Time for a renewed focus on the role of cleaners in achieving safe health care in low- and middle-income countries

Research priorities to strengthen environmental cleaning in healthcare facilities: the CLEAN Group Consensus

Environmental cleaning is essential to patient and health worker safety, yet it is a substantially neglected area in terms of knowledge, practice, and capacity-building, especially in resource-limited settings. Public health advocacy, research and investment are urgently needed to develop and implement cost-effective interventions to improve environmental cleanliness and, thus, overall healthcare quality and safety. We outline here the CLEAN Group Consensus exercise yielding twelve urgent research questions, grouped into four thematic areas: standards, system strengthening, behaviour change, and innovation.

Infection prevention and control: knowledge, practices and associated factors among cleaners at a National Referral Hospital in Uganda

Background

While most infection prevention and control (IPC) studies focus on healthcare professionals, IPC is everyone's responsibility in any healthcare facility. There is little known about the IPC knowledge among the cleaners who are responsible for housekeeping, environmental cleaning, and waste management within hospitals. This study sought to evaluate the knowledge and practice of IPC among cleaners at Mulago National Referral Hospital (MNRH) to establish a foundation for empowering a strategic workforce that will improve IPC practices within the hospital.

Methods

A cross-sectional study was conducted among the cleaners in a national referral hospital in Uganda. The participants were purposively sampled, and data was collected using a web-based, interviewer-administered, questionnaire about IPC knowledge and practices.

Results

Of the 120 cleaners recruited, 52.5% were female. Good IPC knowledge was demonstrated in 58.3%, and 30.8% reported good IPC practices. Participants with at least 5 years' work experience had higher knowledge levels (aOR: 10.3, P=0.006, 95% CI: 2-54). Those closely supervised had lower IPC knowledge compared with those with less supervision. Participants with fixed work schedules (aOR: 0.2, P=0.028, 95%CI: 0-0.8), were less likely to exhibit good IPC practices. In addition, 63.1% were knowledgeable about waste segregation, recognising bin colours and the correct disposal of sharps and needles. Despite good compliance with personal protective equipment, poor hand-washing practices were reported. A positive correlation between knowledge and practice scores was established.

Conclusion

Hospital cleaners in a national referral hospital in Uganda IPC reported poor infection prevention practices despite good knowledge. For IPC knowledge and practice to correlate positively, ongoing practical training is vital to maintain knowledge and good practice to establish a successful IPC program.

Housefly gut microbiomes as a reservoir and facilitator for the spread of antibiotic resistance

Arthropods, such as houseflies, play a significant role in the dissemination of antimicrobial resistance (AMR); however, their impact has often been overlooked in comparison to other AMR vectors. Understanding the contribution of arthropods to the spread of AMR is critical for implementing robust policies to mitigate the spread of AMR across One Health sectors, affecting animals and environmental habitats as well as humans. In this study, we investigated the in situ transfer of a gfp-labelled AMR plasmid (IncA/C carrying an mcr-8 gene, pA/C_MCR-8) in the gut microbiota of houseflies (Musca domestica) by applying single-cell sorting, 16S rRNA gene amplicon sequencing and whole-genome sequencing. Our findings demonstrate that the pA/C_MCR-8-positive Escherichia coli donor strain is capable of colonizing the gut microbiome of houseflies and persists in the housefly intestine for 5 days; however, no transfer was detectable above the detection threshold of 10-5 per cell. The conjugative plasmid pA/C_MCR-8 demonstrated a high transfer frequency ranging from 4.1 × 10-3 to 5.0 × 10-3 per cell in vitro and exhibited transfer across various bacterial phyla, primarily encompassing Pseudomonadota and Bacillota. Phylogenic analysis has revealed that Providencia stuartii, a human opportunistic pathogen, is a notable recipient of pA/C_MCR-8. The conjugation assays further revealed that newly formed P. stuartii transconjugants readily transfer pA/C_MCR-8 to other clinically relevant pathogens (e.g. Klebsiella pneumoniae). Our findings indicate the potential transfer of AMR plasmids from houseflies to human opportunistic pathogens and further support the adoption of a One Health approach in developing infection control policies that address AMR across clinical settings.

