Healthcare-associated infections and antimicrobial use at a major referral hospital in Papua New Guinea: a point prevalence survey.

Background: Healthcare-associated infections (HAI) and antimicrobial use (AMU) are drivers for antimicrobial resistance, and robust data are required to inform interventions and track changes. We aimed to estimate the prevalence of HAI and AMU at Port Moresby General Hospital (PMGH), the largest hospital in Papua New Guinea. Methods: We did a point prevalence survey (PPS) on HAI and AMU at PMGH in May 2023 using the European Centre for Disease Prevention and Control (ECDC) PPS protocol. We included all critical care patients and randomly sampled half of the patients in other acute-care wards. We calculated weighted HAI and AMU prevalence estimates to account for this sampling strategy. Weighted HAI estimates were also calculated for an expanded definition that included physician diagnosis. Findings: Of 361 patients surveyed in 18 wards, the ECDC protocol identified 28 HAIs in 26 patients, resulting in a weighted HAI prevalence of 6.7% (95% CI: 4.6, 9.8). Surgical site infections (9/28, 32%) were the most common HAI. When adding physician diagnosis to the ECDC definitions, more skin and soft tissue, respiratory, and bloodstream HAIs were detected, and the weighted HAI prevalence was 12.4% (95% CI: 9.4, 16.3). The prevalence of AMU was 66.5% (95%CI: 61.3, 71.2), and 73.2% (263/359) of antibiotics were from the World Health Organization Access group. Interpretation: This is the first reported hospital PPS of HAI and AMU in Papua New Guinea. These results can be used to prioritise interventions, and as a baseline against which future point prevalence surveys can be compared. Funding: Australian Government Department of Foreign Affairs and Trade and Therapeutic Guidelines Limited Australia.

"Tell us what's going on": Exploring the information needs of pregnant and post-partum women in Australia during the pandemic with 'Tweets', 'Threads', and women's views.

INTRODUCTION: The provision of maternity services in Australia has been significantly disrupted in response to the COVID-19 pandemic. Many changes were initiated quickly, often with rapid dissemination of information to women. The aim of this study was to better understand what information and messages were circulating regarding COVID-19 and pregnancy in Australia and potential information gaps. METHODS: This study adopted a qualitative approach using social media and interviews. A data analytics tool (TIGER-C19) was used to extract data from social media platforms Reddit and Twitter from June to July 2021 (in the middle of the third COVID-19 wave in Australia). A total of 21 individual semi-structured interviews were conducted with those who were, or had been, pregnant in Australia since March 2020. Social media data were analysis via inductive content analysis and interview data were thematically analysed. RESULTS: Social media provided a critical platform for sharing and seeking information, as well as highlighting attitudes of the community towards COVID-19 vaccines in pregnancy. Women interviewed described wanting further information on the risks COVID-19 posed to themselves and their babies, and greater familiarity with the health service during pregnancy, in which they would labour and give birth. Health providers were a trusted source of information. Communication strategies that allowed participants to engage in real-time interactive discussions were preferred. A real or perceived lack of information led participants to turn to informal sources, increasing the potential for exposure to misinformation. CONCLUSION: It is vital that health services communicate effectively with pregnant women, early and often throughout public health crises, such as the COVID-19 pandemic. This was particularly important during periods of increased restrictions on accessing hospital services. Information and communication strategies need to be clear, consistent, timely and accessible to reduce reliance on informal and potentially inaccurate sources.

A bolder One Health: expanding the moral circle to optimize health for all.

One Health is a ground-breaking philosophy for improving health. It imaginatively challenges centuries-old assumptions about wellbeing and is now widely regarded as the 'best solution' for mitigating human health problems, including pandemic zoonotic diseases. One Health's success is imperative because without big changes to the status quo, great suffering and ill-health will follow. However, even in its more ambitious guises, One Health is not radical enough. For example, it has not embraced the emerging philosophical view that historical anthropocentrism is an unfounded ethical prejudice against other animals. This paper argues that One Health should be more imaginative and adventurous in its core philosophy and ultimately in its recommendations and activities. It must expand the circle of moral concern beyond a narrow focus on human interests to include nonhuman beings and the environment. On this bolder agenda, progressive ethical and practical thinking converge for the benefit of the planet and its diverse inhabitants-human and nonhuman.

Consequences of the evolutionary cardiovascular challenge of human bipedalism: orthostatic intolerance syndromes, orthostatic hypertension.

