Re-analysis of health and educational impacts of a school-based deworming programme in western Kenya: a pure replication.

BACKGROUND: Helminth (worm) infections cause morbidity among poor communities worldwide. An influential study conducted in Kenya in 1998-99 reported that a school-based drug-and-educational intervention had benefits regarding worm infections and school attendance. Effects were seen among children treated with deworming drugs, untreated children in intervention schools and children in nearby non-intervention schools. Combining these effects, the intervention was reported to increase school attendance by 7.5% in treated children. Effects on other outcomes (worm infections, anaemia, nutritional status and examination performance) were also investigated. METHODS: In this pure replication, we used data provided by the original authors to re-analyse the study according to their methods. We compared these results against those presented in the original paper. RESULTS: Although most results were reproduced as originally reported, we identified discrepancies of several types between the original findings and re-analysis. For worm infections, re-analysis showed reductions similar to those originally reported. For anaemia prevalence, in contrast to the original findings, re-analysis found no evidence of benefit. For nutritional status, both original findings and re-analysis described modest evidence for a small improvement. For school attendance, re-analysis showed benefits similar to those originally found in intervention schools for both children who did and those who did not receive deworming drugs. However, after correction of coding errors, there was little evidence of an indirect effect on school attendance among children in schools close to intervention schools. Combining these effects gave a total increase in attendance of 3.9% among treated children, which was no longer statistically significant. As in the original results, re-analysis found no effect of the intervention on examination performance. CONCLUSIONS: Re-applying analytical approaches originally used, but correcting various errors, we found little evidence for some previously-reported indirect effects of a deworming intervention. Effects on worm infections, nutritional status, examination performance and school attendance on children in intervention schools were largely unchanged

Strengthening surveillance systems for Antimicrobial Resistance in Urinary Tract infections in Kenya – Report from Fleming Fund fellowship programme

Background: Urinary Tract Infection (UTI) is one of the most common reasons for outpatient attendance and antibiotic use worldwide. Tackling the problem of antimicrobial resistance (AMR) in Low- and Middle-Income Countries such as Kenya requires laboratory surveillance systems that can correctly identify bacterial pathogens from urine samples and perform antimicrobial susceptibility testing (AST). In Kenya, there are many shortcomings in public-sector microbiology laboratories, including limited professional expertise in the clinical interpretation of urine samples. Methods: This project aimed to deliver training on identification and AST for staff at five hospital laboratories participating in the Kenyan AMR surveillance network. We made local needs assessments, delivered practical training sessions face-to-face and administered written and practical competency assessments for all participants. Results: Trainings were conducted between November 2021 and January 2022 with a total of 13 laboratory staff trained. Participants had previously received a median of 2.3 months (IQR 1-7 months) of training time in microbiology. There was a substantial improvement in written assessment scores from a median of 46/100 pre-training (IQR 36-64) to a median of 90/100 post-training (IQR 85-92). The largest improvements were seen amongst staff with the lowest prior levels of microbiology training (MLS Diploma), though improvements were also seen for staff with BSc and MSc qualifications. Practical assessment included use of standardized organisms – all participants performed well in this practical assessment. Conclusion: We found that prior to the training, all staff performed relatively poorly on a standardized assessment regarding knowledge and processing of urine samples. However, all staff substantially improved following this 5-day training delivered by a single trainer. We estimated that the cost of delivering this training for one hospital was approximately KES 500,000. Training microbiology staff in the accurate processing of urine sample will be an important activity for a Kenyan AMR surveillance system. These training materials, if delivered by an experienced trainer, can achieve a clear improvement in knowledge levels and practical competence

Re-analysis of health and educational impacts of a school-based deworming programme in western Kenya: a statistical replication of a cluster quasi-randomized stepped-wedge trial.

