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Contents

List of Contributors ix
Preface: An Introduction to Practical Hospital Epidemiology xiii
Ebbing Lautenbach, Preeti N. Malani, Jennifer H. Han, Jonas Marschall,
Emily K. Shuman, and Keith Woeltje

Section 1 – Getting Started Section 3 – Major HAI Categories: Surveillance

1 Ethical Aspects of Infection Prevention 1 and Prevention
Loreen A. Herwaldt and Lauris C. Kaldjian
2 The Infection Control Committee 13
David A. Pegues
3 Product Evaluation 18
David A. Pegues
4 The Business Case for Healthcare Epidemiology and
Antimicrobial Stewardship 22
Eli N. Perencevich
5 Quality Improvement in Healthcare
Epidemiology 30
Mohamad G. Fakih, Susan MacArthur, and Louise-
Marie Dembry
Section 2 – Infection Prevention Basics
6 Epidemiologic Methods in Infection Control 41
Jeffrey S. Gerber
7 Isolation 52
Daniel J. Morgan and Gonzalo M. L. Bearman
8 Disinfection and Sterilization in Healthcare
Facilities 58
William A. Rutala and David J. Weber
9 Improving Hand Hygiene in Healthcare
Settings 82
Katherine D. Ellingson and Janet P. Haas
10 Surveillance: An Overview 92
Trish M. Perl and Kathleen A. Gase
11 Outbreak Investigations 119
Alison Laufer Halpin, Alice Y. Guh, and Alexander
J. Kallen
12 Urinary Tract Infection 133
Emily K. Shuman
13 Ventilator-Associated Events 140
Michael Klompas
14 Basics of Surgical Site Infection: Surveillance and
Prevention 147
Deverick J. Anderson and Trish M. Perl
15 Surveillance and Prevention of Infections
Associated with Vascular Catheters 162
Walter Zingg and Jonas Marschall
Section 4 – Antimicrobial-Resistant
Organisms
16 Control of Gram-Positive Multidrug-Resistant
Pathogens 177
Trevor C. Van Schooneveld and Mark E. Rupp
17 Control of Gram-Negative Multidrug-Resistant
Pathogens 190
Pranita Tamma and Anthony D. Harris
18 Clostridium Difficile Infection 201
Jennie Kwon and Erik R. Dubberke
19 Antimicrobial Stewardship 213
Sharon Tsay and Keith Hamilton
Section 5 – Special Settings
20 Infection Control in Long-Term Care Facilities 229
Jennifer H. Han and Nimalie Stone

vii
 Contents
21 Infection Prevention in the Outpatient
Setting 238
Sarah S. Lewis and Rebekah W. Moehring
22 Infection Prevention in Resource-Limited
Settings 251
Anucha Apisarnthanarak, Nuntra Suwantarat,
and Virginia R. Roth
Section 6 – Special Topics
23 The Role of the Laboratory in
Prevention of Healthcare-Associated
Infections 271
Michael A. Pfaller and Daniel J. Diekema
24 Biological Disasters 287
Sandro Cinti and Eden Wells
25 Exposure Workups 325
David B. Banach, Hilary Babcock, and Louise-Marie
Dembry
viii
26 Employee Health and Infection Control 350
Tara N. Palmore and David K. Henderson
27 Tuberculosis Infection Control in Healthcare
Settings 361
Henry M. Blumberg
28 Patient Safety 380
Darren R. Linkin and Patrick J. Brennan
29 Infection Prevention in Design, Renovation, and
Construction 387
Loie Ruhl Couch, Loreen A. Herwaldt, and Linda
L. Dickey
30 Regulatory Issues Concerning Healthcare
Epidemiology and Infection Prevention 411
Stephen Weber and Pranavi Sreeramoju
Index 428
Contributors

Deverick J. Anderson Daniel J. Diekema

Division of Infectious Diseases, Duke Center for Antimicrobial Division of Infectious Diseases, The University of Iowa College
Stewardship and Infection Prevention, Durham, NC, USA of Medicine, Iowa City, IA, USA

Anucha Apisarnthanarak Erik R. Dubberke

Division of Infectious Diseases, Thammasat University Division of Infectious Diseases, Washington University in
Hospital, Pathum Thani, Thailand St. Louis, St. Louis, MO, USA

Hilary M. Babcock Katherine D. Ellingson

Division of Infectious Diseases, Washington University School Public Health Division, Oregon Health Authority, Portland,
of Medicine and BJC HealthCare, St Louis, MO, USA OR, USA

David B. Banach Mohamad G. Fakih

Division of Infectious Diseases, University of Connecticut Care Excellence, Ascension Healthcare, St. Louis, MO, USA
School of Medicine, Farmington, CT USA
Kathleen A. Gase
Gonzalo M. L. Bearman Infection Prevention, BJC HealthCare, St. Louis, MO, USA
VCU Medical Center, Virginia Commonwealth University
Health System, Richmond, VA, USA Jeffrey S. Gerber
Division of Infectious Diseases, Children’s Hospital of
Henry M. Blumberg Philadelphia, Philadelphia, PA, USA
Division of Infectious Diseases, Emory University School of
Medicine, Atlanta, GA, USA Alice Y. Guh
Division of Healthcare Quality Promotion,
Patrick J. Brennan Centers for Disease Control and Prevention,
Perelman Center for Advanced Medicine, University of Atlanta, GA, USA
Pennsylvania Health System, Philadelphia, PA, USA
Janet P. Haas
Sandro Cinti Infectious Diseases and Epidemiology, Lenox Hill Hospital,
Infectious Diseases, University of Michigan, Ann Arbor, MI, New York, NY, USA
USA
Alison Laufer Halpin
Loie Ruhl Couch Division of Healthcare Quality Promotion, Centers for Disease
Infection Prevention Specialist, Barnes-Jewish Hospital, Control and Prevention, Atlanta, GA, USA
St. Louis, MO, USA
Keith Hamilton
Louise-Marie Dembry Division of Infectious Diseases, Perelman
Yale Infectious Diseases, Yale–New Haven Hospital, New School of Medicine, University of Pennsylvania,
Haven, CT, USA; and Infectious Diseases, VA Connecticut Philadelphia, PA, USA
Healthcare, West Haven, CT, USA
Jennifer H. Han
Linda L. Dickey Division of Infectious Diseases, Perelman School of
Quality and Patient Safety, University of California, Irvine, Medicine, University of Pennsylvania, Philadelphia,
Laguna Niguel, CA, USA PA, USA

ix
 List of Contributors

Anthony D. Harris Daniel J. Morgan

Department of Epidemiology and Public Health,
University of Maryland School of Medicine, Baltimore,
MD, USA
David K. Henderson
Clinical Care and Quality Assurance and Hospital
Epidemiology, NIH Clinical Center, Bethesda, MD, USA
Loreen A. Herwaldt
CQSPI Internal Medicine, University of Iowa Hospitals and
Clinics, Iowa City, IA, USA
Lauris C. Kaldjian
Department of Internal Medicine, University of Iowa
Hospitals and Clinics, Iowa City, IA, USA
Alexander J. Kallen
Division of Healthcare Quality Promotion, Centers for Disease
Control and Prevention, Atlanta, GA, USA
Michael Klompas
Population Medicine, Harvard Pilgrim Healthcare, Boston,
MA, USA
Jennifer H. Kwon
Division of Infectious Diseases, Washington University in
St. Louis, St. Louis, MO, USA
Ebbing Lautenbach
Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA
Sarah S. Lewis
Division of Infectious Diseases, Duke Center for Antimicrobial
Stewardship and Infection Prevention, Durham, NC, USA
Darren R. Linkin
Division of Infectious Diseases, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA, USA
Susan MacArthur
Infection Prevention, Connecticut Children’s Medical Center,
Hartford, CT, USA
Preeti N. Malani
Infectious Diseases, University of Michigan, Ann Arbor, MI,
USA
Jonas Marschall
Department of Infectious Diseases, Inselspital, Bern University
Hospital, University of Bern, Bern, Switzerland; Division of
Infectious Diseases, Washington University School of
Medicine, St. Louis, MO, USA.
Department of Epidemiology and Public Health, University of
Maryland School of Medicine, Baltimore, MD, USA
Tara N. Palmore
Infectious Diseases Fellowship Program and Hospital
Epidemiology, NIH Clinical Center, Bethesda, MD, USA
David A. Pegues
Division of Infectious Diseases, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA, USA
Eli N. Perencevich
Perencevich Research Group, University of Iowa, Iowa City,
IA, USA
Trish M. Perl
Department of Medicine, University of Texas Southwestern,
Dallas, TX, USA
Michael A. Pfaller
Department of Pathology, University of Iowa, Iowa City, IA, USA
Virginia R. Roth
Infectious Diseases, Infection Prevention and Control, Ottawa,
ON, Canada
Mark E. Rupp
Department of Internal Medicine, University of Nebraska
Medical Center, Omaha, NE, USA
William A. Rutala
Division of Infectious Diseases, University of North Carolina
School of Medicine, Chapel Hill, NC, USA
Emily K. Shuman
The Division of General Medicine, University of Michigan,
Ann Arbor, MI, USA
Pranavi Sreeramoju
Department of Internal Medicine, UT Southwestern Medical
Center, Dallas, TX, USA
Nimalie Stone
Division of Healthcare Quality Promotion, Centers for Disease
Control and Prevention, Atlanta, GA, USA
Pranita Tamma
Division of Infectious Diseases, Department of Pediatrics, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
Sharon Tsay
Division of Infectious Diseases, Perelman School of Medicine,
University of Pennsylvania \ Philadelphia, PA, USA

Rebekah W. Moehring Trevor C. Van Schooneveld

Division of Infectious Diseases, Duke Center for Antimicrobial Department of Internal Medicine, University of Nebraska
Stewardship and Infection Prevention, Durham, NC, USA Medical Center, Omaha, NE, USA

x
 List of Contributors

David J. Weber Keith Woeltje

Division of Infectious Diseases, University of North Carolina Division of Infectious Diseases,
School of Medicine, Chapel Hill, NC, USA Washington University School
of Medicine, St. Louis,
Stephen Weber MO, USA
Clinical Effectiveness, the University of Chicago Medicine,
Chicago, IL, USA Walter Zingg
Infection Control Program, University of Geneva Hospitals and
Eden Wells WHO Collaborating Centre on Patient Safety, Geneva,
Michigan Department of Health and Human Services, Lansing, Switzerland
MI, USA

