Infection Prevention and Control: Difference between revisions
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Effective '''IPC''' is a public health issue that is fundamental in patient safety and health system strengthening. The prevention of healthcare-associated infections (HAI), epidemics (including the 2013-2016 [[Ebola Virus|Ebola virus]] disease outbreak), and pandemics of international concern (ie. 2009 flu pandemic and the [[Coronavirus Disease (COVID-19)|coronavirus disease 2019]]) are rooted in effective IPC measures<ref name=":4">World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. World Health Organization; 2016.</ref>. A guiding principle on WHO's core components of IPC is that "access to health care services designed and managed to minimize the risks of avoidable HAI for patients and health care workers is a basic human right<ref name=":4" />." | Effective '''IPC''' is a public health issue that is fundamental in patient safety and health system strengthening. The prevention of healthcare-associated infections (HAI), epidemics (including the 2013-2016 [[Ebola Virus|Ebola virus]] disease outbreak), and pandemics of international concern (ie. 2009 flu pandemic and the [[Coronavirus Disease (COVID-19)|coronavirus disease 2019]]) are rooted in effective IPC measures<ref name=":4">World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. World Health Organization; 2016.</ref>. A guiding principle on WHO's core components of IPC is that "access to health care services designed and managed to minimize the risks of avoidable HAI for patients and health care workers is a basic human right<ref name=":4" />." | ||
An | |||
== Infection and Spread of Infectious Disease == | |||
An '''infection''' is defined as the successful '''transmission''' of pathogenic microorganisms, such as bacteria, viruses, parasites or fungi that are spread<ref>Mayhall CG. Hospital epidemiology and infection control. Lippincott Williams & Wilkins; 2012 Feb 20.</ref><ref name=":1">CDC centers for disease control and prevention.infection control. Available from:https://www.cdc.gov/infectioncontrol/index.html</ref><ref name=":2">Wilson J. Infection control in clinical practice. Elsevier Health Sciences; 2006 Jun 21.</ref>: | |||
* Directly | * Directly | ||
** | ** From person to person | ||
** During childbirth | ** Through respiratory droplets (i.e. coughing or sneezing) or body fluids | ||
** During childbirth from mother to fetus | |||
* Indirectly | * Indirectly | ||
** | ** Via contaminated environmental sources, such as contaminated food or water | ||
** | ** By a vector such as a mosquito or a tic | ||
** animal to human transmission ([[Zoonotic Diseases|zoonotic diseases]]) | ** Through animal to human transmission ([[Zoonotic Diseases|zoonotic diseases]]) | ||
== | ** Airborne transmission | ||
=== Epidemiological Triad === | |||
In humans, infections occur when an infectious microorganism enters the body, multiplies, and leads to a reaction in the body and a potential infectious disease. The spread of infectious disease requires three variables, known as the '''epidemiological triad'''<ref>US Department of Health and Human Services. [https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section8.html Principles of Epidemiology in Public Health Practice Third Edition An Introduction to Applied Epidemiology and Biostatistics. Chapter 8, Lesson 1]. Atlanta, Georgia, USA Accessed 15 March 2020</ref>: | |||
* The agent - this microorganism that causes the infection and can be in the form of bacteria, viruses, parasites or fungi | * The agent - this microorganism that causes the infection and can be in the form of bacteria, viruses, parasites or fungi | ||
* The host - the target of the disease | * The host - the target of the disease | ||
* The environment - surroundings and conditions | * The environment - surroundings and conditions (these are external to the host) | ||
{{#ev:youtube|2JWku3Kjpq0}} | {{#ev:youtube|2JWku3Kjpq0}} | ||
== Controlling Infectious Diseases within Communities == | === Infection Spread in Healthcare === | ||
The first step when looking at infection control can start at the community level by changing behaviour: | Healthcare facilities, whether hospitals or outpatient clinics, are a an area with elevated risk of disease transmission due to the presence and relative ratio of susceptible individuals. In a healthcare setting, the three components required for infection spread are the following<ref name=":3">How Infections Spread | Infection Control | CDC [Internet]. Cdc.gov. 2020 [cited 15 March 2020]. Available from: <nowiki>https://www.cdc.gov/infectioncontrol/spread/index.html</nowiki></ref>: | ||
