“At risk” groups in the home – caring for family
members who are at increased risk of infection
In any home, there are likely to be one or more family members who, for one
reason or another, have reduced immunity to infection. This leaflet has been
put together to provide background information on these groups. This
briefing material has been produced for those who work in healthcare
professions, the media, and others who are looking for some background
understanding of hygiene issues related to vulnerable family members,
and/or those who are responsible for providing guidance to the public on
coping with hygiene issues associated with vulnerable family members.
Impaired immunity to infection
Throughout our daily lives we are constantly exposed to microbes which have the
potential to cause infectious disease. In order for a person to become infected, these
microbes must gain entry to the body – through the mouth, the respiratory tract, the
skin and mucosal membranes, the cornea of the eye etc. The fact that we do not
constantly become infected is due to the body’s complex system of defences that
these microbes first have to overcome. These defences include the intact nature of
the skin and mucous membrane, the presence of “phagocytic” cells in the blood
stream which engulf and destroy microbial cells which gain access to the body, and
the immune system which produces “antibodies” that interact with and “neutralise”
the disease-producing properties (pathogenicity) of invading microbes.
For some people, under certain conditions, one or more components of the immune
system become impaired or fail to develop. This may be as simple as a cut or
abrasion to the skin, or as complex as the changes to the immune system which
accompany HIV/AIDS infection, or are associated with cancer chemotherapy. As a
result of these changes, these individuals become more susceptible to infection.
Increased susceptibility to hygiene-related infections may relate to the fact that, for
risk groups (as compared with “normal” individuals), exposure to smaller numbers of
infectious particles of the pathogens is sufficient to cause clinical infection.
Who are the “at rick” groups in the home?
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The greatest proportion of people in the home who are at increased risk of
infection are the elderly whose immune system has declined. This group has a
generally reduced immunity to infection which is often exacerbated by other basic
illnesses such as diabetes mellitus or malignant illnesses. It is estimated that by
2025 there will be more than 800 million people over 65 years old in the world,
two-thirds of them in developing countries.
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Risk groups in the home also include the very young. The immune system
develops after birth and the first few months of life are the most important, but the
immune system continues to develop, and may not be fully mature until 5 years
of age.
Other risk groups include:
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patients discharged recently from hospital,
family members with invasive devices such as catheters
individuals whose immuno-competence is impaired, either as a result of chronic
and degenerative illness (including those who are infected with HIV/AIDS), or
because they are taking certain drugs or other therapies. This includes those
undergoing irradiation or chemotherapy for cancer, and organ transplant
recipients.
Immunosuppressed persons are often also on other medications such as
antibiotics, which can further increase their susceptibility to infections.
Demographic changes and changes in health service structure (shorter hospital
stays for example) mean that the number of people in the home needing special
care, because they are at increased risk of infection is increasing. A survey in the
USA and several European countries, suggests that at least 1 in 5 of the population
belongs to an “at risk” group (Table 1). These data suggest that between 12 and
18% of the population of these countries are >65 years of age.
Table 1 - Prevalence of “at risk” individuals in the domestic setting
Total population
Over 65 years old
Living with cancer –significant
proportion in the
community, and undergoing
chemotherapy
Under 1 year old
Discharged from hospital within
previous 2 weeks
Hospital outpatients at home
HIV cases*
AIDS cases
People in homecare
Total “at risk” persons
US
290
million
35.6 million
UK
60
million
9 million
2 million
1 million
4 million
1.25 million
600,000
200,000
40,000
Germany
82 million
13 million
Holland
16
million
2 million
Russia
145
million
16 million
Ukraine
50
million
14 million
1.3 million
400,000
177,000
500,000
>1 in 8
>1 in 3
160,000
800,000
100,000
60,000
1, 270,000
50,000
15,000
0.5 million
>1 in 7
>1 in 6
>1 in 5.6
>1 in 6.3
*This does not include those who are HIV positive who may also have lowered
resistance to infection
Care of “at risk” groups in the home
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Increasingly, many of these “at risk” groups are cared for at home by a carer who
may be a household member.
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In North America there has been a dramatic decrease in the number of acute
care hospital admissions. Over the period 1978–1998, the number of days per
capita spent in hospital dropped from 12 days to just over 5.
Ensuring that homecare is not accompanied by increased infectious disease (ID)
risks is a key factor, otherwise cost savings gained by current policies of shorter
hospital stays are likely to be overridden by additional costs of re-hospitalisation.
Day-to-day hygiene practices, other than those specific to caring for the “at risk”
family member (e.g. changing dressings or catheters) are no different for those at
increased risk of infection than for other family members, The difference is that, if
hygiene practices are not correctly carried out, the risk of infection is much greater.
Care of “at risk” groups in the home is described in more detail in the section on
“when there is more risk”. IFH training resources on home hygiene which are
downloadable from the IFH website:
IFH Guidelines and Training Resources on Homes Hygiene
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Guidelines for prevention of infection and cross infection the domestic
environment. International Scientific Forum on Home Hygiene. Available from:
http://www.ifh-homehygiene.com/best-practice-care-guideline/guidelinesprevention-infection-and-cross-infection-domestic
Guidelines for prevention of infection and cross infection the domestic
environment: focus on issues in developing countries. International Scientific
Forum
on
Home
Hygiene.
