A cluster-randomised controlled trial comparing school and community-based deworming for soil transmitted helminth control in school-age children: The CoDe-STH trial protocol

Background: Current guidelines and targets for soil-transmitted helminth (STH) control focus on school-based deworming for school-age children, given the high risk of associated morbidity in this age group. However, expanding deworming to all age groups may achieve improved STH control among both the community in general and school-age children, by reducing their risk of reinfection. This trial aims to compare school-based targeted deworming with community-wide mass deworming in terms of impact on STH infections among school-age children. Methods: The CoDe-STH (Community Deworming against STH) trial is a cluster-randomised controlled trial (RCT) in 64 primary schools in Dak Lak province, Vietnam. The control arm will receive one round of school-based targeted deworming with albendazole, while in the intervention arm, community-wide mass deworming with albendazole will be implemented alongside school-based deworming. Prevalence of STH infections will be measured in school-age children at baseline and 12 months following deworming. The primary outcome is hookworm prevalence in school-age children at 12 months, by quantitative PCR. Analysis will be intention-to-treat, with outcomes compared between study arms using generalised linear and non-linear mixed models. Additionally, cost-effectiveness of mass and targeted deworming will be calculated and compared, and focus group discussions and interviews will be used to assess acceptability and feasibility of deworming approaches. Individual based stochastic models will be used to predict the impact of mass and targeted deworming strategies beyond the RCT timeframe to assess the likelihood of parasite population 'bounce-back' if deworming is ceased due to low STH prevalence. Discussion: The first large-scale trial comparing mass and targeted deworming for STH control in South East Asia will provide key information for policy makers regarding the optimal design of STH control programs. Trial registration: ACTRN12619000309189

Cost-Effectiveness of a Telephone-Delivered Intervention for Physical Activity and Diet

Background: Given escalating rates of chronic disease, broad-reach and cost-effective interventions to increase physical activity and improve dietary intake are needed. The cost-effectiveness of a Telephone Counselling intervention to improve physical activity and diet, targeting adults with established chronic diseases in a low socio-economic area of a major Australian city was examined. Methodology/Principal Findings: A cost-effectiveness modelling study using data collected between February 2005 and November 2007 from a cluster-randomised trial that compared Telephone Counselling with a “Usual Care” (brief intervention) alternative. Economic outcomes were assessed using a state-transition Markov model, which predicted the progress of participants through five health states relating to physical activity and dietary improvement, for ten years after recruitment. The costs and health benefits of Telephone Counselling, Usual Care and an existing practice (Real Control) group were compared. Telephone Counselling compared to Usual Care was not cost-effective ($78,489 per quality adjusted life year gained). However, the Usual Care group did not represent existing practice and is not a useful comparator for decision making. Comparing Telephone Counselling outcomes to existing practice (Real Control), the intervention was found to be cost-effective ($29,375 per quality adjusted life year gained). Usual Care (brief intervention) compared to existing practice (Real Control) was also cost-effective ($12,153 per quality adjusted life year gained). Conclusions/Significance: This modelling study shows that a decision to adopt a Telephone Counselling program over existing practice (Real Control) is likely to be cost-effective. Choosing the ‘Usual Care’ brief intervention over existing practice (Real Control) shows a lower cost per quality adjusted life year, but the lack of supporting evidence for efficacy or sustainability is an important consideration for decision makers. The economics of behavioural approaches to improving health must be made explicit if decision makers are to be convinced that allocating resources toward such programs is worthwhile

Cleaning Staff’s Attitudes about Hand Hygiene in a Metropolitan Hospital in Australia: A Qualitative Study

Background: In 2009, the National Hand Hygiene Initiative (NHHI) was implemented in hospitals across Australia with the aim of improving hand hygiene practices and reducing healthcare-associated infections. Audits conducted post-implementation showed the lowest rates of compliance with hand hygiene practices are among operational staff including hospital cleaners. There is limited information about hand hygiene issues in hospital cleaners to inform development of evidence-based interventions to improve hand hygiene compliance in this group. Aim: This qualitative study was undertaken to explore the attitudes of hospital cleaning staff regarding hand hygiene and the National Hand Hygiene Initiative. Methodology: Focus groups were conducted with 12 cleaning staff at a large Australian hospital implementing the National Hand Hygiene Initiative. Findings: Hospital cleaners recognise the importance of hand hygiene in preventing healthcare-associated infections. Cleaners cite peer support, leadership, and the recognition and reward of those excelling in hand hygiene as strong motivators. Barriers to optimal hand hygiene practice include the presence of multiple conflicting guidelines, hand hygiene “overload„ and a lack of contextualised education programs. This exploratory qualitative study reveals three themes about attitudes of hospital cleaning staff towards hand hygiene. These themes are: (1) “The culture of hand hygiene: It’s drummed into us„; (2) “Reminders and promotion for hand hygiene: We just need a big ‘Please wash your hands’ sign„; and (3) “The personal value of hand hygiene: Like he said, it’s second nature to us„. Conclusion: Hand-hygiene messages and training need to be more consistent and contextualised to achieve improvements in hand hygiene practices in hospital cleaning staff in Australia

Incidence of community onset MRSA in Australia: least reported where it is most prevalent

This is the first review of literature and synthesis of data on community onset methicillin resistant (CO-MRSA) infections in Australia. Incidence of CO-MRSA varies considerably in Australia, depending on geographic and demographic factors.Data for the rates of MRSA infections were collected from articles identified using PubMed, Scopus, the grey literature and data from State and Federal Government Surveillance Systems. We synthesized data and developed a framework for how data was selected, collated, linked, organized and interpreted.The results of our literature search demonstrates considerable gaps in the reporting of CO-MRSA in Australia. Consequently, total incidences were under reported; however the available data suggests the incidence varied between 44 (Tasmania) and 388 (southern Northern Territory) cases per 100,000 person years. Hospitalised cases of CO-MRSA varied between 3.8 (regional Victoria) and 329 (southern Northern Territory). Taking the median percentage of infections by site for all regions available, skin and soft tissue infections (SSTIs) consisted of 56% of hospitalized CO-MRSA, compared with bacteremias, which represented 14%. No region had a complete data set of CO-MRSA infections treated in out-patient settings and so incidences were underestimates. Nevertheless, estimates of the incidence of CO-MRSA treated outside hospitals varied between 11.3 (Melbourne) and 285 (Northern Territory) per 100,000 person-years. These infections were chiefly SSTIs, although urinary tract infections were also noted.Incidences of CO-MRSA blood-stream infections and outpatient skin and soft tissue infections have been increasing with time, except in Tasmania. CO-MRSA is observed to affect people living in remote areas and areas of socioeconomic disadvantage disproportionately.We generated the first estimates of the incidence of CO-MRSA infections in Australia and identified stark regional differences in the nature and frequency of infections. Critically, we demonstrate that there has been a lack of consistency in reporting CO-MRSA and a general dearth of data. The only government in Australia that requires reporting of CO-MRSA is the Tasmanian, where the infection was least prevalent. Some regions of Australia have very high incidences of CO-MRSA. To improve surveillance and inform effective interventions, we recommend a standardized national reporting system in Australia that reports infections at a range of infection sites, has broad geographic coverage and consistent use of terminology. We have identified limitations in the available data that hinder understanding the prevalence of CO-MRSA

Cost-effectiveness of a central venous catheter care bundle

Background: A bundled approach to central venous catheter care is currently being promoted as an effective way of preventing catheter-related bloodstream infection (CR-BSI). Consumables used in the bundled approach are relatively inexpensive which may lead to the conclusion that the bundle is cost-effective. However, this fails to consider the nontrivial costs of the monitoring and education activities required to implement the bundle, or that alternative strategies are available to prevent CR-BSI. We evaluated the cost-effectiveness of a bundle to prevent CR-BSI in Australian intensive care patients. ---------- Methods and Findings: A Markov decision model was used to evaluate the cost-effectiveness of the bundle relative to remaining with current practice (a non-bundled approach to catheter care and uncoated catheters), or use of antimicrobial catheters. We assumed the bundle reduced relative risk of CR-BSI to 0.34. Given uncertainty about the cost of the bundle, threshold analyses were used to determine the maximum cost at which the bundle remained cost-effective relative to the other approaches to infection control. Sensitivity analyses explored how this threshold alters under different assumptions about the economic value placed on bed-days and health benefits gained by preventing infection. If clinicians are prepared to use antimicrobial catheters, the bundle is cost-effective if national 18-month implementation costs are below $1.1 million. If antimicrobial catheters are not an option the bundle must cost less than$4.3 million. If decision makers are only interested in obtaining cash-savings for the unit, and place no economic value on either the bed-days or the health benefits gained through preventing infection, these cost thresholds are reduced by two-thirds.---------- Conclusions: A catheter care bundle has the potential to be cost-effective in the Australian intensive care setting. Rather than anticipating cash-savings from this intervention, decision makers must be prepared to invest resources in infection control to see efficiency improvements