* Source - places where infectious agents survive (e.g. sinks, hospital equipment, countertops, medical devices) | |||
** Environment - patient care areas, sinks, hospital equipment, countertops, medical devices | |||
** People - patients, healthcare workers, or visitors | |||
* Susceptible person - someone (patient, healthcare worker, or visitor) who is not vaccinated or immune to a particular infectious disease, or an individual with a compromised immune system (ie. immunodeficient)<ref name=":3" /> | |||
** In addition, susceptibility can be heightened in individuals due to underlying medical conditions, medications, and necessary treatments and procedures that increase risk of infection (e.g. surgery) | |||
* Transmission - | |||
** Touch, including via medical equipment or a susceptible person (e.g. MRSA or VRE) | |||
** Sprays or splashes (e.g. pertussis) | |||
** Inhalation of aerosolized particles (e.g. TB or measles) | |||
** Sharps injuries introducing bloodborne pathogens (e.g. HIV, HBV, HCV) | |||
== Infection Prevention and Control == | |||
Infection control and prevention is a global issue and there are many protocols and guidelines that can be followed to minimise the spread of infection between people, within a population and globally<ref name=":4" />. | |||
=== Controlling Infectious Diseases within Communities === | |||
The first step when looking at infection control can start at the community level by changing behaviour, including: | |||
* Using condoms when having sex, especially with a new partner | * Using condoms when having sex, especially with a new partner | ||
* Regular [[Hand Hygiene|hand washing]] | * Regular [[Hand Hygiene|hand washing]] | ||
* Using insect | * Using insect repellents | ||
* Ensuring up to date routine vaccinations and participating in immunisation programmes | * Ensuring up-to-date routine vaccinations and participating in immunisation programmes | ||
* Taking prescribed medications such as antibiotics as directed by health professionals | * Taking prescribed medications, such as antibiotics, as directed by health professionals | ||
=== Medical Interventions === | ==== Medical Interventions ==== | ||
Importance of Vaccinations | Importance of Vaccinations | ||
| Line 39: | Line 60: | ||
Antibicrobial Resistance | Antibicrobial Resistance | ||
=== Environmental Measures === | ==== Environmental Measures ==== | ||
Modifying environments | Modifying environments | ||
| Line 48: | Line 69: | ||
Air quality | Air quality | ||
==Infection Control | ===Infection Control in Healthcare Facilities=== | ||
Another important factor in controlling and preventing the control of infection is | Another important factor in controlling and preventing the control of infection is by improving practices in healthcare facilities. It is the duty of healthcare professionals worldwide to ensure the develop strategies and implement policies that protect those who may be immunocompromised in order to keep susceptible patients safe from healthcare associated infections (HAIs). Globally, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI<ref name=":4" /><ref>Sydnor ER, Perl TM. Hospital epidemiology and infection control in acute-care settings. Clinical microbiology reviews. 2011 Jan 1;24(1):141-73.</ref>. HAIs are one of the most common detrimental effects in care delivery and both the endemic burden and the occurrence of epidemics are a major public health concern. HAIs have a significant impact on morbidity, mortality<ref>Borg MA. Cultural determinants of infection control behaviour: understanding drivers and implementing effective change. Journal of Hospital Infection. 2014 Mar 1;86(3):161-8.</ref> and quality of life and present an economic burden at the societal level. However, a large proportion of HAI are preventable and there is a growing body of evidence to help raise awareness of the global burden of harm caused by these infections, including strategies to reduce their spread. {{#ev:youtube|LZapz2L6J1Q}} | ||
=== Steps to Improve Infection Control<ref name=":0" /> === | ==== Steps to Improve Infection Control<ref name=":0" /> ==== | ||
* Leadership<ref>Gould DJ, Gallagher R, Allen D. Leadership and management for infection prevention and control: what do we have and what do we need?. Journal of Hospital Infection. 2016 Oct 1;94(2):165-8.</ref> | * Leadership<ref>Gould DJ, Gallagher R, Allen D. Leadership and management for infection prevention and control: what do we have and what do we need?. Journal of Hospital Infection. 2016 Oct 1;94(2):165-8.</ref> | ||
