Quality of water for reprocessing of medical devices in healthcare facilities in Nepal.

Reusable medical devices are decontaminated and sterilized often many times by healthcare facilities across the globe. Reprocessing of medical devices comprises several processes and water plays an important role in some of these, including cleaning and steam sterilization. The water used is required to have certain qualities to ensure the effectiveness of the processes. In this short communication, we report findings of our study which measured quality parameters (pH, total hardness) for water used for medical device reprocessing in 13 primary and secondary care public hospitals in Nepal. The mean pH of water used for reprocessing of medical devices varied from 6.48 to 8.05 across the hospitals whereas the mean total hardness of water varied from 5.93 to 402.50 mg/L CaCO3. Although the range of the mean water pH across hospitals fell within the recommended range, many of the hospitals had mean total hardness higher than recommended for cleaning medical devices. None of the hospitals had mean total hardness suitable for using as feed-water for steam generation. Public hospitals in Nepal should have appropriate water treatment systems so that the recommended water quality can be achieved to ensure effective decontamination and reprocessing of medical devices.

Compliance of primary and secondary care public hospitals with standard practices for reprocessing and steam sterilization of reusable medical devices in Nepal: findings from nation-wide multicenter clustered audits.

BACKGROUND: Reusable medical devices in healthcare facilities are decontaminated and reprocessed following standard practices before each clinical procedure. Reprocessing of critical medical devices (those used for invasive clinical procedures) comprises several processes including sterilization, which provides the highest level of decontamination. Steam sterilization is the most used sterilization procedure across the globe. Noncompliance with standards addressing reprocessing of medical devices may lead to inadequate sterilization and thus increase the risk of person-to-person or environmental transmission of pathogens in healthcare facilities. We conducted nationwide multicenter clustered audits to understand the compliance of primary- and secondary-care public hospitals in Nepal with the standard practices for medical device reprocessing, including steam sterilization. METHODS: We developed an audit tool to assess compliance of hospitals with the standard practices for medical device reprocessing including steam sterilization. Altogether, 189 medical device reprocessing cycles which included steam sterilization were assessed in 13 primary and secondary care public hospitals in Nepal using the audit tool. Percentage compliance was calculated for each standard practice. Mean percentage compliances were obtained for overall primary and secondary care hospitals and for each hospital type, specific hospital and process involved. RESULTS: For all primary and secondary care hospitals in Nepal, the mean percentage compliance with the standard practices for medical device reprocessing including steam sterilization was 25.9% (95% CI 21.0-30.8%). The lower the level of care provided by the hospitals, the lower was the mean percentage compliance, and the difference in the means across the hospital types was statistically significant (p < 0.01). The mean percentage compliance of individual hospitals ranged from 14.7 to 46.0%. The hospitals had better compliance with the practices for cleaning of used devices and transport and storage of sterilized devices compared with the practices for other processes of the medical device reprocessing cycle. CONCLUSION: The primary and secondary care hospitals in Nepal had poor compliance with the standard practices for steam sterilization and reprocessing of medical devices. Interventions to improve compliance of the hospitals are immediately required to minimize the risks of person-to-person or environmental transmission of pathogens through inadequately reprocessed medical devices.

Multiple sclerosis in New Zealand Maori.

The prevalence of MS in New Zealand in 2006 was 73.2 (age standardized per 100,000) while for those with indigenous Maori ancestry it was 3.6 times lower at 20.6. Earlier regional surveys (1968-2001) all reported much lower, or zero, prevalence for Maori than European. There was no evidence for differences in MS between those with and without Maori ancestry in either clinical features or latitude, confirming that Maori ancestry does not produce the reported increase in prevalence with latitude. It is likely that prevalence is increasing in low risk Maori; however, MS prognosis is independent of Maori ancestry.

Investing in public health: barriers and possible solutions.

BACKGROUND: Health care is a less important determinant of health than behaviour and the environment but paradoxically, spending on health in most countries suggests the opposite. What determines these health policy and funding decisions, and might there be ways to increase investment in public health? METHODS: Published papers, reviews and reports on the cost-effectiveness of public health interventions and barriers to investment in public health were reviewed. RESULTS: There is evidence to support investment in public health. Many public health interventions have been shown to save money, and some have cost-effectiveness ratios better than or equivalent to health care interventions. Despite this, there are recognized barriers to investing in public health. These barriers include the greater requirements for cost-effectiveness sometimes placed on public health interventions, the belief that in the long run prevention may cost more than treatment, the timeframes required for some public health interventions, the 'identifiable victim effect', the influence of interest groups, and the reality that evidence alone does not drive health policy. CONCLUSIONS: Investment in public health has the potential to deliver improved health outcomes. Strategies to address the barriers and increase investment in public health are suggested.

Healthcare workers' knowledge and attitudes towards sterilization and reuse of medical devices in primary and secondary care public hospitals in Nepal: A multi-centre cross-sectional survey.

BACKGROUND: Healthcare facilities reprocess and sterilize reusable medical devices before each invasive clinical procedure, such as surgery, to prevent person-to-person or environmental transmission of pathogens through medical devices. We conducted a nationwide multi-centre cross-sectional survey in primary and secondary-care public hospitals in Nepal to assess the knowledge and attitudes of healthcare workers towards sterilization and reuse of medical devices. METHODS: We carried out a multi-centre cross-sectional survey comprising eleven primary-care (two district-level and nine district hospitals) and two secondary-care (zonal hospitals) public hospitals which covered all seven provinces of Nepal. Survey questionnaires were distributed to 234 healthcare workers including doctors, nurses, paramedics, and office assistants (involved in medical device reprocessing); 219 (93.6%) returned the completed questionnaire. Descriptive analyses of demographic information, knowledge and attitude responses of survey participants were performed. Logistic regression and ordinal regression models for complex samples were used to investigate associations between responses and independent variables. RESULTS: Except for a few areas, more than 70% of healthcare workers had proper knowledge about different aspects of sterilization and reuse of medical devices. Paramedics and office assistants were less likely to have the correct knowledge in different aspects compared to nurses. Permanent staff were more likely to give correct answers to some knowledge questions compared to temporary staff. Previous infection control training was positively associated with correct responses to some knowledge items. Most of the healthcare workers had positive attitudes towards different aspects of sterilization and reuse of medical devices, and nurses were more likely to have positive attitudes compared with other staff categories. CONCLUSIONS: Most of the healthcare workers had correct knowledge and positive attitudes towards most areas of sterilization and reuse of medical devices. However, they need proper education and training in some areas such as sterilization procedures, storage of sterilized devices, prion decontamination and standard precautions.

Method of contraception and risk of ovarian cancer data.

The data presented here were obtained for a New Zealand nationwide population-based case-control analysis undertaken to assess the association between ovarian cancer and depot medroxyprogesterone acetate (DMPA), intrauterine contraceptive devices (IUDs), and vasectomy of a woman's sexual partner (Chesang et al., 2021). The research involved women aged 35 to 69 years. Controls were randomly selected from the New Zealand electoral roll. Cases were women with a diagnosis of incident ovarian cancer recruited from the New Zealand Cancer Registry and had to be listed on the electoral roll. Data collection was conducted between 1st May 2013 and 31st October, 2015. A structured postal questionnaire was used to gather information. Data were analysed using IBM Statistical Package for the Social Sciences (IBM SPSS statistics 22). Odds ratios adjusted for age were calculated using the method of Mantel and Haensze (Rosner et al., 2007). For multivariable analyses, binary logistic regression was used. Description of study participants and age-adjusted and multivariable analyses of the association between ever-use and specifics of use of DMPA, IUDs, and vasectomy were presented in a journal article (Chesang et al., 2021). Here, we present data from analyses of the risk of ovarian cancer by histological type associated with the use of DMPA, IUDs and ever having had a vasectomised partner. In addition, analyses assessing the association between ovarian cancer and these contraceptives restricted to ever-users and never-users of hormonal contraceptives (defined as oral contraceptives or DMPA) are presented. Data from analyses of the association between history of tubal ligation and the risk of ovarian cancer are also presented. These data, including the findings of a related study (Chesang et al., 2021) and the raw data, can be included in a collaborative analysis of existing studies undertaken to assess the association between IUDs, long-acting progestogen-based contraceptives, and partner vasectomy and the risk of ovarian cancer.

