A cholera outbreak among semi-nomadic pastoralists in northeastern Uganda: epidemiology and interventions.

In sub-Saharan Africa, many nomadic pastoralists have begun to settle in permanent communities as a result of long-term water, food, and civil insecurity. Little is known about the epidemiology of cholera in these emerging semi-nomadic populations. We report the results of a case-control study conducted during a cholera outbreak among semi-nomadic pastoralists in the Karamoja sub-region of northeastern Uganda in 2010. Data from 99 cases and 99 controls were analysed. In multivariate analyses, risk factors identified were: residing in the same household as another cholera case [adjusted odds ratio (aOR) 6·67, 95% confidence interval (CI) 2·83-15·70], eating roadside food (aOR 2·91, 95% CI 1·24-6·81), not disposing of children's faeces in a latrine (aOR 15·76, 95% CI 1·54-161·25), not treating drinking water with chlorine (aOR 3·86, 95% CI 1·63-9·14), female gender (aOR 2·43, 95% CI 1·09-5·43), and childhood age (10-17 years) (aOR 7·14, 95% CI 1·97-25·83). This is the first epidemiological study of cholera reported from a setting of semi-nomadic pastoralism in sub-Saharan Africa. Public health interventions among semi-nomadic pastoralists should include a two-faceted approach to cholera prevention: intensive health education programmes to address behaviours inherited from insecure nomadic lifestyles, as well as improvements in water and sanitation infrastructure. The utilization of community-based village health teams provides an important method of implementing such activities.

The sixth vital sign: HIV status assessment and severe illness triage in Uganda.

Setting: Four in-patient health facilities in western Uganda. Objective: To determine the impact of an innovative multi-modal quality improvement program on human immunodeficiency virus (HIV) status assessment and the impact of HIV status on severe illness conditions and mortality. Design: This was a staggered, pre-post quasi-experimental study designed to assess a multi-modal intervention (collaborative improvement meetings, audit and feedback, clinical mentoring) for improving quality of care following formal training in the management of severe illness in low-income settings. Results: From August 2014 to May 2015, 5759 patients were hospitalized, of whom 2451 (42.6%) had their HIV status assessed; 395 (16.1%) were HIV-infected. HIV-infected patients were significantly more likely to meet criteria for shock (27.5% vs. 15.1%, risk ratio [RR] 1.8, 95% confidence interval [CI] 1.7-1.9, P < 0.001) and severe respiratory distress (6.7% vs. 4.3%, RR 1.5, 95%CI 1.2-2.0, P < 0.001), and were significantly more likely to die in hospital (12.0% vs. 2.9%, RR 4.1, 95%CI 3.2-5.4, P < 0.001). There was no evidence of improved HIV status assessment during the intervention period (36.5% vs. 44.8%, +8.3%, 95%CI -8.3 to 24.8, P = 0.33). Conclusions: Hospitalized HIV-infected patients in western Uganda are at high risk for severe illness and death. Novel quality improvement strategies are needed to enhance hospital-based HIV testing in high-burden settings.