* | * Connecting and coordinating<ref>Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices. American journal of infection control. 1998 Jun 1;26(3):245-53.</ref> | ||
* Campaigns and advocacy | * Campaigns and advocacy | ||
* Technical guidance and implementation | * Technical guidance and implementation | ||
| Line 60: | Line 81: | ||
* Measuring and learning | * Measuring and learning | ||
=== Examples of Infection Control in Healthcare Facilities === | ==== Examples of Infection Control in Healthcare Facilities ==== | ||
[[File:Protect-Your-Hands.png|right|frameless]] | [[File:Protect-Your-Hands.png|right|frameless]] | ||
There are many areas in which infection control can be implemented: <ref name=":0" /><ref name=":1" /><ref name=":2" /> | There are many areas in which infection control can be implemented: <ref name=":0" /><ref name=":1" /><ref name=":2" /> | ||
* Hand hygiene<ref>Pittet D. The Lowbury lecture: behaviour in infection control. Journal of hospital infection. 2004 Sep 1;58(1):1-3.</ref><ref>Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control & Hospital Epidemiology. 2002 Dec;23(S12):S3-40.</ref> | * [[Hand Hygiene|Hand hygiene]]<ref>Pittet D. The Lowbury lecture: behaviour in infection control. Journal of hospital infection. 2004 Sep 1;58(1):1-3.</ref><ref>Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control & Hospital Epidemiology. 2002 Dec;23(S12):S3-40.</ref> | ||
* Prevention of surgical site infections | * Prevention of surgical site infections | ||
* IPC to combat antimicrobial resistance | * IPC to combat antimicrobial resistance | ||
* Injection safety | * Injection safety | ||
* Burden of healthcare-associated infections | * Burden of healthcare-associated infections | ||
* Ebola response and recovery | * [[Ebola Virus|Ebola]] response and recovery | ||
* IPC country capacity-building | * IPC country capacity-building | ||
* Prevention of sepsis and catheter-associated bloodstream infections | * Prevention of sepsis and catheter-associated bloodstream infections | ||
* Prevention of catheter-associated [[Urinary Tract Infection|urinary tract infections]] | * Prevention of catheter-associated [[Urinary Tract Infection|urinary tract infections]] (CAUTI) | ||
* Isolation precautions | * Isolation precautions for multidrug-resistant organisms (MDRO) | ||
* Intravascular catheter-related infection (BSI) | * Intravascular catheter-related infection (BSI) | ||
* Organ transplantation | * Organ transplantation surgical site infection (SSI) | ||
* Norovirus | * Norovirus pneumonia prevention dialysis | ||
* Infection | * Infection control in healthcare personnel | ||
* Post exposure | * Post-exposure prophylaxis in healthcare workers | ||
{{#ev:youtube|https://www.youtube.com/watch?v=QgqTW0FjN08|width}}<ref>Health portal Infection control, Available from: https://www.youtube.com/watch?v=QgqTW0FjN08 (last accessed 22.4.2019)</ref> | {{#ev:youtube|https://www.youtube.com/watch?v=QgqTW0FjN08|width}}<ref>Health portal Infection control, Available from: https://www.youtube.com/watch?v=QgqTW0FjN08 (last accessed 22.4.2019)</ref> | ||
To assist in the assessment of infection control programs and practices in acute care hospital the Centers for Disease Control and Prevention suggest that management can be divided into [https://www.cdc.gov/infectioncontrol/pdf/icar/hospital.pdf 4 sections]: | To assist in the assessment of infection control programs and practices in acute care hospital the U.S. Centers for Disease Control and Prevention (CDC) suggest that management can be divided into [https://www.cdc.gov/infectioncontrol/pdf/icar/hospital.pdf 4 sections]: | ||
* Section 1: Facility Demographics | * Section 1: Facility Demographics | ||
* Section 2: Infection Control Program and Infrastructure | * Section 2: Infection Control Program and Infrastructure | ||
| Line 87: | Line 108: | ||
=== Environmental Cleaning/Disinfection === | === Environmental Cleaning/Disinfection === | ||
If a suspected or confirmed case an infectious disease has attended your clinic, all surfaces that the person has come into contact with must be cleaned. | If an individual with a suspected or confirmed case of an infectious disease has attended your clinic, all surfaces that the person has come into contact with must be cleaned. | ||
* The room where they were placed/isolated should not be cleaned or used for one hour and the door to the room should remain shut | * The room where they were placed/isolated should not be cleaned or used for one hour and the door to the room should remain shut | ||