INTRODUCTION: Helminth (worm) infections cause morbidity among poor communities worldwide. An influential study conducted in Kenya in 1998-99 reported that a school-based drug-and-educational intervention had benefits for worm infections and school attendance. METHODS: In this statistical replication, we re-analysed data from this cluster quasi-randomized stepped-wedge trial, specifying two co-primary outcomes: school attendance and examination performance. We estimated intention-to-treat effects using year-stratified cluster-summary analysis and observation-level random-effects regression, and combined both years with a random-effects model accounting for year. The participants were not blinded to allocation status, and other interventions were concurrently conducted in a sub-set of schools. A protocol guiding outcome data collection was not available. RESULTS: Quasi-randomization resulted in three similar groups of 25 schools. There was a substantial amount of missing data. In year-stratified cluster-summary analysis, there was no clear evidence for improvement in either school attendance or examination performance. In year-stratified regression models, there was some evidence of improvement in school attendance [adjusted odds ratios (aOR): year 1: 1.48, 95% confidence interval (CI) 0.88-2.52, P = 0.147; year 2: 1.23, 95% CI 1.01-1.51, P = 0.044], but not examination performance (adjusted differences: year 1: -0.135, 95% CI -0.323-0.054, P = 0.161; year 2: -0.017, 95% CI -0.201-0.166, P = 0.854). When both years were combined, there was strong evidence of an effect on attendance (aOR 1.82, 95% CI 1.74-1.91, P < 0.001), but not examination performance (adjusted difference -0.121, 95% CI -0.293-0.052, P = 0.169). CONCLUSIONS: The evidence supporting an improvement in school attendance differed by analysis method. This, and various other important limitations of the data, caution against over-interpretation of the results. We find that the study provides some evidence, but with high risk of bias, that a school-based drug-treatment and health-education intervention improved school attendance and no evidence of effect on examination performance

Feasibility of informing syndrome-level empiric antibiotic recommendations using publicly available antibiotic resistance datasets.

Background: Antibiotics are often prescribed empirically to treat infection syndromes before causative bacteria and their susceptibility to antibiotics are identified. Guidelines on empiric antibiotic prescribing are key to effective treatment of infection syndromes, and need to be informed by likely bacterial aetiology and antibiotic resistance patterns. We aimed to create a clinically-relevant composite index of antibiotic resistance for common infection syndromes to inform recommendations at the national level. Methods: To create our index, we used open-access antimicrobial resistance (AMR) surveillance datasets, including the ECDC Surveillance Atlas, CDDEP ResistanceMap, WHO GLASS and the newly-available Pfizer ATLAS dataset. We integrated these with data on aetiology of common infection syndromes, existing empiric prescribing guidelines, and pricing and availability of antibiotics. Results:  The ATLAS dataset covered many more bacterial species (287) and antibiotics (52) than other datasets (ranges = 8-11 and 16-32 respectively), but had a similar number of samples per country per year. Using these data, we were able to make empiric prescribing recommendations for bloodstream infection, pneumonia and cellulitis/skin abscess in up to 44 countries. There was insufficient data to make national-level recommendations for the other six syndromes investigated. Results are presented in an interactive web app, where users can visualise underlying resistance proportions to first-line empiric antibiotics for infection syndromes and countries of interest. Conclusions: We found that whilst the creation of a composite resistance index for empiric antibiotic therapy was technically feasible, the ATLAS dataset in its current form can only inform on a limited number of infection syndromes. Other open-access AMR surveillance datasets are largely limited to bloodstream infection specimens and cannot directly inform treatment of other syndromes. With improving availability of international AMR data and better understanding of infection aetiology, this approach may prove useful for informing empiric prescribing decisions in settings with limited local AMR surveillance data

Implementation of a surgical unit-based safety programme in African hospitals: a multicentre qualitative study.

Background: A Surgical Unit-based Safety Programme (SUSP) has been shown to improve perioperative prevention practices and to reduce surgical site infections (SSI). It is critical to understand the factors influencing the successful implementation of the SUSP approach in low- and middle-income settings. We undertook a qualitative study to assess viability, and understand facilitators and barriers to implementing the SUSP approach in 5 African hospitals. Methods: Qualitative study based on interviews with individuals from all hospitals participating in a WHO-coordinated before-after SUSP study. The SUSP intervention consisted of a multimodal strategy including multiple SSI prevention measures combined with an adaptive approach aimed at improving teamwork and safety culture. Results: Thirteen interviews (5 head surgeons, 3 surgeons, 5 nurses) were conducted with staff from five hospital sites. Identified facilitators included influential individuals (intrinsic motivation of local SUSP teams, boundary spanners, multidisciplinary engagement, active leadership support), peer-to-peer learning (hospital networking and positive deviance, benchmarking), implementation fitness (enabling infrastructures, momentum from previous projects), and timely feedback of infection rates and process indicators. Barriers (organisational 'constipators', workload, mistrust, turnover) and local solutions to these were also identified. Conclusions: Participating hospitals benefitted from the SUSP programme structures (e.g. surveillance, hospital networks, formation of multidisciplinary teams) and adaptive tools (e.g. learning from defects, executive rounds guide) to change perceptions around patient safety and improve behaviours to prevent SSI. The combination of technical and adaptive elements represents a promising approach to facilitate the introduction of evidence-based best practices and to improve safety culture through local team engagement in resource-limited settings

The effect of behavioural interventions targeting hand hygiene practices among nurses in high-income hospital settings: a systematic review.

