Carbapenem-resistant Enterobacteriaceae in sink drains of 40 healthcare facilities in Sindh, Pakistan: A cross-sectional study.

In Pakistan, antimicrobial resistance (AMR) is expected to greatly increase the already high mortality and morbidity rates attributed to infections, making AMR surveillance and prevention a priority in the country. The aims of the project were to characterize the prevalence of carbapenem-resistant Enterobacteriaceae (CRE) in healthcare facility sink drains in Pakistan and to characterize how physical characteristics of sinks and healthcare facility rooms were associated with CRE in those sinks. The study took place in 40 healthcare facilities in Jamshoro Pakistan. Swabs were collected from sink drains in each facility that had a sink, and structured observations of sinks and facilities were performed at each facility. Swabs were plated on CHROMagar KPC to screen for carbapenem-resistant Enterobacteriaceae, which were then isolated on Mueller-Hinton agar plates. Antibiotic susceptibility was determined using the disk diffusion method to assess resistance to carbapenems, cephalosporins, and fluoroquinolones. Thirty-seven of the healthcare facilities had at least one sink, and thirty-nine total sinks were present and sampled from those healthcare facilities. Sinks in these facilities varied in quality; at the time of sampling 68% had water available, 51% had soap/alcohol cleanser at the sink, 28% appeared clean, and 64% drained completely. Twenty-five (64%) of the sink samples grew Enterobacteriaceae on CHROMagar KPC, sixteen (41%) of which were clinically non-susceptible to ertapenem. Seven of the 39 sampled sinks (18%) produced Enterobacteriaceae that were resistant to all three antibiotic classes tested. Several facilities and sink characteristics were associated with CRE. Sinks and drains can serve as undetected reservoirs for carbapenem-resistant Enterobacteriaceae. Control and remediation of such environments will require both systemic strategies and physical improvements to clinical environments.

Drinking water, sanitation, and hygiene (WASH) situation in primary schools of Pakistan: the impact of WASH-related interventions and policy on children school performance.

The United Nation's Sustainable Development Goals include the target of ensuring access to water and sanitation and hygiene (WASH) for all; however, very few studies have assessed comprehensive school WASH service in Pakistan. The purpose of this study was to identify WASH services in primary schools of Pakistan, and to assess how recent WASH interventions and policies are associated with the school's academic performance. A representative cross-sectional study was conducted in primary schools in the Sindh province of Pakistan. Structured observations and interviews were done to ascertain the schools' WASH conditions. The primary exposures of interest were the implementation of previous WASH interventions and National WASH policy in the school and the WASH coverage. Outcomes of interest included WASH conditions and school performance. The structural equation modeling (SEM) using a bootstrap resampling procedure was employed to characterize how WASH exposures were associated with WASH conditions and school performance. Data were collected from 425 schools. The Basic WASH facilities coverage in the primary schools of Sindh remains overall low according to WHO WASH service ladder criteria. Also, inconsistency in all three inclusive domains of WASH (availability, accessibility, and functionality) facilities were found. The school performance was significantly associated (P<0.001) with the presence of WASH interventions and/or WASH policy, while WASH policy and/or recent WASH intervention at the school were not associated with overall water quality. Our assessment unveiled several WASH gaps that exist, including high heavy metal and fecal contamination. Adoption of national WASH policy and financing of evidence-based WASH interventions are recommended in primary schools to improve educational outcomes.

Heavy metals drinking water contamination and health risk assessment among primary school children of Pakistan.

The purpose of this study was to characterize the concentrations of lead (Pb), cadmium (Cd), manganese (Mn), and Fe (Fe) in drinking water sources in primary schools in Sindh Province, Pakistan and to quantify potential health risks among those school children. We conducted a representative, cross-sectional study among 425 primary schools in Sindh province of Pakistan. We used risk assessment models to estimate the metal index, pollution index, lifetime cancer risk, and hazard quotient index. Across the 425 sampled schools, the levels of heavy metals in the drinking water often exceeded the WHO permissible limits (67% of schools exceeded Pb limit, 17% for Cd, 15% for Fe). The average incremental lifetime cancer risk (ILCR) for Pb exceeded tolerable limits in all of the districts under study. The findings, particularly for Pb, are of concern, as Pb may negatively influence children's growth, development, school performance, and long-term health.

Quantitative Microbial Risk Assessment of Drinking Water Quality to Predict the Risk of Waterborne Diseases in Primary-School Children.

Primary-school children in low- and middle-income countries are often deprived of microbiologically safe water and sanitation, often resulting in a high prevalence of gastrointestinal diseases and poor school performance. We used Quantitative Microbial Risk Assessment (QMRA) to predict the probability of infection in schoolchildren due to consumption of unsafe school water. A multistage random-sampling technique was used to randomly select 425 primary schools from ten districts of Sindh, Pakistan, to produce a representative sample of the province. We characterized water supplies in selected schools. Microbiological testing of water resulted in inputs for the QMRA model, to estimate the risks of infections to schoolchildren. Groundwater (62%) and surface water (38%) were identified as two major sources of drinking water in the selected schools, presenting varying degrees of health risks. Around half of the drinking-water samples were contaminated with Escherichia coli (49%), Shigella spp. (63%), Salmonella spp. (53%), and Vibrio cholerae (49%). Southern Sindh was found to have the highest risk of infection and illness from Campylobacter and Rotavirus. Central and Northern Sindh had a comparatively lower risk of waterborne diseases. Schoolchildren of Karachi were estimated to have the highest probability of illness per year, due to Campylobacter (70%) and Rotavirus (22.6%). Pearson correlation was run to assess the relationship between selected pathogens. V. cholerae was correlated with Salmonella spp., Campylobacter, Rotavirus, and Salmonella spp. Overall, the risk of illness due to the bacterial infection (E. coli, Salmonella spp., V. cholerae, Shigella, and Campylobacter) was high. There is a dire need for management plans in the schools of Sindh, to halt the progression of waterborne diseases in school-going children.