Associations of history of mental illness with smoking and vaping among university students aged 18-24 years in New Zealand: Results of a 2018 national cross-sectional survey.

OBJECTIVE: Data on associations of history of mental illness (HMI) with smoking and vaping in New Zealand (NZ) are lacking. This study examines these associations in university students aged 18-24 years. METHODS: Data came from a 2018 national cross-sectional study of university students and included information on demographic characteristics, smoking, vaping and participant health in the previous 12-months. χ2 tests compared patterns of smoking and vaping, and logistic regression assessed associations of HMI with smoking and vaping, controlling for age, gender and ethnicity. An HMI was defined as a diagnosis/treatment for depression, anxiety/nervous disorder, or other mental health condition in the previous 12-months. RESULTS: The sample comprised 1293 students: 61.3% aged 18-20; 62.8% female; 7.8% Maori, 92.2% non-Maori, and 18.5% reported an HMI. Smoking: 49.7% (95% CI 47.0-52.5) reported ever, 10.5% (8.9-12.3) current and 5.0% (3.9-6.4) daily smoking. Vaping: 38.7% (36.0-41.4) reported ever, 6.3% (5.1-7.8) current and 1.9% (1.3-2.8) daily vaping. Participants with HMI were significantly more likely to smoke: ever (64.9% vs 46.3%, p < .001), current (15.1% vs 9.5%, p = .011) and daily (7.5% vs 4.5%, p = .050), and vape: ever (49.4% vs 36.3%, p < .001) and current (9.2% vs 5.7%, p = .044) than participants without HMI. The model containing all predictors of HMI was significant, χ2 (5, N = 1293) = 24.09, p < .001. Gender (OR 0.54, (0.4-0.75)), current smoking (OR 1.82, (1.19-2.78)) and current vaping (OR 1.73, (1.02-2.93)) made unique significant contributions to the model. CONCLUSIONS: The prevalence of smoking and vaping were significantly higher in students with HMI, and there were strong associations between HMI and smoking and vaping.

Association of partner vasectomy, depot medroxyprogesterone acetate and intrauterine contraceptive devices with ovarian cancer.

PURPOSE: To assess the associations between ovarian cancer and depot medroxyprogesterone acetate (DMPA), intrauterine contraceptive devices (IUDs), and partner vasectomy. METHODS: We undertook a New Zealand-wide population-based case-control study. During 2013-2015, 205 eligible cases were identified from the cancer registry (152 [74%] participated) and 1,735 eligible controls were randomly selected from the electoral roll (837 [48%] participated). A postal questionnaire was used to gather information. RESULTS: Ever-use of vasectomy was inversely associated with ovarian cancer in age-adjusted analysis, but not in multivariable analysis (OR = 0.67, 95% CI = 0.46-0.96, and OR = 0.82; 95% CI = 0.54-1.23, respectively). A suggestive trend towards lower risk with longer duration of reliance on partner vasectomy was observed (P-trend = 0.08). Ever-use and duration of use of DMPA were not associated with ovarian cancer. Although ever-use of IUDs was not associated with ovarian cancer, duration of use of IUDs was associated with higher risk (P-trend = 0.04). There were also statistically significant inverse associations between ovarian cancer and use of oral contraceptives, parity, and breastfeeding. CONCLUSIONS: Prolonged use of IUDs may increase the risk of ovarian cancer. It is also possible that an inverse association exists between ovarian cancer and partner vasectomy.

