This blog highlights findings from NACCHO’s Project Brief, “Reducing the Threat of Healthcare-Associated Infections & Antimicrobial Resistance,” which you can read here.

Background

On any given day, one in 31 hospitalized patients has a healthcare-associated infection (HAI)¹ which amounts to more than one million HAIs occurring in the United States every year.² An HAI is an infection a patient catches in a healthcare setting while seeking treatment for another health issue. It may complicate care, lengthen patients’ hospitalization, and put their lives at risk. Tens of thousands of deaths occur each year in the United States.²

Many patients overcome these infections, but HAIs are a leading cause of preventable deaths in the US, and antimicrobial resistance (AR) is raising the stakes even higher. More than 2.8 million antimicrobial-resistant infections occur each year in the US, and on average more than 35,000 people die annually as a result.

Antimicrobial resistance (AR) is a significant hurdle for healthcare providers, making treating infections, including HAIs, increasingly difficult. Many organisms that were once easily treated with antibiotics have developed resistance. This resistance is a direct result of the misuse and overuse of antibiotics. The CDC estimates that US doctors’ offices and emergency departments prescribe about 47 million antibiotic courses yearly for infections that don’t require antibiotics.¹ The situation was further exacerbated by the COVID-19 pandemic, which added another layer of complexity to proper prescription of antibiotics.

Leaders in public health are taking charge and working to mitigate the risk of HAI/AR in high-risk settings across the US. Local health departments (LHDs) are on the frontlines, serving as a vital part of the solution. LHDs are well-positioned to serve as 1) trusted partners for healthcare facilities who can jump in and help with assessing and improving Infection Prevention and Response (ICAR) practices, 2) subject matter experts, 3) conveners and communicators across multiple public health and healthcare facilities, 4) providers of education and guidance, and 5) providers of essential data and analysis.

COVID-19 Response Provided a Pathway to Enhance HAI/AR Efforts

NACCHO serves over 3,300 LHDs across the United States and provides cutting-edge, skill-building, professional resources and programs. Through funding, training, technical assistance, and the creation of tailored guides and resources, NACCHO helps LHDs prevent and interrupt the spread of HAIs and AR in the communities they serve.

Chronic underfunding for public health is a long-standing issue, leading to diminished infrastructure, workforce shortages, technological deficiencies, insufficient laboratory capacity, and a weakened ability to protect Americans’ health.³ In this context, when the COVID-19 pandemic struck, local health department (LHD) staff were thrust into the spotlight and required to rapidly scale IPC efforts, including those for HAI/AR, to protect and save lives.

In response, NACCHO, in collaboration with the CDC’s Division of Healthcare Quality Promotion (DHQP), took decisive action to launch six project initiatives over three years, providing $8.2 million and customized technical assistance to 202 LHDs. These initiatives were designed to combat the immediate threat of COVID-19 and HAI/AR and help LHDs rebuild the essential infrastructure and capabilities necessary for promoting and safeguarding public health (Appendix A).

We saw devastating impacts in nursing homes and long-term care facilities in particular, and these were some of the settings that LHDs stepped up to support.

– Christina Baum, NACCHO Director, Infectious Disease

In addition to funding, NACCHO offered extensive technical assistance grounded in a theory of change that included both systems- and organizational-level investments to achieve community impact.

In 2024, NACCHO engaged WE Public Health, LLC to review 138 products from across the six initiatives, including evaluation reports, grantee reports, case studies, meeting presentations, newsletters, training materials, and other documents, to identify accomplishments, lessons learned, and opportunities to continue supporting LHDs’ HAI/AR efforts. Highlights from the review are enclosed in this project brief. This is not a complete representation of all results.

NACCHO’s Tailored Assistance Boosts HAI/AR Efforts

In addition to funding specific HAI/AR activities, NACCHO provided comprehensive technical assistance, including access to subject matter experts, training opportunities, peer-to-peer learning, and resources and tools. NACCHO’s technical assistance is distinguished by its adaptable, responsive, and tailored approach, grounded in a theory of change involving both systems-level and organizational-level investments to achieve community impact (Figure xx). Through NACCHO’s investments, LHDs developed internal organizational and workforce capacity, enhancing partnerships and improving IPC practices within communities, ultimately reducing HAI/AR infections and the spread of multidrug-resistant organisms (MDROs).

NACCHO’s technical assistance is designed to be adaptable, responsive, and tailored to LHD needs. Staff regularly engage with LHD members to provide timely support in the ever-changing public health landscape, ensuring the assistance directly applies to LHDs’ unique environments. Throughout the six initiatives, NACCHO continually assessed the value of the technical assistance provided and adapted its approach based on participant feedback.

Results

Between July 2020 and July 2023, these initiatives empowered LHDs to fully assume their critical role as HAI/AR prevention and response leaders. LHDs developed internal organizational and workforce capacity and enhanced partnerships for more comprehensive IPC. These capacities and partnerships led to increased delivery of HAI/AR services and IPC practices within communities, reducing the spread of multidrug-resistant organisms (MDROs) and HAI/AR infections. Check out the full results here.

While each initiative had a unique focus shaped by the evolving public health landscape and input from LHDs, there was a common thread of progress across all participating LHDs. The funding and tailored technical assistance provided by NACCHO helped LHDs to:

1. Increase staff confidence in leading HAI/AR efforts,
2. Improve organizational capacity for IPC and HAI/AR work,
3. Build more robust partnerships with facilities critical to HAI/AR prevention and response, and thus
4. Provide more IPC and HAI/AR services and expand the reach of those services.

One of the greatest successes was transforming our relationships with [high-risk] facilities in the community. I don’t think we can ever go back to the status quo of interacting mostly in a regulatory way…Facilities are now contacting the health department for guidance.

– LHD Project Participant

Learn More

How 5 LHDs Responded to HAI Threats:

• Alameda County Public Health Department: Carbapenem-resistant organisms (CROs)
• Tacoma-Pierce County Health Department: Multidrug-resistant organisms (MDROs) & Enhanced Barrier Precautions (EBP)
• Fresno County Department of Public Health: Candida auris
• North Central District Health Department: Legionella
• Stark County Health Department: Mitigating a Norovirus Outbreak in a Long-Term Care Facility

How 3 LHDs used the CDC’s LHD HAI/AR Strategy:

• Kern County Public Health Department
• Monongalia County Health Department
• Cincinnati Health Department

References

¹Healthcare-associated Infections (HAI), Centers for Disease Control and Prevention. 2024. https://www.cdc.gov/healthcare-associated-infections/programs/index.html#cdcreference_1

²Health Care - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. https://psnet.ahrq.gov/primer/health-care-associated-infections

³The Impact of Chronic Underfunding on America’s Public Health System: TRENDS, RISKS, AND RECOMMENDATIONS ISSUE REPORT, Trust for America’s Health. 2023.
https://www.tfah.org/report-details/funding-2023/