Wastewater-based monitoring reveals geospatial-temporal trends for antibiotic-resistant pathogens in a large urban community

Antimicrobial resistance (AMR) is one of the top ten global health threats, and current surveillance programs rarely monitor it outside healthcare settings. This limits our ability to understand and manage the spread of AMR. Wastewater testing has the potential to simply, reliably and continuously survey trends in AMR outside the healthcare settings, as it captures biological material from the entire community. To establish and evaluate such a surveillance, we monitored wastewater for four clinically significant pathogens across the urban area of Greater Sydney, Australia. Untreated wastewater from 25 wastewater treatment plants (WWTPs) covering distinct catchment regions of 5.2 million residents was sampled between 2017 and 2019. Isolates for extended-spectrum β-lactamases-producing Enterobacteriaceae (ESBL-E) were consistently detected, suggesting its endemicity in the community. Isolates for carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) were only occasionally detected. The flow normalized relative (FNR) ESBL-E load was positively correlated with the proportion of the population between 19 and 50 years of age, completion of vocational education and the average length of hospital stay. Collectively, these variables explained only a third of the variance of the FNR ESBL-E load, indicating further, yet-unidentified factors as a contributor to the distribution. About half of the variation in the FNR CRE load was explained by the average length of hospital stay, showing healthcare-related drivers. Interestingly, variation in the FNR VRE load was not correlated to healthcare-related parameters but to the number of schools per 10,000 population. Our study provides insight into how routine wastewater surveillance can be used to understand the factors driving the distribution of AMR in an urban community. Such information can help to manage and mitigate the emergence and spread of AMR in important human pathogens.

National Infection Control Program in Turkey: The healthcare associated infection rate experiences over 10 years

BACKGROUND

The prevalence of healthcare associated infection (HAI) is generally higher in countries with limited resources than developed countries. To address the high prevalence of HAI, Turkish Ministry of Health introduced a national infection control program in 2005.

METHODS

Device associated (DA)-HAIs routinely surveyed included ventilator associated events, urinary catheter associated urinary tract infection and central line associated blood stream infection. Rates in DA-HAI were examined from 2008 to 2017 by type of hospitals, bed capacity, and geographic location of hospitals.

RESULTS

All DA-HAIs declined significantly from 2008 to 2017 nationally for ventilator associated events from 16.69 to 4.86 per 1,000 device days (IRR = 0.29, P < .0001), catheter associated urinary tract infection from 4.98 to 1.59 per 1,000 catheter days (IRR = 0.31, P < .0001) and central line associated blood stream infection from 5.65 to 2.82 per 1,000 catheter days (IRR = 0.47, P < .0001). The rates for DA-HAIs declined significantly in hospitals with ≥200 beds and <200 bed capacity and in all 4 type of hospitals. By 2017 all DA-HAI had significantly improved across all regions.

CONCLUSIONS

The introduction of a new national surveillance system supported by a national infection control program has significantly reduced 3 major DA-HAIs that are associated with risk of treatment failure and death. The next critical step in sustaining this crucial improvement will require timely feedback to hospitals using technology and continued buy-in from clinicians for their commitment to safety associated with DA-HAIs using aspirational DA-HAI rates.

Multicultural presentation of chest pain at an emergency department in Australia

OBJECTIVE

To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non-CALD chest pain (CP) patients presenting to the ED.

METHODS

A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2-week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records.

RESULTS

There were 155 (60%) CALD and 103 (40%) non-CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac-specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8).

CONCLUSION

Both CALD and non-CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences.

Comparison of seroprevalence of SARS-CoV-2 infections with cumulative and imputed COVID-19 cases: Systematic review

BACKGROUND

Accurate seroprevalence estimates of SARS-CoV-2 in different populations could clarify the extent to which current testing strategies are identifying all active infection, and hence the true magnitude and spread of the infection. Our primary objective was to identify valid seroprevalence studies of SARS-CoV-2 infection and compare their estimates with the reported, and imputed, COVID-19 case rates within the same population at the same time point.

METHODS

We searched PubMed, Embase, the Cochrane COVID-19 trials, and Europe-PMC for published studies and pre-prints that reported anti-SARS-CoV-2 IgG, IgM and/or IgA antibodies for serosurveys of the general community from 1 Jan to 12 Aug 2020.

