Assessing knowledge, attitudes, and practices of healthcare workers regarding medical waste management at a tertiary hospital in Botswana: A cross-sectional quantitative study

Background

Medical waste management (MWM) is of concern to the medical and general community. Adequate knowledge regarding management of healthcare waste is an important precursor to the synthesis of appropriate attitudes and practices of proper handling and disposal of medical waste by healthcare workers (HCWs).

Aims and Objectives

This study was designed to investigate knowledge, attitudes, and practices of doctors, nurses, laboratory technicians, and housekeeping staff, regarding MWM at a tertiary hospital in Gaborone, Botswana.

Materials and Methods

This was a cross-sectional quantitative study using a self-administered questionnaire involving 703 participants. Data were analyzed using SAS software. Descriptive statistics were used to summarize the data. Responses for attitude of respondents were analyzed using nonparametric tests.

Results

The completion rate for this study was 90% with (632/703) questionnaires analyzed. Majority of respondents were nurses 60% (422/703), followed by housekeeping staff 24.3% (171/703), doctors 10.95% (77/703), and laboratory technicians 4.7% (33/703). The study showed that 66.9% (423/632) of respondents had some training in MWM, and 90.5% (572/632) claimed to have knowledge regarding the consequences of poor MWM, particularly health risks. There was a significant agreement among the respondents that segregation of medical waste should be done at the point of generation (mean score = 4.43 out of 5). Majority of respondents reported that the healthcare facility had a color-coding system (mean score = 4.59) and identified "lack of knowledge of the dangers of improper waste management by HCWs" as the major obstacle to MWM.

Conclusion

This study showed that MWM practice at this facility was above average, although improvements were required in accessing waste disposal points and availability of personal protective equipment. Ongoing training should be provided to HCWs on MWM, with more attention to knowledge of regulatory requirements, and involvement of HCWs in development of MWM policies to enhance compliance.

"Because I want to be informed, to be part of the decision-making": Patients' insights on informed consent practices by healthcare professionals in South Africa

BACKGROUND

Informed consent (IC) is a legally enforceable right in South Africa based on constitutionally protected rights to bodily integrity and well-being. In terms of the law, patients cannot be involved in medical treatment or research without IC. Healthcare providers must inform patients about diagnosis, risks, benefits, treatment options, and right of refusal in a language patients understand based their literacy level. This study reports an empirical study on patients' perceptions of IC as practiced by doctors and nurses in South Africa.

MATERIALS AND METHODS

A cross-sectional study, using a bilingual semi-structured questionnaire was conducted among patients attending randomly selected public hospitals in eThekwini Metropolitan Municipality (Durban), KwaZulu-Natal province. Competent patients or legal surrogates were eligible for inclusion. IC was obtained from all participants.

RESULTS

Four hundred and four participants completed questionnaires of which 68% were female. The median age of participants was 35 years (range 11-91 years). Most respondents spoke IsiZulu (55%), were single (56%), unemployed (66%), and with secondary school education (69%). Patients were generally informed about the diagnosis (81%), risks (57%), and benefits of treatment (61%). Few were informed about treatment options (41%), recommended treatment (28%), and right of refusal (25%). IC was obtained verbally in 73% of cases. Patients favored disclosure of all material risks (78%) and few consulted surrogates before decision-making (76%). There was an association between participant's age and knowledge of the age of consent (P = 0.005). Most patients were satisfied with information disclosed (91%) and did not feel coerced. Some were afraid to ask questions for fear of losing free treatment (8%).

CONCLUSION

This study reveals that South African patients are aware of the right to IC, but many were vulnerable due to indigence. Barriers to IC include poverty, language, and low educational level. South African patients prefer disclosure of all material risks, better communication skills by healthcare workers, and a shift toward informed or shared healthcare decision-making.

Ethical and legal dilemmas around termination of pregnancy for severe fetal anomalies: A review of two African neonates presenting with ventriculomegaly and holoprosencephaly

