Rajat Kumar, a two-year-old boy, was admitted to a leading hospital in the capital for meningitis of the brain. A shunt, essentially a plastic valve meant to drain out the fluid from the brain, was inserted into his cranial cavity. Within two days, instead of him showing signs of improvement, the wound became septic and the infection spread to other parts of the body. Despite the best efforts of the medical team that rushed Kumar to ICU, peritonitis (pus in the abdominal cavity) set in. Kumar died last week after battling the infection for a fortnight.

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DINESH GUPTA The 12-year-old boy was admitted to a Delhi hospital with a kidney problem. After the insertion of an infected catheter during the treatment he now suffers from chronic renal failure.

Hospital infection is the killer within. Patients who come to a hospital or a clinic for treatment often face and suffer from a callous disregard for fundamental sterilisation measures. Like Kumar, the list of people dying or suffering from hospital infections in India is growing at an alarming rate. Dinesh Gupta, 12, is one of the many on that list. He was admitted to a Delhi hospital with a kidney problem. Instead of cure, he got an infected catheter. Now he suffers from a chronic renal failure.

Unlike popular perception, the malady is not confined to the poorly maintained government hospitals-it is rampant in rural areas and metros, PHCs and upmarket hospitals. And it is contracted through the most ordinary things-reused surgical gloves, non-sterilised syringes and intravenous sets, contaminated gauze, germ-laden instruments and medical products without proper certification. Only that in a medical environment, they turn killers. No wonder hospital infection is now considered one of the leading causes of death in the country. According to the Hospital Infection Society, Mumbai, 10-25 per cent of patients admitted to city hospitals become casualties of hospital infection.

Awareness regarding the seriousness of the problem is slowly trickling in. In April this year, Principal Scientific Adviser to the Government R. Chidamabaram set up a working group to examine the high rate of hospital infections and to look at the current sterilisation procedures in hospitals. Believed to be the first of its kind, the 10-member group headed by paediatric surgeon Dr Sudhir Krishna comprised seven doctors, a microbiologist and a radiation specialist.

Krishna and the doctors visited some of the leading hospitals in the metros to get a first-hand experience of the way they function. Ignorance of basic sterilisation norms and the absence of sanitation were rampant in the majority of hospitals. The findings, now part of a report being finalised by the PSA's Office, are a rude wake-up call to the medical community. It says:

Even when the hospitals are equipped with a Central Sterile Supply Department (CSSD), which is responsible for the sterilisation of gauze, linen and surgical instruments, the disinfecting methods are defective. Non-metallic surgical equipment which cannot be subjected to steam sterilisation are being extensively used, exposing patients to the risk of infection.

The sanitation and janitorial staff are inadequately trained. Some of them handling the sterilised products at the CSSD suffer from "skin diseases" and "chronic ailments".

Where autoclaving or sterilisation using steam is concerned, no standard procedures are followed for maintaining the pressure or temperature required for proper sterilisation. In many hospitals, the gauge is non-functional. Otherwise the autoclave is faulty and leaking. Most often the linen and gowns needed for surgery come out moist from the autoclave-another source of infection.

THE REPORT   The expert group set up by the Centre reveals glaring lapses.
1 Open to danger The study shows that gauze and cotton pads, the most common surgical care products, are kept in unsterilised steel containers in most hospitals. That is one sure way to spread infections.	2 Germinating infection The study says blood-infected gauze is carelessly disposed, often next to instruments. Wrapping surgical trays in cloth is risky. The team found the practice ubiquitous in hospitals.
3 Missing gloves The expert group points out that in many hospitals, the staff cut cotton and gauze in the open, without even wearing gloves. It should be done by trained people in disinfected places.	4 Unkindest cut The report reveals that in many hospitals and clinics, surgical instruments are spread out in the open, exposed to germs, dust and insects, instead of being kept steam-sterilised.
	5 Cloth hazard The linen used in the operation theatre must be germ-free and stored in hygienic conditions. The team found many hospitals using sheets that carry pus and blood stains.