BACKGROUND: Hand hygiene is a critical behaviour for infection control but efforts to raise compliance among clinical professionals have been met with mixed success. The aim of this systematic review was to identify the effectiveness of the behaviour change techniques utilised in recent hand hygiene interventions that seek to improve hand hygiene compliance among nurses in hospitals in high-income countries. Nurses are at the frontline of healthcare delivery, and so improving their HH behaviour and thus increasing HHC rates will have a relatively large impact on reducing transmission and preventing healthcare acquired infections. METHODS: High-quality studies among nurses in high-income countries were surveyed from the scientific literature, following PRISMA guidelines, to identify which kinds of behaviour change mechanisms have been used to effectively increase hand hygiene compliance. Only seven studies met all inclusion criteria. A formal meta-analysis was not conducted due to the heterogeneity of the included studies. Instead, the review analysed studies in line with the Intervention Component Analysis approach to identify which differences in intervention characteristics appear to be important. Analysis proceeded in two steps: first, the Effective Practice and Organization of Care Data Extraction Checklist was used to identify the study design and to describe the intervention, target population, setting, results, outcome measures, and analytic approach. The second step involved inferring the behavioural change techniques used in the complex study interventions. Following coding, logic models were then inferred for each study to identify the Theory of Change behind each intervention. These Theories of Change were then examined for suggestions as to which BCTs were likely to have been responsible for any effectiveness observed. RESULTS: Goals and planning (to achieve specific ends), comparison of behaviour (to peers or some ideal) and feedback and monitoring (observing and providing feedback about behaviour or outcomes) were the most frequently used behaviour change technique groupings used across studies and within interventions. CONCLUSION: The complexity of the interventions used and lack of sufficient studies makes assignment of responsibility for behaviour change to specific behaviour change techniques difficult. Delivery channels and activities identified in the study Theories of Change were also highly individualized and so difficult to compare. However, we identified a temporal shift in types of techniques used in these recent studies on HH interventions, as compared with studies from prior to the review period. These newer interventions did not focus on providing access to alcohol-based hand rub or trying to solely encourage administrative support. Instead, they had nurses create goals and plan how to best facilitate HH, compared both individuals' and the group's behaviour to others, and focused on providing feedback

Chronic Hospital Nurse Understaffing Meets COVID-19

A study of hospitals in New York and Illinois at the start of the COVID-19 pandemic found that most did not meet benchmark patient-to-nurse staffing ratios for medical-surgical or intensive care units. New York City hospitals had especially low staffing ratios. Understaffed hospitals were associated with less job satisfaction among nurses, unfavorable grades for patient safety and quality of care, and hesitance by nurses and patients to recommend their hospitals

Interventional studies for preventing surgical site infections in sub-Saharan Africa - A systematic review.

BACKGROUND: There is a great need for safe surgical services in sub-Saharan Africa, but a major difficulty of performing surgery in this region is the high risk of post-operative surgical site infection (SSI). METHODS: We aimed to systematically review which interventions had been tested in sub-Saharan Africa to reduce the risk of SSI and to synthesize their findings. We searched Medline, Embase and Global Health databases for studies published between 1995 and 2010 without language restrictions and extracted data from full-text articles. FINDINGS: We identified 24 relevant articles originating from nine countries in sub-Saharan Africa. The methodological quality of these publications was diverse, with inconsistency in definitions used for SSI, period and method of post-operative follow-up and classification of wound contamination. Although it was difficult to synthesise information between studies, there was consistent evidence that use of single-dose pre-operative antibiotic prophylaxis could reduce, sometimes dramatically, the risk of SSI. Several studies indicated that alcohol-based handrubs could provide a low-cost alternative to traditional surgical hand-washing methods. Other studies investigated the use of drains and variants of surgical technique. There were no African studies found relating to several other promising SSI prevention strategies, including use of checklists and SSI surveillance. CONCLUSIONS: There is extremely limited research from sub-Saharan Africa on interventions to curb the occurrence of SSI. Although some of the existing studies are weak, several high-quality studies have been published in recent years. Standard methodological approaches to this subject are needed

Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design.

INTRODUCTION: In low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals. METHODS: We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design. RESULTS: From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these. CONCLUSION: Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution