On the podcast is Dr. Seif Salem Al-Abri, the Director-General for Disease Surveillance and Control at the Ministry of Health of Oman. Seif is a practicing consultant in Infectious Diseases at the Royal hospital of Oman, and he has been the head of the infectious diseases department and head of medicine.
He has done his training at the Royal Liverpool University Hospital and Liverpool School of Tropical Medicine. He is an accredited Royal College of Physicians educator, an international advisor for the Royal College of Physicians of London, and a member of the Governing Council of the National University for Science and technology. Finally, he is an associate editor to Sultan Qaboos University Medical Journal, Journal of Infection and Public Health, and Annals of Clinical Microbiology and Antimicrobials.
A few key takeaways:
On overcoming Antimicrobial Resistance
We know what should be done; unfortunately, still, to this day, I get calls from hospitals, from colleagues. They think it's a business of the infection, professional control. And the infectious diseases or microbiology, it's not. It’s the business of everybody. It starts from the decision-makers, down to the community, down to the general population, because they will go to, they will go to a health center insisting on antibiotics.
On getting published
Research and published papers are one of the best career investments and boosters, career posters, so do your best to study and write.
On changes in Healthcare-Associated Infections over time
I think it's too soon to find this because you need to measure it if you want to manage it.
When I was a student in school, I was interested in chemistry. So when I applied to the university, I applied, for example, to the College of Education and chemistry. I applied to the College of Science in chemistry and also like there's chemistry and medicine. So I applied to the College of Medicine, unfortunately, or unfortunately, I've been selected to go for medicine, then you decided on specializing in infectious diseases, how can that be? When I was a medical student, I had the opportunity of going to Austria, mainly to Vienna. And I have done the routine weeks in the infectious disease department there is the host called Aika hospital. And I was inspired by my supervisor at that time. So after that, I developed a passion for infectious diseases. When I finished my membership of the Royal College of Physicians, and I wanted to go for specialization, I will take contagious disease as a career. So then I went to Liverpool initially to do a Diploma of Tropical Medicine, because I was hoping to go to Australia at that time, most of the oma and go to Australia for two years for sub-specialty. But when I went to Liverpool, and then I met my mentor conduct on neck pitching, and then it started from there. So I just came back to him and to finalize the process for the scholarship. So like I went for the DTM NH in September. So I came back in December 2001. By May 2002. I went back to the UK, that is so interesting.
You have a very international profile. And I'm curious to know-how if the UK healthcare system is different from the health care system in Oman?
Dr. Seif Salem Al-Abri 04:24
There are some differences, but also there are some similarities. One of the similarities is that both publicly funded health systems, which from my point of view, make it much better. Also, it's more of evidence-based medicine practice rather than the effect of the insurance companies and the defensive medicine that is practiced by physicians in other countries. In addition, there are both demands on the good structure of primary health care. We have a good infrastructure of primary health care similar to the UK system, although it's not identical to how we forget. Are some major differences as well. So one of the major differences is that in the UK, it's only the national health services, the NHS, which delivers health care. In Oman, we have different stakeholders, from the Minister of Health we have in first the hospital, we have the army, the police, we also have a good chunk of the ambulatory healthcare is conducted or done by a private health sector. Another major difference is that, man, we don't have a General Medical Council, as in the UK. And also, we don't have solid scientific societies similar to those which are in the UK; for example, we don't have a Royal College of Physicians, we don't have good societies for whatever sub-specialties of medicine or surgery or charges.
Dr. Marco Bo Hansen 05:51
Thank you, Seif. I'm curious to know if the landscape of their career has changed since you started. Are there more IP specialists now in Oman? Yes, they are. Because I can tell you, for example, when I started practicing infection control in 2007, we're having fuel-efficient control preventionists or infection preventionists in some major hospitals, and because infection prevention was only a team, rather than a department. But what has happened, we had a major outbreak of Acinetobacter, or over the center back. And it was for the first time we have to recognize that in Oman, at the Royal Hospital in our ICU. And that has sparked a new era for infection control, whether we realize it or not, because we discover that all hospitals have it. Then we started a diploma in infection professional control for nurses. And each year, around 25 nurses graduate; these are already qualified nurses who are working. They spend one full year full-time training and infection professional control diploma. They go back to their hospitals and even into ambulatory care, like in primary health care. So now, almost in every single health care institution, there's a minimum of two or three infection professionals; some of them have five or eight infection preventionists. And even we have established that we had a new structure of the Minister of Health in 2014. And now, infection prevention and control is a department that belongs directly to the CEO or the director of the hospital. So they are sort of onboard as well. And that sounds like a very structured organization of infection prevention. Have you seen any changes in healthcare-associated infections over time?