RESULTS

Of the 2199 studies identified, 170 were assessed for full text and 17 studies representing 15 regions and 118,297 subjects were includable. The seroprevalence proportions in 8 studies ranged between 1%-10%, with 5 studies under 1%, and 4 over 10%-from the notably hard-hit regions of Gangelt, Germany; Northwest Iran; Buenos Aires, Argentina; and Stockholm, Sweden. For seropositive cases who were not previously identified as COVID-19 cases, the majority had prior COVID-like symptoms. The estimated seroprevalences ranged from 0.56-717 times greater than the number of reported cumulative cases-half of the studies reported greater than 10 times more SARS-CoV-2 infections than the cumulative number of cases.

CONCLUSIONS

The findings show SARS-CoV-2 seroprevalence is well below "herd immunity" in all countries studied. The estimated number of infections, however, were much greater than the number of reported cases and deaths in almost all locations. The majority of seropositive people reported prior COVID-like symptoms, suggesting that undertesting of symptomatic people may be causing a substantial under-ascertainment of SARS-CoV-2 infections.

Estimating the extent of asymptomatic COVID-19 and its potential for community transmission: Systematic review and meta-analysis

BACKGROUND

Knowing the prevalence of true asymptomatic coronavirus disease 2019 (COVID-19) cases is critical for designing mitigation measures against the pandemic. We aimed to synthesize all available research on asymptomatic cases and transmission rates.

METHODS

We searched PubMed, Embase, Cochrane COVID-19 trials, and Europe PMC for primary studies on asymptomatic prevalence in which (1) the sample frame includes at-risk populations and (2) follow-up was sufficient to identify pre-symptomatic cases. Meta-analysis used fixed-effects and random-effects models. We assessed risk of bias by combination of questions adapted from risk of bias tools for prevalence and diagnostic accuracy studies.

RESULTS

We screened 2,454 articles and included 13 low risk-of-bias studies from seven countries that tested 21,708 at-risk people, of which 663 were positive and 111 asymptomatic. Diagnosis in all studies was confirmed using a real-time reverse transcriptase-polymerase chain reaction test. The asymptomatic proportion ranged from 4% to 41%. Meta-analysis (fixed effects) found that the proportion of asymptomatic cases was 17% (95% CI 14% to 20%) overall and higher in aged care (20%; 95% CI 14% to 27%) than in non-aged care (16%; 95% CI 13% to 20%). The relative risk (RR) of asymptomatic transmission was 42% lower than that for symptomatic transmission (combined RR 0.58; 95% CI 0.34 to 0.99, p = 0.047).

CONCLUSIONS

Our one-in-six estimate of the prevalence of asymptomatic COVID-19 cases and asymptomatic transmission rates is lower than those of many highly publicized studies but still sufficient to warrant policy attention. Further robust epidemiological evidence is urgently needed, including in subpopulations such as children, to better understand how asymptomatic cases contribute to the pandemic.

Estimating the extent of asymptomatic COVID-19 and its potential for community transmission: Systematic review and meta-analysis

BACKGROUND

Knowing the prevalence of true asymptomatic coronavirus disease 2019 (COVID-19) cases is critical for designing mitigation measures against the pandemic. We aimed to synthesize all available research on asymptomatic cases and transmission rates.

METHODS

We searched PubMed, Embase, Cochrane COVID-19 trials, and Europe PMC for primary studies on asymptomatic prevalence in which (1) the sample frame includes at-risk populations and (2) follow-up was sufficient to identify pre-symptomatic cases. Meta-analysis used fixed-effects and random-effects models. We assessed risk of bias by combination of questions adapted from risk of bias tools for prevalence and diagnostic accuracy studies.

RESULTS

We screened 2,454 articles and included 13 low risk-of-bias studies from seven countries that tested 21,708 at-risk people, of which 663 were positive and 111 asymptomatic. Diagnosis in all studies was confirmed using a real-time reverse transcriptase-polymerase chain reaction test. The asymptomatic proportion ranged from 4% to 41%. Meta-analysis (fixed effects) found that the proportion of asymptomatic cases was 17% (95% CI 14% to 20%) overall and higher in aged care (20%; 95% CI 14% to 27%) than in non-aged care (16%; 95% CI 13% to 20%). The relative risk (RR) of asymptomatic transmission was 42% lower than that for symptomatic transmission (combined RR 0.58; 95% CI 0.34 to 0.99, p = 0.047).

