include the hashtag #askWorldSepsisDay so we can find them.

The most asked questions will be published and answered in the Q&A section of our new COVID-19 information page. Please note that your questions will not necessarily be answered via email - in fact, you don’t need to provide your email address if you don’t want to.

We are looking forward to hearing from you and answering your questions!

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Today, we are very happy to release the “Life After Sepsis”-Guide - a free downloadable brochure that aims at guiding survivors and their families, who are the most vulnerable when sepsis occurs.

It wants to inform the general public, patients, their relatives, and healthcare professionals about sepsis. The brochure explains that there is a need for an urgent response due to the consequences of sepsis, including lifelong disabilities. It is not intended to be a substitute for medical advice, but rather to ensure that more people are better equipped to recognize sepsis, prevent it, and cope with its long-lasting effects.

As always, we are looking forward to hearing your feedback, including suggestions for improvements or a typo we overlooked.

The rapid global spread of the novel coronavirus SARS-CoV-2 has caused societal, economic, and medical upheaval not seen since the 1918 influenza pandemic. As of April 7th, the World Health Organization has confirmed cases in 203 countries, areas or territories, with over 1.2 million confirmed cases and over 65,000 deaths.  Further, many experts believe these numbers to be a gross underestimate for a variety of reasons, including inadequate testing capacity and suboptimal reporting of cases. Despite extensive modeling by epidemiologists all over the world, it is not possible to accurately predict the course and duration of this pandemic. It is important that we continue to obtain objective data on which we base recommendations. A calm and rational approach from both society and individuals is necessary during these uncertain times.

There remains considerable confusion regarding the differences between seasonal influenza and COVID-19 (the illness caused by SARS-CoV-2). While both viruses are capable of causing severe illness and can spread rapidly, it appears that SARS-CoV-2 is a more deadly pathogen on a case-by-case basis, can be spread during the asymptomatic phase, and is capable of much more rapid spread. The higher burden and mortality may be attributed to the fact that SARS-CoV-2 is a “newly emerged” virus, and consequently, there is very little innate immunity to it among humans, unlike with influenza where both prior infection and annual vaccination can provide protection. Overall, however, the sheer contagiousness of this new virus has led to the high morbidity and mortality seen globally – simply put, healthcare systems have been unable to cope with the number of infected persons seeking care. Indeed, a proportion of the reported deaths are due to overwhelmed medical systems rather than the virulence of COVID-19. This is a crucial factor explaining the “flatten the curve” strategy adopted by many countries. 

Now that more scientific data are available on COVID-19, the Global Sepsis Alliance can more definitively state that COVID-19 does indeed cause sepsis. Sepsis is “a life-threatening organ dysfunction caused by a dysregulated host response to infection.” In the case of COVID-19, the effects on the respiratory system are well-known, with most people requiring hospital admission developing pneumonia of varying severity; however, virtually all other organ systems can be affected. This is consistent with a combination of direct viral invasion and sepsis. For example, in a recently published case series of severe COVID-19 cases from the Seattle area in the United States, over 30% had evidence of liver injury and 75% had evidence of a depressed immune response¹; another series from the same region reported acute kidney failure in almost 20% of affected patients requiring ICU care ², and both series reported septic shock severe enough to require drugs to support the heart and circulation in almost 70% of patients. A recent study from China reported that in patients hospitalized with COVID-19, 28% had evidence of significant heart damage (potentially from direct invasion of cardiac muscle by the virus), resulting in heart failure and abnormal heart rhythms – this damage was associated with a five-fold increase in the risk of death³. As there are no proven therapies effective against the virus itself, it is apparent that the best COVID-19 care includes good sepsis care.

Effective and safe treatments for COVID-19 are urgently being sought by scientists across the world. Although it is hoped that the first batches of a COVID-19 vaccine will begin to be tested in humans in April 2020⁴, large-scale distribution of a viable vaccine may still be a year or more away. Treatment trials are underway with antiviral agents such as Lopinavir/ritonavir (LPV/r), Hydroxychloroquine (HCG), Hydroxychloroquine plus azithromycin, Favipiravir (FPV), Remdesivir (RDV), and with immunomodulators such as Tocilizumab, the anti-C5a antibody IFX-1, and Intravenous Immunoglobulin (IVIG). In addition, potential treatment with convalescent serum is being attempted and trialed.

However, despite these efforts, presently there are no specific treatments for COVID-19. As such, the Global Sepsis Alliance continues to strongly advocate for strict adherence to the basic protective measures recommended by the WHO – handwashing, maintaining social distancing, avoiding touching one’s face, practicing proper respiratory hygiene, staying at home if feeling unwell, and obtaining prompt medical care if fever, cough, and breathing difficulty develop together. We also recommend close attention and adherence to the restrictions on social gatherings set by local health authorities and government bodies. We encourage you to assess the particular challenges faced by the healthcare systems in your area, and if you are able to materially assist in any way (including something as simple as volunteering to be a blood donor), please do so. We are in this together. Be safe.

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This article was published on April 7th, 2020, with the most recent data from the WHO Situation Report from April 6th, 2020 - we expect both cases and deaths to rise further. The views in this news post are not intended or implied to be a substitute for professional medical advice. Special thanks to Nathan Nielsen, Niranjan ‘Tex’ Kissoon, Konrad Reinhart, Dennis Kredler, Mahawi Aljuaid, and Simon Finfer for helping to put this article together.

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References

¹ (Bhatraju PK, et al. NEJM 2020)
² (Arentz M, et al. JAMA 2020)
³ (Guo T, et al. JAMA 2020)
⁴ https://time.com/5790545/first-COVID-19-vaccine/

Sepsisfonden is a Swedish sepsis trust that started in 2015. Since the start, one of their main objectives has been to increase awareness around sepsis in Sweden.

This spring, they have launched a school project where they target young people in their awareness work, especially kids in the ages around 13 to 17. The first step has been producing a film that explains how the immune system works and what happens when you develop sepsis, embedded above.

Later this year, they will also send out a pedagogical material to all science teachers, teaching in year 8 (kids around 14 years), together with this film, and encourage them to take the time to talk about sepsis in class.