xi
Preface
An Introduction to Practical Hospital Epidemiology
Ebbing Lautenbach, Preeti N. Malani, Jennifer H. Han, Jonas Marschall,
Emily K. Shuman, and Keith Woeltje
It is with great pleasure that we introduce the fourth edition
of Practical Healthcare Epidemiology. As noted by Dr. Loreen
Herwaldt in the introduction to the first edition of this text,
“Hospital epidemiology and infection control have become
increasingly complex fields.”1 While certainly true then, it is
even more so now. The healthcare epidemiologist today faces
an abundance of both challenges and opportunities. One
need look no further than the recent emergence or reemer-
gence of multidrug-resistant gram-negative bacteria, Middle
East Respiratory Syndrome, and Ebola, to appreciate the
dynamic nature of this field. Ongoing emphasis on such
issues as pandemic preparedness, patient safety, and complex
regulatory requirements related to infection prevention,
highlights the need for the expertise of the healthcare epide-
miologist in many arenas. The requirement for knowledge-
able and well-trained healthcare epidemiologists has never
been greater.
Healthcare-associated infections (HAIs) exact a tremendous
toll in morbidity, mortality, and costs. A recent survey esti-
mated that 4 percent of all patients admitted to US acute-care
hospitals in 2011 developed HAIs, for a total of 721,800 such
infections.2 Among these patients, about 75,000 died during
their hospitalizations. Total annual costs for the five major
HAIs (surgical site infection, central line–associated blood-
stream infection, catheter-associated urinary tract infection,
Clostridium difficile infection, and ventilator-associated pneu-
monia) have recently been estimated at around $9.8 billion.3
The primary focus of the healthcare epidemiologist remains
the prevention of HAIs. In this regard, there has been substan-
tial progress over the past several years, with significant reduc-
tions in the incidence of several HAIs, including central
line–associated bloodstream infection, surgical site infection,
and C. difficile infection.4 However, as indicated by the
ongoing burden of HAIs noted above, there remains much
work to be done. Indeed, the healthcare epidemiologist must
deal with all aspects of the healthcare setting to prevent
patients or staff from acquiring infection. These include out-
break investigation, surveillance, policy development, audits,
teaching, advice, consultation, community links, and research.
With the increasing acuity of the hospitalized patient
population and the growing utilization of other healthcare
settings, (e.g., long-term acute care, outpatient, home care),
the need for the healthcare epidemiologist will continue to
increase dramatically in the coming years.
The knowledge and skills of the healthcare epidemiologist
also lend themselves extremely well to addressing many other
issues at the forefront of patient care today. Knowledge of
healthcare epidemiology is useful for antimicrobial steward-
ship, quality improvement, technology assessment, product
evaluation, and risk management. In particular, application
of healthcare epidemiology–based practices has offered much
to the patient safety movement. These include establishing
clear definitions of adverse events, standardizing methods for
detecting and reporting events, creating appropriate risk
adjustments for case-mix differences, and instituting evidence-
based intervention programs.5,6
We recognize that several comprehensive textbooks of
hospital epidemiology exist as excellent resources for infec-
tion control professionals.7–9 This book is not meant to repli-
cate these textbooks but rather to complement them as
a pragmatic, easy-to-use reference emphasizing the essentials
of healthcare epidemiology. As a starting point, this overview
of the important aspects of healthcare epidemiology should
provide a good foundation for those entering the field of
infection prevention. The practical nature of the book lends
itself well to the very nature of healthcare epidemiology as
a field that requires constant action (e.g., surveillance, inter-
ventions). While daily decisions must be based on a thorough
evaluation of the data, they must also be practical in the
context of the healthcare setting and surroundings of the
practitioner.
This book is also distinguished by its focus on experience.
While based solidly on the existing medical literature, this
resource also offers real-world advice and suggestions from
professionals who have grappled with many of the longstand-
ing and newer issues in infection prevention. As with earlier
editions of this book, we asked the authors to write their
chapters as if they were speaking to an individual who would
be running an infection prevention program and who was just
starting in this field. The authors’ task was to prepare future
xiii
 Preface
hospital epidemiologists for their new careers by summarizing
basic data from the literature and by providing essential refer-
ences and resources. In addition, we asked the authors to share
their own experiences of what works and what does not work
in particular situations.
We hope that this book will provide trainees and profes-
sionals in infection prevention, particularly the fledgling
healthcare epidemiologist, the knowledge and tools to estab-
lish and maintain a successful and effective healthcare epide-
miology program. Ours is a vibrant and exciting field that
presents new challenges and opportunities daily. The pro-
spects for the healthcare epidemiologist are virtually limitless,
whether they are in infection prevention, antimicrobial stew-
ardship, patient safety, or beyond. We hope that this textbook
provides the foundation upon which many future years of
further learning, innovation, and advancement are based.
References
1. Herwaldt LA, Decker MD. An introduction to practical hospital
epidemiology. In: Herwaldt LA, Decker M, eds. A Practical Handbook
for Hospital Epidemiologists. Thorofare, NJ: Slack Inc., 1998.
xiv
2. Magill SS, Edwards JR, Bamberg W, et al. Multistate
point-prevalence survey of healthcare-associated infections.
N Engl J Med 2014;370:1198–208.
3. Zimlichman E, Henderson D, Tamir O, et al. Health
care-associated infections: a meta-analysis of costs and financial
impacts on the US health care system. JAMA Intern Med
2013;173:2039–46.
4. Centers for Disease Control and Prevention. 2014 national and
state healthcare-associated infections progress report. Published,
March 2016. Available at www.cdc.gov/hai/progress-report/index
.html.
5. Scheckler WE. Healthcare epidemiology is the paradigm for
patient safety. Infect Control Hosp Epidemiol 2002;23:47–51.
6. Gerberding JL. Hospital-onset infections: a patient safety issue.
Ann Intern Med 2002;137:665–70.
7. Bennett JV, Brachman PS and eds. Hospital Infections. 6th ed.
Philadelphia, PA: Wolters Kluwer, 2013.
8. Mayhall CG, ed. Hospital Epidemiology and Infection Control. 4th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2012.
9. Wenzel RP, ed. Prevention and Control of Nosocomial
Infections. 4th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2003.
 Section 1 Getting Started
Chapter
Ethical Aspects of Infection Prevention
1 Loreen A. Herwaldt, MD, and Lauris C. Kaldjian, MD, PhD
Hospital epidemiologists and infection preventionists make
countless decisions every day. In general, we do not make life-
or-death decisions, such as whether to withdraw life support or
whether to withhold possibly life-sustaining therapies. Few of
our decisions require court injunctions or provide the fodder
for eager journalists. We simply decide whether to isolate
patients, whether to let healthcare workers continue to work,
or whether to investigate clusters of infections – all very rou-
tine decisions in the life of anyone who practices infection
control. These decisions are so ordinary that they could not
possibly have any ethical implications. Or could they?
In fact, many of the decisions we make every day, even those
we consider quite straightforward, are also ethical decisions –
which is to say, they compel us to choose between competing
moral values. Such choices are rarely easy, and their intrinsic
difficulty is not eased by the fact that few of us have received
more than cursory training in ethics. Moreover, if we attempt to
train ourselves, we find that very little has been written about
the ethics of our specialty, infection prevention and control.
Common Infection Prevention Decisions
with Ethical Implications
We may easily overlook the ethical component of our everyday
decisions; thus, we may misconstrue the decision confronting
us, thinking that it is without ethical consequences when, in
fact, ethical principles are at stake. Take, for example, the
practice of isolating a patient colonized with a drug-resistant
organism. Isolating a patient constrains the patient’s freedom
of movement but protects the rights of other patients to be
treated in an environment without unnecessary risk. Similarly
the practice of removing healthcare workers with contagious
diseases from patient care follows from epidemiologic data but
also from the ethical concepts of beneficence, nonmaleficence,
and utility – with an overall goal of maximizing good outcomes
and minimizing harm. In such cases, we restrict the freedom of
healthcare workers to obtain the greater benefit of protecting
patients and fellow workers. Or, when stocking the hospital
formulary, we consider the efficacy and cost of drugs, but we
also balance the benefit of lower cost (to the patient and the
hospital) and the risk of selecting resistant microorganisms
against physicians’ freedom to prescribe any available drug.
Infection prevention personnel confront additional ethical
dilemmas in many of their daily activities. For example, when
managing an outbreak, infection prevention personnel must
identify the offending pathogen’s source and mode of transmis-
sion, and then intervene appropriately. This is simple enough if
the reservoir is a contaminated drain that is easy to replace or
a nursing assistant with no political clout in the hospital. But what
if the reservoir is a powerful physician with a large practice and
tremendous influence with the administration? Or what if the
administration thinks your recommendations are too expensive
and excessive? Would you bow to the pressures and recommend
interventions that you think are less than optimal, or would you
risk the wrath of the physician or the administration and state
your best advice regardless of the consequences?
Infection prevention personnel frequently inform patients
or healthcare workers that they have been exposed to an infec-
tious disease. When the pathogen is varicella zoster virus, the
problem is relatively simple. Yet infection prevention personnel
must still consider ethical issues. Do you permit some suscep-
tible employees to continue working, if they wear masks, but
restrict others? Or do you restrict all susceptible healthcare
workers regardless of their position or their economic status?
If you are very busy at work or have plans for the evening, do
you delay your response or ignore the exposure altogether?
Other exposures, such as those to the hepatitis B virus, the
human immunodeficiency virus (HIV), or the prion agent that
causes Creutzfeldt-Jakob disease, provoke emotional responses
and raise challenging ethical questions. For example, what do
you tell employees in the pathology laboratory who were not
informed that the patient might have Creutzfeldt-Jakob disease
and, therefore, did not use the recommended precautions when
they processed the brain tissue? Do you recall and resterilize
instruments used for the implicated brain biopsy? Do you
notify patients who subsequently had surgical procedures and
might have been exposed to instruments that were not steri-
lized in the manner recommended to kill the infectious agent?
We hope these examples enable you to see that ethical
considerations abound within the practice of infection preven-
tion. Clearly, ethics is not the esoteric discipline some misun-
derstand it to be. Ethics is part of our daily practice. We should
not delegate ethical deliberations to others, though we will
need to include professional ethicists, hospital managers,
accountants, and lawyers in our discussions. We all must
recognize that maintaining our ethical integrity is an essential
professional responsibility. This chapter is a brief introduction
to the intricate intersection of ethics and infection prevention.
Taxonomy
In the introductory paragraphs, we described some routine
infection prevention activities that have ethical implications.
These descriptions are, in essence, a “narrative taxonomy” of
1
 Loreen A. Herwaldt and Lauris C. Kaldjian

Table 1.1 A taxonomy of ethical problems in infection prevention

Control of the patient to limit spread of pathogenic organisms

Isolate patients who are colonized or infected with drug-resistant organisms
Isolate patients who are infected with highly infectious and/or dangerous organisms
Control of healthcare workers to limit spread of pathogenic organisms
Restrict the activities of healthcare workers who have been exposed to infectious diseases
Restrict the activities of healthcare workers who have infectious diseases
Restrict the activities of healthcare workers who refuse vaccinations (e.g., influenza vaccine)
Control of medications to limit selection and spread of antimicrobial resistance
Limit the antimicrobial agents included on the hospital formulary
Develop guidelines regarding the use of antimicrobial agents
Provide computer decision support for clinicians’ antimicrobial choices
Mandating or recommending best practice and interventions to reduce the risk of infection
Mandate or recommend treatment to eradicate carriage of resistant pathogens
Mandate implementation of isolation precautions
Mandate pre-employment vaccination and/or immunity to certain pathogens
Organize and promote yearly influenza vaccination campaigns
Develop policies and procedures
Mandate postexposure testing of patients and healthcare workers
Recommend postexposure prophylactic treatment of patients and healthcare workers
Resource allocation
Establish a threshold for investigating clusters of infections
Evaluate products to assess their cost relative to their safety and efficacy
Determine whether single-use items may be reused
Guide choices regarding materials, design, number of sinks, etc., for construction projects (cost vs. safety)
Limit hospital formularies to reduce costs and control antimicrobial resistance
Information disclosure
Report exposures to staff and patients
Report outbreaks and cases of reportable diseases to the public health department
Report data on healthcare-associated infections to the Centers for Disease Control and Prevention’s National Health Safety Network
Identify patients colonized with resistant organisms before intra- or inter-institutional transfers
Protect the confidentiality of patients’ medical records and laboratory results
Protect the identity of index patients in outbreaks
Protect confidentiality of patients who test positive for human immunodeficiency virus
Conflicting and competing interests
Managing outbreaks
Staff, especially institutional leaders, may refuse to comply
Administrators may balk at the cost of investigating outbreaks
Hospital epidemiologists who chose unpopular interventions may lose referrals or their jobs
Managing exposures
Staff, especially institutional leaders, may refuse to comply
Selecting the hospital formulary
Relationships between the staff on the formulary committee and the pharmaceutical industry may compromise decisions
Staff physicians may prefer specific antimicrobial agents not on the formulary
Individual professionalism
Act altruistically (prompt intervention vs. personal convenience)
Mediate in-house disputes between administrators, clinicians, unions, and the hospital
Act courageously when necessary, despite inadequate or conflicting data
Keep up with new developments in the field
Personal
Protect yourself from acquiring infectious diseases
Protect your family from acquiring secondary infections

ethical problems in infection prevention and hospital epide-
miology. A taxonomy is an orderly listing or categorization of
things. Infection prevention personnel are probably familiar
with taxonomy as it refers to microorganisms, but not with
2
respect to our profession. On the basis of our experience in
infection prevention (LAH) and ethics (LCK), we developed
a taxonomy that we think will be helpful to infection preven-
tion personnel as they think about their own work (Table 1.1).
 Ethical Aspects of Infection Prevention