CONCLUSIONS

Our one-in-six estimate of the prevalence of asymptomatic COVID-19 cases and asymptomatic transmission rates is lower than those of many highly publicized studies but still sufficient to warrant policy attention. Further robust epidemiological evidence is urgently needed, including in subpopulations such as children, to better understand how asymptomatic cases contribute to the pandemic.

Hand hygiene - social network analysis of peer-identified and management-selected change agents

Background

Hand hygiene compliance can be improved by strategies fostering collaborative efforts among healthcare workers (HCWs) through change agents. However, there is limited information about how change agents shape the social networks of work teams, and how this relates to organisational culture. The objectives of this study were to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion.

Methods

This study, stratified in pre-, during, and post-intervention periods, was conducted between February 2017 and March 2018 in two wards at a tertiary care hospital in Malaysia. Hand hygiene promotion was facilitated either by PICAs (study arm 1) or MSCAs (study arm 2), and the two wards were randomly allocated to one of the two interventions. Outcomes were: 1) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; 2) the social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and 3) hand hygiene leadership attributes obtained from HCWs in the post-intervention period by questionnaires.

Results

Hand hygiene compliance in study arm 1 and study arm 2 improved by from 48% (95% CI: 44–53%) to 66% (63–69%), and from 50% (44–55%) to 65% (60–69%), respectively. There was no significant difference between the two arms. Healthcare workers perceived that PICAs lead by example, while MSCAs applied an authoritarian top-down leadership style. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement.

Conclusion

Despite experiencing successful hand hygiene improvement from PICAs, HCWs expressed a preference for the existing top-down leadership structure. This highlights the limits of applying leadership models that are not supported by the local organisational culture.

The association between child Schistosoma spp. infections and morbidity in an irrigated rice region in Mali: A localized study

Background

Schistosomiasis is one of the neglected tropical diseases endemic to Mali. There has been insufficient investigation of the morbidity burden in highly endemic irrigated rice areas with the ongoing mass drug administration with praziquantel. In February 2005, a year after an initial mass drug administration in 2004, we performed the first cross-sectional survey of schistosomiasis in the Kokry-Bozo village in the Office du Niger rice irrigation region. In the fourteen years since this survey, there has been almost no research into schistosomiasis morbidity in Mali due to lack of funding. Therefore, the 2005 survey supplies near-baseline data for any future research into the treatment impacts in the area.

Methods

One hundred and ninety-four children aged 6–14 years from two schools were assessed for bladder pathology by ultrasound, and for anaemia and micro-haematuria by laboratory tests. Schistosoma eggs were examined microscopically in fresh stool and urine samples. Multivariate logistic regression analysis quantified the association of Schistosoma infections with anaemia, bladder pathology and micro-haematuria. Akaike’s information criterion was used to test the assumption of linear effects of infection intensity classes and used to compare across models.

Results

The overall prevalence of schistosomiasis in 189 school children was 97%; 17% (33/189) had a single infection (S. mansoni,13%, or S. haematobium, 4%) and 80% (156/189) were co-infected with S. mansoni and S. haematobium. The overall prevalence of S. mansoni with light infection was 27% (53/194), moderate infection was 24% (47/194) and heavy infection was 42% (81/194). Of the 194 of children investigated for S. haematobium 59% (114/194) had light infection and 26% (50/194) had heavy infection. No hookworm eggs were detected.

The level of abnormal bladder pathology was 18% (35/189) with the highest found in 10–14 year old children. The prevalence of anaemia was 91% (172/189) and was twice as likely to be associated (OR 2.0, 95% CI 1.1–3.9) with S. mansoni infections than in children without infection. As infection intensity with S. mansoni increased the risk of anaemia (OR 2.0, 95% CI 1.1–3.9) also increased. As infection intensity with S. haematobium increased bladder pathology (OR 2.4, 95%CI 1.3–4.5), haematuria (OR 6.7, 95%CI 3.3–13.6) and micro-haematuria increased (OR 2.4, 95%CI 1.3–4.5).

