Infection prevention and control in tertiary care hospitals of Bangladesh: results from WHO infection prevention and control assessment framework (IPCAF).

INTRODUCTION: Infection prevention and control (IPC) in healthcare settings is imperative for the safety of patients as well as healthcare providers. To measure current IPC activities, resources, and gaps at the facility level, WHO has developed the Infection Prevention and Control Assessment Framework (IPCAF). This study aimed to assess the existing IPC level of selected tertiary care hospitals in Bangladesh during the COVID-19 pandemic using IPCAF to explore their strengths and deficits. METHODS: Between September and December 2020, we assessed 11 tertiary-care hospitals across Bangladesh. We collected the information from IPC focal person and/or hospital administrator from each hospital using the IPCAF assessment tool.. The score was calculated based on eight core components and was used to categorize the hospitals into four distinct IPC levels- Inadequate, Basic, Intermediate, and Advanced. Key performance metrics were summarized within and between hospitals. RESULTS: The overall median IPCAF score was 355.0 (IQR: 252.5-397.5) out of 800. The majority (73%) of hospitals scored as 'Basic' IPC level, while only 18% of hospitals were categorized as 'Intermediate'. Most hospitals had IPC guidelines as well as environments, materials and equipments. Although 64% of hospitals had IPC orientation and training program for new employees, only 30% of hospitals had regular IPC training program for the staff. None of the hospitals had an IPC surveillance system with standard surveillance case definitions to track HAIs. Around 90% of hospitals did not have an active IPC monitoring and audit system. Half of the hospitals had inadequate staffing considering the workload. Bed occupancy of one patient per bed in all units was found in 55% of hospitals. About 73% of hospitals had functional hand hygiene stations, but sufficient toilets were available in only 37% of hospitals. CONCLUSION: The majority of sampled tertiary care hospitals demonstrate inadequate IPC level to ensure the safety of healthcare workers, patients, and visitors. Quality improvement programs and feedback mechanisms should be implemented to strengthen all IPC core components, particularly IPC surveillance, monitoring, education, and training, to improve healthcare safety and resilience.

Rationale and guidance for strengthening infection prevention and control measures and antimicrobial stewardship programs in Bangladesh: a study protocol.

BACKGROUND: Hospital-acquired infections (HAIs) and antimicrobial resistance (AMR) are major global health challenges. Drug-resistant infectious diseases continue to rise in developing countries, driven by shortfalls in infection control measures, antibiotic misuse, and scarcity of reliable diagnostics. These escalating global challenges have highlighted the importance of strengthening fundamental infection prevention and control (IPC) measures and implementing effective antimicrobial stewardship programs (ASP). This study aims to present a framework for enhancing IPC measures and ASP efforts to reduce the HAI and AMR burden in Bangladesh. METHODS: This implementation approach will employ a mixed-methods strategy, combining both quantitative and qualitative data from 12 tertiary hospitals in Bangladesh. A baseline assessment will be conducted using the Infection Prevention and Control Assessment Framework (IPCAF) developed by the WHO. We will record IPC practices through direct observations of hand hygiene, personal protective equipment (PPE) utilization, and hospital ward IPC infrastructure. Additionally, data on healthcare providers' knowledge, attitudes, and practices regarding IPC and antibiotic prescribing will be collected using both structured questionnaires and qualitative interviews. We will also assist the hospital leadership with establishing and/or strengthening IPC and ASP committees. Based on baseline assessments of each healthcare facility, tailored interventions and quality improvement projects will be designed and implemented. An end-line assessment will also be conducted after 12 months of intervention using the same assessment tools. The findings will be compared with the baseline to determine changes in IPC and antibiotic stewardship practices. DISCUSSION: Comprehensive assessments of healthcare facilities in low-resource settings are crucial for strengthening IPC measures and ASP activities,. This approach to assessing existing IPC and ASP activities will provide policy-relevant data for addressing current shortfalls. Moreover, this framework proposes identifying institutionally-tailored solutions, which will ensure that response activities are appropriately contextualized, aligned with stakeholder priorities, and offer sustainable solutions. CONCLUSION: Findings from this study can guide the design and implementation of feasible and sustainable interventions in resource-constrained healthcare settings to address gaps in existing IPC and ASP activities. Therefore, this protocol will be applicable across a broad range of settings to improve IPC and ASP and reduce the burden of hospital-acquired infections and AMR.

Incidence of respiratory virus illness and hospitalizations in a Panama and El Salvador birth cohort, 2014-2018.

