Baseline assessment findings of the Africa Society for Blood Transfusion Step-Wise Accreditation Programme in 10 sub-Saharan African countries, 2016-2018.

BACKGROUND AND OBJECTIVES: The accreditation of blood services promotes continuous quality improvement in blood and transfusion services. The Africa Society for Blood Transfusion (AfSBT) conducted 20 baseline assessments of National Blood Transfusion Services (NBTS) or blood banks as part of the Step-Wise Accreditation Programme (SWAP) in 10 sub-Saharan African (SSA) countries from 2016 to 2018. This paper aims to elucidate the process and findings of the baseline assessments. MATERIALS AND METHODS: This is a descriptive study of 20 baseline assessments of NBTS. Eleven sections of the AfSBT assessment were reviewed, and 48 out of 68 standards and 356 out of 466 criteria were assessed. Each standard was assigned a value of 1 if it was fully achieved, 0.5 if partially achieved and 0 if not achieved. We defined average section scores >75% as having 'met AfSBT Standards', ≤25% as not meeting standards, 26%-50% as needs major improvement, and 51%-75% as needs some improvement and >75% as meets standards. RESULTS: The AfSBT SWAP standards were met in 4 out of the 11 sections: donor management, blood collection, component production and compatibility testing. Three sections were determined to need some improvement (quality system; handling, transport and storage and testing of donated blood), and three sections were determined to need major improvement (haemovigilance, blood administration and national blood service accreditation). One section (receipt, ordering, and issuing of blood) did not meet standards. CONCLUSION: Despite improvements in the quality of blood services in SSA over the past two decades, governments may consider the importance of prioritizing investments in NBTS, ensuring these institutions meet international accreditation standards that are aligned with safe blood transfusion services.

Evaluation of the WHO global database on blood safety.

OBJECTIVE: While the Global Database on Blood Safety (GDBS) helps to monitor the status of adequate and safe blood availability, its presence alone does not serve as a solution to existing challenges. The objective of this evaluation was to determine the GDBS usefulness in improving the availability of adequate safe blood and its ability to function as a surveillance system. METHODS: The GDBS was evaluated using methods set out by the Centers for Disease Control and Prevention (CDC) Guidelines for assessing surveillance systems. Six recommended tasks were used to evaluate if the GDBS met the requirements of a surveillance system in a public health context. RESULTS: The majority of stakeholders engaged with GDBS found it was unique and useful. The GDBS answered all six questions essential for determining a blood safety surveillance system's usefulness. The GDBS fully met the needs to six of the eleven attributes used for evaluating the usefulness of a surveillance system. CONCLUSION: The GDBS is a unique global activity that provides vital data on safety of blood transfusion services across countries and regions. However, aspects of the GDBS such as timeliness of reporting and improvement of WHO Member States national blood information systems could enhance its effectiveness and potential to serve as a global surveillance system for blood safety.

Improving injection safety practices of Cambodian healthcare workers through training.

BACKGROUND: This study evaluated the impact of a safe injection safety training on healthcare worker (HCW) practice and knowledge following an HIV outbreak in Roka commune, Cambodia. METHODS: Surveys were conducted at baseline (September 2016) and seven months after a training intervention (March 2018) using the World Health Organization standardized injection practices assessment tool. HCWs were sampled at 15 purposively government health facilities in two provinces. HCWs were observed during injection practices and interviewed by trained experts from Becton-Dickinson and the Ministry of Health Cambodia. The Rao-Scott chi square test was used test for differences between baseline and follow-up. RESULTS: We completed 115 observations of practice at baseline and 206 at post-training follow-up. The proportion of patients whose identification was confirmed by HCWs prior to procedure being performed increased from 40.4% to 98% (p <0.0001). The proportion of HCWs who practiced correct hand hygiene increased from 22.0% to 80.6% (p = 0.056) [therapeutic observations] and 17.2% to 63.4% (p = 0.0012) [diagnostic observations]. Immediate disposal of sharps by HCWs decreased from 96.5% to 92.5% (p = 0.0030). CONCLUSIONS: We found significant improvements in the practice of patient identity confirmation and hand hygiene but not in the immediate disposal of sharps in the post-training intervention. However, findings are not representative of all HCWs in the country. Further pre-service and in-service training and monitoring are necessary to ensure sustained behavior change.

Trends and Gaps in National Blood Transfusion Services - 14 Sub-Saharan African Countries, 2014-2016.