Conclusion

Our research contributes an important micro-geographical assessment of the heavy burden of schistosomiasis and associated morbidity in children who live in the rice irrigation regions. Our literature review found that there has been very limited research conducted on the impact of the treatment to control morbidity in the ON. Therefore, there is a need to do a comparable, but more extensive, study to identify any changes in morbidity and to indicate current requirements for the control programme. Our results from 2005 called for routine integration of iron supplementation, food fortification and diet diversification into the deworming program.

Modified glove use for contact precautions: Health care workers' perceptions and acceptance

BACKGROUND

Patients colonized or infected with methicillin-resistant Staphylococcus aureus and or vancomycin-resistant Enterococcus are placed under contact precautions. Contact precautions require patients to be placed in single rooms and their health care workers (HCWs) to wear gowns, aprons and gloves on entry and doffing on exit. Glove use is widely accepted to be associated with poor hand hygiene compliance. We trailed the removal of gloves for contact precautions for contacts not expected to involve body fluids to improve hand hygiene between multiple contacts of the patient and patient zone.

METHODS

We have conducted a 5 phase study of the removal of gloves for contacts without body fluids in 250 HCWs using pretrial focus groups (N = 12), hand microbiology (N = 40) (reported elsewhere), development of a modified contact precautions poster, trial of modified poster (n = 100), posttrial focus group discussion (n = 22), and a survey of HCWs postrollout in additional locations (n = 76).

RESULTS

Pretrial focus groups identified 4 themes, and the leading theme identified as the facilitator for glove use as self-protection. HCWs viewed current contact precaution guidelines as preventing them from making their own judgement regarding the need for gloving for patient contacts, leading continuous glove use without changing gloves between multiple contacts. Participants believed that the trial empowered them to make their own clinical judgment for gloves and to consciously use hand hygiene between dry (no body fluid) contacts. Four themes were discussed during the posttrial focus groups and although self-protection remained the central theme, hand hygiene replaced glove use. Participants spoke of an appreciation of and increased trust in hand hygiene during nonglove use for dry contacts. The survey responses from additional sites were mostly positive for the safety of nonglove use for dry contacts, it improved hand hygiene and that the adoption of the modified guidelines was empowering.

CONCLUSIONS

The trial of nonglove use for expected dry contact, while caring for patients under contact precautions for methicillin-resistant S aureus and or vancomycin-resistant Enterococcus, was successful in refocusing HCWs reliance on hand hygiene for self-protection. Mandatory glove use for contact precautions was believed to contribute to their failure to change gloves between procedures on the same patient and patient zone, with HCWs now recognizing multiple contacts with the same gloves as a risk for contamination.

Prevalence of hepatitis B and C virus infections in hemodialysis patients in Vietnam: A systematic review and meta-analysis

Background and Aim

Chronic hemodialysis patients are at high risk of contracting hepatitis B (HBV) and C (HCV) virus infections. In Vietnam, the seroprevalence of HBV and HCV infections is approximately 10 and 4%, respectively. Although the chronic hemodialysis population is increasing, relatively little epidemiology is available for HBV and HCV infections in this population. To address this, we reviewed the current literature on the magnitude of these infections in the hemodialysis population in Vietnam.

Methods

Four databases were used to search for publications containing the prevalence of HBV and/or HCV infections in hemodialysis patients in Vietnam. Grey literature search was utilized to identify local publications. Prevalence and 95% confidence interval were used or calculated, and a meta‐analysis was conducted on HBV and HCV prevalence for comparison.

Results

Sixteen studies were included in the review. The search identified knowledge gaps in the current literature. Available data show that HBV and HCV infections remain prevalent in the hemodialysis population. HBV prevalence is not different between the north and the south of Vietnam. The pattern of HCV prevalence is different, with recent reports of lower prevalence in the south than in the north, while HCV prevalence varies between hemodialysis units in the same regions.

Conclusions

A national prevalence survey of hemodialysis patients would improve the reliability and generalizability of the findings. However, the review confirmed that both HBV and HCV were prevalent in hemodialysis patients. The findings support a reinforcement of infection prevention to minimize the risk of HBV and HCV transmission in hemodialysis facilities.

Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?