* The person assigned to clean the room should wear gloves (disposable single-use nitrile or household gloves) and a disposable apron (if one is available) then physically clean the environment and furniture using a household detergent solution followed by a disinfectant or combined household detergent and disinfectant, for example one that contains a hypochlorite (bleach solution) | * The person assigned to clean the room should wear gloves (disposable single-use nitrile or household gloves) and a disposable apron (if one is available) then physically clean the environment and furniture using a household detergent solution followed by a disinfectant or combined household detergent and disinfectant, for example one that contains a hypochlorite (bleach solution) | ||
Revision as of 21:53, 15 March 2020
Original Editor '- Rewan Elsayed Elkanafany
Top Contributors - Shaimaa Eldib, Kim Jackson, Naomi O'Reilly, Richard Benes, Rachael Lowe, Lucinda hampton, Wanda van Niekerk, Shreya Pavaskar, Rewan Elsayed Elkanafany, Tarina van der Stockt, Jess Bell, Admin, Khloud Shreif, Tony Lowe, Stacy Schiurring, Simisola Ajeyalemi, Vidya Acharya, Tolulope Adeniji and Laura Ritchie
Introduction[edit | edit source]
According to the World Health Organization (WHO), infection prevention and control (IPC) is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers. It is a subset of epidemiology, but also serves an essential function in infectious diseases, social sciences and global health[1].
Effective IPC is a public health issue that is fundamental in patient safety and health system strengthening. The prevention of healthcare-associated infections (HAI), epidemics (including the 2013-2016 Ebola virus disease outbreak), and pandemics of international concern (ie. 2009 flu pandemic and the coronavirus disease 2019) are rooted in effective IPC measures[2]. A guiding principle on WHO's core components of IPC is that "access to health care services designed and managed to minimize the risks of avoidable HAI for patients and health care workers is a basic human right[2]."
Infection and Spread of Infectious Disease[edit | edit source]
An infection is defined as the successful transmission of pathogenic microorganisms, such as bacteria, viruses, parasites or fungi that are spread[3][4][5]:
- Directly
- From person to person
- Through respiratory droplets (i.e. coughing or sneezing) or body fluids
- During childbirth from mother to fetus
- Indirectly
- Via contaminated environmental sources, such as contaminated food or water
- By a vector such as a mosquito or a tic
- Through animal to human transmission (zoonotic diseases)
- Airborne transmission
Epidemiological Triad[edit | edit source]
In humans, infections occur when an infectious microorganism enters the body, multiplies, and leads to a reaction in the body and a potential infectious disease. The spread of infectious disease requires three variables, known as the epidemiological triad[6]:
- The agent - this microorganism that causes the infection and can be in the form of bacteria, viruses, parasites or fungi
- The host - the target of the disease
- The environment - surroundings and conditions (these are external to the host)
Infection Spread in Healthcare[edit | edit source]
Healthcare facilities, whether hospitals or outpatient clinics, are a an area with elevated risk of disease transmission due to the presence and relative ratio of susceptible individuals. In a healthcare setting, the three components required for infection spread are the following[7]:
- Source - places where infectious agents survive (e.g. sinks, hospital equipment, countertops, medical devices)
- Environment - patient care areas, sinks, hospital equipment, countertops, medical devices
- People - patients, healthcare workers, or visitors
- Susceptible person - someone (patient, healthcare worker, or visitor) who is not vaccinated or immune to a particular infectious disease, or an individual with a compromised immune system (ie. immunodeficient)[7]
- In addition, susceptibility can be heightened in individuals due to underlying medical conditions, medications, and necessary treatments and procedures that increase risk of infection (e.g. surgery)
- Transmission -
- Touch, including via medical equipment or a susceptible person (e.g. MRSA or VRE)
- Sprays or splashes (e.g. pertussis)
- Inhalation of aerosolized particles (e.g. TB or measles)
- Sharps injuries introducing bloodborne pathogens (e.g. HIV, HBV, HCV)
Infection Prevention and Control[edit | edit source]
Infection control and prevention is a global issue and there are many protocols and guidelines that can be followed to minimise the spread of infection between people, within a population and globally[2].
