Community-based situation analysis of maternal and neonatal care in South Africa to explore factors that impact utilization of maternal health services

This community situational analysis determined factors impacting the utilization of maternal health services in South Africa. Quantitative and qualitative research methods were used, including semistructured household interviews, case studies of women with no antenatal care and/or home birth, and verbal/social autopsies of maternal and infant deaths, conducted in three diverse sites across the country. Data analysis used quantitative statistics for the semistructured interviews and a qualitative thematic content approach for the case studies and verbal/social autopsies. Each component was analyzed separately and then triangulated. The following themes emerged: 1) transport and distance to care were the biggest problems, particularly in rural areas; 2) providers' communication with families was very poor; 3) health-seeking behavior was better than anticipated; 4) treatment by health providers and quality of care showed mixed results; 5) HIV/AIDS is a major issue; however, basic maternity and neonatal service quality cannot be overlooked; and 6) families and communities are an untapped resource for improving maternal and neonatal health. Implications for maternal and infant health care in developing countries are discussed, with a particular focus on barriers to utilization and involvement of communities and families in maternity care.     

Factors in the Selection of Surface Disinfectants for Use in a Laboratory Animal Setting

Because surface disinfectants are an important means of pathogen control within laboratory animal facilities, these products must have an appropriate spectrum of antimicrobial activity. However, many other factors must also be considered, including effects on human health, environmental safety, and animal behavior. Aqueous solutions of sodium hypochlorite often are considered to be the ‘gold standard’ for surface disinfection, but these products can be corrosive, caustic, and aversive in odor. This study was designed to identify disinfectants that are as effective as hypochlorite solutions but more acceptable for use in a laboratory animal setting. An antiviral disinfectant-efficacy assay was developed by using viral vectors that expressed green fluorescence protein as surrogates for wild-type viruses of concern in laboratory animals. Efficacy testing revealed that most of the products were highly effective when used against viral vectors in suspension. However, when the disinfectants were challenged by buffering virus in protein or drying virus on nonporous surfaces, the hypochlorite and peroxymonosulfate products performed the best. Review of safety data sheets for the agents indicated that a peroxide-based product was considerably safer than the other products tested and that the pH of most products was not conducive to disposal down a drain. Behavioral testing of Swiss Webster, C57Bl/6, and BALB/c mice showed that the hypochlorite- and peroxide-based products were clearly aversive, given that the mice consistently avoided these products. All of these factors must be considered when choosing the appropriate disinfectant.Abbreviations: CCM, complete culture medium; EPA, Environmental Protection Agency; HEK, human embryonic kidney; HMIS, Hazardous Material Information System; SDS, Safety Data SheetThe selection of appropriate disinfectants for use in animal facilities requires consideration of multiple factors, including spectrum of activity, human safety, and effects on the health and behavior of animals exposed to these agents. Multiple engineering standards are rigidly enforced to limit the spread of pathogens within animal facilities.^100,43 Chemical disinfectants are often the first line of defense against these pathogens; however, guidelines for their selection and usage often are defined less strictly. Because disinfectant use is critical in preventing the spread of adventitious disease within animal colonies and is an essential component of laboratory animal facility management,⁸⁷ a fact-based approach is imperative when selecting an appropriate product.Disinfection is the process of eliminating many or all pathogenic microorganisms, other than bacterial spores, on inanimate objects.⁸³ A hierarchy originally designed by Earle H Spaulding defined disinfectants as either high-, intermediate-, or low-level, based on their ability to kill various microorganisms.^92,93 According to the current usage of this hierarchy, high-level disinfectants are those capable of killing most pathogens, including all types of viruses, vegetative bacteria, mycobacteria, and bacterial spores, with the only exception being large numbers of spores.^66,83 Intermediate-level disinfectants are usually able to inactivate most viruses, vegetative bacteria, mycobacteria, and fungi but are unlikely to eliminate most bacterial spores. Low-level disinfectants are capable of eliminating vegetative bacteria and most enveloped viruses but are ineffective against some nonenveloped viruses, mycobacteria, some fungi and most bacterial spores. Since the establishment of the Spaulding hierarchy, there have been multiple schemes designed to classify microorganisms by their susceptibility to particular chemicals, including work by Klein and Deforest, who specified 3 levels of viral sensitivity to disinfectants, based the presence or absence of viral envelopes, in addition to their solubility.