I think it's too soon to find this because you need to measure it if you want to manage it. Yeah. I mean, yes, as a practice, there's far much difference. I can't remember for example, during a trial and one in 2009 2010, we were visiting hospitals, as simple as we don't have, for example, dispensable, alcohol handheld for hand hygiene, even if there is an isolation room, there are no signs, there are no policies. Now, at least, the processes there. And infrastructure is there. It will be really difficult to measure the impact of it. But as a process, there's a good impact as an impact. Like if we say, how many infections are we preventing? Maybe it's too soon? Yes, I completely understand that it is very difficult to document how many diseases you are preventing. The prevention part is very difficult to document. I completely agree. So most healthcare workers are working from patient to patient on a patient-based case. You can say you are the director-general for deceased civilians and control at the Ministry of Health of Oman. How do you work with deceased civilians and controlled from a national perspective? And what are your focus areas besides COVID-19? I mean, it was a complete shift for me, almost 180 degrees, because, in the hospital, you are more patient-centered. But when you work at the ministry or the national level, you are more community-based, or you need to change your vision to more of a community. So I take the holistic approach to health with an integrated approach and looking for sustainable deliverables and financing. And we concentrate much more on the process itself, so producing national policies and guidelines. We are now establishing a fully digital surveillance system for the public and private health sectors. That's integrated, for example, surveillance of infectious diseases. Is trauma poisoning, including AMR and healthcare-associated infections, we are doing our best to establish a national Infection Prevention and Control program. Now we had a code of conduct for professional infection control that makes hospitals obliged to follow the national code of conduct, i.e., they have to have certain standards they need to meet for professional infection control. We started surveillance for AMR. And we are in the process of establishing hospital-acquired infections. We manage it to get now. We use the coffered as an opportunity, negative pressure rooms in almost every single Hospital in the country, whether they are the district referral hospitals or even the smaller hospitals within the small districts. As I mentioned before, we also started certificate infection professional control; we hope that we'll be able to start this September, a certificate in central sterilization services for two years. And this will be for the first time in Oman; the way I look at it that we want to work from our health approach. And we work along with other stakeholders in the country. For example, zoonotic diseases picked up on AMR diseases; we do a lot of work with the other stakeholders, environmental health; we managed to get certification for measles and rubella elimination in 2019. And we are now in the process this year, and we hope we'll get it. We are working on eliminating of mother to child transmission of HIV and syphilis. And now we are also in the process of establishing malaria, I mean, certification of the malaria establishment. Thank you for sharing that. I think it is so important the work you are doing and this systematic approach. And I'm sure that many other countries can learn from this approach. And that leads me to my next question because we have received an interesting question from a listener asking you what you think will be the next global infectious disease challenge that we will need to be more aware of; I think we never know what may come up again. It could be another pandemic, maybe influenza, but we also have other risks, whether nuclear or radiation. But if we concentrate more on pandemics, there is still a global challenge. In this part of the world, like in the Gulf states, we have the Maersk, Coronavirus, which is a major challenge for us, and the times we do get even hospital outbreaks of Merced coffee. However, the major question should be, what can we do to be ready? Yankees, we have another pandemic, exactly. I had the honor to be a member of the HR Review Committee, which the director-general of the wh O. has established, And we have submitted the report just last April, just before the World Health Assembly. And maybe if there's only one thing we can say about it, we need to invest in public health for Preparedness and Response and readiness. The European Union and some other countries are leading an initiative for a global 3g and pandemic preparedness response. And there's going to be a global meeting next November to discuss this issue. So now, at least the pandemics or the risk from communicable diseases is at high stake. But I think this pandemic, the COVID-19 brought back the importance of communicable diseases.
