Self-reported hand hygiene practices, and feasibility and acceptability of alcohol-based hand rubs among village healthcare workers in Inner Mongolia, China.

BACKGROUND: Good hand hygiene is critical to reduce the risk of healthcare-associated infections. Limited data are available on hand hygiene practices from rural healthcare systems in China. AIM: To assess the feasibility and acceptability of sanitizing hands with alcohol-based hand rubs (ABHRs) among Chinese village healthcare workers, and to assess their hand hygiene practice. METHODS: Five hundred bottles of ABHR were given to village healthcare workers in Inner Mongolia, China. Standardized questionnaires collected information on their work load, availability, and usage of hand hygiene facilities, and knowledge, attitudes, and practices of hand hygiene. FINDINGS: In all, 369 (64.2%) participants completed the questionnaire. Although 84.5% of the ABHR recipients believed that receiving the ABHR improved their hand hygiene practice, 78.8% of recipients would pay no more than US$1.5 out of their own pocket (actual cost US$4). The majority (77.2%) who provided medical care at patients' homes never carried hand rubs with them outside their clinics. In general, self-reported hand hygiene compliance was suboptimal, and the lowest compliance was 'before touching a patient'. Reported top three complaints with using ABHR were skin irritation, splashing, and unpleasant residual. Village doctors with less experience practised less hand hygiene. CONCLUSION: The overall acceptance of ABHR among the village healthcare workers is high as long as it is provided to them for free/low cost, but their overall hand hygiene practice is suboptimal. Hand hygiene education and training is needed in settings outside of traditional healthcare facilities.

Fatal Apophysomyces elegans infection transmitted by deceased donor renal allografts.

Two patients developed renal mucormycosis following transplantation of kidneys from the same donor, a near-drowning victim in a motor vehicle crash. Genotypically, indistinguishable strains of Apophysomyces elegans were recovered from both recipients. We investigated the source of the infection including review of medical records, environmental sampling at possible locations of contamination and query for additional cases at other centers. Histopathology of the explanted kidneys revealed extensive vascular invasion by aseptate, fungal hyphae with relative sparing of the renal capsules suggesting a vascular route of contamination. Disseminated infection in the donor could not be definitively established. A. elegans was not recovered from the same lots of reagents used for organ recovery or environmental samples and no other organ transplant-related cases were identified. This investigation suggests either isolated contamination of the organs during recovery or undiagnosed disseminated donor infection following a near-drowning event. Although no changes to current organ recovery or transplant procedures are recommended, public health officials and transplant physicians should consider the possibility of mucormycosis transmitted via organs in the future, particularly for near-drowning events. Attention to aseptic technique during organ recovery and processing is re-emphasized.

Asthma and respiratory symptoms in hospital workers related to dampness and biological contaminants.

UNLABELLED: The National Institute for Occupational Safety and Health investigated respiratory symptoms and asthma in relation to damp indoor environments in employees of two hospitals. A cluster of six work-related asthma cases from one hospital department, whose symptoms arose during a time of significant water incursions, led us to conduct a survey of respiratory health in 1171/1834 employees working in the sentinel cases hospital and a nearby hospital without known indoor environmental concerns. We carried out observational assessment of dampness, air, chair, and floor dust sampling for biological contaminants, and investigation of exposure-response associations for about 500 participants. Many participants with post-hire onset asthma reported diagnosis dates in a period of water incursions and renovations. Post-hire asthma and work-related lower respiratory symptoms were positively associated with the dampness score. Work-related lower respiratory symptoms showed monotonically increasing odds ratios with ergosterol, a marker of fungal biomass. Other fungal and bacterial indices, particle counts, cat allergen and latex allergen were associated with respiratory symptoms. Our data imply new-onset of asthma in relation to water damage, and indicate that work-related respiratory symptoms in hospital workers may be associated with diverse biological contaminants. PRACTICAL IMPLICATIONS: In healthcare facilities with indoor dampness and microbial contamination, possible associations between such conditions and respiratory health effects should be considered. Good building maintenance and housekeeping procedures should lead to improvements in employee respiratory health.

Use of surrogate markers of biological agents in air and settled dust samples to evaluate a water-damaged hospital.

UNLABELLED: An environmental survey was conducted in two hospital buildings in Montana, one of which had historical water incursion on the top floors and higher prevalence of reported respiratory symptoms that improved when the occupants were away from work. We measured culturable fungi and bacteria, fungal spores, endotoxin, and sub-micron particles in air; and culturable fungi and bacteria, endotoxin, markers of fungi (extra-cellular polysaccharides specific for Penicillium/Aspergillus, ergosterol, and beta(1-->3) glucans) and cat allergen in chair and floor dusts. For the analytes measured in air, the correlation coefficients ranged from 0.43 to 0.78 (P < 0.05). In chair dust, beta(1-->3) glucan concentrations correlated with culturable fungi and ergosterol concentrations. We found that sub-micron particles and markers of microbiological agents, but not culturable microbiological agents, were significantly positively associated with the building that had both historical water damage and higher prevalence of reported respiratory symptoms. Chair dust measurements tended to be higher in the non-complaint building. These results suggest that air and floor dust measurements of marker compounds may be better indicators of current health risk in a water-damaged environment than chair dust measurements or measurements of culturable fungi or bacteria in air or settled dust. PRACTICAL IMPLICATIONS: Detection and quantification of nonculture-based microbiological markers and/or agents of disease may be useful methods to assess microbial contamination and to more accurately evaluate microbial exposures in the indoor environment for exposure-response studies.