Table 1.2 Differences in emphasis between epidemiologic ethics and Table 1.3 Differences in approach between infection prevention and
medical ethics medical care in the care of a patient with a transmissible infection

Variable Epidemiologic Medical ethics Variable Epidemiologic Medical

ethics approach approach
Scope of concern Populations Individuals Microbial Possible treatment Observation
colonization
Goal Prevent Treat and prevent
infection infection Confidentiality Qualified (e.g., posting Maintained
signs on patients’
Typical principles Nonmaleficence Beneficence and
doors)
nonmaleficence
Freedom of May limit with Maintained
Justice (fairness) Respect for patient
movement isolation precautions
autonomy
Freedom of May limit with Maintained
Utility
contact isolation precautions
Purpose of Investigation Diagnosis
disclosure
Information Confidential Confidential
handling reporting documentation However, the principles are applied according to the public
health model,5,7 which requires commitment to improving the
health of populations, not only individual patients.8 Although
both medical ethics and epidemiologic ethics stress nonmale-
The taxonomy not only describes the most important ethi-
ficence and confidentiality, medical ethics emphasizes privacy
cal problems in infection prevention but also helps us define
at times when epidemiologic ethics emphasizes investigation
the individuals, groups, and organizations to which infection
and reporting to protect the population. Furthermore, medical
prevention personnel have specific obligations. In particular,
ethics stresses patient autonomy, whereas epidemiologic ethics
infection prevention personnel have obligations to inpatients
places special priority on justice. Put more practically, medical
and outpatients as groups, to individual patients, to visitors as
ethics demands that the clinician treat an infected patient while
a group, to individual visitors, to healthcare workers as
maintaining the patient’s confidentiality, privacy, dignity, free-
a group, to individual healthcare workers, to the healthcare
dom, and contact with other human beings (Table 1.3).
facility for which they work, to public health entities both local
In contrast, epidemiologic ethics might stress treating both
and federal, to facilities to which their facility refers or transfers
infected and colonized patients to protect patients and health-
patients, to referring or transferring facilities, and to the public
care workers. In particular cases, epidemiologic ethics might
in general. Different groups often have different interests that
require healthcare workers to post isolation signs on the doors
are in competition. We can use the taxonomy to help us
to patients’ rooms; or insist that patients stay in their rooms
identify the type of ethical problem we are facing and the
except when going to essential tests, in which case they must
competing obligations that may surround that problem.
wear surgical masks; or require healthcare workers to wear
gowns, gloves, and masks to avoid direct contact with patients.
An Approach to Ethical Problems in Infection By now it should be clear that ethically challenging situa-
Prevention tions are common in the practice of infection prevention and
Most discussions of medical ethics ignore the epidemiologist- hospital epidemiology. To respond effectively to these chal-
population relationship and concentrate instead on the clin- lenges, infection prevention staff must address each problem
ician-patient relationship.1,2 Infection prevention personnel systematically. Kaldjian et al.9 developed an approach to ethics
are frequently clinicians; however, we must differentiate our that is clinically oriented and helps the user state the problem
clinical and epidemiologic roles because the fiduciary duties clearly, collect data comprehensively, formulate an impression,
associated with these different roles do not always coincide. and, finally, articulate a justified plan. In outline form, we
Medical ethics are “person-oriented,” while epidemiologic present a modified version of this approach tailored to the
ethics are “population-oriented” (Table 1.2).3–5 Even so, the particular demands of infection prevention (Table 1.4), and
standard principles of medical ethics also apply to hospital we employ this approach (in abbreviated form) as we discuss
epidemiology. These principles are as follows:6,7 three core topics.
• Autonomy (respecting the decisions of a competent patient)
• Beneficence (doing good) Core Ethical Topics in Infection Prevention
• Nonmaleficence (doing no harm)
• Justice (being fair and allocating resources equitably) Staff Vaccination Programs
• Utility (maximizing benefits and reducing harms to all Vaccines were one of the public health movement’s major
concerned) triumphs during the twentieth century, and in that very

3
 Loreen A. Herwaldt and Lauris C. Kaldjian
Table 1.4 An approach to ethical problems in infection prevention
1. State the problem plainly
2. Gather and organize data
a. Medical facts
b. Goals and procedures of infection prevention and
control
c. Interests of patients, healthcare workers, hospital,
community, and public health agencies
d. Context
3. Ask: Is the problem ethical?
4. Ask: Is more information or discussion needed?
5. Determine the best course of action and support it with
reference to one or more sources of ethical value
a. Ethical principles: beneficence, nonmaleficence,
respect for autonomy, justice, utility
b. Rights: protections that are independent of
professional obligations
c. Consequences: estimating the goodness or
desirability of likely outcomes
d. Comparable cases: reasoning by analogy from prior
“clear” cases
e. Professional guidelines: for example, APIC/CHICA-
Canada professional practice standards48
f. Conscientious practice: preserving epidemiologists’
moral integrity
6. Confirm the adequacy and coherence of the conclusion
NOTE: APIC, Association for Professionals in Infection Control and
Epidemiology; CHICA-Canada, Community and Hospital Infection Control
Association–Canada.
triumph are the seeds of a substantial controversy and an
ethical problem. Because use of vaccines effectively decreased
the incidence of many infectious diseases, the public no longer
knows how dreadful these infections can be and how many
complications and deaths they have caused. The public is now
more aware of vaccine complications than they are of the
infections the vaccines were developed to prevent.
In addition, parents of “vaccine-damaged children,” the nat-
ural health movement, television, radio talk shows, and the
Internet have all become important participants in this
“debate.”10,11
The controversy about the pertussis vaccine is illustra-
tive. In the 1940s, pertussis was the leading cause of death
among children under 14 years of age. Pertussis, in fact,
killed more children than measles, scarlet fever, diphtheria,
polio, and meningitis combined.12 The incidence of per-
tussis was already decreasing before the killed whole-cell
vaccine was introduced, which was probably related to
changes in social conditions, hygiene, and nutrition.
However, the incidence declined significantly after the vac-
cine was introduced.13
Because the whole cell pertussis vaccine is composed
of dead Gram-negative bacteria, it includes many toxic
4
components and is, thus, quite reactogenic. Recipients
often have significant pain, swelling, and erythema at
the vaccination site, and they may develop fever, anor-
exia, irritability, and vomiting.14 In addition, some chil-
dren may develop inconsolable crying, excessive
somnolence, seizures, or hypotonic-hyporesponsive
episodes.14 Encephalopathy, which is very rare, is the
most severe complication of pertussis vaccination.14
Opponents of the vaccine allege that the vaccine not
infrequently causes serious permanent neurological
damage. In some countries, such as Sweden, Japan, and
the United Kingdom, the antivaccine movements gained
such prominence that the countries either stopped vacci-
nating children or the rate of vaccination decreased sig-
nificantly. All three of these countries had outbreaks of
pertussis that affected thousands of children and caused
numerous deaths.14
The controversy over the pertussis vaccine suggests that
the ethical debate over vaccines in both the public health
arena and in the hospital revolves around providing the
greatest good for the greatest number of people (i.e., pro-
tecting them against harmful infections) and protecting the
individual from harm that could be caused by
a vaccination. The ethical dilemma occurs because, in gen-
eral, the population benefits (i.e., an immunized population
that is less susceptible to infection), but individual persons
bear the risk of vaccine complications.15–19 In highly vac-
cinated populations, a single person can refuse a vaccine
and may avoid both the potential complications of the
vaccination and the infection itself because he or she is
protected by the vaccinated population. However, one may
ask whether this is fair to persons who are willing to bear
the burdens of being vaccinated (potential
complications).15 Furthermore, if this scenario is repeated
often enough, the vaccination rate in the population will
drop, and nonimmune people will be at risk.
The ethical dilemma just described also occurs in
healthcare facilities that require healthcare workers to be
immune to certain infections. For example, most health-
care facilities require that healthcare workers be immune to
rubella, which means that employees must present proof
that they have had the infection or that they have had at
least two rubella vaccinations. The reasons healthcare facil-
ities have this requirement are that rubella is easily trans-
mitted within healthcare facilities and that this virus can
cause severe congenital defects if a pregnant woman
becomes infected.20,21 Thus, healthcare facilities caring for
pregnant women seek to protect these patients by requiring
staff to be immune to this infection. Pregnant employees
also benefit from this requirement. However, the individual
healthcare provider may not benefit from receiving this
vaccine, because rubella causes very mild disease in adults,
and an adult vaccine recipient might develop complica-
tions. Thus, the hospital puts limits on the autonomy of
its staff members to avoid harming pregnant patients and
employees.