Controlling Infectious Diseases within Communities[edit | edit source]
The first step when looking at infection control can start at the community level by changing behaviour, including:
- Using condoms when having sex, especially with a new partner
- Regular hand washing
- Using insect repellents
- Ensuring up-to-date routine vaccinations and participating in immunisation programmes
- Taking prescribed medications, such as antibiotics, as directed by health professionals
Medical Interventions[edit | edit source]
Importance of Vaccinations
Vaccinations have slowed down and in some cases eradicated certain diseases (name) and go some way into improving the immunisation of a community. This type of protection is known as herd immunity.
Antibicrobial Resistance
Environmental Measures[edit | edit source]
Modifying environments
Surveillance of Diseases
Food safety
Air quality
Infection Control in Healthcare Facilities[edit | edit source]
Another important factor in controlling and preventing the control of infection is by improving practices in healthcare facilities. It is the duty of healthcare professionals worldwide to ensure the develop strategies and implement policies that protect those who may be immunocompromised in order to keep susceptible patients safe from healthcare associated infections (HAIs). Globally, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI[2][8]. HAIs are one of the most common detrimental effects in care delivery and both the endemic burden and the occurrence of epidemics are a major public health concern. HAIs have a significant impact on morbidity, mortality[9] and quality of life and present an economic burden at the societal level. However, a large proportion of HAI are preventable and there is a growing body of evidence to help raise awareness of the global burden of harm caused by these infections, including strategies to reduce their spread.
Steps to Improve Infection Control[1][edit | edit source]
- Leadership[10]
- Connecting and coordinating[11]
- Campaigns and advocacy
- Technical guidance and implementation
- Capacity-building
- Measuring and learning
Examples of Infection Control in Healthcare Facilities[edit | edit source]
There are many areas in which infection control can be implemented: [1][4][5]
- Hand hygiene[12][13]
- Prevention of surgical site infections
- IPC to combat antimicrobial resistance
- Injection safety
- Burden of healthcare-associated infections
- Ebola response and recovery
- IPC country capacity-building
- Prevention of sepsis and catheter-associated bloodstream infections
- Prevention of catheter-associated urinary tract infections (CAUTI)
- Isolation precautions for multidrug-resistant organisms (MDRO)
- Intravascular catheter-related infection (BSI)
- Organ transplantation surgical site infection (SSI)
- Norovirus pneumonia prevention dialysis
- Infection control in healthcare personnel
- Post-exposure prophylaxis in healthcare workers
To assist in the assessment of infection control programs and practices in acute care hospital the U.S. Centers for Disease Control and Prevention (CDC) suggest that management can be divided into 4 sections:
- Section 1: Facility Demographics
- Section 2: Infection Control Program and Infrastructure
- Section 3: Direct Observation of Facility Practices (optional)
- Section 4: Infection Control Guidelines and Other Resources
Environmental Cleaning/Disinfection[edit | edit source]
If an individual with a suspected or confirmed case of an infectious disease has attended your clinic, all surfaces that the person has come into contact with must be cleaned.
- The room where they were placed/isolated should not be cleaned or used for one hour and the door to the room should remain shut
- The person assigned to clean the room should wear gloves (disposable single-use nitrile or household gloves) and a disposable apron (if one is available) then physically clean the environment and furniture using a household detergent solution followed by a disinfectant or combined household detergent and disinfectant, for example one that contains a hypochlorite (bleach solution)
- Products with these specifications are available in different formats including wipes.
- No special cleaning of walls or floors is required
- Pay special attention to frequently touched flat surfaces, backs of chairs, couches, door handles or any surfaces that the affected person has touched.
- Discard waste including used tissues, disposable cleaning cloths)into a healthcare risk waste bag or if one is not available
- Remove the disposable plastic apron (if worn) and gloves and discard into a healthcare risk waste bag.
- If a healthcare risk waste bag (yellow) is not available, place the waste in a small household waste bag and tie securely. Do not overfill. Then place the bag in a second household waste bag and tie securely. Store in a safe location. If the case is not confirmed the waste can be disposed of as per usual. If a case is confirmed public health will then advise you what to with the waste.
