Implementing a multimodal intervention using local resources to improve hand hygiene compliance in a comprehensive specialized hospital in Mekelle, Northern Ethiopia.

BACKGROUND: Hand hygiene (HH) is known to be the most effective practice to reduce Healthcare-associated infections (HAIs). The main barriers to HH practices among healthcare workers (HCWs) in Sub-Saharan Africa are heavy workload, infrastructural deficits, and poorly positioned facilities. There is limited data on HH compliance and particularly on the impact of the World Health Organization's (WHO) multimodal HH strategy in low- and middle-income countries. This study aimed to provide insights into a strategy to implement the WHO concept adapted to local conditions and obstacles encountered at a tertiary university hospital in Mekelle, Tigray, Ethiopia. METHODS: We conducted a study aiming at increasing the quality of the HH practice of HCWs using the WHO HH improvement strategy. The study adopted a pre-and post-interventional design from April 2018 to May 2019. In the pre-intervention phase, a baseline infrastructural survey was made. The intervention consisted of in-house production of hand sanitizer and dispensers for every patient bed, staff education and motivation, and implementation of a multidisciplinary infection prevention committee. The intervention was followed by two one-week compliance observations of HH practice among HCWs within the six months post-intervention period and microbiological sample collection from HCWs' hands to assess the quality of HH. RESULTS: We observed 269 (baseline), 737 (first follow-up) and 574 (second follow-up) indications for HH among HCWs. The overall baseline hand rub compliance was 4.8%, which significantly increased to 37.3% (first follow-up) and 56.1% (second follow-up) (p < 0.0001). Consistent and significant increases in hand rub compliance during the entire follow-up period were observed before touching a patient, after touching a patient, and after touching the patient's surroundings (all p < 0.01). Nurses and medical interns achieved consistent and significant increases in hand rub compliance during the entire follow-up period (all p < 0.01). CONCLUSION: Implementing the WHO HH improvement strategy significantly increased HH compliance despite a shortage of water and other resources. Hand rub was accepted as the main HH method in the hospital. HH campaigns in developing settings profit from multimodal strategies, knowledge exchange and utilization of local resources.

Air quality in the operating room: Surgical site infections, HVAC systems and discipline - position paper of the German Society of Hospital Hygiene (DGKH).

In recent years, there has been an ongoing discussion about the value of laminar airflow (LAF=low turbulence displacement ventilation) in the operating room for prevention of surgical site infections (SSI). Some publications, e.g., from the WHO, issued the demand to no longer build LAF ceilings in operating rooms. The present statement deals critically with this position and justifies the use of LAF ceilings in different ways: Many of the papers cited by the WHO and others for the case against LAF do not provide reliable data.The remaining studies which might be used for answering the question give quite different results, also in favor of LAF.The size of the LAF ceiling in many studies is not given or mostly too small in comparison to actual technical requirements.LAF in different countries can mean quite different techniques (e.g., the US in comparison to Germany) so that the results of studies that do not take this into account may not be comparable.LAF has positive effects in terms of reducing particulate and bacterial load, associated with increased airflow in the surgical working area. A reduction of carcinogenic substances in the air may also be assumed, which would increase workers' safety. Thus, this paper recommends building LAF ceilings in the future as well, depending on the operations intended. Further, this paper gives an overview of possible reasons for surgical site infections and highlights the importance of discipline in the operating theatre.

Hygiene guideline for the planning, installation, and operation of ventilation and air-conditioning systems in health-care settings - Guideline of the German Society for Hospital Hygiene (DGKH).

Since the publication of the first "Hospital Hygiene Guideline for the implementation and operation of air conditioning systems (HVAC systems) in hospitals" (http://www.krankenhaushygiene.de/informationen/fachinformationen/leitlinien/12) in 2002, it was necessary due to the increase in knowledge, new regulations, improved air-conditioning systems and advanced test methods to revise the guideline. Based on the description of the basic features of ventilation concepts, its hygienic test and the usage-based requirements for ventilation, the DGKH section "Ventilation and air conditioning technology" attempts to provide answers for the major air quality issues in the planning, design and the hygienically safe operation of HVAC systems in rooms of health care.