Empty waiting rooms: the New Zealand general practice experience with telehealth during the COVID-19 pandemic.

AIM: The primary care response to the coronavirus disease 2019 (COVID-19) pandemic in early 2020 required significant changes to the delivery of healthcare by general practices. This study explores the experiences of New Zealand general practice teams in their use of telehealth during the early stages of the COVID-19 pandemic in New Zealand. METHOD: We qualitatively analysed a subtheme on telehealth of the General Practice Pandemic Experience New Zealand (GPPENZ) study, where general practice team members across the country were invited to participate in five surveys between 8 May 2020 to 27 August 2020. RESULTS: 164 participants enrolled in the study during survey one, with 78 (48%) completing all surveys. Five telehealth themes were identified: benefits, limitations, paying for consults, changes over time and plans for future use. Benefits included rapid triage, convenience and efficiency, and limitations included financial and technical barriers for practices and patients and concerns about clinical risk. Respondents rapidly returned to in-person consultations and wanted clarification of conditions suited to telehealth, better infrastructure and funding. CONCLUSION: To equitably sustain telehealth use, the following are required: adequate funding, training, processes communicated to patients, improved patient access to technology and technological literacy, virtual physical examination methods and integration with existing primary health care services.

Population-based cases control study of inflammatory bowel disease risk factors.

BACKGROUND AND AIM: The rapid increase in inflammatory bowel disease (IBD) incidence confirms the importance of environment in its etiology. We aimed to assess the role of childhood and other environmental risk factors in IBD. METHODS: A population-based case-control study was carried out in Canterbury, New Zealand. Participants comprised 638 prevalent Crohn's disease (CD) cases, 653 prevalent ulcerative colitis (UC) cases and 600 randomly-selected sex and age matched controls. Exposure rates to environmental risk factors were compared. Unadjusted and adjusted odds ratios (OR) with 95% confidence intervals (CI) are presented. RESULTS: A family history of IBD (CD OR 3.06 [2.18-4.30], UC OR 2.52 [1.90-3.54]), cigarette smoking at diagnosis (CD OR 1.99 [1.48-2.68], UC OR 0.67 [0.48-0.94]), high social class at birth (CD and UC trend, P < 0.001) and Caucasian ethnicity (CD OR 2.04 [1.05-4.38], UC OR 1.47 [1.01-2.14]) were significantly associated with IBD. City living was associated with CD (P < 0.01). Being a migrant was associated with UC (UC OR 1.40 [1.14-2.01]). Having a childhood vegetable garden was protective against IBD (CD OR 0.52 [0.36-0.76], UC OR 0.65 [0.45-0.94]) as was having been breast-fed (CD OR 0.55 [0.41-0.74], UC OR 0.71 [0.52-0.96]) with a duration-response effect. Appendicectomy, tonsillectomy, infectious mononucleosis and asthma were more common in CD patients than controls (P < 0.01). CONCLUSIONS: The importance of childhood factors in the development of IBD is confirmed. The duration-response protective association between breast-feeding and subsequent development of IBD requires further evaluation, as does the protective effect associated with a childhood vegetable garden.

VOICES: South Island pilot survey of bereaved people.

AIMS: To test the feasibility of surveying bereaved next-of-kin in the South Island about their perceptions of end-of-life care for people over 18 years of age; to report results; and to identify issues for future research. METHOD: The study used the VOICES (Views of Informal Carers Evaluation of Services) questionnaire from the UK, adapted for use in Aotearoa New Zealand. Identification of next-of-kin for all South Island deaths September-November 2017 was undertaken by a commercial firm specialising in such work. Addresses of next-of-kin were sought from the Electoral Roll, with 1,813 eligible people identified and 272 (15.0%) next-of-kin unable to be traced. Surveys were posted out once only, with options to complete by mail, online, by telephone or with a face-to-face interview. RESULTS: Of the 1,541 surveys distributed, 514 (33.4%) were completed. Results confirmed the suitability of the locally modified VOICES instrument and research process. The quality of care overall was rated most highly in hospice or own home, but only a minority were able to die in these settings. Nevertheless, relatives indicated that most people died 'in the best place'. CONCLUSIONS: The VOICES questionnaire is acceptable to respondents and there are viable methods for seeking a population sample. Aspects of the questionnaire require modification before wider use. The information obtained can help district health boards, hospices other healthcare providers, and consumers in planning for end-of-life care.