Background: Respiratory viruses remain a key cause of early childhood illness, hospitalization, and death globally.The recent pandemic has rekindled interest in the control of respiratory viruses among paediatric populations. We estimate the burden of such viruses among children <2 years. Methods: Enrolled neonates were followed until two years of age. Weekly active symptom monitoring for the development of acute respiratory illnesses (ARI) defined as cough, rhinorrhoea, difficulty breathing, asthenia, anorexia, irritability, or vomiting was conducted. When the child had ARI and fever, nasopharyngeal swabbing was performed, and samples were tested through singleplex RT-PCR. Incidence of respiratory viruses was calculated by dividing the number of laboratory-confirmed detections by the person-time accrued during weeks when that virus was detectable through national surveillance then corrected for under-ascertainment among untested children. Findings: During December 2014-November 2017, 1567 enrolled neonates contributed 2,186.9 person-years (py). Six in ten (64·4%) children developed ARI (total 2493 episodes). Among children <2 years, incidence of respiratory syncytial virus (RSV)-associated ARI episodes (21·0, 95%CI 19·3-22·8, per 100py) and rhinovirus-associated (20·5, 95%CI 20·4-20·7) were similar and higher than parainfluenza 1-3-associated (14·2, 95%CI 12·2-16·1), human metapneumovirus-associated (9·2, 95%CI 7·7-10·8), influenza-associated (5·9, 95%CI 4·4-7·5), and adenovirus-associated ARI episodes (5·1, 95%CI 5·0-5·2). Children aged <3 months had the highest rates of RSV ARI (49·1, 95%CI 44·0-54·1 per 100py) followed by children aged 3-5 (25·1, 95%CI 20·1-30·0), 6-11 (17·6, 95%CI 13·2-21·9), and 12-23 months (11·9, 95%CI 10·8-12·9). One in ten children with RSV was referred to the hospital (2·5, 95%CI 2·1-2·8, per 100py). Interpretation: Children frequently developed viral ARI and a substantive proportion required hospital care. Such findings suggest the importance of exploring the value of new interventions and increasing uptake of existing prevention measures to mitigate burden of epidemic-prone respiratory viruses. Funding: The study was supported by the Centers for Disease Control and Prevention.

Self-medication and ILI etiologies among individuals presenting at pharmacies with influenza-like illness: Guatemala City, 2018 influenza season.

OBJECTIVES: We aimed to characterize the proportion of clients presenting to community pharmacies with influenza-like illness (ILI) and the severity of their illness; the proportion with detectable influenza A, influenza B, and other pathogens (i.e., parainfluenza I, II, and III, adenovirus, respiratory syncytial virus, human metapneumovirus); and to describe their self-medication practices. METHODS: A cross-sectional study was conducted in six pharmacies in Guatemala City. Study personnel collected nasopharyngeal and oropharyngeal swabs from participants who met the ILI case definition and who were self-medicating for the current episode. Participants were tested for influenza A and B and other pathogens using real-time RT-PCR. Participants' ILI-associated self-medication practices were documented using a questionnaire. RESULTS: Of all patients entering the pharmacy during peak hours who responded to a screening survey (n = 18,016) 6% (n = 1029) self-reported ILI symptoms, of which 45% (n = 470/1029) met the study case definition of ILI. Thirty-one percent (148/470) met inclusion criteria, of which 87% (130/148) accepted participation and were enrolled in the study. Among 130 participants, nearly half tested positive for viral infection (n = 55, 42.3%) and belonged to groups at low risk for complications from influenza. The prevalence of influenza A was 29% (n = 35). Thirteen percent of the study population (n = 17) tested positive for a respiratory virus other than influenza. Sixty-four percent of participants (n = 83) reported interest in receiving influenza vaccination if it were to become available in the pharmacy. Medications purchased included symptom-relieving multi-ingredient cold medications (n = 43/100, 43%), nonsteroidal anti-inflammatory drugs (n = 23, 23%), and antibiotics (n = 16, 16%). Antibiotic use was essentially equal among antibiotic users regardless of viral status. The broad-spectrum antibiotics ceftriaxone and azithromycin were the most common antibiotics purchased. CONCLUSIONS: During a typical influenza season, a relatively low proportion of all pharmacy visitors were experiencing influenza symptoms. A high proportion of clients presenting to pharmacies with ILI tested positive for a respiratory virus. Programs that guide appropriate use of antibiotics in this population are needed and become increasingly important during pandemics caused by respiratory viral pathogens.

Biosurveillance in outbreak investigations.