For decades, aged care facility residents at risk of pressure ulcers (PUs) have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week (24/7). Yet, PUs still develop. We used a cross-sectional survey of eighty randomly selected medical records of residents aged ≥ 65 years from eight Australian Residential Aged Care Facilities (RACFs) to determine the number of residents at risk of PUs, the use of two-hourly repositioning, and the presence of PUs in the last week of life. Despite 91 per cent (73/80) of residents identified as being at risk of PUs and repositioned two-hourly 24/7, 34 per cent (25/73) died with one or more PUs. Behaviours of concern were noted in 72 per cent (58/80) of residents of whom 38 per cent (22/58) were restrained. Dementia was diagnosed in 70 per cent (56/80) of residents. The prevalence of behaviours of concern displayed by residents with dementia was significantly greater than by residents without dementia (82 per cent v 50 per cent, p = 0.028). The rate of restraining residents with dementia was similar to the rate in residents without dementia. Two-hourly repositioning failed to prevent PUs in a third of at-risk residents and may breach the rights of all residents who were repositioned two-hourly. Repositioning and restraining may be unlawful. Rather than only repositioning residents two-hourly, we recommend every resident be provided with an alternating pressure air mattress.

Screening haemodialysis patients for hepatitis C in Vietnam: The inconsistency between common hepatitis C virus serological and virological tests

Selecting the appropriate screening method and interval for the early detection of hepatitis C virus (HCV) infection in low-resourced haemodialysis settings is a challenge. The challenge occurs when patients are classified as HCV-RNA positive but negative to HCV-core antigen (HCV-coreAg), anti-HCV and genotyping tests. We aim to clarify the inconsistency between HCV-RNA, HCV-coreAg, anti-HCV and HCV genotyping tests in haemodialysis patients and determine the reliability of HCV-coreAg as a routine two-monthly screening strategy. Haemodialysis patients were tested every 2 months between 2012 and 2014 at the largest district haemodialysis unit in Ho Chi Minh City, Vietnam, for aminotransferases, anti-HCV antibodies, HCV-coreAg, HCV-RNA and HCV genotype. HCV-coreAg and anti-HCV results were tested against HCV-RNA for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV). All 201 patients participated in the study. The HCV-coreAg test performed better than the anti-HCV test for sensitivity (100% vs 31%), NPV (100% vs 90%) and accuracy (100% vs 90%). The HCV-coreAg and anti-HCV tests performed no differently for specificity (100% and 98%, respectively) or PPV (100% and 73%, respectively). Kappa values for HCV-coreAg and anti-HCV tests were 1 and 0.39, respectively. Early detection of HCV for the purpose of infection prevention requires a high level of sensitivity and HCV-coreAg performed better in our chronic haemodialysis population as a two-monthly screening method than routine anti-HCV testing. HCV-coreAg test is less labour-intensive with a higher level of accuracy in patients with low viral loads making it cost effective for low-resourced settings. Repeating genotyping may be required in HCV-coreAg positive patients with a low viral load.

Diagnosis and drug resistance of human soil-transmitted helminth infections: A public health perspective

Soil-transmitted helminth (STH) infections represent a major public health problem globally, particularly among socio-economically disadvantaged populations. Detection of STH infections is often challenging, requiring a combination of diagnostic techniques to achieve acceptable sensitivity and specificity, particularly in low infection-intensity situations. The microscopy-based Kato-Katz remains the most widely used method but has low sensitivity in the detection of, for instance, Strongyloides spp. infections, among others. Antigen/antibody assays can be more sensitive but are parasite species-specific. Highly sensitive PCR methods have been developed to be multiplexed to allow multi-species detection. Novel diagnostic tests for all STH species are needed for effective monitoring, evaluation of chemotherapy programmes, and to assess the potential emergence of parasite resistance. This review discusses available diagnostic methods for the different stages of STH control programmes, which vary in sensitivity and spectrum of detection requirements, and tools to evaluate drug efficacy and resistance.

The Coroner's Role in the Prevention of Elder Abuse: A Study of Australian Coroner's Court Cases Involving Pressure Ulcers in Elders

The prevention of elder abuse is a health priority around the globe. The Australian Law Reform Commission's 2017 report on Australian residential aged care facilities found that neglect may constitute elder abuse and that painful pressure ulcers (PUs) fall into this category. The purpose of this article is to examine deaths from PUs in elders 65 years and older. A database search of Australian cases identified four coroner's court cases. This article considers the role and potential of coroners' recommendations to prevent PUs. The origin and site of PUs, prevention, wound and pain management, quality of care and coronial recommendations were examined. Coronial recommendations were made in two of the cases. As judicial officers with a statutory public health function, coroners have the potential to play an important role in the prevention of deaths attributable to PUs. This article makes recommendations to harness the potential of the coronial jurisdiction to prevent PUs.