The approach many facilities take to influenza vaccine
illustrates another extreme. The influenza virus is quite con-
tagious and can cause serious complications, hospitalization,
and death, particularly among elderly people and people with
significant underlying diseases. Healthcare facilities, particu-
larly hospitals, care for many people who are at risk for com-
plications of influenza. Moreover, outbreaks of influenza have
occurred in healthcare facilities. These outbreaks are difficult
to recognize and, therefore, are underreported.22 Thus, many
hospitals offer the vaccine free of charge to employees each fall.
But employees, even those who work with high-risk patients,
usually are not required to be vaccinated.23 In this case, hospi-
tals have elected not to mandate vaccination with a safe and
effective vaccine that could prevent at least as many severe
complications as does the rubella vaccine. Instead, they have
elected to preserve their healthcare workers’ autonomy rather
than allowing the interests of vulnerable patients to take pre-
cedence over that autonomy.23
Why do hospitals manage rubella one way and influenza
another? To our knowledge, no one has studied this issue.
However, we might speculate that society considers the birth
of even one child with congenital rubella to be a tragedy.
By contrast, we might speculate that society is not as alarmed
by the fact that thousands of elderly people die each year from
complications of influenza. Moreover, a damaged child repre-
sents many impaired life-years, whereas a frail elderly person
who dies represents very few life-years lost. Furthermore,
because influenza outbreaks in healthcare facilities are rarely
recognized, most hospital administrators probably feel that the
risk to the patients is very low and, thus, do not require all staff
to be vaccinated. In contrast, the hospital would face a huge
lawsuit if a woman could document that she acquired rubella
while receiving prenatal care in that facility. Though these
different approaches to rubella vaccine and influenza vaccine
present major ethical issues, healthcare providers seem rela-
tively unaware of these issues even though they often discuss
their right to autonomy regarding vaccinations.
We believe that healthcare workers have a moral obligation
to restrict their own freedom when it comes to complying with
interventions such as influenza vaccine if in so doing they
might help preserve their patients’ health. Rea and Upshur23
take this position in their commentary on the issue:
As Harris and Holm wrote of society in general: “There
seems to be a strong prima facie obligation not to harm others
by making them ill where this is avoidable.” But there is
a special duty of care for us as physicians not simply to avoid
transmission once infected, but to avoid infection in the first
place whenever reasonable. Our patients come to us specifi-
cally for help in staying or getting well. We have not just the
general obligation of any member of our community, but
a particular trust: first do no harm.23
The hepatitis B vaccine illustrates another approach to
vaccines within the healthcare setting. The US Occupational
Safety and Health Administration requires healthcare facilities
to offer hepatitis B vaccine to all employees who will have
contact with blood and body fluids to protect them from
acquiring this virus through an occupational exposure.24
Ethical Aspects of Infection Prevention
In this case, the individual vaccinated gets the benefit and
bears the risk associated with the vaccine. In addition, employ-
ees are not required to take the vaccine. If they do not want it,
they simply sign a waiver stating that they decline the vaccine,
in which case they bear the risk if they are exposed to hepatitis
B. The institution, thereby, fulfills its ethical and legal obliga-
tion to the employee, and the employee maintains his or her
freedom to choose whether to be vaccinated.
But a question remains regarding hepatitis B vaccine, and
that is whether all healthcare workers should be required to be
immune to this virus to protect patients from becoming
infected. Given that the risk of transmitting hepatitis B virus
is very low with most healthcare-associated activities, there
does not seem to be a strong ethical argument for requiring
vaccination. However, more than 400 patients have acquired
hepatitis B from infected healthcare workers who performed
invasive procedures.25 It is, therefore, appropriate to ask
whether all healthcare workers who perform invasive proce-
dures that could expose the patient to the healthcare workers’
blood should be vaccinated against hepatitis B. Though some
healthcare workers might argue that mandatory hepatitis
B vaccination infringes on their right to choose, we think that
mandatory vaccination for this group of healthcare workers is
ethically justifiable, given the known benefits of vaccinating
healthcare workers, the minimal risks associated with the vac-
cine, and the possible benefits to patients. Because many med-
ical schools now require medical students to be vaccinated and
the Centers for Disease Control and Prevention recommend
vaccinating all infants, in the near future this question may
become moot.
Isolating Patients Who Carry or Are Infected with
Resistant Organisms
The incidence of colonization or infection with drug-resistant
microorganisms, particularly methicillin-resistant Staphylococcus
aureus (MRSA) and vancomycin-resistant enterococci (VRE), has
increased substantially over time. One of the primary goals for
infection prevention personnel is to protect patients from acquir-
ing pathogenic organisms, including resistant organisms, from
other patients, the environment, and healthcare workers.
Infection prevention personnel have several means to accomplish
this goal: educating staff; implementing isolation precautions,
with or without active screening programs to identify carriers
(see Chapter 7, on isolation precautions); implementing hand
hygiene programs; controlling use of antimicrobial agents (see
Chapter 19, on antimicrobial stewardship); and developing clean-
ing protocols for patients’ rooms and equipment. Of these meth-
ods for controlling spread of resistant organisms, implementing
isolation precautions, with or without active screening, and con-
trolling use of antimicrobial agents have been quite controversial
and are associated with significant ethical issues. We discuss the
ethical implications of using contact precautions to control
spread of MRSA and VRE.
There are numerous reasons to prevent spread of MRSA
and VRE. Both organisms can cause serious infections.26–29
Because MRSA and VRE are resistant to the first-line
5
 Loreen A. Herwaldt and Lauris C. Kaldjian
antimicrobial agents used to treat serious infections caused by
S. aureus and enterococci, these infections may be difficult and
expensive to treat. Moreover, if MRSA becomes resistant to
vancomycin (i.e., if the resistance gene is transferred from VRE
to MRSA), infection with such strains might be virtually
untreatable with currently available antimicrobial agents.
Furthermore, MRSA infections do not replace infections
caused by methicillin-susceptible S. aureus, rather they are
added to them. Thus, in hospitals where the incidence of
MRSA colonization and/or infection increases, the overall
incidence of healthcare-acquired S. aureus infection often
increases as well.26 If MRSA and VRE are transmitted in
a hospital, other organisms, such as Clostridium difficile and
gram-negative organisms that are resistant to extended-
spectrum β-lactam agents or to carbapenems may also be
transmitted, indicating that the overall infection prevention
practice in the hospital is lax.
Some infection prevention personnel argue that data from
numerous institutions document the effectiveness of aggres-
sive prevention and control measures.27 Infection prevention
personnel who take this position would also argue that, as
healthcare professionals, we should first do no harm. Because
MRSA and VRE harm many patients, we should do all we can
to prevent both transmission of these organisms and infections
caused by these organisms. Therefore, infection prevention
programs are obliged to use reasonable means to prevent
selection and spread of these organisms.27
Other infection prevention personnel argue, to the con-
trary, that there are numerous reasons not to invest substantial
resources and time into MRSA and VRE control efforts.29,30
They insist that the incidence of colonization or infection with
these organisms is already so high that control measures are
ineffective and waste precious resources. They would agree
that aggressive measures have worked in some instances, pri-
marily in outbreaks, but that the data on the overall incidence
of MRSA and VRE colonization or infection indicate that
infection control efforts have failed to stop transmission.
They also argue that many colonized patients never become
infected, colonization per se does not harm these patients, and
MRSA and VRE are neither more virulent nor do they cause
greater morbidity and mortality than methicillin-susceptible
S. aureus and vancomycin-susceptible enterococci. Thus, these
patients should not be subjected to decolonization or to isola-
tion from which they will not benefit. These infection preven-
tion personnel also state that efforts to control MRSA and VRE
impair patient care and, therefore, may actually cause worse
patient outcomes than would have occurred if the patients
were not isolated.31–33 Finally, they would argue that eradicat-
ing carriage with antimicrobial agents such as mupirocin may
actually increase antimicrobial resistance.34
Infection prevention personnel who think contact precau-
tions are an important component of a program to prevent
spread of MRSA and VRE offer several arguments to support
their position:35 1) contact precautions have been shown by
numerous investigators to stop transmission of these organ-
isms during outbreaks; 2) contact precautions have reduced
transmission of MRSA and VRE in situations where they are
6
endemic; 3) data from several studies suggest that proximity to
a patient who carries MRSA or VRE is a risk factor for acquir-
ing these organisms;27 and (4) common sense suggests that
housing infected or colonized patients in rooms separate from
patients who do not carry these organisms should reduce
spread of the resistant organisms.
Other infection prevention personnel present arguments
against using isolation precautions to control the spread of
MRSA and VRE:29–33 1) MRSA and VRE are spreading despite
these precautions; 2) patients in contact precautions do not
receive the same level of care as do patients with similar
problems who are not in contact precautions; 3) contact pre-
cautions may actually prevent patients from getting appropri-
ate treatments (e.g., aggressive physical rehabilitation) or from
being transferred out of an acute-care facility to a facility better
suited to the patients’ needs; and 4) contact isolation creates
social isolation that may impair patients’ psychological well-
being.
Other infection prevention experts would argue that the
real question is not whether to invest resources in attempts to
control MRSA and VRE, but which means should be used to
control spread. The major issue in this discussion has been
whether to use intensive active surveillance coupled with con-
tact precautions to control the spread of these organisms 27,36
or to enhance compliance with standard precautions and hand
hygiene.30,32 The crux of this debate revolves around differing
interpretations of the extant data. Those who support active
surveillance and use of contact precautions believe that the
data strongly support this approach,27,36 while those who sup-
port enhancing general infection prevention precautions
believe either that current data suggest these measures are not
effective30,32 or that more data are needed before hospitals
spend large amounts of money and time performing active
surveillance.37
As suggested in the preceding paragraphs, the major ethical
dilemma with respect to using contact precautions to control
the spread of resistant organisms is that the health interests of
patients who are not colonized or infected with a resistant
organism conflict with those of the patients who are colonized
or infected with one or more of these organisms. That is, the
patients who are not colonized or infected expect to be treated
in the safest possible environment, one that is free of organisms
that could complicate or prolong their hospitalizations or
could add costs to their hospital bills. They desire to avoid
untoward consequences or complications of hospitalization.
On the other hand, patients who are colonized or infected with
one of these organisms have the right to full treatment for their
medical problems, which includes receiving adequate attention
from staff and having access to all tests and therapies that are
necessary for their care. These patients want to avoid compli-
cations of inadequate care, such as slower or impaired rehabi-
litation, and complications of social isolation, such as
depression, anger, and nonadherence to recommendations.
Each side in this debate refers to different ethical principles
to support their case. Those in favor of contact precautions
argue that this type of isolation protects unaffected patients
from acquiring organisms that could eventually harm them