Following the terrorist attacks of September 11 and the anthrax attacks in 2001, public health entities implemented automated surveillance systems based on disease syndromes for early detection of bioterror events and to increase timeliness of responses. Despite widespread adoption, syndromic surveillance systems' ability to provide early notification of outbreaks is unproven, and there is little documentation on their role in outbreak response. We hypothesized that biosurveillance is used in practice to augment classical outbreak investigations, and we used case studies conducted in 2007-08 to determine (1) which steps in outbreak investigations were best served by biosurveillance, and (2) which steps presented the greatest opportunities for improvement. The systems used in the case studies varied in how they functioned, and there were examples in which syndromic systems had identified outbreaks before other methods. Biosurveillance was used successfully for all steps of outbreak investigations. Key advantages of syndromic systems were sensitivity, timeliness, and flexibility and as a source of data for situational awareness. Limitations of biosurveillance were a lack of specificity, reliance on chief complaint data, and a lack of formal training for users. Linking syndromic data to triage notes and medical chart data would substantially increase the value of biosurveillance in the conduct of outbreak investigations and reduce the burden on health department staff.

Health effects associated with indoor swimming pools: a suspected toxic chloramine exposure.

OBJECTIVES: A cohort and environmental study tested the hypothesis that suspected exposure to chloramines (by-products of chlorine for disinfection and ammonia from human sources) from a hotel's indoor swimming pool was associated with an outbreak among children who had attended a party at the pool. STUDY DESIGN: Retrospective cohort study. METHODS: A case was defined as any hotel guest/visitor on 5-6 October 2002 who experienced three or more symptoms typical of chloramine exposure on either day after visiting the hotel. A cohort study and an environmental assessment were performed to determine the association between pool exposure and illness. RESULTS: Of 128 individuals interviewed, 32 met the case definition. Common symptoms among case patients were cough (84%), eye irritation (78%) and rash (34%). Illness was associated with entering the pool area [odds ratio (OR) 19.9; 95% confidence interval (CI) 2.3-172], but more strongly with swimming (OR 72.0; 95% CI 9.1-568). Pool chloramine levels on 6 October 2002 were > or = 0.7ppm (optimal level=0ppm; state maximum=0.5ppm). The pool operator lacked formal training in pool maintenance. CONCLUSIONS: High chloramine levels may have caused illness in individuals who were either in or near the pool. This outbreak underscores the need for regular pool maintenance, improved air quality, education and certification for all operators of public and semipublic pools, and education about healthy swimming practices.

Targeted screening for Trichomonas vaginalis with culture using a two-step method in women presenting for STD evaluation.

OBJECTIVES: Trichomonas vaginalis is the most common nonviral sexually transmitted pathogen. Wet mount microscopy performs poorly compared with culture; however, universal screening using culture would be cost-prohibitive. GOAL: The goal of this study was to develop a predictive model for wet mount-negative women who may benefit from targeted use of culture for T. vaginalis detection. STUDY: Women presenting for sexually transmitted disease evaluation were prospectively screened for trichomoniasis using wet mount and culture. Multivariate logistic regression was used to identify predictors of culture-proven trichomoniasis among wet mount-negative women. RESULTS: A total of 2194 women were screened for trichomoniasis; overall, the prevalence of T. vaginalis was 17.5%. Three predictors (any drug use, contact to trichomoniasis, and African-American race) provided the most specific model (100%); any 1 predictor, the most sensitive model (97.8%). CONCLUSIONS: Given the public health impact of trichomoniasis, we recommend using any 1 of 3 predictors to identify women who would benefit from targeted culture for T. vaginalis.

Trichomoniasis in men and HIV infection: data from 2 outpatient clinics at Lilongwe Central Hospital, Malawi.

BACKGROUND: Little is known about the epidemiologic profile of trichomoniasis in men and its relationship to human immunodeficiency virus (HIV) infection. Among men presenting for care for symptomatic sexually transmitted infections (STIs) in Malawi, trichomoniasis is not considered for first-line treatment. METHODS: We conducted a cross-sectional survey of 1187 men attending either a dermatology or STI outpatient clinic in the capital of Malawi. Men were interviewed, and the etiologies of the STIs were determined. RESULTS: At the STI clinic (n = 756 men), we identified 150 men (20%) with Trichomonas vaginalis infection, 358 men (47%) with HIV infection, and 335 men (44%) with Neisseria gonorrhoeae infection. At the dermatology clinic (n = 431 men), we identified 54 (13%), 118 (27%), and 2 (0.5%) men, respectively. At both clinics, a lower education level and reporting never having used a condom were predictive of T. vaginalis infection. Only at the dermatology clinic was older age associated with infection, and only at the STI clinic were marital, genital ulcer disease, and HIV-infection status associated with T. vaginalis infection. At the STI clinic, urethral symptoms attributable to trichomoniasis were more severe among HIV-positive men than among HIV-negative men. CONCLUSIONS: Given its high prevalence and the increased risk for HIV transmission, T. vaginalis infection should be reconsidered for inclusion in the Malawi STI-treatment regimen for men.