Awesome. Thank you so much for sharing that. So I'm going to move on to the next part, which I call research. And I'm much interested in this and hearing your thoughts about it because I have read this fascinating study. Were you also a co-author, with the title effective vaccine management and Oman's healthcare system challenge to maintain high global standards. And what I can read in this study is that Oman has experienced a sharp decline in vaccine-preventable deaths over the last 40 years due to the introduction of new vaccines and the maintenance of high vaccination coverage of over 99%. I believe it was. So man underwent the assessment by the UNICEF and who in 2016 and scored the best score to date. What did you do to achieve and maintain these high global standards? And what were some of the challenges? The immunization program in Oman was started in 1983. And it was looked at not only by the Minister of Health but also by the government as the crown’s jewel. The country has invested a lot in the program itself, whether through availability and training of human resources, protected budget for the vaccines. For example, the budget for immunization is protected. Even from the Minister of Health, that's directly from the Minister of Finance. So even during the 2014 drop in the oil prices, maybe other health services got affected, but not the vaccines. Also, health promotion, supplies, cold chain, and legislation, as you have mentioned, have followed a sharp decline in vaccine-preventable diseases. And that was the biggest promotional thing for the vaccines themselves. And for the people to take vaccines, we do have some challenges. Now, we need to train more people in immunization. And also, we need to retain those who have already been trained, and on the surface, we need more strategic vaccine stores in some of the governorates. So that in case of emergencies, we have enough stocks of the vaccines that the immunization program is not disrupted in those areas. If, for example, there are any challenges, we also aim to establish additional digital monitoring of the vaccine called chain down to the each has center down to the like the last thing in the chain, which is the Health Centre. So wherever there is a fridge, we want to monitor it and remain, as you know, is having an enormous surface area. So this is one of the things that we aim to establish to have nationally digital monitoring for all the cold chains in the country. That is so fascinating, very inspiring. I'm also curious, how did you achieve this high vaccination coverage of over 99%? I think, first of all, it's the acceptance from the community itself. At the same time, also legislation we have the child protection law, which it's not most sort of a mandate that the child has the right to have vaccines. Still, we didn't use it much, but it's more off because there is follow-up if we have the user to be the pink card for each child, and they will be linked to a health institution. There is a follow-up for defaulters, and it used to be. I'm not sure it's still there now that even they go to the houses of each child if they are defaulters because the father is working somewhere far away and the mother contact the child for vaccination. Their immunization team will go to the house of that child and the different vaccination. And that is an exciting approach. So instead of having people go to a medical center, then you come out to the persons needing the vaccines, yes. And also, they can take the vaccine anywhere, not necessarily in their own linked health center. Okay, let's talk about research. Because I know you are an associate editor to three different medical journals. So perhaps you can highlight a recent exciting study that you came across that you think our listeners should know about and read.
We can learn from that. We need to be open-minded. We need to have a question to answer when we do research, and also, we should use data for decision-making. It's not only that we should do the study or for the sake of analysis, because now I'm talking again, public health, but we should also use data for decision making. And we should use research to help us with our privatizing surfaces, parameterizing resources or privatizing, other research priorities. Yes, I agree. And you’re also telling the listeners about the editorial process because they’re for sure are some upcoming researchers who want to know more about the process.
And perhaps you have some advice to give when considering submitting a manuscript?
Dr. Seif Salem Al-Abri 20:51
What are the dos and don'ts? The first thing to do is screen the paper upfront, decision-making, whether to accept it or not; I better rejected it from the beginning rather than sending it for a peer review when I know that the labor may not get through. And then accordingly, I decide if I do send it for a peer review, then we choose whether to reject again or send it back to the author for his feedback. However, there are significant challenges with the COVID-19. Nowadays, because it's really very hard to find B reviewers, or at least could be reviewers, or one is busy really with the response to COVID-19. And so, at times, we need to recently manuscripts for a different group of peer reviewers. And nowadays, it takes months for waivers to come out. And then many authors they write to us, oh, I've submitted this paper last February or last March. And you didn't reply to me. It was almost four months ago. But the major challenges are that it's very hard nowadays to get reviewers; maybe things started to improve a bit, but still a challenge. Also, I look to whether the manuscript will add value to the international reader, many papers and ask people to consider this okay for local journals rather than international journals. So they better invest their time and effort in submitting locally rather than internationally. The quality of the study is important, and the message out of it with a positive or negative outcome is also very important. My advice for people who are interesting and doing research and publishing their papers are the following. If a question to answer is possible, do the homework if you are going to do the research project, especially for example, in the methodology, selection of the parameters for your study the power of this study, try to connect with a good epidemiologist or a statistician who is good with health subjects or with health research. Try your best to write a good discussion. Also, get your paper English edited and formatted to the journal before submission. This makes a lot of difference. And I can tell you, even the editors in chief at times are subjective. Because if your paper is not well written, if your paper doesn't match the journal’s style, most of the time, it will be rejected. I mean, unless it has something really like rocket science, they think it is okay, although it's badly written and not formatted. But we can help it because the subject, there's a good there, there's meat there. But this is not that common to tell you the truth. Also, there's a major difference between writing a study report and outbreak than writing a manuscript for publication. So take your time in preparing the manuscript, although Don't take too long before submitting it; otherwise, your data will be updated. Have a good literature search always. I mean, that always helps and shows that you have mastered the subject. Don't miss the major studies which have been published. Like when they publish, some people only published from their institutions or their work. They don't include others. And the times they don't include their rifles, which is against them rather than it's good for them. No, I would say that research and has published papers are one of the very best career investments and boosters, career posters, so do your best to study and write. I think this is important.
Dr. Marco Bo Hansen 24:38
Some very good advice here, both global and international journals, aligns with a good statistician. Be sure that you get the written language in place, adapt to the journal’s guidelines, and be patient. It's very interesting to hear that the covid 19 pandemics have increased the review process; I want to talk a bit more about patient and healthcare workers’ safety because that's one of my great passions. And I believe that we can learn so much from each other. So how do you tackle these challenges related to safety in hospitals, especially regarding healthcare-associated infections?