Environmental impacts of mass drug administration programs: exposures, risks, and mitigation of antimicrobial resistance

Mass drug administration (MDA) of antimicrobials has shown promise in the reduction and potential elimination of a variety of neglected tropical diseases (NTDs). However, with antimicrobial resistance (AMR) becoming a global crisis, the risks posed by widespread antimicrobial use need to be evaluated. As the role of the environment in AMR emergence and dissemination has become increasingly recognized, it is likewise crucial to establish the role of MDA in environmental AMR pollution, along with the potential impacts of such pollution. This review presents the current state of knowledge on the antimicrobial compounds, resistant organisms, and antimicrobial resistance genes in MDA trials, routes of these determinants into the environment, and their persistence and ecological impacts, particularly in low and middle-income countries where these trials are most common. From the few studies directly evaluating AMR outcomes in azithromycin MDA trials, it is becoming apparent that MDA efforts can increase carriage and excretion of resistant pathogens in a lasting way. However, research on these outcomes for other antimicrobials used in MDA trials is sorely needed. Furthermore, while paths of AMR determinants from human waste to the environment and their persistence thereafter are supported by the literature, quantitative information on the scope and likelihood of this is largely absent. We recommend some mitigative approaches that would be valuable to consider in future MDA efforts. This review stands to be a valuable resource for researchers and policymakers seeking to evaluate the impacts of MDA.

A Qualitative Study of Factors Influencing Unsafe Work Behaviors Among Environmental Service Workers: Perspectives of Workers, and Safety Managers: The Case of Government Hospitals in Addis Ababa, Ethiopia

BACKGROUND

Environmental Service (EVS) is a term that refers to cleaning in healthcare facilities. EVS personnel are exposed to a variety of hazards, including physical, chemical, ergonomic, cognitive, and biological hazards that contribute to the development of diseases and disabilities. Recognizing the conditions that promote unsafe behavior is the first step in reducing such hazards. The purpose of this study was to (a) investigate the attitudes and perceptions of safety among employees and safety managers in Addis Ababa hospitals, and (b) figure out what factors inhibit healthy work behaviors.

METHODS

The data for this study was gathered using 2 qualitative data gathering methods: key informant interviews and individual in-depth interviews. About 25 personnel from 3 Coronavirus treatment hospitals were interviewed to understand more about the factors that make safe behavior challenging. The interviews were recorded, transcribed, and then translated into English. Open Code 4.02 was used for thematic analysis.

RESULTS

Poor safety management and supervision, a hazardous working environment, and employee perceptions, skills, and training levels were all identified as key factors in the preponderance of unsafe work behaviors among environmental service workers.

CONCLUSIONS

Different types of personal and environmental factors were reported to affect safe work behavior among environmental service personnel. Individual responsibility is vital in reducing or eliminating these risk factors for unsafe behaviors, but management's involvement in providing resources for safe work behavior is critical.

A Better Disinfectant for Low-Resourced Hospitals? A Multi-Period Cluster Randomised Trial Comparing Hypochlorous Acid with Sodium Hypochlorite in Nigerian Hospitals: The EWASH Trial

Environmental hygiene in hospitals is a major challenge worldwide. Low-resourced hospitals in African countries continue to rely on sodium hypochlorite (NaOCl) as major disinfectant. However, NaOCl has several limitations such as the need for daily dilution, irritation, and corrosion. Hypochlorous acid (HOCl) is an innovative surface disinfectant produced by saline electrolysis with a much higher safety profile. We assessed non-inferiority of HOCl against standard NaOCl for surface disinfection in two hospitals in Abuja, Nigeria using a double-blind multi-period randomised cross-over study. Microbiological cleanliness [Aerobic Colony Counts (ACC)] was measured using dipslides. We aggregated data at the cluster-period level and fitted a linear regression. Microbiological cleanliness was high for both disinfectant (84.8% HOCl; 87.3% NaOCl). No evidence of a significant difference between the two products was found (RD = 2%, 90%CI: -5.1%-+0.4%; p-value = 0.163). We cannot rule out the possibility of HOCl being inferior by up to 5.1 percentage points and hence we did not strictly meet the non-inferiority margin we set ourselves. However, even a maximum difference of 5.1% in favour of sodium hypochlorite would not suggest there is a clinically relevant difference between the two products. We demonstrated that HOCl and NaOCl have a similar efficacy in achieving microbiological cleanliness, with HOCl acting at a lower concentration. With a better safety profile, and potential applicability across many healthcare uses, HOCl provides an attractive and potentially cost-efficient alternative to sodium hypochlorite in low resource settings.