Though the shelf life of autoclaved products is between 48 and 72 hours, many are in use after the expiry time. In some hospitals, they are lying unused in open cupboards for weeks on end. Even the strips used as sterilisation indicators are substandard.

The world over, hospitals have stopped using clothes to wrap surgical trays. In India, however, the practice survives in the ubiquitous green fabric and most hospitals use filthy material. Blood stains and pus are often found on the wraps. Even surgical gowns and cottons are not properly washed and are dried on dirty floors. Many of these carry a high bio burden.

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REMYA KHAN The two-week-old infant contracted an infection from a leading hospital in Delhi where she was born. Now the little girl is on a life-support system and battling for her life.

Most of the doctors the team has spoken to are aware of the improper sterilisation procedures employed but express their helplessness. Krishna's medical team has come across another risk factor-many products like gloves, catheters, syringes, endotracheal tubes, drainage tubes and laproscopic instruments which are bought by pharmacies in packets stamped "sterile" are fakes. These products have wrong batch numbers, are badly packaged and skip the stringent tests of sterilisation before being marketed. And there are no measures in place to check the cottage industry that has been growing over the years, putting lives at risk.

The absence of any legislation on quality control compounded by the shocking disregard by hospital administrations for standards and regulations even in ICUs and operation theatres have only contributed to this silent killer stalking the health centres. Even as many of India's surgeons compare with the best in the world, their efforts are rendered worthless when patients contract secondary infection in the hospital. The success of a surgery hinges a lot on the sterile environs that would prevent a post-operative infection. Most often, doctors prefer to put the patient on costly antibiotics, its price an add-on to the escalating bill, rather than enforce some basic precautionary measures. Often the incidence of aids, tetanus, gangrene and hepatitis B and C can be traced back to one callous moment when the nurse forgot to disinfect the needle.

The situation is no better even in advanced countries. In the United States, hospital infections are the fourth-leading cause of death, after heart disease, cancer and stroke, according to the Center for Disease Control and Prevention (CDC). Each year, the CDC says, about 90,000 people die from hospital-acquired infections. In the UK, every year around 100,000 patients contract infections in hospitals and about 15 per cent of these are preventable. That would mean saving the patients pain and the National Health Service an estimated £150 million (Rs 1,080 crore) a year.

To prevent the situation from snowballing in India, the PSA's expert group has suggested a plethora of reforms in the health sector. On the top of its wish list is a legislation to establish an organisation that adopts the best international practices to ensure the use of sterilised products. Though the Drug Control Act of India, 1945, exists, it has been a toothless piece of legislation. To give more bite to it, the Drug Controller of India should be empowered to punish those who manufacture and market substandard and unsterilised products.

A regulation system too has to be in place. A licence from the DCI should be made mandatory for all hospitals. This would ensure the quality control of all items of surgical use at all levels: from the point of their manufacture to the point of use.

The other proposals include a comprehensive plan to implement modern sterilisation techniques required for medical products. That would mean clearly laid out procedures for the CSSD, ethylene oxide (ETO) sterilisation and gamma radiation. Further, the team has suggested that steel drums, trays and the green cloth used in operation theatres be replaced immediately by standardised and packaged material.

One of the villains is gas sterilisation or ETO, a disinfectant process for heat-sensitive instruments. The packaging of ETO instruments is often faulty and the liquid gas that is left behind because of poor aeration can cause infection. As syringes, needles, catheters, tubes and most medical devices are sterilised using ETO, there is every possibility that it could be the principal source of infections. The team has suggested a phasing out of ETO. On the priority list is the use of gamma irradiation, which detects contamination, for sterility tests of instruments.

The plan is in place but it may be a long while before these recommendations get translated into action. That the very centres of healthcare can be the contact point of diseases is a worrying thought. From contaminated cotton to spurious drugs, our medical environment is in urgent need of some intensive care itself.

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