The association between water, sanitation, and hygiene infrastructure, environmental contamination, and neonatal sepsis at two healthcare facilities in Amhara, Ethiopia Public
Stone, Erin (Spring 2021)
Published
Abstract
Abstract
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
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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