Available
from:
http://www.ifhhomehygiene.org/best-practice-care-guideline/guidelines-preventioninfection-and-cross-infection-domestic-0
Recommendations for suitable procedure for use in the domestic environment
(2001). International Scientific Forum on Home Hygiene. http://www.ifhhomehygiene.org/best-practice-care-guideline/recommendations-suitableprocedure-use-domestic-environment-2001
Home hygiene - prevention of infection at home: a training resource for carers
and their trainers. (2003) International Scientific Forum on Home Hygiene.
Available from: http://www.ifh-homehygiene.com/best-practice-training/homehygiene-%E2%80%93-prevention-infection-home-training-resource-carersand-their
Home Hygiene in Developing Countries: Prevention of Infection in the Home
and Peridomestic Setting. A training resource for teachers and community
health professionals in developing countries. International Scientific Forum on
Home Hygiene. Available from: www.ifh-homehygiene.org/best-practicetraining/home-hygiene-developing-countries-prevention-infection-home-andperi-domestic. (Also available in Russian, Urdu and Bengali)
Some further facts and figures:
Gastroenteritis and the elderly
The elderly are at increased risk of death from foodborne and diarrhoeal disease.
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Between 1979 and 1987, 28,538 persons in the USA had diarrhoea as an
immediate or underlying cause of death; 51% of these individuals were more than
74 years of age, 27% were adults age 55–74, and 11% were children under the
age of 5.
For elderly people, the communal living environment, combined with problems of
faecal incontinence, create an environment in which enteric and foodborne
pathogens are easily spread.
Incidence of salmonellosis and campylobacter diarrhoea appears to be higher
among the elderly.
HIV/AIDS and reduced immunity to infection
The population of people in the community with HIV/AIDS-related immunodeficiencies is rapidly increasing.
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Globally, the number of people living with HIV/AIDS, as recorded in 2013 is now
around 35 million, the majority living in developing countries. Country statistics
can be obtained from http://www.who.int/gho/countries/en/
In the past 20 years, Toxoplasma gondii, Cryptococcus neoformans,
Cryptosporidium parvum, Yersinia enterocolitica, and Listeria monocytogenes
have all made comebacks, initially in the AIDS population.
HIV/AIDS patients are not only more vulnerable to infection but, once infected,
they are also a source of infection for other family members.
Hygiene is of key importance for HIV/AIDS patients. A study of 148 patients with
AIDS showed that patients who were exposed to handwashing promotion,
compared with those who were not, developed fewer episodes of diarrhoeal
illness (1.24+/-0.9 vs 2.92+/-0.6 new episodes of diarrhoea, respectively) during a
1-year observation period.
Studies indicate that persons with AIDS show increased susceptibility to infection
with Salmonella, Campylobacter and Listeria species. Data suggest that risk for
non-typhoidal Salmonella infections is increased 20- to 100-fold among AIDS
patients with increased risk for septicaemia.
More information can be obtained from http://www.who.int/topics/hiv_aids/en/
Cancer chemotherapy and immunity to infection
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The number of new cancer cases has steadily increased over the past 20 years,
Patients are also surviving longer.
Cancer patients undergoing immunosuppression therapy have higher risk rates of
septicaemia and foodborne infections.
Organ transplantation and immunity to infection
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The number of people living in the community who have received organ
transplants is increasing.
In the past 45 years, there have been more than 500,000 transplants of various
organs world-wide, with increasing success rates as a result of advancements in
suppression of graft rejection.
Drugs such as cyclosporins aid in the suppression of graft rejection but also
prevent the immune system from reacting to infectious agents.
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According to the USA United Network of Organ Sharing, approximately 15% of all
deaths are a result of infection in the first 3 months.
Malnutrition and immunity to infection
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Malnutrition is an important contributor to increased population susceptibility to
infection.
One estimate suggests that malnutrition results in a 30-fold increase in the risk for
diarrhoea-associated death
Problems are accentuated in developing countries, in areas of political unrest,
and among marginalised populations in the USA and other affluent nations.
Malnutrition increases host susceptibility through a number of mechanisms:
- it weakens epithelial integrity which can then affect cell-mediated immunity
causing functional deficiencies in immunoglobulins and defects in
phagocytosis.
- it can initiate a “vicious cycle” of infection predisposing to malnutrition and
growth faltering, which in turn leads to increased risk for further infection.
- a study in Bangladesh showed that malnourished and well-nourished
children had the same number of infections with diarrhoeal pathogens such
as enterotoxigenic E. coli; however, diarrhoea in malnourished children was
of longer duration and had greater potential for long-term nutritional
consequences.
Other Sources of information
1. The changing hygiene climate: a review of infectious disease in the home and
community 2008 International Scientific Forum on Home Hygiene. http://www.ifhhomehygiene.org/2003/2library/hygieneclimate_review608_23july_4.doc
2. Sattar SA, Tetro J, Springthorpe VS. Impact of changing societal trends on the
spread of infections in American and Canadian homes. American Journal of
Infection Control. 1999;27:S4-21.
3. Morris JG, Potter M. Emergence of new pathogens as a function of changes in
host susceptibility. Emerging Infectious Diseases. 1997;3:435-41.
4. Black RE, Brown KH, Becker S. Malnutrition is a determining factor in diarrheal
duration, but not incidence, among young children in a longitudinal study in rural
Bangladesh. American Journal of Clinical Nutrition. 1984;37:87-94.
This fact sheet was last updated in 2015
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