A Socio-ecological Framework for Understanding Workplace Violence in China's Health Sector: A Qualitative Analysis of Health Workers' Responses to an Open-ended Survey Question.

Workplace violence (WPV) in the health sector is a global public health issue. The magnitude of WPV is a particular concern in China's health system. To examine the potential causes of WPV, we analyzed 3,045 qualitative responses to an open-ended question in a survey with health workers in the Zhejiang province, China. We adapted a four-level socio-ecological framework (societal/systemic, community/organizational, interpersonal, and individual) to thematically analyze the data. Ten sub-themes emerged. Within the societal/systemic level, we identified three sub-themes: (a) lack of legislation against WPV, (b) suboptimal accessibility and affordability of health services due to maldistributed health resources, commercialized health services, and inadequate health insurance, and (c) unregulated mass media reports. Within the community/organizational level, three sub-themes emerged: (a) lack of supportive health facility leadership, (b) inaction by government authorities, and (c) inefficient law enforcement agencies. Within the interpersonal level, two sub-themes were identified: (a) poor provider-patient communication and (b) distrust between health workers and patients. Finally, we identified the personal characteristics of health workers (e.g., competence and professionalism) and patients (e.g., sociodemographic background and expectations/satisfaction) as two individual-level sub-themes.We recognized interactions among different levels. The weak state of Chinese legislation in this area and lack of high-level political will and guidance (societal/systemic) has left health facilities and law enforcement agencies (community/organizational) unclear about how to address WPV. The maldistribution of quality health resources (societal/systemic) has led to overcrowded outpatient clinics at higher-level care facilities (community/organizational). In light of the insufficient government funding and profit-oriented health services (societal/systemic), health workers were motivated to seek profits by providing unnecessary services, which compromised their professionalism (individual). Provider-patient relationships deteriorated (interpersonal), and patients sometimes held unrealistically high expectations associated with high medical expenses (individual). We propose multisectoral prevention strategies to address WPV in the health sector at all levels using a socio-ecological framework.

[Whole genome sequencing reveals the distribution of resistance and virulence genes of pathogenic Escherichia coli CCHTP from giant panda].

Pathogenic Escherichia coli (E. coli) is the most common pathogen causing urinary tract infection in animals. We investigated the antibiotic resistance and virulence genes of pathogenic E. coli CCHTP derived from urine with occult blood of the giant panda by whole genome sequencing. The flanking sequencing of resistance and virulence genes in genomic islands were also analyzed. Our results demonstrate that E. coli CCHTP contains different families of antibiotic resistance genes, most of which are efflux pump related genes, including multiple drug resistance efflux pump genes mdfA, emrE, and mdtN. A total of 166 virulence factors and 563 virulence genes were identified, and the most virulence factors and related genes are involved in host cell attachment and invasion processes. Furthermore, sequence analysis of 19 genomic islands revealed that antibiotic and virulence genes are associated with mobile genetic elements (transposon and insertion sequence) in GIs011 and GIs017. These structures can mediate horizontal transfer of antibiotic and virulence genes. Our work described the distribution of antibiotic resistance genes and virulence genes in E. coli CCHTP, which may provide an important guidance for treatment and rational drug use of E. coli CCHTP infection in the giant panda.

Workplace violence and its aftermath in China's health sector: implications from a cross-sectional survey across three tiers of the health system.

OBJECTIVES: To determine the prevalence of physical violence and threats against health workers and the aftermath in tertiary, secondary and primary care facilities in China. DESIGN: A cross-sectional questionnaire study. SETTING: 5 tertiary hospitals, 8 secondary hospitals and 32 primary care facilities located in both urban and rural areas of Zhejiang Province, China, were chosen as the study sites. PARTICIPANTS: A total of 4862 health workers who have contact with patients completed a survey from July 2016 to July 2017. OUTCOME MEASURES: The prevalence of physical violence, threats and Yi Nao, specific forms of physical violence and their aftermath were measured by a self-designed and verified questionnaire. Multivariable logistic regression models were used to examine the association between perceived organisational encouragement of reporting workplace violence (WPV) and physical violence, threats and Yi Nao after controlling for age, sex, level of facility, professional ranking and type of health worker. RESULTS: Among all respondents, 224 (4.6%) were physically attacked and 848 (17.4%) experienced threats in the past year. Respondents in secondary hospitals were more likely to experience physical violence (AOR=3.29, 95% CI 2.21 to 4.89), threats (AOR=1.61, 95% CI 1.32 to 1.98) and Yi Nao (AOR=2.47, 95% CI 2.10 to 2.91), compared with primary care providers. Lack of organisational policies to report WPV was associated with higher likelihood of physical violence (AOR=3.64, 95% CI 2.57 to 5.18) and threats (AOR=2.21, 95% CI 1.76 to 2.78). Among physical violence cases, only 29.1% reported the attack to police mainly because most felt it useless to do so (58.8%). Only 25.7% were investigated and 72.4% of attackers received no punishment. Of all those attacked or threatened, 59.4% wanted to quit current post and 76.0% were fearful of dealing with urgent or severe cases. CONCLUSIONS: Proper management of the aftermath of violence against health workers is inadequate. Formal guidelines for reporting and managing WPV are urgently needed.