and thus supports the ethical principle of nonmaleficence.
The opposition argues that use of contact precautions violates
affected patients’ autonomy and may violate the principles of
beneficence and nonmaleficence, as well.
Some infection prevention leaders have begun to question
whether contact precautions should be used as a primary com-
ponent of a program to prevent spread of MRSA and VRE
within healthcare facilities.38–40 They argue that most studies
addressing this issue are of low quality and were done before
intensive efforts to improve hand hygiene were begun or before
hospitals introduced bathing patients with antiseptics like chlor-
hexidine. Moreover, they argue that contact precautions do not
prevent infections in colonized patients, that contact precau-
tions may harm patients, that the incremental benefit of contact
precautions is likely to be small, and that contact precautions
increase costs and healthcare waste considerably.38–40 Recent
studies by Gandra et al.41 and Edmond et al.42 found that
MRSA and VRE transmission rates and device-associated hos-
pital-acquired infection rates, respectively, did not change sig-
nificantly after they stopped using contact precautions for
patients colonized or infected with these organisms. While the
data are suggestive, neither study assessed whether the rate of
MRSA and VRE transmission changed. Both studies had meth-
odological weaknesses, and thus they do not provide a definitive
answer to this question.
Those who still support using contact precautions cite the
results of recent studies that did not find an increased risk of
adverse events among patients treated with contact precau-
tions compared with patients who were not.43–47 In fact, the
cluster randomized trial study conducted by Harris et al. found
that universal gown and glove use by healthcare workers caring
for patients in intensive care units significantly reduced the
risk of MRSA acquisition as measured by routine surveillance
cultures and did not increase the risk of adverse events.45,47
MRSA and VRE are the two most common resistant bac-
terial pathogens in most US hospitals. Nevertheless, as we have
discussed in this section, experts in infection prevention still
debate the merits and the ethics of placing patients in contact
precautions simply because they are colonized or infected with
one of these organisms. This discussion also illustrates that as
medical information changes, one’s ethical assessment of the
merits of infection prevention interventions may change as
well. Consequently, hospital epidemiologists and infection
preventionists cannot take refuge in the old adage “we’ve
always done it this way.” Rather, we must constantly reassess
the literature and then reassess our practices in light of new
data and ethical principles.
Ethical Issues Associated with Caring for Patients
Infected with Highly Transmissible and Virulent
Organisms such as Ebola Virus
Highly transmissible and virulent organisms present special
challenges for healthcare providers, including infection preven-
tion staff. Outbreaks of Severe Acute Respiratory Syndrome
(SARS), Middle East Respiratory Syndrome (MERS), and
Ethical Aspects of Infection Prevention
Ebola have demonstrated the ease with which such organisms
can spread in healthcare facilities. In fact, spread of these organ-
isms has been amplified in the healthcare setting; many patients
and healthcare workers have acquired these infections in health-
care facilities, and many of these patients and healthcare workers
have died. Thus, outbreaks of these infections have shown how
important protecting patients, visitors, and staff – infection
prevention programs’ primary responsibility – truly is.
In this section, we will use the example of Ebola virus
infection to illustrate how the ethical principles of autonomy,
beneficence, nonmaleficence, justice, and utility apply when
healthcare workers care for patients infected with a highly
transmissible and virulent organism. We will also discuss the
following additional ethical values that are relevant when
addressing such challenging situations: altruism, solidarity,
and conscientious practice.
Infection prevention personnel direct much of their work
toward preventing harm to patients, visitors, and healthcare
workers. Thus, many routine infection prevention practices
are designed to maximize beneficence and nonmaleficence.
In contrast, some routine practices, such as implementing iso-
lation precautions or restricting ill healthcare workers, place
explicit limits on autonomy for patients or for healthcare work-
ers. In addition, infection prevention personnel generally focus
most of their attention on providing benefit and preventing
harm to patients while at the same time ensuring that visitors
and healthcare workers are also safe. When healthcare workers
care for patients with infections caused by highly transmissible
and virulent organisms, infection prevention staff members
must increase their efforts to ensure that other patients, visitors,
and healthcare workers are safe (nonmaleficence) and must
place more limits on patients’ autonomy. During outbreaks of
these infections or during other crises, infection prevention staff
may also apply the principle of utility more frequently to ensure
that benefits within a healthcare population are maximized,
harms are minimized, and scare resources are preserved.
Autonomy: The principle of respect for patient autonomy
indicates that patients have the right to request and receive
available treatment even for infections caused by highly trans-
missible and virulent organisms. Healthcare workers must
always respect the patient’s right to self-determination while
balancing this right against the important interests of other
patients and of healthcare workers themselves. Because Ebola
virus is transmitted easily in healthcare facilities and infections
are often severe, infection prevention programs implement
more stringent infection prevention practices that necessarily
limit the infected patient’s autonomy to protect the interests of
other patients, visitors, and healthcare workers. Thus, to protect
other patients and healthcare workers, healthcare facilities place
a patient with Ebola virus infection in rigorously enforced
isolation precautions and limit the diagnostic tests and treat-
ments offered.
Beneficence: The principle of beneficence indicates that
healthcare workers must promote patients’ best interests.
In most situations, this means that infection prevention
measures address primarily the patient’s welfare and that
7
 Loreen A. Herwaldt and Lauris C. Kaldjian
healthcare professionals work primarily to ensure the
patient’s welfare when deciding which diagnostic tests and
treatments are appropriate. When a patient is infected with
a highly transmissible virulent organism such as Ebola
virus, infection prevention personnel and clinicians must
increase their attention to the welfare of other patients,
visitors, and healthcare workers, thereby expanding the
extent to which the principle of beneficence is applied also
to these groups. When trying to maximize the principle of
beneficence, we should try to balance the best interests of all
concerned parties (maximizing beneficence in this way can
be seen as being related to promoting utility). On the basis
of the principles of autonomy and beneficence, healthcare
workers should strive to meet the patient’s needs and
should never abandon the patient.
Nonmaleficence: The principle of nonmaleficence indicates
that healthcare workers must avoid harming patients. This
principle can be applied to healthcare workers, even during
routine patient care. For example, the Centers for Disease
Control and Prevention introduced standard precautions to
protect healthcare workers from the harm of acquiring patho-
genic organisms while caring for infected patients, including
those infected with common organisms such as MRSA, hepa-
titis B, hepatitis C, and HIV.
When a patient is infected with a highly transmissible and
highly virulent organism, such as Ebola virus, the principle of
nonmaleficence can be seen as indicating that, in addition to
protecting the patient from harm, we must also protect other
patients, visitors, and healthcare workers from harm. As noted
previously, healthcare workers still must accept some risk
because they cannot abandon patients. Healthcare facilities
and infection prevention programs must do all they reasonably
can to minimize the risks for each front-line staff member by
providing safeguards such as optimal personal protective
equipment, education and practical training, an optimal work
environment, and other staff members who monitor and coach
the staff members caring for the patients.48,49
Justice: In general, the principle of justice indicates that
persons should have equal access to healthcare resources,
that persons in similar situations should be treated simi-
larly, and that available benefits or necessary burdens
should be distributed fairly among the group of individuals
under consideration. When healthcare workers must care
for patients infected with highly transmissible and virulent
organisms, the principle of justice indicates that risks and
burdens of caring for these patients should be distributed
fairly and consistently among staff. This principle also indi-
cates that healthcare workers who do not accept this risk
have likely transferred the risk to someone else. Thus,
a healthcare worker who will not care for a patient with
Ebola or who does not report to work during an influenza
pandemic has shifted to other healthcare workers both the
risk intrinsic to caring for the patient and the responsibility
for not abandoning the patient.50
Utility: The principle of utility indicates that infection pre-
vention programs and healthcare workers should work to
8
maximize benefits and minimize risks to all persons con-
cerned, including the affected patients, other patients, health-
care workers, and members of the community. Under usual
circumstances, infection prevention programs’ and health-
care workers’ primary focus is on maximizing the benefits
and minimizing the harms for individual patients while
maintaining a safe environment for other patients, visitors,
and healthcare workers. However, when caring for a patient
infected with Ebola virus or with another highly transmissi-
ble virulent organism, infection prevention programs must
increase their efforts to ensure that other patients, visitors,
and healthcare workers benefit and are not harmed. In these
situations, infection prevention personnel and clinicians
must consider both the likelihood that the patient will benefit
from a diagnostic test or a procedure and the likelihood that
healthcare workers or other people will be harmed in the
process.49 For example, clinicians may choose to intubate the
patient and insert a central venous catheter before the
patient’s condition deteriorates (i.e., preemptively) to
decrease the likelihood of harm to healthcare workers asso-
ciated with performing procedures under emergent condi-
tions. Or clinicians may deem the likelihood that a moribund
patient will benefit from a procedure, such as dialysis, to be
very low and the likelihood that a healthcare worker could be
harmed to be high and, therefore, decide not to offer the
patient this intervention.49,51 During widespread outbreaks,
such as the Ebola outbreak in West Africa, healthcare admin-
istrators, clinicians, infection prevention personnel, and pub-
lic health officials may justifiably apply the principle of utility
(alongside other principles and values) to protect healthcare
workers because healthcare workers are a limited resource
that is essential to the community’s well-being.49 To protect
healthcare workers, it may be necessary to preferentially
provide them prophylaxis or treatment, and it may be neces-
sary to triage patients48 to limit healthcare workers’ exposure
to patients who are least likely to respond to treatment.
Altruism: The principle of altruism indicates that healthcare
workers have a duty to care for infected patients regardless of
the causative organism’s transmissibility or virulence. Because
they have promised to care for the sick and to make patients’
needs their primary professional concern, healthcare workers
are committed to responding to their patients’ needs, even
when responding entails some degree of risk to their own
welfare. The basis for healthcare workers’ duty to care results
from:
• A professional’s promise to respond to the needs of the sick;
• The actual need of one or more patients;
• The ability of an actual professional to meet that need.
Various professionals, organizations, agencies, employers, and
governments have assessed the extent of a professional’s duty
to care for patients during disasters or outbreaks that pose
serious risks to the healthcare workers’ lives. However, they
have come to very different conclusions.48–50,52,53 Some have
stated that the duty to serve is an absolute duty regardless of the
healthcare worker’s risk; others have stated that the individual
healthcare worker can decide how much risk he or she is
 Ethical Aspects of Infection Prevention

