New research conducted in seven sub-Saharan African counties highlights the health and financial impact of inadequate water, sanitation, and hygiene (WASH) in healthcare facilities.

In a report published late last week, non-governmental organization WaterAid estimated that inadequate WASH in healthcare facilities in Ethiopia, Ghana, Malawi, Mali, Nigeria, Uganda, and Zambia contributed to 2.6 billion healthcare-associated infections (HCAIs) and 277,160 excess deaths in 2022. At least 50% of the HCAIs are believed to have been caused by antimicrobial-resistant (AMR) bacteria.

The economic costs of these infections is estimated to range from 2.5% to 10.9% of the healthcare budgets in the seven countries, while lost wages and productivity due to infections accounted for 0.4% to 2.9% of the countries' gross domestic product.

Poor WASH paves way for healthcare-related infections

The report notes that globally, nearly 4 million people—predominantly those living in low- and middle-income countries (LMICs)—lack basic hygiene services at their healthcare facility, and one in five lack basic water services. Inadequate WASH at healthcare facilities in LMICs contributes to a rate of HCAIs that is more than twice that of high-income countries (15.5% vs 7.6%).

"The major transmission pathway for HCAIs is lack of cleanliness and hygiene measures provided during the delivery of healthcare," the report states. "Beyond the health impacts, poor WASH in HCF [healthcare facilities] has additional negative consequences as it relates to other aspects of quality care, including patient satisfaction, dignified and respectful care, future healthcare seeking behaviours and healthcare worker morale, motivation and retention, all of which ultimately impact health outcomes."

WaterAid says the problem is likely to get worse as AMR rates rise, and argues that the less than US$1 per capita needed to provide basic wash services at healthcare facilities in these countries would be covered by savings from a reduction in the medical costs associated with HAIs. The group calls on national governments to develop a dedicated budget line for WASH in healthcare facilities and urges donors, G7 countries, and multilateral financing institutions to prioritize WASH when working with national governments in LMICs.

A study today in CMAJ describes the characteristics of family practice physicians who see the largest share of patients unvaccinated against COVID-19, and reveals that the largest percentage practice in marginalized, lower-income neighborhoods. 

The study also suggests that family practice physicians who practice alone, without a team-based model, were less likely to have vaccinated patients. 

The study was based on 9,060 family physicians in Ontario who treat more than 10 million patients. Researchers looked at characteristics of the 10% of physicians who had the most unvaccinated patients as of November 1, 2021, when everyone in Canada was eligible for at least two doses of vaccine.

Older docs more likely to have unvaccinated patients

Physicians with the largest proportion of unvaccinated patients were more likely to be male (64.6% vs 48.1%), to have trained outside of Canada (46.9% vs 29.3%), and to be older (mean age, 56 vs 49 years).

More unvaccinated patients were recent immigrants to Canada, had higher rates of material deprivation, and had lower incomes, the authors said. Though family practice physicians were not the first line of COVID-19 vaccinators in Canada, their influence and recommendations shape patient care. 

We know that relationships with trusted family physicians can positively influence patients' decisions.

"We know that relationships with trusted family physicians can positively influence patients' decisions," said senior author Noah Ivers, MD, in a CMAJ press release. "Our study highlights the need to create equitable systems and processes that create opportunities for primary care teams to play a crucial role in influencing both general and SARS-CoV-2-specific vaccine-related decision-making."

A systematic review and meta-analysis found that the use of antibiotics prior to invasive dental procedures was associated with a reduced risk of infective endocarditis (IE) in high-risk patients, but not in those considered moderate- or low-risk, US and European researchers reported late last week in JAMA Cardiology.

The findings support current antibiotic prophylaxis (infection prevention) guidelines from the American Heart Association (AHS) and the European Society of Cardiology (ESC), which recommend that patients with cardiac conditions that are associated with the highest risk of adverse outcome from IE—an infection of the heart valve—should receive antibiotics before invasive dental procedures. Previous guidelines from the organizations had recommended antibiotic prophylaxis for a wider range of patients.

59% less risk of infection in high-risk patients

A total of 30 studies covering 1,152,345 IE cases were included in the review; 8 of the studies were case-control/crossover, cohort, or self-controlled case series studies, and 22 were time-trend studies. Meta-analysis of the group of 8 studies found that high-risk patients who received antibiotic prophylaxis were 59% less likely to develop IE (pooled risk ratio [RR], 0.41; 95% confidence interval [CI], 0.29 to 0.57) than those who didn't receive antibiotic prophylaxis. No significant associations were found for individuals at moderate or low/unknown risk. 

Results from the time-trend studies were inconsistent, with 9 studies finding no significant changes in IE incidence since the AHA and ESC antibiotic prophylaxis guidelines for invasive dental procedures were narrowed in 2017, 7 finding a significant increase in IE incidence for the overall population, and 3 finding a significant decrease.

The authors of the study say that while the findings add valuable evidence for defining the role of antibiotic prophylaxis in preventing IE following invasive dental procedures, studies with a more rigorous scientific approach, such as randomized clinical trials, are needed.

• In its latest weekly update the US Centers for Disease Control and Prevention (CDC) reported 16 more measles cases, raising the national total to 113. The number of affected jurisdictions remained at 18. Of the 113 cases, 83 (73%) are related to outbreaks, seven of which have been reported so far. Sixty-five people were hospitalized for measles complications, with the highest percentages in young children and adults. Of the outbreak total, 83% of people were unvaccinated or had an unknown vaccination status. For comparison, the CDC reported 58 cases for all of last year, of which 28 (48%) were part of four outbreaks.
• The World Health Organization (WHO) polio emergency committee met for the 38th time on March 20 to assess the latest developments and recommended that the situation still warrants a public health emergency of international concern (PHEIC), which was declared in May 2014. In a statement today, the WHO said some of the factors involved in extending the health emergency include wild poliovirus type 1 (WPV1) infections in critical areas and historic reservoirs in Pakistan and Afghanistan, with lineages seen in Afghanistan in 2022 now being detected in Pakistan in 2023 and 2024. Also, the agency said the risk of further spread of circulating vaccine-derived poliovirus type 2 (cVDPV2) remains high, with ongoing cross-border detections in Africa and a new emergence in South Sudan, despite never having used the oral poliovirus type 2 vaccine. The group also noted that vaccination gaps are still a threat, given weak routine immunization and lack of access in northern Yemen and Somalia, which have large unvaccinated populations.