Hand hygiene compliance rates: Fact or fiction?

BACKGROUND

The mandatory national hand hygiene program requires Australian public hospitals to use direct human auditing to establish compliance rates. To establish the magnitude of the Hawthorne effect, we compared direct human audit rates with concurrent automated surveillance rates.

METHODS

A large tertiary Australian teaching hospital previously trialed automated surveillance while simultaneously performing mandatory human audits for 20 minutes daily on a medical and a surgical ward. Subtracting automated surveillance rates from human audit rates provided differences in percentage points (PPs) for each of the 3 quarterly reporting periods for 2014 and 2015.

RESULTS

Direct human audit rates for the medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, 2.8-3.1 times higher than automated surveillance rates. The rates for the surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, 1.6 times higher than automated surveillance rates. Over the 6 mandatory reporting quarters, human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter. The magnitude of the Hawthorne effect on direct human auditing was not trivial and produced highly inflated compliance rates.

CONCLUSIONS

Mandatory compliance necessitates accuracy that only automated surveillance can achieve, whereas daily hand hygiene ambassadors or reminder technology could harness clinicians' ability to hyperrespond to produce habitual compliance.

Hygiene and Health: Who Do Mothers in Vanuatu Communicate with about Health?

Health information-seeking behaviour of mothers with children five years of age and younger in Vanuatu was examined using the structural properties of social networks. Data were collected from a rural village from two islands and an urban settlement in the capital, Port Vila, by face-to-face interviews using a structured questionnaire. Sociometric data on the structure of the network, the characteristics of key informants, and associations with outside sources of health information were analysed as interpersonal predictors of health promotion and behavior change. Rural mothers preferred the health advice of biomedical practitioners for diarrheal disease over traditional custom practitioners. Interpersonal connections were restricted in the urban mother network indicating that mothers were merely acquaintances or do not seek health advice from each other. Our findings suggest that biomedical practitioners are the best option for diffusing health and hygiene information for rural and urban mothers. Traditional healers and paraprofessionals could be strategically used to complete the missing links in network connectedness to optimally spread new information. The novel use of cross-sectional social network data can create a baseline evaluation to purposefully frame a health intervention. Our study provided a unique explanation of how network analysis offers insight into how key players can be identified and the circumstances in which they are likely to be able to influence hygiene practices of their peers.

Pervasive antibiotic misuse in the Cambodian community: antibiotic-seeking behaviour with unrestricted access

Background

Antibiotic misuse is widespread in resource-limited countries such as Cambodia where the burden of infectious diseases is high and access to antibiotics is unrestricted. We explored healthcare seeking behaviour related to obtaining antibiotics and drivers of antibiotic misuse in the Cambodian community.

Methods

In-depth interviews were held with family members of patients being admitted in hospitals and private pharmacies termed pharmacy attendants in the catchment areas of the hospitals. Nurses who run community primary healthcare centres located within the hospital catchment areas were invited to attend focus group discussions. Nvivo version 10 was used to code and manage thematic data analysis.

Results

We conducted individual interviews with 35 family members, 7 untrained pharmacy attendants and 3 trained pharmacists and 6 focus group discussions with 30 nurses. Self-medication with a drug-cocktail was widespread and included broad-spectrum antibiotics for mild illness. Unrestricted access to antibiotics was facilitated by various community enablers including pharmacies or drug outlets, nurse suppliers and unofficial village medical providers referred to as “village Pett” whose healthcare training has historically been in the field and not at university. These enablers supplied the community with various types of antibiotics including broad spectrum fluoroquinolones and cephalosporins. When treatment was perceived to be ineffective patients would prescriber-shop various suppliers who would unfailingly provide them with antibiotics. The main driver of the community’s demand for antibiotics was a mistaken belief in the benefits of antibiotics for a common cold, high temperature, pain, malaria and ‘Roleak’ which includes a broad catch-all for perceived inflammatory conditions. For severe illnesses, patients would attend a community healthcare centre, hospital, or when their finances permitted, a private prescriber.