⁵¹ According to the Klein–Deforest scheme, hydrophilic nonenveloped viruses, such as parvoviruses, are the least sensitive to disinfectants, whereas partially lipophilic nonenveloped viruses of intermediate solubility, such as adenoviruses and rotaviruses, are slightly more sensitive, and lipophilic, or enveloped viruses, such as retroviruses, herpesviruses, paramyxoviruses, and coronaviruses, are the most sensitive.^51,80,87 Prince and colleagues further elaborated on this scale, categorizing the susceptibility of multiple human and animal pathogens.⁸⁰ Based on extrapolations from previous work, hierarchies have been developed specifically to classify pathogens affecting laboratory animals, including bacterial spores and parasites, which are even less sensitive to disinfection than are hydrophilic nonenveloped viruses.⁸⁷ These schemes are accepted guidelines for disinfectant differentiation and denote that chemicals capable of killing pathogens at a higher point in the spectrum are also capable of killing all of the more sensitive organisms. These general hierarchies may not provide fine distinctions between similar organisms,⁶⁰ but to this day, the Spaulding hierarchy is still considered to be as applicable as when it was first established and is considered as new products are developed and tested.⁶⁶Chemical disinfectants can be further categorized into 3 classes according to their method of action—denaturants, reactants, and oxidants.^80,87 Denaturants, such as quaternary ammonium compounds, phenolics, and alcohols, act by disrupting protein and lipid structures, making these products particularly effective against lipophilic enveloped viruses.^4,54,83 These chemicals are widely available, cost-effective, and are generally considered to be bactericidal, fungicidal, and variably tuberculocidal. They are not usually sporocidal or virucidal against nonenveloped viruses and therefore cannot be used as high-level disinfectants. Disinfectants that are reactants, including aldehydes (formaldehyde and glutaraldehyde) and ethylene oxide, form and break covalent bonds, altering DNA, RNA, and protein structure and synthesis.^4,54,83 These products are most commonly used as high-level disinfectants but are not typically applied as routine surface disinfectants because they are expensive and are considered relatively toxic, acting as both irritants and carcinogens. Oxidant disinfectants are the largest group and include halogens—hypochlorites, chlorine dioxide, and iodine—peroxides, and peroxymonosulfates. These disinfectants oxidize proteins, enzymes, and amino acids, making their spectrum of activity relatively broad.^4,54,83 Oxidants are inexpensive and fast-acting and are often considered to be mycobacteriocidal, sporocidal, and fungicidal; they also have the ability to kill nonenveloped viruses. However, some oxidant disinfectants present considerable health hazards and can be corrosive to equipment.^13,23,84 Given the obvious advantages and disadvantages of each disinfectant class, many variables must be considered as these disinfectants are assessed.When selecting a disinfectant for use in a laboratory animal facility, its spectrum of activity is arguably the most important factor to consider. A disinfectant must be able to eliminate the most resistant pathogens under conditions that vary among facilities, depending on the biosafety level, barrier agent exclusions, and immunocompetency of the animals being housed.⁵² Animal pathogens of concern often include retroviruses, herpesviruses, adenoviruses, parvoviruses, coronaviruses, and coxsackieviruses, and bacterial organisms such as Mycobacterium spp., Staphylococcus spp., Clostridium spp., and Corynebacterium bovis among many others.^15,16,37,87 Infectious diseases, whether experimentally induced or naturally occurring, can have profound effects on research animals,³⁷ potentially leading to invalidation of research, extensive depopulation within vivaria, and significant economic loss.^15,16,44 In addition, containment facilities house specific pathogenic agents that pose considerable risk to personnel and public health if proper controls are not in place.^52,71,100 The Biosafety in Microbial and Biomedical Laboratories (BMBL) manual contains an overview of disinfection concepts and decontamination strategies, in addition to defining specific microbiologic practices, including the need for routine decontamination of work surfaces with an appropriate disinfectant.¹⁰⁰ However, this manual does not specify the type or class of disinfectant that is to be used, limiting guidance to the statement that intermediate- and low-level disinfectants can be sufficient for most environmental surfaces. The ultimate decision is left to the facility, after an appropriate risk assessment.^33,52In our facility, as well as others, Environmental Health and Safety departments are taking a more prevalent role in overseeing the risk assessment and use of disinfectants, and in making their assessments, spectrum of activity is considered to be of great importance. If a disinfectant is intended for use in a facility that is biosafety level II or higher—and therefore contains pathogens capable of causing disease in healthy humans¹⁰⁰—it must meet certain requirements for broad-spectrum activity. The first requirement for a disinfectant with public-health claims is inclusion in the US Environmental Protection Agency (EPA) list of Hospital Sterilants, Disinfectants, and Tuberculocides—a compilation of disinfectants that have been tested and shown through the Antimicrobial Testing Program to be effective against Pseudomonas aeruginosa and Staphylococcus aureus at minimum, as well as Mycobacterium bovis BCG when tuberculocidal claims are made.