- Once this process has been completed and all surfaces are dry the room can be put back into use.
Improving Social Determinants[edit | edit source]
Another important factor in the control of infectious diseases is to address and improve social determinants within societies. There is a direct link between a person's health and their environment. WHO have identified 3 "common interventions" for improving health conditions world wide[15]
- Education - there is a strong link between health and education[16]
- Social Protection - Access to affordable health care and some form of social security system can also determine the health and behaviours in a community[17]
- Urban Development - How our villages, towns and cities are designed can have a big impact on health and the spread of diseases. Living in overcrowded environments or in housing that is damp that don't have adequate facilities and sanitation can increase the spread of infectious diseases.[18]
Conclusion[edit | edit source]
There is no one solution to controlling the spread of infectious diseases and it does indeed require the interventions of Governments and a collaboration between these agencies, individuals and whole communities. Until certain factors can be controlled and behaviours changed the war against infectious diseases will continue to be a major health issue around the world.
Resources[edit | edit source]
The following resources expand further on the four sections mentioned above https://www.cdc.gov/infectioncontrol/pdf/icar/hospital.pdf
https://www.publichealthontario.ca/-/media/documents/checklist-clinical-office-core.pdf?la=en
References[edit | edit source]
- ↑ 1.0 1.1 1.2 WHO.infection prevention&control .Available from:https://www.who.int/infection-prevention/about/ipc/en/
- ↑ 2.0 2.1 2.2 2.3 World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. World Health Organization; 2016.
- ↑ Mayhall CG. Hospital epidemiology and infection control. Lippincott Williams & Wilkins; 2012 Feb 20.
- ↑ 4.0 4.1 CDC centers for disease control and prevention.infection control. Available from:https://www.cdc.gov/infectioncontrol/index.html
- ↑ 5.0 5.1 Wilson J. Infection control in clinical practice. Elsevier Health Sciences; 2006 Jun 21.
- ↑ US Department of Health and Human Services. Principles of Epidemiology in Public Health Practice Third Edition An Introduction to Applied Epidemiology and Biostatistics. Chapter 8, Lesson 1. Atlanta, Georgia, USA Accessed 15 March 2020
- ↑ 7.0 7.1 How Infections Spread | Infection Control | CDC [Internet]. Cdc.gov. 2020 [cited 15 March 2020]. Available from: https://www.cdc.gov/infectioncontrol/spread/index.html
- ↑ Sydnor ER, Perl TM. Hospital epidemiology and infection control in acute-care settings. Clinical microbiology reviews. 2011 Jan 1;24(1):141-73.
- ↑ Borg MA. Cultural determinants of infection control behaviour: understanding drivers and implementing effective change. Journal of Hospital Infection. 2014 Mar 1;86(3):161-8.
- ↑ Gould DJ, Gallagher R, Allen D. Leadership and management for infection prevention and control: what do we have and what do we need?. Journal of Hospital Infection. 2016 Oct 1;94(2):165-8.
- ↑ Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices. American journal of infection control. 1998 Jun 1;26(3):245-53.
- ↑ Pittet D. The Lowbury lecture: behaviour in infection control. Journal of hospital infection. 2004 Sep 1;58(1):1-3.
- ↑ Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control & Hospital Epidemiology. 2002 Dec;23(S12):S3-40.
- ↑ Health portal Infection control, Available from: https://www.youtube.com/watch?v=QgqTW0FjN08 (last accessed 22.4.2019)
- ↑ World Health Organization (2013). The economics of social determinants of health and health inequalities: a resource book (PDF). World Health Organization. ISBN 978-92-4-154862-5
- ↑ Von dem Knesebeck O, Verde PE, Dragano N. Education and health in 22 European countries. Social science & medicine. 2006 Sep 1;63(5):1344-51.
- ↑ Chung H, Muntaner C. Welfare state matters: a typological multilevel analysis of wealthy countries. Health Policy, 2007, 80(2):328–339
- ↑ Thomson H, Atkinson R, Petticrew M, Kearns A. Do urban regeneration programmes improve public health and reduce health inequalities? A synthesis of the evidence from UK policy and practice (1980–2004). Journal of Epidemiology & Community Health. 2006 Feb 1;60(2):108-15.