Reduction of pulmonary toxicity of Stachybotrys chartarum spores by methanol extraction of mycotoxins.

The fungus Stachybotrys chartarum has been implicated in cases of nonspecific indoor air quality complaints in adults and in cases of pulmonary hemorrhaging in infants. The effects that have been described have been attributed to mycotoxins. Previous dose-effect studies focused on exposure to a single mycotoxin in a solvent, a strategy which is unlikely to accurately characterize the effects of inhaled spores. In this study we examined the role of mycotoxins in the pulmonary effects caused by S. chartarum spores and the dose dependency of these effects. S. chartarum spores were extracted in methanol to reduce the mycotoxin content of the spores. Then either untreated (toxin-containing) or methanol-extracted S. chartarum spores were intratracheally instilled into male 10-week-old Charles River-Dawley rats. After 24 h, the lungs were lavaged, and the bronchoalveolar lavage fluid was analyzed to determine differences in lactic dehydrogenase, albumin, hemoglobin, myeloperoxidase, and leukocyte differential counts. Weight change was also monitored. Our data show that methanol extraction dramatically reduced the toxicity of S. chartarum spores. No statistically significant effects were observed in the bronchoalveolar lavage fluids of the animals that were treated with methanol-extracted spores at any dose. Conversely, dose-dependent effects of the toxin-containing spores were observed when we examined the lactic dehydrogenase, albumin, and hemoglobin concentrations, the polymorphonuclear leukocyte counts, and weight loss. Our findings show that a single, intense exposure to toxin-containing S. chartarum spores results in pulmonary inflammation and injury in a dose-dependent manner. Importantly, the effects are related to methanol-soluble toxins in the spores.

The time course of responses to intratracheally instilled toxic Stachybotrys chartarum spores in rats.

Stachybotrys chartarum is a fungal species that can produce mycotoxins, specifically trichothecenes. Exposures in the indoor environment have reportedly induced neurogenic symptoms in adults and hemosiderosis in infants. However, little evidence has linked measured exposures to any fungal agent with any health outcome. We present here a study that focuses on quantitatively assessing the health risks from fungal toxin exposure. Male, 10 week old Charles River-Dawley rats were intratracheally instilled with approximately 9.6 million Stachybotrys chartarum spores in a saline suspension. The lungs were lavaged 0 h (i.e., immediately post-instillation), 6, 24 or 72 h after instillation. Biochemical indicators (albumin, myeloperoxidase, lactic dehydrogenase, hemoglobin) and leukocyte differentials in the bronchoalveolar lavage fluid and weight change were measured. We have demonstrated that a single, acute pulmonary exposure to a large quantity of Stachybotrys chartarum spores by intratracheal instillation causes severe injury detectable by bronchoalveolar lavage. The primary effect appears to be cytotoxicity and inflammation with hemorrhage. There is a measurable effect as early as 6 h after instillation, which may be attributable to mycotoxins in the fungal spores. The time course of responses supports early release of some toxins, with the most severe effects occurring between 6 and 24 h following exposure. By 72 h, recovery has begun, although macrophage concentrations remained elevated.

Review of quantitative standards and guidelines for fungi in indoor air.

Existing quantitative standards/guidelines for fungi in indoor air issued by governmental agencies are based primarily on baseline data (rather than health effects data), and are either absolute (numerical) or relative (indoor/outdoor comparisons) or a combination of the two. The Russian Federation is the only governmental agency that has binding quantitative regulations for bioaerosols. Recommended guidelines have been proposed or sponsored by North American and European governmental agencies and private professional organizations. A considerable number of frequently cited guidelines have been proposed by individuals based either on baseline data or on personal experience. Quantitative standards/guidelines range from less than 100 CFU/m3 to greater than 1000 CFU/m3 (total fungi) as the upper limit for non-contaminated indoor environments. Major issues with existing quantitative standards and guidelines are the lack of connection to human dose/response data, reliance on short term grab samples analyzed only by culture, and the absence of standardized protocols for data collection, analysis, and interpretation. Urgent research needs include the study of human responses to specific fungal agents, development and widespread use of standard protocols using currently available sampling methodologies, and the development of long term, time-discriminating personal samplers that are inexpensive, easy to use, and amenable to straightforward, relevant analysis.

Combined modality therapy for stage IIIMO non-oat cell bronchogenic carcinoma.

Thirty-nine patients with stage IIIMO non-cell bronchogenic carcinoma (NOBC) were treated with combined modality therapy: radiation therapy and chemotherapy with cyclophosphamide, adriamycin, methotrexate, and procarbazine. The median survival for all patients treated was 9.6 months compared to 6.4 months for historical controls (P = 0.015). Patients who responded to the treatment program had a significantly longer survival (median, 15.2 months) compared to nonresponders and historical controls (P less than 0.005). It is concluded that combined modality therapy is moderately effective therapy in stage IIIMO NOBC.