³⁰ The Antimicrobial Testing Program follows performance standards developed by AOAC International (formerly, the Association of Official Analytical Chemists); these standards primarily focus on the specific bacterial organisms just listed but not on viruses or other pathogens that may be less sensitive to disinfection.²⁹ In addition, when human bloodborne pathogens may be present, as is the case in situations involving human cells or humanized animals, a disinfectant must be proven effective against HIV and hepatitis B virus at least, and potentially against Mycobacterium tuberculosis as well, when tuberculocidal action is indicated.⁷⁶ Still, agents known to require a higher level of disinfection must be treated with either diluted bleach or other disinfectants of appropriate spectrum.^61,83,102 For some products, efficacy is also tested by the former American Society for Testing and Materials, ASTM International, an additional third-party organization that has developed standards for disinfectant-efficacy testing.^6,7,75 Although these standards are well defined and accepted by many disinfectant companies, they are not requirements, given that enrollment in the organization is voluntary. With all of the potential testing agencies and methods considered, it is difficult to determine the degree of testing that is sufficient for a specific facility, and in some cases, even these listed standards may not be sufficiently stringent to allow use against less-sensitive pathogens. Lastly, contact times for products listed as appropriate for specific pathogens may be as long as 10 min,⁶¹ which does not reflect the short spray-and-wipe method of disinfection that is practiced in most animal facilities.⁸³ It therefore becomes increasingly important to consider possibilities for quality control when assessing disinfectant efficacy.Multiple methods have been developed to assess the efficacy of disinfectants.^{9,11,95,99,101} Virucidal activity has been a primary focus of researchers working not only in the veterinary field, but also in human medicine and in food and water safety.^34,57,88 Although wild-type viruses are often used as the subjects of efficacy testing,^1,26,57 these agents themselves may represent potential hazards to people and animals, and some are not easily cultured in a laboratory setting.⁹⁶ Therefore, it is often ideal to use less pathogenic or more easily propagated viruses as surrogates^24,31,45,97—for example, feline calicivirus is used as a surrogate for norovirus, another calicivirus that cannot be cultivated in vitro.^46,69,104 One question to consider is whether modified, nonreplicating agents, such as viral vectors used in gene therapy, can serve as surrogates for agents that are similarly sensitive to disinfection. The benefits of this approach include a decreased risk to animals and personnel in the testing facility, the availability of high-titer viral stocks, the extensive use of these vectors in some facilities, and the possibility of using fluorescence markers for detection and quantification of surviving virus. The use of fluorescence expressing viral vectors allows easy and rapid assessment of viral survival, because microscopy or flow cytometry can be used to detect viral transduction and expression soon after exposure. The value of viral vectors as surrogates for wild-type viruses is further supported by the use of adenovirus types 5 and 6 to predict the inactivation of similarly structured adenovirus-based vectors.⁶⁴Virucidal and bactericidal test methods have included suspension tests and carrier tests. Suspension testing involves exposing virus in suspension to a disinfectant and monitoring for survival, and is often the primary means of efficacy testing.^{9,79,95,101,102} Carrier tests are used to mimic practical applications, such as virus dried on a hard surface, instruments, or hands.^1,2,9,11,26 The value of carrier tests is that they represent typical challenges faced by disinfectants during normal use and therefore may be more informative than is suspension testing.⁹⁵ Additional variables that can influence disinfectant efficacy include the amount of organic material present in the environment, the amount and degree of aggregation of pathogen, the complexity of the surface being disinfected, the amount of agitation once the disinfectant is applied, the age of the disinfectant, and the method of application.^33,58,60,66In addition to their focus on spectrum of activity, Environmental Health and Safety departments consider a multitude of regulations and recommendations from several different agencies and organizations. To be considered for use in a facility, a disinfectant must meet several specifications. The disinfectant must be registered as a pesticide on both a national and state level.³² According to both the EPA, which enforces the Federal Insecticide, Fungicide, and Rodenticide Act, and the California Department of Pesticide Regulation, a pesticide is any substance that is used to control, destroy, or mitigate any pest, including microorganisms such as viruses or bacteria.³² It is therefore necessary that a disinfectant meets the requirements for registration with the EPA, in addition to the state requirements, which may be more stringent, as is the case in California.³² Lastly, disinfectants that are disposed of down a drain (for example, as mop water or expired product) and through the sewer system to publically owned treatment works must meet appropriate disposal requirements. The product must have a pH between 2 and 12.5, or it is considered to be corrosive hazardous waste, according to the Resource Conservation and Recovery Act.