Application of tools to monitor environmental conditions, identify exposures, and inform decision-making to improve infection prevention and control practices in Malawian maternity wards.

Healthcare-acquired infections (HAIs) contribute to maternal and neonatal morbidity and mortality, especially in low- and middle-income countries (LMICs). Deficient environmental health (EH) conditions and infection prevention and control (IPC) practices in healthcare facilities (HCFs) contribute to the spread of HAIs, but microbial sampling of sources of contamination is rarely conducted nor reported in low-resource settings. The purpose of this study was to assess EH conditions and IPC practices in Malawian HCFs and evaluate how EH deficiencies contribute to pathogen exposures and HAIs, and to provide recommendations to inform improvements in EH conditions using a mixed-methods approach. Thirty-one maternity wards in government-run HCFs were surveyed in the three regions of Malawi. Questionnaires were administered in parallel with structured observations of EH conditions and IPC practices and microbial testing of water sources and facility surfaces. Results indicated significant associations between IPC practices and microbial contamination. Facilities where separate wards were not available for mothers and newborns with infections and where linens were not used for patients during healthcare services were more likely to have delivery tables with surface contamination (relative risk = 2.23; 1.49, 3.34). E. coli was detected in water samples from seven (23%) HCFs. Our results suggest that Malawian maternity wards could reduce microbial contamination, and potentially reduce the occurrence of HAIs, by improving EH conditions and IPC practices. HCF staff can use the simple, low-cost EH monitoring methods used in this study to incorporate microbial monitoring of EH conditions and IPC practices in HCFs in low-resource settings.

Occupational health outcomes among sanitation workers: A systematic review and meta-analysis.

BACKGROUND: Sanitation workers are essential to global public health and societal wellbeing. However, the health risks and outcomes associated with exposure to occupational risk factors among sanitation workers are neither well understood nor well quantified. We undertook a systematic review to (1) identify occupational risk factors among sanitation workers and (2) assess the effect of occupational exposure to human fecal sludge and wastewater on selected health outcomes among these workers. METHODS: We searched four databases (i.e., PubMED, MEDLINE, EMBASE, and LILACS) for eligible studies from inception through to January 01, 2020. The included population was workers ≥15 years engaged, formally or informally, in installing, operating, servicing, cleaning or emptying a sanitation technology at any step of the sanitation chain. The included comparator was workers in other occupations or the general population. Eligible outcomes were: mortality (any or all causes), gastroenteritis, occupational injuries, respiratory diseases, musculoskeletal disorders, and mental and social health conditions. Risk of bias was assessed separately on exposure assessment and health outcome using a modified Liverpool Quality Assessment Tool (LQAT). We pooled sufficiently homogenous studies using inverse variance meta-analysis with random effects. RESULTS: A total of 65 studies (9 cohort studies, 56 cross-sectional studies) met the inclusion criteria. One quarter of studies (n = 15) were from middle-income countries. Few studies assessed occupational risk factor exposures directly; most assigned exposure via proxy of occupation of sanitation worker. We judged nearly all studies to have "high risk of bias" in exposure and outcome assessment. Despite these limitations, the consistency of the overall evidence suggests that sanitation workers are at increased risk of gastroenteritis and respiratory conditions, and may be at increased risk of musculoskeletal disorders and mental/social health conditions. The pooled odds ratio for hepatitis A--the only outcome deemed suitable for meta-analysis--was 2.09 (95% Predicted Interval: 1.39-3.00, 12 studies). There was conflicting evidence from studies of increased risk of mortality; only one study reported on injuries. CONCLUSION: Despite a large number of studies, there is limited evidence to date of the health risks faced by sanitation workers, particularly among groups that may be at particular risk-- women, informal workers and those living in low-income countries. Nevertheless, the research to date provides suggestive evidence of elevated occupational risk among sanitation workers across a range of health condition. More research is needed to improve the current bodies of evidence for all included health outcomes to be able to quantify disease burden among this occupational group.