Contexte : Quatre structures de santé hospitalières dans l'ouest de l'Ouganda.Objectif : Déterminer l'impact d'un programme innovant multimodal d'amélioration de la qualité sur l'évaluation du statut du virus de l'immunodéficience humaine (VIH) et l'impact du statut VIH sur les états de maladie grave et la mortalité.Schéma : Une étude échelonnée, pré-post et quasi-expérimentale conçue pour évaluer une intervention multimodale (réunions d'amélioration concertée, audit et rétro-information, tutorat clinique) pour améliorer la qualité des soins après la formation initiale sur la prise en charge de maladies graves dans un contexte de faibles ressources.Résultats : Entre août 2014 et mai 2015, 5759 patients ont été hospitalisés : 2451 (42,6%) ont eu une évaluation de leur statut VIH et 395 (16,1%) se sont avérés infectés par le VIH. Ces derniers ont été significativement plus susceptibles de répondre à des critères de choc (27,5% contre 15,1% ; rapport de risque [RR] 1,8 ; intervalle de confiance [IC] 95% 1,7­1,9 ; P < 0,001) et de détresse respiratoire grave (6,7% contre 4,3 ; RR 1,5 ; IC95% 1,2­2,0 ; P < 0,001), et ont été significativement plus susceptibles de décéder à l'hôpital (12,0% contre 2,9% ; RR 4,1 ; IC95% 3,2­5,4 ; P < 0,001). Il n'y a pas eu d'éléments en faveur d'une amélioration de l'évaluation du statut VIH pendant la période d'intervention (36,5% contre 44,8% ; +8,3% ; IC95% −8,3 à 24,8 ; P = 0,33).Conclusions : Les patients infectés par le VIH hospitalisés dans l'ouest de l'Ouganda ont un risque élevé de maladie grave et de décès. De nouvelles stratégies d'amélioration de qualité sont requises afin d'augmenter les tests VIH en hôpital dans les contextes à fardeau élevé de maladie.

Marco de referencia: Cuatro establecimientos hospitalarios en la zona occidental de Uganda.Objetivo: Determinar la repercusión de un programa innovador multimodal de mejora de la calidad sobre la evaluación de la situación frente al virus de la inmunodeficiencia humana (VIH) y la repercusión del estado frente al VIH en materia de enfermedades graves y mortalidad.Método: Se realizó un estudio semi-experimental escalonado pre y post con el fin de evaluar una intervención multimodal (reuniones de colaboración para mejorar de la calidad, auditorías y retroalimentación, tutoría clínica) encaminada a mejorar la calidad de la atención, tras una capacitación formal sobre el manejo de las enfermedades graves en entornos con bajos ingresos.Resultados: De agosto del 2014 a mayo del 2015 se hospitalizaron 5759 pacientes; en 2451 se examinó su situación frente al VIH (42,6%) y 395 presentaban infección por el VIH (16,1%). Los pacientes afectados por el VIH exhibieron una probabilidad significativamente mayor de cumplir con los criterios diagnósticos de choque (27,5% contra 15,1%; cociente de riesgos [RR] 1,8; intervalo de confianza [IC] del 95% 1,7­1,9; P < 0,001) y de insuficiencia respiratoria grave (6,7% contra 4,3%, RR 1,5; IC95% 1,2­2,0; P < 0,001) y la probabilidad de morir en el hospital fue significativamente más alta en estos pacientes (12,0% contra 2,9%, RR 4,1; IC95% 3,2­5,4; P < 0,001). No se encontraron pruebas en favor de una mejor evaluación de la situación frente al VIH durante el período de la intervención (36,5% contra 44,8%; +8,3%; IC95% −8,3 hasta 24,8; P = 0,33).Conclusión: Los pacientes hospitalizados aquejados de infección por el VIH en Uganda occidental son muy susceptibles de sufrir una enfermedad grave o la muerte. Se precisan nuevas estrategias de mejora de la calidad que refuercen la práctica de las pruebas diagnósticas de infección por el VIH en los entornos con alta carga de morbilidad.

Inverting the pyramid: increasing awareness of mycobacterial sepsis in sub-Saharan Africa.

Disseminated Mycobacterium tuberculosis is a leading cause of bloodstream infection and severe sepsis in sub-Saharan African settings with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. Despite the high prevalence of M. tuberculosis bacteremia in these settings it is under-recognized. This is in part because timely diagnosis of M. tuberculosis bacteremia is difficult using traditional TB diagnostics. Novel triage algorithms and rapid diagnostic tests are needed to expedite the identification and treatment of patients with severe sepsis due to M. tuberculosis bacteremia. In this article, we emphasize the importance of M. tuberculosis bacteremia as an under-recognized etiology of severe sepsis, and discuss the potential role of two emerging rapid diagnostic tests in the triage and prognostication of critically ill patients with advanced HIV infection and suspected disseminated M. tuberculosis. We conclude with the recommendation that clinicians in high TB-HIV burden settings strongly consider empiric anti-tuberculosis treatment in patients with advanced HIV infection and severe sepsis in the appropriate clinical context. Future studies are needed to assess diagnostic and prognostic algorithms for severe sepsis caused by disseminated M. tuberculosis in these settings, and the safety, efficacy, and duration of empiric anti-tuberculosis treatment.

Implementing and evaluating a system of generic infection precautions: body substance isolation.

Body substance isolation (BSI) is a system of infection precautions intended to reduce nosocomial transmission of infectious agents among patients and to reduce the risk of transmission of hepatitis B virus, human immunodeficiency virus, and other infectious agents to health care personnel. Harborview Medical Center in Seattle, Wash., was the first facility in the United States to implement the BSI system. Between 1984 and 1988 a systematic evaluation of the implementation process was conducted and the effects of BSI on appropriate glove use by hospital personnel and on the incidence of nosocomial colonization and infection by sentinel organisms was measured. Results of the evaluation showed (1) significant increments in knowledge of infection control procedures and practices as measured by comparing written examination responses before and after training sessions, (2) significant increases in appropriate glove use as determined by direct observation of hospital employees for 18 months, and (3) significant reductions in nosocomial colonization and infection caused by sentinel microorganisms during the period from 1984 to 1988.

AIDS and health care workers. Safety measures that prevent transmission.

Despite the fears of health care professionals that they might contract AIDS from their patients, they actually run a low risk. By identifying existing situations that routinely expose them to body substances and by taking reasonable preventive measures when caring for all patients, these workers can institute habits that will afford them excellent protection against not only AIDS but all infectious diseases. Needlesticks and other puncture or cutting accidents are the prime cause for seroconversion among such personnel. The authors set forth elemental rules for body substance isolation and laboratory procedures that should be followed by all health care professionals.

Prevalence of antibody to human immunodeficiency virus and hepatitis B surface antigen in blood samples submitted to a hospital laboratory. Implications for handling specimens.

The prevalence of hepatitis B surface antigen (HBsAg) and antibody to human immunodeficiency virus (HIV) was determined in serum or plasma specimens of 506 patients submitted to the clinical chemistry laboratory of an urban teaching hospital, and the results were correlated with "biohazard" warning labels on the specimens. Hepatitis B surface antigen, HIV antibody, or either of these were present in 32 (6.3%), 15 (3.0%), and 44 specimens (8.7%), respectively. Ten (67%) of 15 specimens with HIV antibody and nine (28%) of 32 with HBsAg bore biohazard labels. Among 473 unlabeled specimens, HIV antibody was present in five (1.1%), HBsAg was present in 23 (4.9%), and 27 (5.7%) contained either or both of these markers. All clinical and laboratory personnel should be vaccinated against hepatitis B and should handle all blood specimens as if they were infected, regardless of biohazard labeling. By fostering complacency in handling unlabeled specimens, the use of biohazard labels may paradoxically increase the risk that health care workers will be exposed to HIV and hepatitis B virus.

Rethinking the role of isolation practices in the prevention of nosocomial infections.

To prevent nosocomial infections, hospitals use two types of procedures: routine patient care practices (handwashing, for example), which are used in appropriate circumstances on all patients, and more intensive isolation precautions, which are implemented only when patients are suspected of having particular infections. Aspects of these current practices, however, may limit their effectiveness. We propose the use of body substance isolation, a simpler alternative system that is used for all patients, not just in response to a specific diagnosis, and that emphasizes the increased use of barrier precautions, especially gloving, when contact with potentially infectious bodily secretions is anticipated. Because of its rationale and simplicity, body substance isolation has been enthusiastically accepted at our hospitals, and we encourage others to consider and evaluate this approach.