²⁸ Once that requirement is met, disinfectants often must meet additional, stricter regulations for disposal through publically owned treatment works that are enforced on a state or local level. For example, in the city of Los Angeles, a product that is poured down a drain must have a pH between 5.5 and 11, and dilution in water is not considered a valid means of achieving this goal.²⁵In addition, the importance of human occupational safety cannot be overstated, because this factor may be used as the basis for rejecting products with an ideal spectrum of activity. The hazards considered in the Safety Data Sheets (SDS) are reflected in guidelines set forth by the National Research Council,⁷² and the observation of appropriate precautions when using disinfectants in the laboratory is regulated on a federal level by OSHA.⁷⁷ Having a knowledge of the potential health risks of disinfectants is vital, because the incorrect usage of products may lead to occupational illness.¹⁴ Adverse effects experienced by those exposed to a disinfectant could include skin sensitivity, ocular or nasal mucous membrane irritation, and reaction to strong odors.^5,8 Thorough review of the SDS is necessary to understand the risks associated with using each product and the precautions that must be taken to prevent human exposure, including personal protective equipment and fume hoods for the reconstitution of various chemicals. The health hazards associated with these products can be compounded by inappropriate usage or toxic combinations of incompatible products.⁸¹ As noted previously, pH is a major consideration, not only for human safety but also in the context of environmental safety and disposal requirements. Corrosiveness is important because it relates to both human safety and damage to laboratory equipment.^39,74One final consideration that is often overlooked but that definitely should not be discounted is the effect of these disinfectants on the animals living in a facility. The potential health risks to humans pose similar threats to animals, including risk of contact dermatitis^50,86 and irritation of mucous membranes.³ In addition, disinfectants have the potential to produce aversive odors that may have negative effects on animal behavior and wellbeing.³⁵ Disinfectants may have a variety of uses within a facility, and those intended for treating only floors, walls, and lab benches may not be appropriate for situations where the potential for animal exposure exists—for example, when they are applied to forceps used transferring mice, hoods used for changing cages, or behavioral testing equipment. Whether a disinfectant is intended for use only on surfaces that come into intimate contact with animals or as an all-purpose product in a facility, which is often the goal, it is important that it be unlikely to cause irritation or aversion in animals when used at the recommended concentration.The most widely used and highly regarded surface disinfectant is household bleach, an aqueous solution of 5.25% to 6.15% sodium hypochlorite, typically used after a 10:1 dilution in water.^83,84,102 Bleach is therefore the standard recommendation made by most institutional Environmental Health and Safety departments.⁸⁴ Household bleach has a broad spectrum of antimicrobial activity, and is relatively inexpensive, fast-acting, resistant to water hardness, and capable of penetrating biofilms and dried organisms.^67,83,84 However, bleach is offensive in odor and relatively caustic, being capable of inducing ocular and respiratory irritation, electrolyte imbalances if ingested, and cutaneous, oropharyngeal, esophageal, and gastric burns.^{23,36,42,56,82,103} In addition, bleach releases toxic gas when mixed with ammonia-based products.^70,81 Other disadvantages are that bleach is inactivated by organic matter, can discolor fabrics, and is corrosive to metals, even when compared with other chlorine-based products, such as chlorine dioxide.^13,17,84The current study was designed to determine suitable alternatives to bleach as a universal disinfectant and to discern whether any products might truly be used for all purposes in a given facility. The hypothesis was that alternative disinfectants are as effective and well-accepted as chlorine bleach for use against viral agents of concern within animal facilities. The expectation was that a disinfectant that could be used for all purposes in a given facility would be identified, with the understanding that this product would still be unlikely to be superior in all parameters being considered. We selected 4 disinfectants—3 oxidants and one denaturant—for comparison on the basis of several criteria, including mechanism of action, reported broad-spectrum activity, accessibility, and relevance to the testing facility.Three specific aims were assessed. First, the spectrum of activity of the 4 disinfectants was compared with that of bleach. Comparative efficacy against GFP-expressing viral vectors was assessed under various conditions, including in suspension, buffered in fetal bovine serum, and dried on a nonporous surface. Second, human and environmental exposure risks associated with each of the disinfectants were assessed through interpretation of the SDS information. Lastly, the behavioral effect of disinfectants on mice was assessed by using an innate aversion test developed to monitor avoidance of potentially aversive odors.     