Attitudes towards the New Zealand Government's Smokefree 2025 goal associated with smoking and vaping in university students aged 18 to 24 years: results of a 2018 national cross-sectional survey.

OBJECTIVE: In March 2011, New Zealand (NZ) launched an aspirational goal to reduce smoking prevalence to 5% or less by 2025 (Smokefree 2025 goal). Little is known about university students' awareness of, support for and perceptions about this goal. We sought to narrow the knowledge gap. SETTING: University students in NZ. METHODS: We analysed data from a 2018 cross-sectional survey of university students across NZ. Logistic regression analysis examined the associations between responses about the Smokefree goal with smoking and vaping, while controlling for age, sex and ethnicity. Confidence intervals (95% CI) were reported where appropriate. PARTICIPANTS: The sample comprised 1476 students: 919 (62.3%) aged 18 to 20 and 557 (37.7%) aged 21 to 24 years; 569 (38.6%) male and 907 (61.4%) female; 117 (7.9%) Maori and 1359 (92.1%) non-Maori. Of these, 10.5% currently smoked (ie, smoked at least monthly) and 6.1% currently vaped (ie, used an e-cigarette or vaped at least once a month). RESULTS: Overall awareness of the Smokefree goal was 47.5% (95% CI: 44.9 to 50.1); support 96.9% (95% CI: 95.8 to 97.8); belief that it can be achieved 88.8% (95% CI: 86.8 to 90.7) and belief that e-cigarettes/vaping can help achieve it 88.1% (95% CI: 86.0 to 89.9).Dual users of tobacco cigarettes and e-cigarettes had greater odds of being aware of the Smokefree goal (OR=3.07, 95% CI: 1.19 to 7.92), current smokers had lower odds of supporting it (OR=0.13, 95% CI: 0.06 to 0.27) and of believing that it can be achieved (OR=0.15, 95% CI: 0.09 to 0.24) and current vapers had greater odds of believing that e-cigarettes/vaping can help to achieve it (OR=8.57, 95% CI: 1.18 to 62.52) compared with non-users. CONCLUSIONS: The results suggest strong overall support for the Smokefree goal and belief that it can be achieved and that e-cigarettes/vaping can help achieve it. Smoking and vaping were associated with high awareness of the Smokefree goal, but lower support and optimism that it can be achieved.

Opportunistic Screening of Oral Potentially Malignant Disorders: A Public Health Need for India.

PURPOSE: Oral cancer (OC) is the leading cancer in 25% of Indian cancer registries, and 80% of OCs are diagnosed in advanced stages. OC screening is a topic of debate. Studies from other countries have used a variety of study designs as OC screening strategies. There are not many studies from India on strategic screening, and there is a need to review the literature to provide insights and knowledge about screening programs. The purpose of this narrative review is to present broad epidemiologic evidence on the OC burden in India, to discuss and summarize the currently available evidence for OC screening strategies, and to highlight a feasible opportunistic screening strategy for addressing OC burden in India. METHODS: Medline and EMBASE were used to identify articles. Data from GLOBOCAN and government reports were obtained from websites. As many key concepts and divergent views cannot be addressed with a single research question, a narrative review was considered appropriate, but to ensure a comprehensive literature search, a systematic review search strategy was used. RESULTS: OC rates are rising more rapidly in India than projected. Wide variations in OC incidence within India reflect regional diversity of risk factors. Studies abroad have demonstrated the feasibility of opportunistic screening of oral potentially malignant disorders by dentists; however, although recommendations exist in India, no studies of opportunistic screening by dentists have been reported. CONCLUSION: The projected major increases in the OC burden necessitate an OC screening program; opportunistic screening of high-risk groups by dentists using oral visual examination is recommended as a cost-effective strategy. As a way forward, a pilot project to assess the feasibility of regional opportunistic screening is in progress.