The use of specimens from various genitourinary sites in men, to detect Trichomonas vaginalis infection.

Variations in estimates of prevalence of trichomoniasis in men may reflect true differences in the burden of disease but are also affected by the performance of diagnostic methods and the type of specimen tested. In this study, men were evaluated at baseline and at follow-up, to evaluate syndromic management of urethritis and the effects of human immunodeficiency virus and trichomoniasis, in Lilongwe, Malawi. First-void urine specimens and urethral swabs were obtained at enrollment, for Trichomonas vaginalis culture; semen specimens were also obtained at follow-up. The sensitivities of testing methods using urine specimens and urethral swabs were equal; 67% of cases were identified by use of either specimen, and, in 47% of cases, both specimens tested positive. When semen specimens were included, all 3 specimens tested positive in only 19% of cases. Semen was the most sensitive single specimen, and, in 25.6% of cases, only semen specimens tested positive. Thus, prevalence of T. vaginalis infection in men is underestimated if only 1 specimen is tested.

Body temperature monitoring and SARS fever hotline, Taiwan.

In Taiwan, a temperature-monitoring campaign and hotline for severe acute respiratory syndrome (SARS) fever were implemented in June 2003. Among 1,966 calls, fever was recorded in 19% (n = 378); 18 persons at high risk for SARS were identified. In a cross-sectional telephone survey, 95% (n = 1,060) of households knew about the campaign and 7 households reported fever.

Addition of treatment for trichomoniasis to syndromic management of urethritis in Malawi: a randomized clinical trial.

BACKGROUND: Male urethritis is generally treated syndromically, but failure of empirical treatment is common. GOAL: The study goal was to evaluate the addition of metronidazole to the syndromic management of urethritis in Malawi in a randomized clinical trial. STUDY DESIGN: Men with urethritis were randomized to receive either 2 g of metronidazole by mouth or placebo, in addition to standard care for urethritis (i.e., a single intramuscular dose of 240 mg gentamicin and 100 mg doxycycline twice daily for 7 days). The primary endpoints of the study included measurement of the effects of treatment on Trichomonas vaginalis, signs and symptoms of urethritis, and the concentration of HIV RNA in semen in dually infected subjects. RESULTS: The overall prevalence of T vaginalis was 17.3% (71/411), and treatment with metronidazole cleared 95% of culture-positive infections, compared with 54% clearance among men receiving placebo (P = 0.006). Prevalence of persistent urethritis was observed in approximately 16% of both groups at the end of 1 week (29/179 of those receiving metronidazole versus 29/187 in the placebo group; P = 0.86). For a subset of HIV-infected men with trichomoniasis, the seminal plasma HIV RNA concentration was higher than in a group of HIV-positive control subjects (median copies/mL:35,000 vs. 1800 P = 0.06) [correction]. CONCLUSION: In areas with a high prevalence of trichomoniasis, the addition of metronidazole to the syndromic management of male urethritis can eliminate infection with T vaginalis and may help to reduce the transmission of HIV. Such treatment should be strongly considered as part of empirical therapy for urethritis in men in Malawi and places where T vaginalis infection in men is common.

Validation of a urine-based PCR-enzyme-linked immunosorbent assay for use in clinical research settings to detect Trichomonas vaginalis in men.

Trichomonas vaginalis infection is highly prevalent worldwide and is associated with urethritis, prostatitis, and urethral strictures in men. However, the natural history and importance of T. vaginalis in men are poorly understood, in part because of difficulties in diagnosing infection. Traditional detection methods rely on culture and wet-mount microscopy, which can be insensitive and time consuming. Urethral swabs are commonly used to detect T. vaginalis in men, but discomfort from specimen collection is a barrier to large studies. One thousand two hundred twenty-five Malawian men attending sexually transmitted disease and dermatology clinics were enrolled in this cross-sectional study to validate detection by urine-based PCR-enzyme-linked immunosorbent assay (ELISA) with urine and urethral swab culture as the reference standard. This assay for detection of amplified T. vaginalis DNA in first-catch urine (< or = 30 ml) performed with a sensitivity of 92.7%, a specificity of 88.6%, and an adjusted specificity of 95.2% compared to culture of urethral swabs or urine sediment. For clinical research settings in which urethral swabs are not available and culture is not feasible, the urine-based PCR-ELISA may be useful for detection of trichomoniasis in men.