Postponing elective hospitalizations for pre-admission MRSA screening and decolonization. A study evaluating eligibility and acceptance among patients of a German university hospital.

There is evidence that pre-admission screening and decolonization (PreASD) of MRSA can reduce costs in elective surgical patients. It is not known whether this strategy could also be successfully applied to general medical patients of a tertiary referral hospital with multiple specialties. Our study retrospectively evaluates the eligibility of patients for MRSA-PreASD in a setting of active targeted MRSA surveillance. We carried out a survey among eligible patients to assess acceptance and feasibility of MRSA-PreASD. Of 10,496 admissions to our university hospital 8912 (84.9%) were screened for MRSA-risk factors. In 5382 admissions at risk swabs were taken and analyzed. Using the Appropriateness Evaluation Protocol (AEP) we retrospectively assessed how many of the 5382 admissions at risk could have been postponed for the duration of an MRSA-PreASD. 36 (17%) of 212 admissions with proven MRSA colonization and 2175 (42%) of 5170 patients without detectable MRSA could have been sent home for MRSA-PreASD to be electively admitted later. Of the 36 admissions (35 patients) with proven MRSA eligible for PreASD 23 patients (65%) responded to an interview. 22 of those (95.6%) would have agreed to PreASD. Additional costs for a screening protocol adapted to the needs of MRSA-PreASD of 52,061€ were estimated. Additional hospitalization costs of 6100-9300€ per MRSA case in Germany have been published. In our study population the successful pre-admission decolonization of 22 cases (63% of 35 patients eligible) may therefore have saved about 134,000-205,000€. Thus from an economic point of view our concept should be justified. In conclusion a relevant number of affected admissions to our tertiary referral hospital is eligible for an MRSA-PreASD. The majority of patients with proven MRSA-colonization eligible for a pre-admission decolonization treatment would prefer such an approach over being isolated at the hospital. The implementation of an MRSA-PreASD-protocol may reduce costs.

Prevalence of nickel sensitization and urinary nickel content of children are increased by nickel in ambient air.

In a cross-sectional study performed in 2000, an unexpected positive association between nickel (Ni) in ambient air, urinary Ni content and the prevalence of Ni sensitization in a subgroup of 6-yr-old children living near a steel mill was observed. Between 2005 and 2006, in a different and larger study population, we examined if Ni from ambient air or urinary Ni concentration was related to Ni sensitization in children living next to Ni-emitting steel mills. We studied 749 school beginners living in four Ni-polluted industrial areas of North Rhine-Westphalia, Germany. We assessed Ni in ambient air, Ni in urine from children and mothers, and Ni in tap water, conducted patch tests in children (including the NiSO(4)-dilution test) and collected questionnaire data. Statistics were done by linear and logistic regression analyses, adjusted for covariates. At increased Ni concentration in ambient air (unit of increase: 10 ng/m(3)), urinary Ni concentrations rose in both mothers (9.1%; 95% CI: 6.8-11.4%) and children (2.4%; 95% CI: 0.4-4.4%). The prevalence of Ni sensitization in children was associated with increased Ni from ambient air (unit of increase: 18 ng/m(3); odds ratio 1.28; 95% CI: 1.25-1.32) and urinary Ni concentration (unit of increase: 7.1 µg/L; odds ratio 2.4; 95% CI: 1.20-4.48). Ni in ambient air of areas with Ni-emitting factories contributes to internal Ni exposure in residents via inhalation and, furthermore, is a risk factor for the development of Ni sensitization in children.

Lack of neurodevelopmental adversity by prenatal exposure of infants to current lowered PCB levels: comparison of two German birth cohort studies.

Polychlorinated biphenyls (PCBs), persistent environmental contaminants, may affect neurodevelopment of infants following prenatal exposure. A negative impact of prenatal PCB exposure on neurodevelopment was found in the Dusseldorf (Germany) cohort study (1993-2000). PCB levels of the sum of the three indicator congeners in breast milk were negatively associated with mental/motor development as assessed by the Bayley Scales of Infant Development (BSID) in infants. Since general exposure to PCB has decreased, a new birth cohort study was initiated in 2000 in the industrial city of Duisburg, which is located 30 km downstream from Dusseldorf on the River Rhine. A subgroup of the Duisburg birth cohort study was used to compare PCB exposure and developmental effects with results from the Dusseldorf cohort. The recruitment phase of the Duisburg cohort study occurred from 2000 to 2002. Mental and motor development was assessed by means of the BSID at the ages of 12 and 24 mo. Prenatal PCB exposure of newborns from Duisburg cohort was about two- to threefold lower than the Dusseldorf cohort. Although in the Dusseldorf birth cohort mental and motor development at ages 18 and 30 mo were negatively associated with PCB exposure, there was no association observed in the Duisburg study. Evidence indicates that exposure to PCB at current exposure levels no longer apparently impair neurodevelopment of infants.

Polychlorinated dibenzo-p-dioxins/polychlorinated dibenzofurans (PCDD/Fs), polychlorinated biphenyls (PCBs), and organochlorine pesticides in human blood of pregnant women from Germany.

Blood samples from 226 pregnant women aged between 19 and 41 yr, living in an industrialized area of Germany (Duisburg birth cohort study), were collected between September 2000 and November 2002 and analyzed for their content of persistent organic pollutants (POPs). Levels of polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), and polychlorinated biphenyls (PCBs) were in the range of 4.34-97.3 pg WHO 1998 TEq/g(lipid base) (median: 25.96) or 3.77-63.56 pg WHO 2005 TEq/g(lipid base) (median: 19.38), respectively. Whole blood volume-based concentrations of organochlorine pesticides and their metabolites were 0.036-0.53 microg/L (median: 0.15) hexachlorobenzene (HCB), 4.5-1300 ng/L (median: 67) beta-hexachlorocyclohexane (HCH), 0.6-520 ng/L (median: 18) 4,4'-dichlorodiphenyltrichloroethane (DDT), and 0.1-9.1 microg/L (median: 0.54) 4,4'-dichlorodiphenyldichloroethene (DDE). Parameters influencing the POP levels in human blood were examined using multiple regression models. Levels and the levels scatter widths of most PCDD/F and PCB congeners and HCB increased significantly with age. Within the multiple regression model a weak age dependence was also found for beta-HCH and DDT, whereas blood levels of alpha- and gamma- HCH and DDE were not age dependent. The total lactation period for earlier born children decreased most POP blood levels, except for alpha- and gamma-HCH. Over the study period of 27 mo only a low decreasing effect on human POP blood levels was observed. The body mass index had in general no or a low positive influence on contaminant levels. Because exposure to PCDD/F and PCB is higher in most industrialized countries in comparison to less industrialized ones, lower levels of these substances were detected in blood samples of women who had lived outside Western Europe for a longer period. In contrast, these women showed higher blood levels of organochlorine pesticides, indicating that these chemicals are still in use outside Western Europe.

The Duisburg birth cohort study: influence of the prenatal exposure to PCDD/Fs and dioxin-like PCBs on thyroid hormone status in newborns and neurodevelopment of infants until the age of 24 months.

Prenatal exposure to polychlorinated biphenyls (PCBs) and polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) can affect neurobehavioral development of infants and children. This effect may be mediated through disruption of thyroid hormone homeostasis. However, epidemiological studies reveal no consistent influence of PCDD/Fs and PCBs on thyroid status and neurodevelopment at environmental background levels. The effects may resolve with time of further decreasing exposure to these compounds. The aim of this study was to find out if there are still effects related to prenatal PCDD/F and PCB observable at the meanwhile decreased levels of exposure by using the same methods which have been applied in similar studies during the last 10 years in Europe. The birth cohort study was initiated in the year 2000 in the industrialized city of Duisburg, Germany. 232 healthy mother-infant pairs were recruited between 2000 and 2002. Dioxins, dioxin-like PCBs and six indicator PCBs were analyzed in maternal blood during pregnancy and in maternal milk following extraction and sample clean-up by HRGC/HRMS. Thyroid stimulating hormone (TSH), total thyroxine (T4), total triiodothyronine (T3), free thyroxine (FT4) and free triiodothyronine (FT3) were measured in serum samples of the pregnant women and in cord serum samples by chemiluminescent immunometric assay. Neurological examinations were performed at ages 2 weeks and 18 months using the neurological optimality score (NOS), mental and motor development were assessed using the Bayley Scales of Infant Development (BSID) at ages 12 and 24 months. Multiple linear regression analysis was used to describe the association of PCDD/F and PCB in maternal blood or milk with the outcome measurements after adjustment for confounding. Blood levels (n=182) of WHO 2005 toxic equivalents (TEQ) (PCDD/F+PCB) were in the range of 3.8-58.4 pg/glipid base (median: 19.3 pg/glipid base). The corresponding data for human milk (n=149) were 2.6-52.4 pg/glipid base (median: 19.7 pg/glipid base). Multiple regression analysis showed no decrease of thyroid hormones related to WHO 2005 TEQ in blood and milk of mothers and their newborns. Furthermore, no associations between exposure and neurological and developmental measures were observed. This study supports the view that the current decreased exposure to PCDD/Fs and PCBs does not impair thyroid function of newborns and neurodevelopment of infants until the age of 24 months.

Environmental exposure to dioxins and polychlorinated biphenyls reduce levels of gonadal hormones in newborns: results from the Duisburg cohort study.

BACKGROUND: Endocrine dysfunction related to the hypothalamic-pituitary-thyroid (HPT) and/or the hypothalamic-pituitary-gonadal axis (HPG) is being discussed as underlying developmental adversity of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) and polychlorinated biphenyls (PCBs). This study was done to evaluate effects related to the HPG axis. METHODS: A birth-cohort study was initiated in the year 2000. Healthy mother-infant pairs were recruited in the industrialized city of Duisburg, Germany. Dioxins, dioxin-like PCBs and six indicator PCBs were measured in maternal blood during pregnancy and in maternal milk. Testosterone and estradiol levels were measured in maternal and cord serum of 104 mother-infant pairs representing a subsample with a complete data set of the total basic sample of 232 participants. Linear regression analysis was used to describe the association of PCDD/Fs or PCB in maternal blood or milk with sex steroid concentrations after adjustment for confounding. RESULTS: Median concentrations for PCDD/Fs in maternal blood fat and milk fat in terms of WHO-TEq were 15.3 and 13.1pg WHO-TEq/g, respectively, and for the sum of the indicator PCBs (#28, #52, #101, #138, #153, #180) 149 and 177ng/g. The adjusted ratio of geometric means when doubling the concentration of PCDD/Fs in maternal blood fat was 0.86, 95% confidence interval (95% CI): 0.72-1.03 for testosterone and 0.73 (0.61-0.87) for estradiol in cord serum. Typically, testosterone reduction was more pronounced in cord serum of female and estradiol reduction in that of male babies. Reduction of hormone levels was generally more pronounced for dioxins than for indicator PCBs. CONCLUSIONS: The hypothalamic-pituitary-gonadal axis of newborn babies is influenced by prenatal exposure to PCDD/Fs and PCBs in a manner suggestive of AhR-mediation. The clinical relevance of this finding remains to be established, however.

PCDD/F and dioxin-like PCB in human blood and milk from German mothers.

Blood samples of pregnant women aged between 19 and 42 years at the time they gave birth and milk samples from the same women following delivery were collected between September 2000 and January 2003 from 169 participants living in an industrialized area of Germany (Duisburg birth cohort study). All samples were analyzed for their content of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/F) as well as dioxin-like and indicator polychlorinated biphenyls (PCB). Levels of WHO-TEq were in the range of 4.34-97.3 pg/g(lipid base) (median: 26.37, arithmetic mean: 28.36) for blood, or 3.01-78.7 pg/g(lipid base) (median: 26.40, arithmetic mean: 27.27) for milk, respectively. The four congeners 12378-PeCDD, 23478-PeCDF, 33'44'5-PeCB (# 126) and 233'44'5-HxCB (# 156) contribute the main share to total WHO-TEq. The contribution of PCDD/F in relation to PCB to total WHO-TEq was 60:40% in blood and 52:48% in milk. Good correlations of the contaminant levels in lipid base between both matrices were found. The distribution between blood and milk depends on the molecular weight of the substances. Higher chlorinated PCDD/F- and PCB-congeners were found in 2-4-fold higher concentrations in blood in relation to milk and the concentrations of lower chlorinated PCB-congeners were up to 2-fold higher in milk in relation to blood. The body burden of PCDD/F and PCB increases with age and decreases over the total nursing period. Women who had lived outside highly industrialized countries showed lower concentrations of PCDD/F and PCB. In some cases, elevated levels of PCB were observed when the women had previously lived in Eastern Europe for a long time. In comparison with recent data, the decline in human PCDD/F and PCB levels observed during the nineties seems to have stopped. The individual exposures of the infants due to breastfeeding within the first 18 months were calculated to be from 4.4 to 318 ng WHO-TEq (median: 106, arithmetic mean: 118). The actual mean daily exposure of a breastfed infant can be estimated to 131 pg WHO-TEq/kg(body weight).

Occupational exposure to polycyclic aromatic hydrocarbons suppresses constitutive expression of CYP1B1 on the transcript level in human leukocytes.

Expression patterns of the cytochromes P450 CYP1A1 and CYP1B1 have been analyzed on the transcript level in leukocytes of persons (n = 30) occupationally exposed to polycyclic aromatic hydrocarbons (PAH). To assess effects on expression levels results were compared with data obtained from a non-exposed control group (n = 68). CYP1B1 transcripts can be detected in all subjects of the control group but vary largely in their levels (factor 35). Statistical analysis shows that this variability is neither due to the age of the persons nor due to cigarette smoking. Furthermore, there is no difference in expression levels between genders. In contrast to CYP1B1, CYP1A1 is detectable in only 14% of the subjects. People involved in graphite electrode production and exposed to PAH show largely decreased CYP1B1 transcript levels. In 67% of the subjects, CYP1B1 is no more detectable at all. Vice versa, expression of CYP1A1 is increased in exposed persons so that 80% become positive for CYP1A1 vs. 14% of the control group. The results show that occupational exposure to PAH apparently leads to effect-relevant internal doses. Both, suppression of CYP1B1 and induction of CYP1A1 in leukocytes can be used as exposure parameters proving both enzymes to be suitable biomarkers of exposure. The suppression of CYP1B1 is an unexpected effect which needs further investigation. It is discussed that CYP1B1 and CYP1A1 indeed share a common Ah receptor mediated transcriptional regulation but that differences in promoter structure of the two genes and tissue-specific expression profiles of transcription factors may cause a differential expression behaviour.

Prevalence of respiratory symptoms in school children and salivary IgA--an epidemiological study in a rural area of Northrhine-Westphalia, Germany.

An elevated frequency of wheezing was found in school children in a rural area of Northrhine-Westphalia, Germany (Duhme and Keil, Institut für Epidemiologie und Sozialmedizin, Universität Münster, Münster, Germany 1997). In this study the prevalence of wheezing was reinvestigated by including main influencing factors. A cross-sectional survey was performed in all school children visiting school classes 1, 2 and 7, 8 (n = 1161). Two corresponding questionnaires were used: a parental questionnaire and a questionnaire for self-completion by the children aged 12-15. The latter included the ISAAC video questionnaire. The levels of immunoglobulins A, G and M were determined in 995 saliva samples. Testing of lung function (whole body plethysmography before and after physical exercise) was performed in children with and without parent-reported wheezing in the last 12 months (n = 377). Response rate (questionnaire: 93%) and participation rates (saliva samples: 86%, lung function tests: 93%) were high. Our study confirmed higher prevalence of asthmatic symptoms in children aged 6-8 in Ochtrup (13.2%) compared to children of the same age in Muenster (8.5% (Duhme et al., Eur. Respir. J. 11, 840-847, 1998)). However, in the age group 12-15 years the prevalence was significantly lower in Ochtrup (9.8%), when compared to the former investigation and in comparison to Muenster (former survey: 17.9%; Muenster: 13.1%). Prevalence of wheezing was consistently higher in families with atopic disease. Additionally, history of respiratory disease, premature birth and presence of pets during 1st year of life showed a positive association with prevalence of wheezing. Mean salivary IgA levels were 61.4 (SD (standard deviation) 35.1, median: 53.7) mg/l in children aged 6-8 years and 83.4 (SD 39.0, median: 76.3) mg/l in children aged 12-15 years. No significant association between salivary immunoglobulins and wheezing was detected.