Electronic cigarette use among university students aged 18-24 years in New Zealand: results of a 2018 national cross-sectional survey.

OBJECTIVES: To examine electronic cigarette use, reasons for use and perceptions of harm among university students. DESIGN: Cross-sectional study. SETTING: University students across New Zealand. METHODS: We analysed data from a 2018 cross-sectional survey of university students, weighted to account for undersampling and oversampling by gender and university size. χ2 tests were used to compare e-cigarette use, reasons for use and perceptions of harm by age, gender, ethnicity and cigarette smoking. PARTICIPANTS: The sample comprised 1476 students: 62.3% aged 18-20 years, 37.7% aged 21-24 years; 38.6% male, 61.4% female; 7.9% Maori and 92.1% non-Maori. RESULTS: 40.5% of respondents (95% CI 37.9 to 43.1) reported ever, 6.1% (4.9-7.4) current and 1.7% (1.1-2.5) daily use. Regardless of frequency, 11.5% of vapers had vaped daily for ≥1 month, 70.2% of whom used nicotine-containing devices; 80.8% reported not vaping in indoor and 73.8% in outdoor smoke-free spaces. Among ever vapers, curiosity (67.4%), enjoyment (14.4%) and quitting (2.4%) were common reasons for vaping. 76.1% (73.4-78.7) of respondents believed e-cigarettes were less harmful than cigarettes.More males than females reported vaping (ever, current, daily and daily for ≥1 month), nicotine use and belief that e-cigarettes were less harmful than cigarettes. More participants aged 18-20 years reported not vaping in outdoor smoke-free spaces, vaping out of curiosity and belief that e-cigarettes were less harmful than cigarettes, while more participants aged 21-24 years vaped daily for ≥1 month and for enjoyment. More Maori than non-Maori ever vaped. More cigarette smokers than non-smokers vaped (ever, current, daily and daily for ≥1 month), used nicotine and vaped to quit, while more non-smokers did not vape in smoke-free spaces and vaped out of curiosity. CONCLUSIONS: Our results suggest high prevalence of e-cigarette ever and current use, particularly among males and smokers. Many vaped out of curiosity and perceived e-cigarettes as less harmful than cigarettes.

Effectiveness of autoclaving in sterilizing reusable medical devices in healthcare facilities.

Medical devices are sterilized before being used for invasive clinical procedures such as surgery, to prevent pathogen transfer. Failure to sterilize medical devices properly presents a risk of healthcare-associated infections. Studies and reports have indicated that inadequately sterilized medical devices are one of the causes of a higher rate of healthcare-associated infections in developing countries. Steam sterilization (autoclaving) is the most widely used method for sterilization and is considered the most robust and cost-effective method for sterilization of medical devices. The effectiveness of steam sterilization can be measured using biological indicators. A literature search was undertaken to understand the effectiveness of autoclaving in sterilizing reusable medical devices in healthcare facilities across the globe. Studies using biological indicators for measuring the effectiveness of autoclaving were obtained. Failures of steam sterilization practices were identified and discussed as a means of identifying factors that might be associated with the ineffectiveness of steam sterilization practices between different countries. The number of studies measuring the effectiveness of steam sterilization is small, and few evaluate the effectiveness of steam sterilization specifically in developing countries. There are fewer studies on higher level healthcare facilities than dental facilities. More evidence about the effectiveness of autoclaving in healthcare facilities is needed to draw firm conclusions, but the data suggest that there are inadequacies in autoclave procedures and operator education.

Cigarette smoking among university students aged 18-24 years in New Zealand: results of the first (baseline) of two national surveys.

