Lessons Learned from a National Healthcare-Associated Infection Mandatory Notification System, France, 2001 – 2008

Background: Healthcare-associated infections (HAI) surveillance systems are voluntary-based and target specific infection sites, micro-organisms or specialties. They do not allow the early detection of unusual infectious events in healthcare facilities (HCF). In 2001, French health authorities made notification of rare or severe HAI mandatory in order to detect those events for their prompt investigation and control.

Objective: To describe methods, outcomes and lessons learned from this mandatory warning system.

Methods: Events are notified by HCF according to selected criteria related to pathogens (e.g., antimicrobial resistance), infection sites, severity of disease or modes of transmission (e.g., a contaminated device or product or practice failures). HCF notify events to regional infection control coordinating centers (CClin) for expertise and assistance, to local health authorities for control, and to the National Institute for Public Health Surveillance (InVS) for second-line assistance and analysis. We analyzed outcomes of this system from 2001 to 2008.

Results: From 2001 to 2008, InVS received 6,657 notifications from 1,231 HCF, accounting for 22,166 NI and 2,097 deaths (9.5%). Of these notifications, 1,892 (8.5%) were about clusters (ranging from 2 to 181 cases).The monthly number of notifications regularly increased from 2001 (n=30) to 2008 (n=110). The system provided HCF with local assistance in investigation by CClin and allowed the early detection and control of outbreaks or emerging pathogens, such as VEB-1 EBSL-producing Acinetobacter baumannii (2004), vancomycine-resistant Enterococci (2005) or 027 Clostridium difficile (2006). Following the first event reports, prompt dissemination of national guidelines and implementation of control measures in affected HCF were associated with a decrease in outbreaks. HAI notifications also led to national audits of practices (e.g., assessing infection control in haemodialysis units after an outbreak of hepatitis C in 2001) or actions to improve products safety (e.g., the international withdrawal of a powdered infant formula after an Enterobacter sakazakii outbreak in 2004). Last, the system also allowed the recognition of severe HAI in outpatient settings (e.g., outbreak of Mycobacterium chelonae associated with inadequate hygiene practices in aesthetic facility in 2008).

Conclusions: Mandatory notification of HAI in France proved to be an effective early warning system, which helped in detecting and controlling unusual infectious events, improving awareness of healthcare professionals (HCP) and patient safety. However, its efficiency relies on HCPs’ adherence, laboratory capacity, and timeliness in the information flow. A web-based system will be implemented in 2011 to improve the information flow and sharing of experiences between HCF and expertise structures.