Table 1.5 Range of possible responsibilities based on the assessment of students, and the community. For this reason, employees of
the duty to care in a crisis situation
these facilities are considered essential and required to report
Expectation Rationale to work as scheduled, or may be called to report to work if not
scheduled.”55
Work is mandatory Duty entails accepting the Table 1.5 describes a range of possible expectations and
associated risks rationales relevant to the duty to care in situations that pose
Exceptions exist Competing duties exist that infectious or other risks to healthcare professionals.
may mitigate a particular
Solidarity: The principle of solidarity indicates that healthcare
healthcare worker’s duty to
care facilities and the community should support healthcare work-
ers who serve at risk to their own and their loved ones’ welfare.
Healthcare workers may Healthcare workers may opt As discussed previously, healthcare facilities have a duty to
volunteer; if a sufficient out of caring for patients in protect their staff (see nonmaleficence), but attention to this
number of healthcare work- risky situations; if some work-
duty is particularly important during times of crisis or high
ers do not volunteer, a lottery ers must be required to work,
anxiety associated with highly transmissible and virulent
system can be used to select a lottery system distributes
additional personnel burdens fairly organisms. The principle of solidarity indicates that healthcare
facilities should: 1) clearly articulate and actively promote the
Healthcare workers may Healthcare workers may opt applicable professional standards of duty and the institutional
volunteer, and those who do out of caring for patients in and societal expectations regarding the duty to care so that the
will receive hazard pay; if risky situations, and those
healthcare workers understand the situation; and 2) provide
a sufficient number of who volunteer should be
venues in which staff members can learn about the infectious
healthcare workers do not compensated for accepting
volunteer, a lottery system the risk; if some workers agent, the risks posed by caring for a patient infected with this
can be used to select addi- must be required to work, agent, and precautions the facility is implementing to protect
tional personnel a lottery system distributes and help staff who care for these patients. Opportunities for
burdens and compensation open dialogue between leadership and frontline staff members
acknowledges the signifi- will allow the concerned parties to calibrate and communicate
cance of the risk their expectations and also acknowledge the boundary between
consensus and controversy.
The principle of solidarity also indicates that healthcare
willing to assume; and yet others have come down somewhere
facilities have additional responsibilities when their staff mem-
between these two alternatives.
bers care for patients infected with highly transmissible and
The American Medical Association’s (AMA) Code of
virulent organisms, such as Ebola virus.48,49,52 For example,
Medical Ethics upholds the duty to care, stating: “Because of
healthcare facilities must protect the staff who care for the
their commitment to care for the sick and injured, individual
patient from discrimination, stigmatization, and harassment
physicians have an obligation to provide urgent medical care
from inside and outside the institution and must help provide
during disasters. This ethical obligation holds even in the face
for the caregivers’ physical needs (e.g., food, water, adequate
of greater than usual risks to their own safety, health or life.”54
breaks from work, a place to stay if necessary) and emotional
But the AMA Code includes a note of caution that effectively
needs (e.g., help making difficult decisions, counseling) given
appeals to the principle of utility: “The physician workforce,
the difficulty of caring for critically ill patients while wearing
however, is not an unlimited resource; therefore, when parti-
extensive personal protective equipment and maintaining con-
cipating in disaster responses, physicians should balance
stant vigilance to avoid exposing themselves to the infecting
immediate benefits to individual patients with ability to care
pathogen. Moreover, because healthcare workers who acquire
for patients in the future.”
Ebola while caring for a patient could become seriously ill and
Unlike most professional societies, some governments have
could subsequently be disabled or die, healthcare facilities
defined healthcare workers’ duty to work and treat patients
should consider developing compensation provisions for
during emergencies as being absolute. In fact, some US states
harms suffered by healthcare workers who knowingly accept
“regard the obligation to treat during an emergency as a legal
serious risks when caring for such patients (e.g., death benefits
duty punishable by criminal sanctions for failure to act or for
for surviving family members).
abandonment of patients.”48 Some employers have developed
strict policies addressing the duty to work during crises, such as Conscientious practice by staff: Conscientious practice refers to
a pandemic. For example, the University of Iowa developed the profound role that conscience, or integrity, plays in our
a policy that focuses on utility and also stipulates that the duty moral lives. It indicates that healthcare workers should
to care is extensive, given that the hospital is an essential have the freedom to determine the degree of risk that is accep-
community resource. The policy states: “The University will table given their life situations and other important responsi-
be considered a ‘community asset’ and a ‘state asset’ in bilities (such as obligations to dependents). In other words,
responding to a pandemic. University of Iowa Hospitals and healthcare workers must balance their duty to care for patients
Clinics and Student Health Services will experience increased in a particular situation against their duties or obligations to
demand for medical treatment and advice from faculty, staff, family, friends, society, and, we might say, even themselves.49,52
9
 Loreen A. Herwaldt and Lauris C. Kaldjian
Respecting conscientious practice protects the individual health-
care provider’s ability to maintain his or her integrity, and doing
so acknowledges that healthcare workers vary in their assess-
ments of how much risk is acceptable based on their personal
obligations and their philosophical, religious, or professional
beliefs.
Moving from Theory to Practice
As should be apparent, ethical principles and values provide
guidance but not absolute or detailed answers to specific ethi-
cal issues. Moreover, different principles can suggest different
and possibly competing responsibilities and may lead admin-
istrators, clinicians, and infection prevention personnel at dif-
ferent healthcare facilities to different conclusions based on
their patient populations, their healthcare worker population,
their resources, and the guidelines and laws governing their
practices. When developing policies and procedures to address
either routine or more challenging infection prevention issues,
infection prevention personnel, clinicians, and administrators
must consider the implications of each principle and deter-
mine which principles are most important for specific indica-
tions or situations. As new information arises, infection
prevention personnel and others must evaluate whether speci-
fic policies and procedures still meet the standards implicit in
the ethical principles.9,52 For example, they may need to eval-
uate whether contact precautions for patients with MRSA or
VRE infection or colonization remain an ethical practice given
intensive use of alcohol-based products for hand hygiene and
antiseptic solutions for bathing patients. If effective treatments
are introduced for Ebola or infections caused by other highly
transmissible and virulent organisms, infection prevention
personnel may need to reevaluate imitations on care offered
to patients infected with these organisms.52
Ethical codes emphasize a profession’s core values and may
help guide decisions and behavior. To our knowledge, neither
the Society for Healthcare Epidemiology of America nor the
Association for Professionals in Infection Control and
Epidemiology (APIC), the two societies concerned with infec-
tion prevention, have developed codes of ethics. However,
APIC and the Community and Hospital Infection Control
Association–Canada (CHICA-Canada) have published
a document describing “professional and practice standards”
for persons practicing infection prevention and control.56
A well-developed and clearly stated ethical code is an
essential guide, yet it is also insufficient. A code of ethics
cannot identify all of the ethical dilemmas that individual
hospital epidemiologists and infection preventionists will face
in the course of their practice. Nor, despite the fond hopes of
professional school administrators, does reciting such a code at
graduation guarantee ethical conduct. Alone, an ethical code
cannot ensure ethical behavior. It must be taught, learned,
affirmed, and lived, if it is to affect our practice. As William
Diehl writes: “Formal codes of ethics are hot items these days.
[But one] thing is certain: any organization that requires all its
employees to review and sign its ethics code each year, and
then does nothing else to encourage high moral behavior, is
wasting its time on the code.”57
10
Any institution that does not act as it preaches wastes time
and also, at least implicitly, encourages unethical behavior.
Institutions reward the conduct they prize. It should be
a warning to us that, at present, we are probably more likely
to hear of inconsiderate behavior excused on the grounds of
a colleague’s academic or technical brilliance than to hear an
individual praised for making a difficult but ethically sound
decision. Perhaps as a community we need to consider the
significance of Ralph Waldo Emerson’s startling and humbling
remark that “character is higher than intellect.”
As our financial and staff resources are stressed without
limit and as the pressures under which we work intensify,
temptation amplifies. Barbara Ley Toffler of Resources for
Responsible Management states:
For many employees, being ethical is getting to be too risky –
something they can’t afford any more. . .. The problem grows
out of what I call the “move it” syndrome. . .. That’s when the
boss tells a subordinate to “move it” – just get it done, meet the
deadline, don’t ask for more money, time, or people, just do it –
and so it goes on down the line.58
For American companies, this peril from within is as ser-
ious as outside threats from competitors. As more employers
are forced to “move it,” companies are increasingly vulner-
able – legally, financially, and morally – to the unethical actions
of decent people trying to [move it just to keep their jobs].58
To “move it,” we may find ourselves declining to issue
appropriate sanctions in an outbreak because we are loath to
alienate an important doctor or lose referrals from a powerful
practice group. Or, fearing management anger over bad pub-
licity and loss of revenue, we may decide against closing a ward
affected by an outbreak. Under pressure to reduce budgets, we
may approve questionable practices or eliminate effective
infection prevention programs. We may be tempted to treat
influential administrators or practice groups preferentially
because they control our budgets or could curtail our pro-
grams. We may be tempted to recommend a particular product
because we have received grants from the company that makes
the product or whose stock we own. We may feel pressure to
withhold information regarding resistant organisms so that we
can transfer patients to other institutions and shorten their
length of stay in our hospital. Or perhaps we may be tempted to
condone altering hospital records to avoid losing accreditation.
What can you as an individual hospital epidemiologist or
infection preventionist do? We would recommend that you
think about your job and identify the most common questions
you answer and decisions you make. Once you have identified
these questions and decisions, you can try to identify the
ethical choices they represent. You can then develop an
approach for dealing with these issues before you face them
again, since it is easier to think more clearly and dispassio-
nately when not in the middle of a crisis. When designing such
approaches, you should obtain help, if necessary or prudent,
from experts in medicine, law, ethics, or other appropriate
disciplines.
We have described but a few of the manifold ethical chal-
lenges that confront us. Against our ambitions and our fears,

we must rely on our enduring values, commitments, and con-
tinual self-examination as we strive to meet the challenges
posed by our work. We must ask ourselves difficult questions.
Are we serving ourselves or patients and healthcare workers?
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 Chapter
The Infection Control Committee
2 David A. Pegues, MD
Introduction
The infection control committee plays an important role in
ensuring patient safety through the prevention and control of
infections in healthcare facilities. This committee is a mechanism
for the infection prevention program to report activities, includ-
ing infection metrics, outbreaks, and infection prevention and
control interventions. The infection control committee also
develops and approves policies and procedures on infection
surveillance, prevention, control, and education. The infection
control committee is an important liaison between departments
responsible for patient care and supporting departments, such as
pharmacy, environmental services, and facilities. The committee
should report to the facility’s medical board and/or senior leader-
ship to ensure executive engagement and support for prevention
activities.
Infection control committees vary in their scope of respon-
sibility and membership size, depending on whether they serve
a single healthcare facility or a local, regional, or national
health system. Regardless of size, most infection control com-
mittees function in a reporting capacity, typically reviewing
and approving reports and policies developed by content
experts who are members of the committee.
Membership
The infection control committee is generally comprised of
members from a variety of disciplines within the healthcare
facility. Representation may include the following: physicians,
nursing staff, infection prevention practitioners, quality assur-
ance personnel, and risk management personnel, as well as
representatives from the microbiology laboratory, surgery
department, central sterilization and processing, environmental
services, pharmacy, facilities management, dietary services,
occupational health, and local public health. Physician and nur-
sing staff members often are drawn preferentially from the high-
volume and high-risk departments and represent important
constituencies in infection control and prevention, including
critical care, surgery, and those that care for immunocompro-
mised patients (e.g., hematology/oncology, solid organ trans-
plantation). Members of the committee should hold leadership
positions or positions of influence in the hospital in order to
serve as opinion leaders and to effect change when necessary.
Members may be nominated by their departments and should
be engaged and effective communicators. Ordinarily, member-
ship on the committee is ongoing with periodic (e.g., annual)
reappointment, but additional staff members may be asked to
provide ad hoc input as the need arises.
Role and Functions of the Committee
The infection control committee functions to prevent and
control healthcare-associated infections by setting infection
control policy and monitoring practices to reduce these risks.
Preventing healthcare-associated infections has become highly
technical. Therefore, the bulk of the committee’s work is best
accomplished by a core of experts that include the hospital
epidemiologist, infection preventionists, a microbiologist, and
the director of employee health. Policies should be developed
by this subgroup along with other experts on an ad hoc basis
and brought to the entire committee for review, approval,
and support from political and administrative standpoints.
Committee members then assist in disseminating, gaining buy-
in, and monitoring issues associated with new and existing
policies from their departments.
There are a number of important core functions of the
infection control committee, including the following:
• Reviewing infection control surveillance data and
developing appropriate infection control goals and control
plan.
The infection control committee collaborates with the
infection prevention team to develop the annual
infection prevention objectives and goals and assists in
effective implementation and monitoring progress
toward these goals. To meet these goals, surveillance
data that have been collected and analyzed by the
infection prevention program are regularly reviewed,
interpreted, and discussed at committee meetings.
Surveillance summaries can be electronically distributed
before the meeting along with the agenda and other
documents for prereview or may distributed at the
meeting. The frequency of reporting should be defined
(e.g., monthly, bimonthly, quarterly) and surveillance
data presented in such a way as to trend performance
over time and compare year-to-date performance
against internal and external benchmarks. Corrective
actions and responsible individuals should be identified
and documented in the meeting minutes. Progress and
barriers to implementation of the action plan are then
discussed and addressed at subsequent meetings.
• Discussing and developing plans for the control of
outbreaks and monitoring implementation as needed.
Reviewing the management of outbreaks is another
important function of the infection control committee (see
Chapter 11 on outbreak investigations). Members of the
13
 David A. Pegues
committee undoubtedly will be leading or participating as
members of the investigation team. These individuals, and
not the committee as a whole, are responsible for making
real-time decisions about control measures and assessing
their impact. The committee’s role primarily should be
advisory and consultative, and this function is an important
part of the quality improvement process. The committee
also is likely to be engaged in preparedness planning and
response to emerging global public health threats (e.g.,
Ebola virus and MERS-CoV) as well as local community
threats (e.g., vaccine-preventable disease outbreak in
a susceptible population). Successful prevention and control
of infections require careful planning, including evaluation
of the technical evidence supporting efficacy of an
intervention, education, measurement, and monitoring to
ensure impact and sustainability. The infection control
committee supports the mission of infection control by
establishing important alliances and advocacy, and
spreading and sustaining prevention and control efforts
throughout the hospital or health system.
• Approving infection control–related policies and
procedures before submission to the medical board.
It is more efficient to have working groups of experts draft
and edit infection control policies before distributing them
to committee members in advance of the next meeting.
New and existing policies are then summarized in the
meeting where committee members offer comments and
formal approval is sought. Once approved by vote of the
committee, these policies and procedures are submitted to
the medical board for approval.
• Providing infection control input and guidance to ensure
the safety of the hospital environmental and employees.
The infection control committee and its members share
responsibility for ensuring the safety of the hospital
environment, including hospital construction and
renovation activities, environmental services, sterilization
and disinfection, and occupational health of employees.
The committee should include standing members
representing each of these departments. These members
typically serve as liaisons to their departments and work
collaboratively with infection prevention program
personnel on relevant infection control issues both within
and outside of the infection control committee meetings.
• Serving in an advisory capacity to senior medical and
administrative leadership of the facility.
The committee serves an important advisory role to senior
leadership, informing them of infection control risks and
hazards and proposing interventions to address these issues.
• Compliance with benchmarks.
The infection control committee should periodically
review compliance with facility-specific and national
infection prevention benchmarks. These may include
employee hand hygiene compliance and seasonal influenza
14
coverage rates, or performance on infection control
process measures such as perioperative antimicrobial
prophylaxis and infection prevention bundles.
By reviewing and discussing such data, the committee can
help to identify variations in practice at the unit or
provider level and address barriers to achieving the goals.
• Compliance with regulatory requirements.
The infection control committee may need to develop
guidelines to help clinicians comply with external regulatory
requirements. Examples include institutional guidelines on
notifiable disease reporting, consent requirements for human
immunodeficiency virus testing, and policies governing work
fitness and professional activities of healthcare workers
infected with bloodborne pathogens or other communicable
diseases. In addition, The Joint Commission requires that
hospitals have written infection control policies and
procedures needed to conduct the organization’s mission
effectively. The infection control committee reviews and
approves the annual infection control surveillance plan and
risk assessment and is charged with evaluating and ensuring
compliance with The Joint Commission infection control
standards, including all relevant elements of performance
and national patient safety goals.
• Promoting and facilitating the education and compliance
of all staff in infection control policies and procedures.
The infection control committee plays an important role in
developing and disseminating infection control education
for employees. The committee may have primary
responsibility for content development or share the
responsibility with the education department. This includes
required infection control and bloodborne pathogen
training for employees at the time of hire and annually
thereafter as well as role-specific infection control (e.g.,
medical device cleaning and disinfection). In addition, the
infection control committee also helps to develop,
coordinate, and disseminate education plans for new
infection control policies and practices. Examples included
interventions that directly affect patient care (e.g.,
chlorhexidine gluconate bathing, catheter dressing
products, nurse-driven urinary catheter removal protocols),
environmental control (e.g., disinfectant products), or
health and safety of employees (e.g., safety sharps devices,
latex-free examination gloves). Whatever the education
methods used (e.g., in-servicing, huddles, screen savers,
posters, email), this information should be effectively
messaged to all impacted employees. In these ways, the
committee acts as a facilitator between other departments to
improve implementation of new infection control practices.
Responsibilities of the Chair
The chair is most often a physician who has training and
expertise in infectious diseases and healthcare epidemiology.
The chair provides scientific and administrative leadership to
the committee and is typically appointed or approved by the

medical board. The chair is responsible for reviewing the
membership list annually to ensure adequate representation
from appropriate departments and for replacing members who
have poor attendance, are unable to fill their role, have
accepted different positions, or have left the organization.
The chair also may appoint special subcommittees or task
forces or ad hoc members to address specific infection control
issues that arise.
To be effective, the chair should be familiar with and utilize
effective meeting practices. These include attention to meeting
preparation, facilitation, participation, and evaluation.
An effective chair, along with his/her administrative support,
organizes meeting logistics and distributes the agenda and
documents that require review before the meeting. The chair
ensures that meetings start and end on time, and keep to the
agenda. For example, the meeting may open with an optional
members “check in,” in which members are invited to contri-
bute immediate concerns to the opening of the meeting. This
“check in” serves to bring busy people to the purpose of the
meeting so that they can receive support or put issues aside for
the meeting. The chair must be an effective facilitator, listening
attentively and respectfully, and he/she should encourage the
participation of many members in the discussions. Verbally
summarizing decisions and assigning action items helps to
avoid misunderstandings and moves the agenda forward.
Minutes record the decisions of the meeting and the actions
for follow-up and help to ensure that the plans and actions
decided upon by the committee are implemented.
In addition to these administrative functions, the chair
serves as an expert consultant to the hospital and departments
on infection control and prevention matters. The chair typi-
cally acts as spokesperson for the infection control committee
when reporting to the medical board and other hospital-wide
committees and often is called upon to justify to senior leader-
ship the evidence supporting the committee’s infection control
recommendations, and their potential costs and benefits.
Responsibilities of the Members
Members of the infection control committee should be selected
both for their willingness to serve and for their ability to work
collaboratively on committee activities. Members should
attend the meetings regularly and, when unable to attend,
should identify a delegate to attend in their place. Members
need to be effective communicators, as they must bring for-
ward infection control–related concerns and report back com-
mittee activities and decisions for those whom they represent.
Ideally, members should be in a position of influence and have
decision-making capacity for their departments to facilitate
implementation and compliance with infection control poli-
cies and practices. In addition, many members of the commit-
tee have important committee reporting functions. Table 2.1
lists the reports that are often presented to the committee
during meetings and the corresponding responsible committee
member. Not all reports or responsible members are applicable
in all healthcare settings. The frequency of these reports will
vary but should occur no less than annually and more often,
depending on the local needs.
The Infection Control Committee
Administrative Matters
Committee meetings should be held at a recurring day, time,
and location with a frequency typically ranging from monthly to
quarterly. The agenda should be planned and distributed to
committee members before the meeting. In addition, all policies
should be distributed before the meeting to allow adequate time
for review and comment by committee members and to improve
meeting efficiency. As a token of appreciation to members, food
and/or beverages should be provided, budget permitting.
The meeting agenda may begin with introduction of new
members or visiting attendees and then correction and
approval of the minutes of the previous meeting. This may be
followed by invitation for the members to provide brief, infor-
mal reports or “check ins,” as appropriate. Old business should
be limited, as much as possible, to updating progress toward
completing action items from prior meetings and to ongoing
outbreak investigations or response to public health emergen-
cies. A healthcare infection surveillance summary is presented,
including infection counts, rates, and benchmark performance
and opportunities for improvement are discussed. Brief, 5-to-
10 minute department-specific infection control reports are
presented on a recurring schedule and should be summarized
in the minutes and the reports attached (Table 2.1). New
business should focus on in-depth reports of selected current
infection prevention and control issues activities. These
reports can be presented either by standing or ad hoc members
or invited guests. Finally, new and revised policies should be
discussed and approved on an ongoing basis to ensure policy
content is current and that regulatory requirements are met.
Meeting Minutes
Well-documented minutes should be kept of each committee
meeting. These minutes have four major purposes: to serve as
communication tools, instruments for guiding current and pro-
posed infection prevention and control practices, legal and reg-
ulatory documents, and historic records. Minutes are useful to
notify or remind individuals of the tasks assigned to them and the
timelines, and to report actions and decisions to the medical
board, senior leadership, and other relevant committees (e.g.,
quality improvement and patient safety). Minutes are important
tools for collaborative project management, moving projects for-
ward with the aid of well-written summaries of progress and
commitments. Infection control committee minutes are consid-
ered to be confidential peer review documents in most states and
therefore are not subjected to subpoena. Regardless of applicable
law, committee minutes are reviewed by regulatory and accred-
iting agencies, and they must be accurately and objectively
reported and recorded. An institution-specific template is typi-
cally used for recording the minutes, and content is guided by the
agenda. The minutes should include sections for each topic dis-
cussed, which contain the following information: a discussion,
which is the analysis of the problem or data; a recommendation,
which describes improvement strategies; an action, which
includes what is to be done and how; and follow-up, which
describes who is responsible for what and when this issue will
be revisited to ensure improvement has occurred.
15
 David A. Pegues

Table 2.1 Infection control committee reports and responsible parties

Responsible party Reports to the infection control committee

Infection preventionist (IP)
Microbiologist or laboratory
representative
Environmental management
services representative
Pharmacist
Wound care nurse
Long-term care unit representative
Home health nurse
Occupational health and safety
Facility maintenance/engineering
representative
Recurring reports
• Healthcare-associated infection rates
• Invasive device utilization rates
• Hand hygiene compliance rates
• Isolation compliance monitoring rates
• Outbreak investigations
• Notifiable disease reports (as applicable)
• Construction project surveillance: current class 3 or 4 Infection Control Risk Assessment
(ICRA) projects
• Mandatory training reports
• Pressure ulcers/wound care report (may be assigned to the Wound Care Nurse or long-term
care facility member)
Annual Reports
• Infection control report
• Infection control plan
• Infection control risk assessment
• Tuberculosis risk assessment
• Infection control education plan
• Bloodborne pathogen exposure control plan
• Blood culture contamination report
• Facility antibiogram (may be assigned to Pharmacy)
• Legionella urinary antigen report
• Seasonal influenza and respiratory virus surveillance report
• Quality Improvement/Quality Assurance monitors (e.g., high-touch surface cleaning report)
• Antimicrobial stewardship activities
• Facility antibiogram (may be assigned to Microbiology)
• Pharmacy compounding area biological environmental monitoring (USP 797 a standard that
outlines the requirement for compounding areas)
• Pressure ulcers/wound care (may be assigned to the IP or long-term care unit representative)
• Residents’ vaccination rates for influenza and pneumococcal vaccines
• Pressure ulcers/wound care (may be assigned to the IP or Wound Care Nurse)
• Infections in the home setting, including catheter-associated bloodstream infections (CLABSI)
• Central line device utilization rates
• Visiting nurse hand hygiene compliance (assessed by home care patient survey)
• Home health bloodborne pathogen exposure control plan
• Employee communicable disease exposure events
• Employee respirator-fit testing report
• Employee influenza vaccination rates
• Annual employee tuberculosis infection/skin test conversion rate
• Annual safety device review
• Annual bloodborne pathogens exposure control plan review
• Airflow (pressure) reports
• Legionella water culture and mitigation report
• Temperature and humidity standards for controlled areas, including operating rooms, labor
and delivery rooms, and isolation rooms

16
 The Infection Control Committee

Table 2.1 (cont.)

Responsible party Reports to the infection control committee

Food services
Surgical services representative
Sterile processing representative
Public health representative
Dialysis
• Food safety quality indicator report
• Food safety and sanitation inspection reports
• Immediate-use steam sterilization (flash) report
• Operating room temperature/humidity report
• Surgical Care Improvement Project quality measure report (e.g., antibiotic prophylaxis)
• Temperature/humidity report
• Sterilizer biologic indicator report
• Instrument recall notifications
• Local community outbreaks and communicable disease trends
• Dialysis water and dialysate culture report

Suggested Reading
Friedman C, Barnette M, Buck AS, et al.
Requirements for infrastructure and
essential activities of infection control
and epidemiology in out-of-hospital
settings: a consensus panel report.
Association for Professionals in Infection
Control and Epidemiology and Society
for Healthcare Epidemiology of America.
Infect Control Hosp Epidemiol 1999;20:
695–705.
Pigeon Y, Khan O. Leadership lesson: tools
for effective team meetings – how I learned
to stop worrying and love my team. Available
at www.aamc.org/members/gfa/faculty_vi
tae/148582/team_meetings.html. Accessed
October 16, 2015.
Schirling J. Effective meeting management.
In: Gassiot CA, Searcy VL, Giles CW, eds.
The Medical Staff Services Handbook:
Fundamentals and Beyond. 2nd ed. Sudbury,
MA: Jones & Bartlett Publishers; 2011.