OBJECTIVES: Although the smoking prevalence continues to decline in New Zealand (NZ) overall, little is known about smoking in university students. A 2013 survey of students aged 17-25 years found that 14% were current smokers, and 3% daily smokers. However, the sample did not include students from all NZ universities. This study examines the prevalence and patterns of cigarette smoking among students aged 18-24 years. SETTING: University students across NZ. METHODS: Data came from a March to May 2018 survey of students from all NZ universities, and were weighted to account for undersampling and oversampling, based on gender and university size. χ2 tests were used to compare smoking by age, gender and ethnicity. PARTICIPANTS: 1476 participants were included: 919 (62.3%) aged 18-20 years and 557 (37.7%) aged 21-24 years; 569 (38.6%) male and 907 (61.4%) female; and 117 (7.9%) Maori and 1359 (92.1%) non-Maori. RESULTS: 49.8% (95% CI 47.2 to 52.4) of respondents reported ever smoking, 11.1% (95% CI 9.5 to 12.9) currently smoked (smoked at least once a month) and 5.9% (95% CI 4.8 to 7.3) smoked at least daily (daily smokers). Of current smokers, 63.6% smoked 1-5 cigarettes/day, 45.8% smoked daily, 73.4% smoked first cigarette >60 min after waking, 86.0% never/almost never smoked in indoor and 64.6% in outdoor smokefree spaces, 69.9% planned to quit and 32.4% had tried to quit. Ever, current and daily smoking were significantly higher in 21-24 compared with 18-20 years olds, and in males compared with females. Older participants were more likely to report smoking more cigarettes/day. Maori were more likely to report ever smoking than non-Maori. CONCLUSIONS: Current smoking among NZ university students aged 18-24 years appears to be declining but daily smoking could be increasing. However, many students appeared less addicted to nicotine, and willing to quit. We recommend increasing the availability of smokefree services for students who wish to quit.

Effectiveness of steam sterilization of reusable medical devices in primary and secondary care public hospitals in Nepal and factors associated with ineffective sterilization: A nation-wide cross-sectional study.

BACKGROUND: Inadequate sterilization of reusable medical devices can lead to healthcare associated infections (HAIs) through person-to-person or environmental transmission of pathogens. Autoclaving (steam sterilization) is most commonly used for sterilizing medical devices in healthcare facilities. We conducted a nation-wide cross-sectional study to evaluate the effectiveness of steam sterilization practices in primary and secondary care public hospitals in Nepal and to identify factors associated with ineffective sterilization. METHODS: Using a stratified clustered random sampling, 13 primary- and secondary-care public hospitals in Nepal were selected. 189 steam sterilization cycles from these hospitals were evaluated for their effectiveness using self-contained biological indicators, class-5 chemical indicators, autoclave indicator tape and physical parameters. Information about the hospitals and the types of autoclaves being used was also collected. Data were analysed to estimate the proportion of ineffective steam sterilization cycles. Logistic regression was used to identify factors associated with ineffective sterilization. FINDINGS: In primary and secondary care public hospitals in Nepal, 71.0% (95% CI 46.8% - 87.2%) of the autoclave cycles were ineffective (i.e. showed positive results) when tested with biological indicators and 69.8% (95% CI 44.4% - 87.0%) showed 'reject' results with class 5 chemical indicators. There was no statistically significant difference in proportions showing positive or reject results by hospital types for either biological (p = 0.51) or class 5 chemical (p = 0.87) indicators. Autoclave type and pressure achieved during sterilization were statistically significantly associated with steam sterilization failures, adjusted for holding period, evenness of pressure and barrier system used. CONCLUSION: Primary and secondary care hospitals in Nepal have a high proportion of steam sterilization failure, indicating a risk of person-to-person transmission of pathogens through reusable medical devices. There is an urgent need to improve steam sterilization processes in these hospitals.

Dying art.

Working in a hospice gives nurses the opportunity to make patients' end of life peaceful, dignified and pain free.