The relationship between mean flow velocity and functional and neurologic parameters of ischemic stroke patients undergoing rehabilitation

OBJECTIVE: To investigate the correlation between mean flow velocity (MFV) as measured by transcranial Doppler ultrasonography (TCD) and functional and neurologic impairment during inpatient rehabilitation after acute stroke. DESIGN: Prospective study comparing results of rehabilitation in patients with different TCD findings. SETTING: Acute neurologic rehabilitation department. PARTICIPANTS: Twenty-four consecutive patients admitted to a rehabilitation center with a diagnosis of a first ischemic stroke in the middle cerebral artery (MCA) territory. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Impairment as measured with the National Institutes of Health Stroke Scale (NIHSS) and disability as assessed with the FIM instrument. RESULTS: Normative or high blood-flow velocity in the MCA of the damaged hemisphere was associated on admission with higher FIM and lower NIHSS scores during 2 months of hospitalization. Absent or low flow velocity correlated with much worse functional and neurologic outcome, especially after 1 and 2 months of inpatient rehabilitation. Statistical correlation was found between MFV in the MCA of the damaged hemisphere, measured by admission TCD, and FIM score on admission and 1 month later. NIHSS scores during hospitalization also correlated with MFV in the MCA of the damaged hemisphere on admission and after 1 month. MFV in the MCA of the undamaged hemisphere 1 month after admission correlated negatively with FIM scores during inpatient rehabilitation. CONCLUSIONS: Our data showed a correlation between blood-flow velocity in the MCA of both hemispheres and the parameters of functional and neurologic status at different stages of acute inpatient rehabilitation after first ischemic stroke in MCA territory. Cerebral blood flow as measured by TCD can be an additional tool for monitoring the rehabilitation process after stroke.     