We in Oman are in the process of establishing a national accreditation system for hospitals. We have a chapter on infection prevention and control and hospital-acquired infections. And it's a core component of this strategy. We have also now rolled out an initiative for the last 40 years. For patient safety-friendly hospitals, hospital-acquired infections are part of it, and infection control is part of it. We have written guidelines, conducted training, made engineering and environmental modifications to help fight hospital-acquired infections. We had, in fact, recently a new regulation, national regulation on the screening and vaccination of healthcare workers, this false vaccination and screening for TB, but also mandatory training on infection prevention and control for all healthcare workers, including students before they are allowed to start training or work in any of the health institutions. And we are in the process of establishing certification and recertification and infection prevention and control for all healthcare workers. So this will help and making professional infection control and prevent hospital-acquired infections a core component of the day-to-day practice, both for hospitals and health institutions. And for healthcare workers. We are also in the process of establishing digital surveillance for healthcare-associated infections. And I think this is very important because nowadays, I can't go to a hospital director and preach to him how good is he or bad about what they do for hospital-acquired infections and the COVID. Now, the COVID-19 pandemic has exposed the weaknesses in some of the hospitals regarding what they have done already with regard to healthcare-associated infections. And we have to admit it, yes, we will die because of COVID. But unfortunately, many people nowadays die because of coffee, but that must be a big challenge because of hospital-acquired infections. And then it's often going back to the basics, which is hand hygiene. So how do you verify that staff performs hand hygiene when needed? And how can we improve even further hand hygiene is a core component of infection prevention and control in our hospitals. And it's a core component even of our code of conduct, which is a legal document, we established a project. And it's still going on, around four years ago, where we had the role of leadership in hand hygiene or role model of leadership in hand hygiene. And it started from the minister, His Excellency, the Minister of Health, down to the hospital directors, down to the heads of sections, whether they are physicians, nurses, or others. And it started with the major hospitals. And now it rolled out since the end of 2018, primary health care, and it was amazing. The results, which we've got some hospitals, their hand hygiene improved from 20%, up to 60%. You may think 60% is too small, but it's not when you're more from 20 to 60. That's high, and some hospitals moved from 70 to 80, or 90. Some of them now are in the 90s. But what it has shown is sustainability, although, like that, a role model of leadership was there for a year. What does it mean is that, for example, the hits of the hospitals or doctors, hospitals, they go to the wards, they charter the sub, they show that they are performing kantarjian they listen to people, how can they help them for the hand hygiene, empowering patients. Still, we monitor that now two years after the intervention. And it's sustainable, and it's statistically significant. So that's one of the things we have done for the handout gene and the fact that we have just submitted a manuscript two days ago, describing phase one of the projects in practice; how does it work as a role model? Is it the manager who will show the staff that they prioritize hand hygiene? Is it via newsletters? How does it work in practice? Yes, the hospital the director will go he will announce it he will go and visit. Initially, we selected few words like acute medicine and acute surgery, where there are many patient contacts. Then for the first year, and then it gets disseminated to the whole hospital. newsletters, a lot of problems
Dr. Seif Salem Al-Abri 30:28
Yeah, it's tough for the work to be done. Now. We know what should be done, unfortunately, still, until today, and I still get calls from hospitals from colleagues. They think it's a business of the infection, professional control. And the infectious diseases or microbiology, it's not. It’s the business of everybody. It starts from the decision-makers, down to the community, down to the general population, because they will go to, they will go to a health center insisting on antibiotics. In Oman, I mean, it's prohibited to dispense antibiotics over the counter. So it has to be by prescription. We also need to do a lot of research. And now, we need to use molecular diagnostics to inform us on where we are going. We should also put a lot of effort into the environment and the antimicrobials within the environment, animal health, and animal sector use of the antimicrobials in the animal husbandry. Yes, maybe we are good, maybe not in Europe, but in other parts. We will know a lot Amr about antimicrobial stewardship. Still, we miss something big: the use of antimicrobials in animal husbandry and as a growth-promoting factor, and not only for growth, even for treating the used by fits. They use colistin freely in large amounts. They use antimicrobials right and left. And unfortunately, there are no regulations. There's nothing called professional infection control in functional medicine. It's now coming up. But it will take us a long time to be there. But just to summarise, I think we need a holistic approach to Amr. We need to measure it. Now. The good thing is that there is tripartite cooperation between the FAO and the IE, but again, it needs the willingness and the commitment from the countries themselves. If they are interested in addressing the Amr issue, they can, but it needs a lot of decision-making. It needs a lot of interest. It requires some hard, dedicated work to get this under control. And it's not something that is done from one day to another safe; thank you for your time and for sharing your thoughts and insights. Thank you very much, Marco, and it has been a great visual for me to join us today. And thank you to our listeners. Be safe, and remember to clean your hands.