Conclusions

Pervasive antibiotic misuse was driven by a habitual supplier-seeking behaviour that was enabled by unrestricted access and misconceptions about antibiotics for mild illnesses. Unofficial suppliers must be stopped by supporting existing regulations with tough new laws aimed at outlawing supplies outside registered pharmacies and fining registered pharmacist/owners of these pharmacies for supplying antibiotics without a prescription. Community primary healthcare centres must be strengthened to become the frontline antibiotic prescribers in the community thereby enabling the community’s access to inexpensive and appropriate healthcare. Community-based education program should target appropriate health-seeking pathways and the serious consequences of antibiotic misuse.

Social cohesion: The missing factor required for a successful hand hygiene program

BACKGROUND

There are limited explorations into hospital staff reactions to automated hand hygiene surveillance or hand hygiene interventions.

METHODS

An automated surveillance system with daily feedback and a behavioral intervention component was trialed in 2 wards in an Australian tertiary teaching hospital. After 9 months, 12 clinicians from each ward were interviewed prior to the completion of the trial to explore satisfaction with the system and behavioral component of nudging each other with a reminder to comply. Only on completion of the trial were transcripts analyzed for themes.

RESULTS

Staff from the ward with improved compliance described a socially cohesive team with a well-liked nurse unit manager who accessed daily compliance rates and worked with staff to set goals. This contrasted with the ward without improvement in compliance, whose staff described their great reluctance and discomfort to nudge each other to comply and distrust of the authenticity of the rates established from the automated system.

CONCLUSIONS

Interventions for improving compliance are more likely to be successful in a ward with a social cohesive team. Patient safety interventions, in the first instance, may benefit from purposeful selection of wards with cohesive teams and skilled leaders who can transform clinicians into early adopters of the program.

STOP THE CYCLE OF CONTAMINATION AND DEATH

Pressure ulcers (PUs) are a serious adverse event for patients that could be prevented (Thomas, 2001). Immobility and the resulting unrelieved pressure (Sharp and McLaws, 2006; Gefen et al. 2008) on muscle tissue overlying bony prominences is thought to be a major risk factor for deep tissue injury (Gefen et al. 2008).

Dangerous practices in a hemodialysis unit in Vietnam identify from mixed methods

BACKGROUND

Non-compliance with infection control practices poses a serious risk to patients receiving chronic hemodialysis. We aimed to identify the type and frequency of non-compliance with infection control practices in a hemodialysis unit in Vietnam where a large outbreak of hepatitis C infection had occurred.

METHODS

Mixed methods approach included observations and discussions of non-compliance with all 12 nurses at the Hemodialysis Unit, District-6 Hospital in Ho Chi Minh City. Observations of nursing care activities were made between September 2013 and January 2014. Compliance with hand hygiene and glove use during nursing care activities were classified according to the potential for a serious risk of transmission of infection and reported as percentages. Each nurse was expected to provide 11 nursing care activities to three patients assigned per hemodialysis sessions. Activities were to be given on an individual patient-centered care basis, that is, one patient was to receive all 11 activities by their assigned nurse. On completion of the observations all nurses were enrolled in a focus group where observed non-compliance was discussed and transcripts were examined for themes.

RESULTS

Hand hygiene compliance rate was low (27%, 95%CI 25%-28%, 1633/6140) regardless of classification of seriousness of risk from this breach. Although glove use (76%, 95%CI 74-78%, 1211/1586) and other personal protective equipment use (81%, 95%CI 78%-83%, 773/959) were high gloves were observed to be reused with multiple patients during a single nursing care activity provided to consecutive patients. Nurses explained the breakdown of providing nursing care activities on an individual patient-centered basis was a response to limited supply of gloves and hand hygiene facilities and was exacerbated by nursing being co-opted by overly demanding patients to provide services without delay.

CONCLUSIONS

The adaption by the nurses to provide 11 single care activities to multiple consecutive patients in the absence of changing gloves and low hand hygiene compliance was potentially the central risk factor that facilitated the hepatitis C outbreak. Patient-centered care needs to be enforced to minimize multiple nurse-patient contacts that are associated with non-compliance classified as serious risk of infection transmission. Nurse empowerment to resist unreasonable patient demands may also be pivotal to assisting their compliance with hand hygiene and single patient-centered care. An audit program to measure infection control resources and practices may facilitate enforcement of the guidelines.