Use of Traditional and Complementary Health Practices in Prenatal, Delivery and Postnatal Care in the Context of HIV Transmission from Mother to Child (PMTCT) in the Eastern Cape, South Africa

The aim of this study was as part of a baseline assessment in PMTCT in the traditional health sector: a) to determine the views of women who have used the services of traditional practitioners before, during and/or after pregnancy, and b) to conduct formative research with traditional health practitioners (THPs), i.e. herbalists, diviners and traditional birth attendants (TBAs) on HIV, pregnancy care, delivery and infant care. The sample included a) 181 postnatal care clients with a child less than 12 months interviewed at postnatal clinic visits from 20 primary care clinics in the Kouga Local Service Area (LSA), Cacadu district, Eastern Cape, and b) 54 traditional birth attendants (TBAs) and 47 herbalists and/or diviners were interviewed from Kouga LSA. Results showed that THP (in particular TBAs and to a certain extend herbalists/diviners) play a significant role in pregnancy and postnatal care, and also with the assistance of delivery. Certain HIV risk practices were reported on the practice of TBAs. THPs also seem to have some role in infant feeding and family planning. THPs should be trained in optimising their services in pregnancy and postnatal care, and preparation for health facility delivery. In addition, they should be trained on HIV risk practices, HIV/AIDS, HIV prevention including PMTCT, infant feeding and family planning.     

Return to work in stroke patients

Purpose. To present the current state of knowledge regarding return to work (RTW) following stroke.

Method. A comprehensive review of the current stroke rehabilitation literature pertaining to prognostic and treatment factors for RTW following stroke.

Results. Stroke is a major healthcare problem and one of the most expensive diseases in modern society. Stroke results not only in impairment and limitation in basic daily activities; it also impacts on participation in community activities, such as returning to work. Return to work in post-stroke patients has been reported to range between 19% and 73%. Various studies report on return to work in diverse populations, using different follow-up periods, while utilizing variable definitions of stroke and successful work outcomes. The factors positively related to RTW in stroke patients, as found in the literature, are age less then 65 years, high education level and white-collar employment. The significant negative predictor is the severity of stroke. This is indicated by neurological parameters including functional measures of the presence and extent of motor and cognitive impairment. Significantly, the side of the brain damaged and stroke location were not found to be correlated with RTW. Social and financial factors also significantly influence RTW.

Conclusions. RTW in stroke patients should be considered one of the indicators of a successful rehabilitation as it influences self-image, well-being and life satisfaction. There is still a considerable lack of knowledge regarding effective assessments and interventions in vocational rehabilitation in stroke patients.     

The impact of patient's weight on post-stroke rehabilitation

Purpose To evaluate the influence of patient’s weight on rehabilitation outcomes in first-event stroke patients. Design Retrospective, observational comparative study. 102 first-time stroke male and female patients admitted to the 52-bed neurology rehabilitation department in a rehabilitation hospital were included in the study. Body mass index (BMI), Functional Independence Measure (FIM) on admission and at discharge, as well as the delta-FIM (FIM on admission – FIM at discharge) were evaluated. The Kruskal–Wallis test was used to compare the FIM and the NIHSS scores between BMI groups (normal, overweight, moderate and severe obesity). Results A statistically significant negative correlation (rho?=??0.20, p?=?0.049) was found between FIM change and BMI, that remained significant after adjustments for age, sex and hospitalisation days. No difference was found between groups in FIM or NIHSS change between BMI groups. Conclusions In sub-acute post-stroke patients undergoing rehabilitation in rehabilitation hospital, BMI was negatively associated with the improvement of functional parameters. Patients’ BMI should be taken into consideration when predicting rehabilitation outcome for stroke patients. Further investigations are needed to identify the functional parameters affected by the patients’ BMI.

• Implications for Rehabilitation

• In sub-acute post-stroke patients undergoing rehabilitation in rehabilitation hospital, BMI was negatively associated with the improvement of functional parameters.

• Patients’ BMI should be taken into consideration when predicting rehabilitation outcome for stroke patients.

• New rehabilitation strategies should be designed to improve the functional outcomes of rehabilitation of obese patients.