Ensuring availability of safe blood products through recruitment of voluntary, nonremunerated, blood donors (VNRDs) and prevention of transfusion-transmissible infections (TTIs), including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis, is important for public health (1,2). During 2004-2016, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) provided approximately $468 million in financial support and technical assistance* to 14 sub-Saharan African countries† with high HIV prevalence to strengthen national blood transfusion services (NBTSs)§ and improve blood safety and availability. CDC analyzed these countries' 2014-2016 blood safety surveillance data to update previous reports (1,2) and summarize achievements and programmatic gaps as some NBTSs begin to transition funding and technical support from PEPFAR to local ministries of health (MOHs) (2,3). Despite a 60% increase in blood supply since 2004 and steady declines in HIV prevalence (to <1% among blood donors in seven of the 14 countries), HIV prevalence among blood donors still remains higher than that recommended by the World Health Organization (WHO) (4). PEPFAR support has contributed to significant reductions in HIV prevalence among blood donors in the majority of PEPFAR-supported countries, and linking donors who screen HIV-positive to confirmatory testing and indicated treatment, as well as further reducing TTIs, remains a public health priority (5).

Findings of Phlebotomy Practices in Kenya in 2010: Need for Action.

BACKGROUND: Phlebotomy, a commonly performed medical procedure in healthcare, is essential for disease diagnosis and patient management. However, poorly performed phlebotomy can compromise patient safety, healthcare worker (HCW) safety, and specimen quality. We carried out a study between June and July 2010 to assess knowledge, quality and safety of phlebotomy before implementation of a public-private partnership between Becton, Dickinson and Company and the US President's Emergency Plan for AIDS Relief. METHODS: This was a cross-sectional observational study in 8 healthcare facilities within 4 regions of Kenya. HCWs were observed conducting venous and capillary blood collections, and pre- and posttests were offered during HCW training. RESULTS: Of 283 blood samples obtained, 194 were venous draws conducted by 72 HCWs and 89 were capillary draws performed by 33 HCWs. Based on 12 preset quality-associated criteria, none of the 194 observed phlebotomies met the standard. In total, 91 HCWs were trained in phlebotomy. The mean knowledge increase between pre- and posttraining test was 41%, ranging from 39% to 45% (95% confidence interval, 29.3%-53.5%;P< .001). CONCLUSIONS: Inadequate knowledge and imperfect phlebotomy procedures were noted. This formed the basis for the safe phlebotomy partnership to address these deficiencies. To ensure sustainability, safe phlebotomy practices were integrated into preservice training.

Occupational exposure to bloodborne pathogens among health care workers in Botswana: Reporting and utilization of postexposure prophylaxis.

BACKGROUND: This study assessed reporting behavior and satisfaction with postexposure prophylaxis (PEP) systems among health care workers (HCWs) at risk for occupational bloodborne pathogen exposure (BPE) in 3 public hospitals in Botswana. METHODS: A cross-sectional survey among HCWs provided information on perceptions, attitudes, and experiences with occupational exposures, reporting, and postexposure care. HCWs potentially in contact with blood or body fluids were surveyed using audio computer-assisted self-interview. RESULTS: Between August 2012 and April 2013, 1,624 HCWs completed the survey; most were women (72%), and almost half (48%) were nurses. Sixty-seven percent of them had ever received training related to BPE management; 62% perceived themselves to be at high risk for BPE. Among the 426 HCWs who were exposed to sharps injuries or splashes in the last 6 months, 160 (37%) reported the exposure. Of these, 111 of the 160 (69%) received PEP, and 79 of the 111 (71%) completed their medication. Whereas >92% of the total HCWs had ever been tested for HIV, only 557 (37%) were tested in their own health facility. Most HCWs (87%, n = 1,406) reported they would be interested in testing themselves. Of HCWs who reported an exposure, less than half (49%, n = 78) were satisfied with existing reporting systems. CONCLUSIONS: Underreporting of occupational exposures and dissatisfaction with PEP management is common among HCWs. Improved PEP management strategies and regular monitoring are needed.

Cluster of HIV Infections Attributed to Unsafe Injection Practices--Cambodia, December 1, 2014-February 28, 2015.

In December 2014, local health authorities in Battambang province in northwest Cambodia reported 30 cases of human immunodeficiency virus (HIV) infection in a rural commune (district subdivision) where only four cases had been reported during the preceding year. The majority of cases occurred in residents of Roka commune. The Cambodian National Center for HIV/AIDS (acquired immunodeficiency syndrome), Dermatology and Sexually Transmitted Diseases (NCHADS) investigated the outbreak in collaboration with the University of Health Sciences in Phnom Penh and members of the Roka Cluster Investigation Team. By February 28, 2015, NCHADS had confirmed 242 cases of HIV infection among the 8,893 commune residents, an infection rate of 2.7%. Molecular investigation of the HIV strains present in this outbreak indicated that the majority of cases were linked to a single HIV strain that spread quickly within this community. An NCHADS case-control study identified medical injections and infusions as the most likely modes of transmission. In response to this outbreak, the Government of Cambodia has taken measures to encourage safe injection practices by licensed medical professionals, ban unlicensed medical practitioners, increase local capacity for HIV testing and counseling, and expand access to HIV treatment in Battambang province. Measures to reduce the demand for unnecessary medical injections and the provision of unsafe injections are needed. Estimates of national HIV incidence and prevalence might need to be adjusted to account for unsafe injection as a risk exposure.

Reporting and case management of occupational exposures to blood-borne pathogens among healthcare workers in three healthcare facilities in Tanzania.

BACKGROUND: In sub-Saharan Africa, blood-borne pathogens exposure (BPE) is a serious risk to healthcare workers (HCW). METHODS: We conducted a cross-sectional study assessing BPE among HCW at three public hospitals in Tanzania. From August to November 2012, HCW were surveyed using Audio-Computer Assisted Self-Interview. All HCW at risk for BPE were invited to participate. Factors associated with reporting BPE were identified using logistic regression. FINDINGS: Of the 1102 eligible HCW, 973 (88%) completed the survey. Of these, 690 (71%) were women and 499 (52%) were nurses and nurse assistants. Of the 357 HCW who had a BPE (32%) in the previous 6 months, 120 (34%) reported it. Among these 120 reported exposures, 93 (78%) HCWs reported within 2 h of exposure, 98 (82%) received pre- and post-HIV test counselling, and 70 (58%) were offered post-exposure prophylaxis (PEP). Independent factors associated with reporting BPE were being female (adjusted odds ratio [AOR], 2.0; 95% confidence interval [CI], 1.2-3.5), having ever-received BPE training (AOR, 2.0; 95% CI, 1.2-3.5), knowledge that HCW receive PEP at another facility (AOR, 2.6; 95% CI, 1.5-4.4), low/no perceived risk related to BPE (AOR, 4.2; 95% CI, 1.9-9.4) and HIV testing within the past year (AOR, 2.3; 95% CI, 1.2-4.4). CONCLUSION: These results highlight the importance of appropriate training on the prevention and reporting of occupational exposure to increase acceptance of HIV testing and improve access to PEP after BPE.

Epidemic parenteral exposure to volatile sulfur-containing compounds at a hemodialysis center.

OBJECTIVE: To determine the cause of acute illness on August 30, 2000, among patients at an outpatient dialysis center (center A). DESIGN: We performed a cohort study of all patients receiving dialysis on August 30, 2000; reviewed dialysis procedures; and analyzed dialysis water samples using microbiologic and chemical assays. SETTING: Dialysis center (center A). PATIENTS: A case-patient was defined as a patient who developed chills within 5 hours after starting hemodialysis at center A on August 30, 2000. RESULTS: Sixteen (36%) of 44 patients at center A met the case definition. All case-patients were hospitalized; 2 died. Besides chills, 15 (94%) of the case-patients experienced nausea; 12 (75%), vomiting; and 4 (25%), fever. Illness was more frequent on the second than the first dialysis shift (16 of 20 vs 0 of 24, P < .001); no other risk factors were identified. The center's water treatment system had received inadequate maintenance and disinfection and a sulfurous odor was noted during sampling of the water from the reverse osmosis (RO) unit. The water had elevated bacterial counts. Volatile sulfur-containing compounds (ie, methanethiol, carbon disulfide, dimethyldisulfide, and sulfur dioxide) were detected by gas chromatography and mass spectrometry in 8 of 12 water samples from the RO unit and in 0 of 28 samples from other areas (P < .001). Results of tests for heavy metals and chloramines were within normal limits. CONCLUSIONS: Parenteral exposure to volatile sulfur-containing compounds, produced under anaerobic conditions in the RO unit, could have caused the outbreak. This investigation demonstrates the importance of appropriate disinfection and maintenance of water treatment systems in hemodialysis centers.

Enterobacter cloacae bloodstream infections in pediatric patients traced to a hospital pharmacy.

The sources of an outbreak of Enterobacter cloacae bloodstream infections in a pediatric hospital were investigated, as were the risk factors for acquiring the infection: Two retrospective case-control studies were conducted. The study sample included all patients admitted to the general pediatric wards from February 5 through March 30, 2001, who had a positive blood culture for E. cloacae. Pediatric ward and pharmacy infection-control practices were reviewed, personnel and environmental cultures were obtained, and pulsed-field gel electrophoresis (PFGE) molecular typing of the bloodstream isolates was conducted. Four subjects were identified. These infants were more likely than control patients to receive i.v. ranitidine (p < 0.01). Among patients receiving i.v. ranitidine, subjects were more likely than controls to receive i.v. ranitidine prepared by a pharmacist. No environmental or personnel cultures yielded E. cloacae. Patients' E. cloacae isolates had four different PFGE patterns, suggesting environmental rather than point-source contamination. Ranitidine multidose vials were kept connected to an automatic compounding machine for up to 48 hours at room temperature after the first dose was drawn, contrary to manufacturer recommendations. Further, preparation of ranitidine infusions was not conducted in accordance with recommendations for risk level 2 sterile i.v. products. The use of contaminated ranitidine multidose vials was the most likely cause of an outbreak of E. cloacae. However, a combination of other factors such as inadequate hand-washing techniques, presence of E. cloacae in the environment, noncompliance with guidelines for the preparation of sterile infusions and medications, and a susceptible population may have contributed to the infections.