: In quadrupeds, the arterial baroreflex has dominance in the reflex homeostatic responses, which protect against haemorrhage. In humans, it is the low pressure cardiopulmonary reflex, which protects against the analogous cardiovascular challenge of gravity-dependent venous pooling with standing. To preserve orthostatic cardiovascular homeostasis with the emergence of bipedalism in humans the low pressure reflex, a minor, subsidiary reflex in quadripeds, was co-opted. Mirroring the imperfect skeletal evolution to bipedalism, this cardiovascular development has been problematic, with dysregulation manifesting as disabling orthostatic intolerance syndromes and, paradoxically, an orthostatic hypertensive response that appears to play a role in the development of essential hypertension in some people. Improved understanding of these evolutionary faults provides new options for postural and pharmacological treatments.

The impact on child wasting of a capacity building project implemented by community and district health staff in rural Lao PDR.

Laos is a low-income food-deficit country with pockets of high levels of wasting in the highland areas. We implemented a 3-year health/nutrition project in 12 villages in the highlands of Savannakhet province to reduce acute malnutrition in children. Volunteer nutrition teams in each village monitored child growth and promoted healthy feeding practices; a multisectoral district committee conducted monthly outreach to assess child growth, manage acute malnutrition and deliver primary health care services. We conducted a cross-sectional assessment before project activities began and at the end of the project. The baseline survey randomly sampled 60% of all households; the endline assessment aimed to survey all eligible registered participants. Anthropometric measures were taken from children aged 6-59 months; mothers with children aged <12 months were asked about infant feeding practices, antenatal and post-partum care; and child immunizations were recorded for children aged between 0-23 months. At baseline, 721 households were sampled, while the endline assessment surveyed between 82% and 100% of eligible participants in each age group. Acute malnutrition reduced from 12.4% (95% CI: 10.4- 14.3) to 6.1% (4.9-7.3). Unhealthy feeding practices declined: in 2008, 40.0% (34.7-45.3) of mothers breastfed their newborn within 2 hours of birth and 30.8% (25.7-35.8) threw the colostrum away; in 2011, these figures were 72% and 8% respectively. Maternal care and child immunisation coverage also improved. Improving the health environment and child feeding practices appears to have markedly reduced the level of wasting. Unsafe feeding practices were common but readily changed by the community-based nutrition teams.

Neonatal vancomycin continuous infusion: still a confusion?

BACKGROUND: Continuous infusions of vancomycin over 24 hours have been shown in adults to reduce drug toxicity, lower treatment costs and require fewer blood samples for therapeutic drug monitoring. They may also improve clinical outcome through earlier attainment of target drug concentrations. In neonates, there is no consensus on vancomycin dosing. We reviewed the literature to assess the evidence for vancomycin dosing regimens for continuous infusion in neonates. METHODS: Medline and Embase were searched for studies about continuous vancomycin dosing regimens in neonates that reported serum drug concentrations. The search identified 469 articles, of which 5 were relevant. RESULTS: Five prospective studies were included; 2 studies used non-linear mixed effects modeling. Vancomycin was administered with parenteral nutrition or 5% dextrose. Target serum concentrations varied (range: 10-30 mg/L). Four studies used loading doses before continuous infusion; only 1 documented achievement of therapeutic concentrations after the load. The time to a therapeutic concentration was not reported for the other studies. Attainment of target concentrations ranged from 56% to 89% of measurements. Only 1 study compared intermittent to continuous infusions, reporting higher attainment of target concentrations with continuous dosing (82% vs. 46%). No adverse effects were reported, although 3 neonates developed a reversible raised serum creatinine in the setting of septicemia. CONCLUSION: Continuous infusions of vancomycin in neonates are well tolerated, require less blood sampling and may result in improved attainment of target concentrations. Further prospective studies are needed in this population.

Bacteraemia in Malawian neonates and young infants 2002-2007: a retrospective audit.

OBJECTIVES: To assess the causes of bacteraemia in young infants and susceptibility to first-line antibiotics (benzylpenicillin plus gentamicin) at the Queen Elizabeth Central Hospital (QECH), Malawi during 2002-2007. DESIGN: Retrospective analysis of demographic and microbiological data using laboratory records. SETTING: QECH is Malawi's largest hospital with 7000 neonates admitted annually, 9% for septicaemia. PATIENTS: All infants aged 60 days or less admitted to QECH that had a blood culture taken over the 6-year period. MAIN OUTCOME MEASURES: 6754 blood cultures were taken. 3323 organisms were isolated: one-third were pathogens, two-thirds contaminants. Gram-positive organisms (53%) were more common than gram-negatives (47%). Four organisms made up half of all pathogens: Staphylococcus aureus (15.3%), group B streptococci (13.5%), non-typhoidal salmonellae (12.6%) and Escherichia coli (10.5%). Apart from non-typhoidal salmonellae and Streptococcus pneumoniae, most organisms were more common in the first week of life than later. Overall, 28% of isolates during 2002-2007 were resistant to first-line antibiotic, higher than observed during 1996-2001 (22%). Penicillin susceptibility fluctuated while gram-negative resistance to gentamicin increased from 17% to 27% over the study period. CONCLUSIONS: In the QECH, pathogens causing young infant sepsis are an unusual mix of organisms seen in both developed and developing countries. Resistance to first-line antibiotics is higher than observed in most studies. Ongoing monitoring is needed and clinical outcome data would aid interpretation of findings. A high proportion of blood cultures were contaminated with skin flora-improved training and supervision of phlebotomists are needed to improve the utility of taking blood cultures.

An online framework for introducing STI point-of-care tests in Pacific island countries and areas

Sexually transmitted infections (STIs) are an important public health issue in Pacific island countries and areas. Diagnosis is challenging, often requiring laboratory facilities and technical expertise rarely available. Patients seldom have results before they leave the health facility, with management primarily based on symptoms. As the delay between testing and treatment increases, so does the potential for complications of infection for the individual, the likelihood of STI transmission to other sexual partners and the chance the client will not return for follow-up. Effective tests that can be used at the point of care (POC) can conceivably overcome these consequences of delayed diagnosis. Such tests for STIs are becoming more available and affordable, with the potential to improve STI control

Learning lessons from field surveys in humanitarian contexts: a case study of field surveys conducted in North Kivu, DRC 2006-2008.

Survey estimates of mortality and malnutrition are commonly used to guide humanitarian decision-making. Currently, different methods of conducting field surveys are the subject of debate among epidemiologists. Beyond the technical arguments, decision makers may find it difficult to conceptualize what the estimates actually mean. For instance, what makes this particular situation an emergency? And how should the operational response be adapted accordingly. This brings into question not only the quality of the survey methodology, but also the difficulties epidemiologists face in interpreting results and selecting the most important information to guide operations. As a case study, we reviewed mortality and nutritional surveys conducted in North Kivu, Democratic Republic of Congo (DRC) published from January 2006 to January 2009. We performed a PubMed/Medline search for published articles and scanned publicly available humanitarian databases and clearinghouses for grey literature. To evaluate the surveys, we developed minimum reporting criteria based on available guidelines and selected peer-review articles. We identified 38 reports through our search strategy; three surveys met our inclusion criteria. The surveys varied in methodological quality. Reporting against minimum criteria was generally good, but presentation of ethical procedures, raw data and survey limitations were missed in all surveys. All surveys also failed to consider contextual factors important for data interpretation. From this review, we conclude that mechanisms to ensure sound survey design and conduct must be implemented by operational organisations to improve data quality and reporting. Training in data interpretation would also be useful. Novel survey methods should be trialled and prospective data gathering (surveillance) employed wherever feasible.

Update on mortality in the Democratic Republic of Congo: results from a third nationwide survey.

BACKGROUND: The humanitarian crisis in the Democratic Republic of Congo (DRC) has been among the world's deadliest in recent decades. We conducted our third nationwide survey to examine trends in mortality rates during a period of changing political, security, and humanitarian conditions. METHODS: We used a 3-stage, household-based cluster sampling technique to compare east and west DRC. Sixteen east health zones and 15 west zones were selected with a probability proportional to population size. Four east zones were purposely selected to allow historical comparisons. The 20 smallest population units were sampled in each zone, 20 households in each unit. The number and distribution of households determined whether they were selected using systematic random or random walk sampling. Respondents were asked about deaths of household members during the recall period: January 2006-April 2007. FINDINGS: In all, 14,000 households were visited. The national crude mortality rate of 2.2 deaths per 1000 population per month (95% confidence interval [CI] 2.1-2.3) is almost 70% higher than that documented for DRC in the 1984 census (1.3) and is unchanged since 2004. A small but significant decrease in mortality since 2004 in the insecure east (rate ratio: 0.96, P = .026) was offset by increases in the western provinces and a transition area in the center of the country. Nonetheless, the crude mortality rate in the insecure east (2.6) remains significantly higher than in the other regions (2.0 and 2.1, respectively). Deaths from violence have declined since 2004 (rate ratio 0.7, P = .02). CONCLUSIONS: More than 4 years after the official end of war, the crude mortality rate remains elevated across DRC. Slight but significant improvements in mortality in the insecure east coincided temporally with recent progress on security, humanitarian, and political fronts.