[Evolution and the flanking sequences of Β-lactamase resistance gene blaOKP].

blaOKP genes are chromosomally encoded beta-lactamases that mediate several classes of antibiotics resistance. To investigate the evolution and flanking sequences of OKP beta-lactamase gene, the gene blaOKP and its flanking sequences from a newly isolated Klebsiella pneumoniae were studied using whole genome sequencing. The flanking sequences of different variant blaOKP genes and blaSHV, another plasmid-encoded beta-lactamase gene, were then compared. These studies show that the blaOKP and blaSHV genes evolve differently and belong to two different evolution branches. The blaOKP gene variants can be divided into subgroups: blaOKP-A and blaOKP-B. Although both blaOKP and blaSHV genes have no mobile genetic elements in their flanking sequences, their genetic environments are quite different. The blaOKP gene is adjacent to KdpC while blaSHV gene is flanked by RecF and ygbN-ygbM-ygbK. Furthermore, there are a variety of mobile genetic elements in the neighboring sequence plasmid-encoded blaSHV genes that are absent in blaOKP genes. These structural differences may slow the evolution of blaOKP gene. Collectively, we demonstrate that the evolution and flanking sequence of blaOKP gene are different from those of the blaSHV gene, which could be an important reason for its relatively slow evolution.

Antibiotic and disinfectant resistance of Salmonella isolated from egg production chains.

To investigate the contamination of Salmonella and its drug resistance in egg production chains, 111 Salmonella strains of different serotypes isolated from egg production chains were used in the study. The minimum inhibitory concentrations (MICs) of antibiotics and disinfectants against Salmonella isolates were determined, meanwhile, antibiotic and disinfectant resistance genes were amplified. The results showed that the resistance frequency of trimethoprim (TMP, N=100, P=90.09%) was highest among Salmonella isolates and all isolates were sensitive to amoxicillin and clavulanate (AMC), ceftiofur sodium (CFS) and gentamicin (CN), respectively. There were six different antibiotic resistance profiles, and TMP profile was the most prevalent type (N=36, P=32.43%). 52.25% of Salmonella isolates appeared multi-drug resistance. The MICs of benzalkonium chloride (BC) and cetylpyridinium chloride (CPC) against Salmonella strains ranged from 8 to 128 µg/mL and 8 to 256 µg/mL, respectively. Compared to quality control strain Escherichia coli ATCC10536, 101 Salmonella isolates (P=90.99%) had dual resistances to BC and CPC. 109 Salmonella (P=98.20%) were co-resistant to antibiotic and disinfectant. Detection of drug resistance genes showed that blaTEM gene was dominant (N=49, P=44.14%). The qnrA, qnrB and qepA genes were not detected. Only qacEΔ1 gene (N=63, P=56.76%) was detected among the disinfectant resistance genes. There was a significant correlation between sul1 gene and qacEΔ1 gene (P < 0.01). S. Derby showed multi-resistances to TMP, oxytetracycline (OTC), amoxicillin (AML) and ciprofloxacin (CIP). Eleven antibiotic resistance genes were found in S. Derby, in which the prevalence of qacEΔ1 gene was 81.25% (N=52). Besides, the drug resistance frequency and the prevalence of drug resistance genes in internal farm environment were higher than those in external environment. High frequency of drug resistances and high prevalence of drug resistance genes were detected in all links of the egg production chains, including package, storage and sale. Our results showed that severe antibiotic and disinfectant resistances existed in egg production chains. Therefore, further hygiene supervision should be implemented to prevent and control Salmonella, and standardize the use of antibiotics and disinfectants.