17
 Chapter
Product Evaluation

3 David A. Pegues, MD

Background desired performance at the lowest overall cost. Value analy-

sis brings together users who have clinical product
According to the Association of Value Analysis Professionals,
knowledge, financial analysts, and those with purchasing
the average healthcare organization utilizes anywhere from
expertise in order to make best-valued product and service
5,000 to 17,000 products, services, and technologies in any
acquisition decisions. In many hospitals, there are separate
given year.1 Medical product evaluation is the process of
value and analysis and products committees. Where such
appraising the value and significance of quality, safety, cost,
a distinction exists, value-analysis committees often focus
standardization, user preference, and serviceability of a device.
their evaluation on higher-cost medical devices and technol-
Product evaluation and selection centers on collaborative deci-
ogies whereas products committees typically focus on high-
sion making within a formal organizational structure, most
volume medical consumables, such as isolation gowns,
often consisting of an interdisciplinary committee with defined
gloves, bathing products, and disinfectants.
membership, governance structure, and policies and proce-
The role of infection prevention in safety product evalua-
dures for reviewing, procuring, and assessing new products
tion was initially emphasized in the US Department of Labor
for the hospital. A wide range of representatives from all
Occupational Safety and Health Administration (OSHA)
relevant clinical and nonclinical areas of the organization
Needlestick Safety Prevention Act of 2000.2 In recent years,
should participate, including nurses, physicians, materials
prevention of healthcare-associated infections is increasingly
management, hospital administrators, finance, and purchas-
a focus in marketing claims that are used to justify the differ-
ing, as well as infection prevention. Interdisciplinary and col-
ential cost of new products and technologies. Infection pre-
laborative evaluation allows stakeholders to voice their
vention personnel have an important role in the evaluation of
opinions and concerns and promotes transparency in the pro-
products that may affect rates of healthcare-associated infec-
duct selection process.
tions to determine whether they are clinically safe, effective,
Product selection and evaluation is an integral part of the
and justify the added cost. This role includes the requirement
value analysis process, but as illustrated by Figure 3.1, value
for technical knowledge and expertise in the following aspects
analysis is more comprehensive, involving the intersection
of product evaluation:
of product selection and evaluation. Value analysis is the
organized, systematic application of recognized techniques • Infection risks to patients and personnel
that identify the functions of a product or service.3 Value • Asepsis of sterile products
analysis seeks ways to enhance value by providing the • Cleaning and disinfection or sterilization of reused
products/equipment
• Proper disposal of items/products if not reusable

PRODUCT In addition to the technical expertise that healthcare epi-

USERS demiologists and infection preventionists possess, there are
VALUE ANALYSIS Clinical Product
Review and Evaluation
regulatory considerations that drive infection prevention per-
Knowledge and
sonnel to be involved in product evaluation. The Joint
Evaluation
Commission infection control standards require that organi-
zations reduce the risk of infections associated with the use of
medical equipment, devices, and supplies, and products eva-
PURCHASING luation is a critical step in the process.
FINANCE Vendor
Cost-Benefit Management
Knowledge and Contracting
Knowledge
Steps in Product Evaluation
The five core product attributes of medical devices are safety,
quality, performance, features, and ease-of-use. The process of
product evaluation includes the following steps that have
Figure 3.1 Central position of value analysis in relation to product users,
purchasing and finance
been adapted from the Centers for Disease Control and
Source: What Is Value Analysis in Healthcare? WellStarr Health System Georgia, Prevention’s (CDC) Workbook for Designing, Implementing,
USA. Available at ww.iienet.org/uploadedfiles/Webcasts/SHS_VA_Presentation.pdf. and Evaluating a Sharps Injury Prevention Program:4
18

1. Organize a product selection and evaluation team:
a. Organizations should designate a team to guide the
selection, evaluation, and implementation of infection-
prevention devices. This team is usually implemented as
a formal, standing product-evaluation committee or
designated subcommittee.
b. Assign responsibility for coordinating the process
and obtain input from persons with clinical expertise
(e.g., Environmental Services director for surface
disinfectants, critical care nurse specialist for central
line dressings).
2. Set priorities for product consideration:
a. Define priorities based upon the facility’s rates of
healthcare-associated infections, needlesticks, and other
data, such as audits of device maintenance practices for
defects in processes of care.
3. Gather information on the use of the conventional
(existing) device:
a. Must obtain information on use of the conventional
product (device) that it is replacing.
b. Frequency of use and purchase volume.
c. Purpose(s) for which device is used.
d. Compatibility issues with other devices it is used with
(e.g., chlorhexidine gluconate and skin care products;
central venous catheter (CVC) lock solutions and CVC
integrity).
e. Unique clinical needs. If yes, representatives from these
areas should be included in the team.
4. Establish criteria for product selection and identify other
issues for consideration:
a. Design criteria – physical attributes of device, required
features for clinical needs.
b. Performance criteria – how a device functions for its
intended patient care and safety needs.
c. The product’s environmental impact should also be
assessed, including whether the product will be recycled
or reused (e.g., isolation gown) and what method is used
for disposal (e.g., high-level disinfectant requiring
stringent handling and disposal).
5. Obtain information on available products from the
following sources:
a. Primary peer-reviewed literature, when available.
b. Evidence reviews from an evaluation organization, such
as University HealthSystem Consortium and ECRI
Institute.
c. Professional resources, including professional societies
(AORN, APIC, SHEA) and the product manufacturers.
Manufacturers’ representatives can provide clinical and
technical data, including product research, material
safety data sheets, and cleaning and disinfection/
sterilization methods, as appropriate.
d. Opinions and experience of materials management and
colleagues in other similar facilities.
Product Evaluation
6. Obtain samples of products under consideration.
7. Develop a product evaluation survey form:
a. This form must contain the information necessary to
make informed decisions for final product selection.
Criteria may include safety, performance, quality,
efficiency, ease of use, compatibility with other
products; clinical effectiveness; financial impact
analysis; sterilization parameters; regulatory
requirements; standardization; environmental impact;
and training requirements.
b. The form that is easiest to complete is usually one or two
pages and allows users to circle or check responses using
standardized scoring criteria, such as use of a graded
opinion or Likert-type scale (e.g., strongly agree, agree,
disagree, strongly disagree).
c. Allow space for comments. Healthcare personnel should
be given an opportunity to comment on a device.
Individual comments can provide useful insights and
identify areas for further questioning.
d. Include questions about product users. Unless a product
evaluation is confined to a single unit and/or group of
staff, information on the respondents (e.g., occupation,
length of employment and/or work in the clinical area,
training on the new device) is helpful in assessing how
different groups react to the new device.
8. Develop a product evaluation plan:
a. Select clinical areas for evaluation. Include patient-care
areas with unique or compelling clinical and at-risk
populations (e.g., intensive care units for products
focused on device-associated infections).
b. Determine the duration of evaluation. Consider
frequency of device use and learning curve to become
familiar with the device. Balance staff interest with need
for sufficient product experience. If more than one
product is being evaluated, use the same population and
trial duration for each product.
c. Plan for staff training. Healthcare personnel
participating in an evaluation must understand how to
use the new device properly. Training should be tailored
to the audience needs and include discussion about why
the change is being proposed, how the evaluation will
proceed, and what criteria will be used to evaluate
product performance (e.g., ease of use, end-user
preference, durability, performance of device)
d. One efficient approach to training is to utilize a team
consisting of in-house staff and device manufacturer’s
representatives
9. Compile data from the survey forms:
a. Depending on the number of staff involved and survey
forms completed, this can be done either by hand or by
use of a computerized database. It is useful to score
each question in addition to the overall response,
particularly if evaluating two or more devices;
responses to each question can be used to compare
devices. In addition, categorize individual comments so
19
 David A. Pegues
they provide a better picture of the clinical experience
with the device.
b. Consider calculating response rates by occupation and
clinical area and analyzing data by these variables, if the
volume of responses permits. This can help identify
differences in opinion that may be influenced by
variations in clinical needs.
10. Perform financial impact analysis:
a. Should be performed on each product and can help to
clarify the choice between different products with
equivalent performance and functionality.
b. This analysis should include direct costs (e.g., cost of the
replacement product), indirect costs (e.g., costs
associated with the use of the device after purchase,
including training, disposal, time analysis) and group
purchasing organization contract pricing.
11. Select and implement the preferred product:
a. Learning reports from the education and training of staff
on the evaluation units are invaluable in spreading use of
the product and standardizing practice across patient-
care areas.
b. Interdepartmental and health system standardization
plan should be developed for each product being
evaluated. Standardization can reduce cost and decrease
variations in practice that contribute to medical errors.
It also reduces inventory and storage requirements and
user training.
12. Perform postimplementation monitoring:
a. New product performance and user satisfaction should
be evaluated at planned intervals, including the
frequency and criteria for reevaluation. This may
correspond to the length of the contract.
b. At the provider level, monitoring should focus on
compliance and satisfaction with use of the product.
c. At the unit and hospital level, it is important to assess
whether the product has been associated with the
desired clinical outcome and if not, why not. In the case
of devices that impact the risk of healthcare-associated
infections, use of surveillance data can help to inform
these periodic evaluations, especially when correlated
with data on compliance with product use.
Assessing the Evidence
When available, evidence from peer-reviewed medical litera-
ture should be utilized when evaluating the clinical efficacy of
a medical product and the data quality, consistency, limita-
tions, and potential biases should be considered.5 However, the
Food and Drug Administration’s (FDA) regulatory policy is
largely responsible for the rapid introduction and large quan-
tity of medical devices coming to market and the lack of clinical
efficacy data for the majority of these devices. While all new
drugs must undergo rigorous premarketing testing in rando-
mized clinical trials to receive FDA approval, most new
20
Table 3.1 Comparison of differences between medical devices and drugs
that impact evaluation of clinical efficacy
Devices Drugs
Constantly evolving Unchanging compound
Complications decrease Complications increase
with use with use
Results vary with operator Results unrelated to provider
skill and experience skill and experience
Limited premarketing assess- Extensive premarketing
ment of safety and efficacy assessment of safety and
efficacy
Low-quality evidence base High-quality evidence base
medical devices and products do not require such evaluation.
Some of the differences between medical devices and drugs are
outlined in Table 3.1. About half of medical devices that are
marketed each year are considered low-risk products (e.g.,
bandages, surgical drapes) and are exempt from premarketing
review. New products that have undergone incremental change
to a previously marketed version (e.g., dialysis catheters, endo-
scopes) are considered medium-risk. For these products, the
FDA requires only a premarketing notification application
(510 k), because they are assumed to be essentially equivalent
to those already approved.6 Because the data are not required,
manufacturers have little incentive to undertake studies to
answer relevant clinical questions, including the impact of
devices on reducing the risk of healthcare-associated infec-
tions. As a result, many manufacturers rely upon data from
in vitro studies or laboratory model systems to support claims
of efficacy in reducing healthcare-associated infections.
Making the Business Case/Cost
Effectiveness
If a change in product that may be more expensive but provides
clinical value is being proposed, it must be shown that the
product will achieve the desired results (e.g., reduce infections,
produce a better clinical outcome).7 Optimally, cost/benefit
analysis should include the facility’s actual costs and revenue.
For example, the difference between reimbursement for
patients and the actual hospital costs associated with patients
is their contribution margin. If the product being evaluated is
aimed at reducing surgical site infections (SSIs), then one
should compare the contribution margin for those patients
with SSIs versus those without this complication. That differ-
ence (delta) provides data on actual costs and can be compared
with clinical/healthcare-associated infection data to determine
whether change is warranted.
Another method to assess cost effectiveness of an infection
control product is to compare direct cost avoided in preventing
infections to the incremental cost of the product. Reductions in
rates of the targeted healthcare-associated infection can be
estimated from pilot evaluations within the facility and from
Another random document with
no related content on Scribd:
 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN