The association between water, sanitation, and hygiene infrastructure, environmental contamination, and neonatal sepsis at two healthcare facilities in Amhara, Ethiopia Open Access

Stone, Erin (Spring 2021)

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Background: Neonatal sepsis rates are high in Ethiopia where there is often inadequate water, sanitation, and hygiene (WASH) capacity in healthcare facilities (HCF). This leads to increased environmental contamination which can be passed to neonates via multiple routes, including contaminated hands, surfaces, and invasive medical devices, and cause healthcare-associated (HA) infections. The main objectives of this study are to determine if there is an association between HA neonatal sepsis, environmental contamination, and WASH capacity at two HCF in Amhara, Ethiopia.

Methods: A modified WASH Conditions Assessment Survey (WASHCon), was deployed over 32 weeks in five neonatal units of two Ethiopian HCF. Surveys were collected in conjunction with environmental and neonatal clinical samples. Multivariable logistic regression was conducted to determine an association between these variables.

Results: Felege Hiwot Hospital had a higher prevalence of neonatal sepsis, antimicrobial resistant (AMR) sepsis, and mortality. Debre Tabor Hospital had a higher frequency of environmental contamination, and environmental AMR isolates. Sepsis due to Klebsiella spp. was associated with hospital of birth (aOR: 0.11 (95%CI: 0.02-0.64); p=0.002), detection of environmental contamination in the NICU (aOR: 35.31 (95%CI: 1.54-808.85), p=0.03), and contaminated hands in the delivery unit (aOR: 5.50= (95%CI: 1.16-25.77), p=0.03). Sepsis due to S. aureus was associated with detection of environmental contamination in the NICU (aOR: 0.01 (95%CI: <0.01-0.50), p=0.024), and the frequency of hand contamination in the delivery (0.036 (95%CI: 0.004-0.33), p=0.0033) and KMC units (aOR: 19.60 (95% CI:2.16-177.52), p=0.0081).

All cases of lab-confirmed neonatal sepsis were resistant to one or more antibiotics, and rates of resistance in environmental contamination isolates were high in both HCFs, making multivariable logistic regression impossible for this outcome. No association was found between WASH capacity and environmental contamination.

Conclusions: This study is the first to report an association between environmental contamination of hands and surfaces and HA neonatal sepsis in two HCF in Ethiopia. The prevalence of AMR environmental contamination was high in the clean and safe healthcare (CASH) certified facility, and resistance was 100% for all lab-confirmed sepsis cases. WASH Capacity did not align with contamination which warrants further investigation into facility cleaning and hand hygiene behaviors.

Table of Contents


Distribution Agreement 1

Literature Review_ 15

Scope and Purpose 15

Neonatal Sepsis 16

Neonatal Sepsis in Ethiopia 16

Neonatal Sepsis Definitions 17

Antimicrobial Resistant Neonatal Sepsis 19

Costs Associated with Neonatal Sepsis 20

Healthcare Facility Environmental Contamination_ 21

Healthcare Facility Environmental Contamination in Ethiopia 23

Antimicrobial Resistant Environmental Contamination_ 24

Water, Sanitation, and Hygiene (WASH) 25

WASH in Ethiopia 25

Clean and Safe Health Facilities (CASH) Initiative 26

Objective 27

Public Health Implications 27

Manuscript 29

Title, Authors, & Abstract 29

Abstract 29

Introduction_ 30

Methods 33

Setting_ 33

Population Sampling Methods 34

Clinical Sample Collection_ 34

Environmental Sampling Methods 34

Environmental Sample Collection_ 35

Environmental Sample Testing_ 35

WASH Capacity_ 35

Antimicrobial Susceptibility Testing_ 36

Data Maintenance, Cleaning, and Analysis 36

Results 37

Neonatal sepsis 37

Environmental Contamination_ 39

Water Sanitation and Hygiene Capacity: WASHCon Lite Surveys 43

Water Quality and Quantity_ 43

Hand Hygiene 44

Environmental Cleanliness and Waste Management 45

Infection Prevention and Control Supplies 45

Unit-specific Practices 46

Multivariable Logistic Regression: Healthcare-associated Neonatal Sepsis 46

Multivariable Logistic Regression: Healthcare Environmental Contamination_ 47

Discussion_ 47

Neonatal Sepsis & Environmental Contamination_ 47

Environmental Contamination, IPC, and WASH_ 50

Strengths & Potential Limitations 53

Summary, Public Health Implications, and Future Directions 54

References 58

Tables and Figures 70

Appendix_ 82

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