Termination of pregnancy (TOP) or feticide for severe fetal anomalies is ethically and morally challenging and maybe considered illegal in countries with restrictive abortion laws. While diagnostic modalities such as fetal ultrasound, magnetic resonance imaging, and genetic screening have improved prenatal diagnosis, these technologies remain scarce in many African countries making diagnosis and counseling regarding TOP difficult. Ethical dilemmas such as women's autonomy rights may conflict with fetus' right to personhood, and doctor's moral obligations to society. In liberal jurisdictions, previable fetuses may not have legal rights of personhood; therefore, appropriate action would be to respect pregnant women's decisions regarding TOP. However, in countries with restrictive abortion laws the fetus maybe imbued with the right of personhood at conception, making TOP illegal and exposing doctors and patients to potential criminal prosecution. Birth of a severely disabled baby with independent legal rights creates further conflicts between parents and clinicians complicating healthcare decision-making. Irrespective of the maternal decision to accept or refuse TOP, the psychological and emotional impact of an impaired fetus or neonate, often lead to moral distress and posttraumatic stress reactions in parents. Doctors have legal and ethical obligations to provide an accurate antenatal diagnosis with full disclosure to enable informed decision making. Failure to provide timely or accurate diagnosis may lead to allegations of negligence with potential liability for "wrongful birth" or "wrongful life" following birth of severely disabled babies. Mismanagement of such cases also causes misuse of scarce healthcare resources in resource-poor countries. This paper describes ethical challenges in clinical management of two neonates born following declined and failed feticide for severe central nervous system anomalies with a critical appraisal of the relevant literature.

Impact of a short biostatistics course on knowledge and performance of postgraduate scholars: Implications for training of African doctors and biomedical researchers

BACKGROUND AND OBJECTIVES

This study was designed to evaluate the impact of a short biostatistics course on knowledge and performance of statistical analysis by biomedical researchers in Africa. It is recognized that knowledge of biostatistics is essential for understanding and interpretation of modern scientific literature and active participation in the global research enterprise. Unfortunately, it has been observed that basic education of African scholars may be deficient in applied mathematics including biostatistics.

MATERIALS AND METHODS

Forty university affiliated biomedical researchers from South Africa volunteered for a 4-day short-course where participants were exposed to lectures on descriptive and inferential biostatistics and practical training on using a statistical software package for data analysis. A quantitative questionnaire was used to evaluate participants' statistical knowledge and performance pre- and post-course. Changes in knowledge and performance were measured using objective and subjective criteria. Data from completed questionnaires were captured and analyzed using Statistical Package for Social Sciences. Participants' pre- and post-course data were compared using nonparametric Wilcoxon signed ranks tests for nonnormally distributed variables. A P < 0.05 was considered statistically significant.

RESULTS

Baseline testing of statistical knowledge showed a median score of 0, with 75th percentile at 28.6%, and a maximum score of 71.4%. Postcourse evaluation revealed improvement in participants' core knowledge with the median score increasing to 28.5%; and the 75th percentile score to 85.7%; signifying improved understanding of statistical concepts and ability to carry out data analyses.

CONCLUSIONS

This study just showed poor baseline knowledge of biostatistics among postgraduate scholars and health science researchers in this cohort and highlights the potential benefits of short-courses in biostatistics to improve the knowledge and skills of biomedical researchers and scholars in Africa.

A legal "right" to mental health care? Impediments to a global vision of mental health care access

Mental health law across many jurisdictions provides a legal framework for the compulsory detention and, where appropriate, treatment in hospital of people with mental health problems. Latent within many of these "systems" of mental health provision is the concern that the quality of care people receive does not always meet legal and ethical norms. For many, there remains the very serious recognition that access to mental health care in its entirety remains elusive. International human rights discourse has influenced the shaping of modern mental health laws in many developed countries. In 2008, the Convention on the Rights of Persons with Disabilities (CRPD) entered into force. For many countries, such as South Africa, the CRPD provides a human rights instrument with the scope to establish a worldwide means of bolstering human rights. This paper examines both the UK and the broader African position with regard to the extent redress can be sought if and when an individual does not receive the care and treatment needed. Within this, consideration will be given to one of the paradoxes of mental health care which bedevil mental health systems: How do legal frameworks for detaining and treating people without their consent work when there is no corresponding enforceable right that appropriate treatment or suitable conditions of detention must be provided. The focus of this paper is the question of whether there is indeed a legal "right" to mental health care.

New JC virus (JCV) genotypes from papua new guinea and micronesia (type 8 and type 2E) and evolutionary analysis of 32 complete JCV genomes

The JC virus (JCV) is a ubiquitous human polyomavirus that frequently resides in the kidneys of healthy individuals and is excreted in the urine of a large percentage of the population. Geographic-specific JCV variants, isolated from urine and from brain of progressive multifocal leukoencephalopathy (PML) patients, have been grouped into seven distinct genotypes based on whole genome analysis and by individual polymorphic nucleotides (typing sites) in the VP1 coding region. Mutations in the archetypal regulatory region, sometimes consisting of deletions and/or duplications, are also useful taxonomic characters for further characterizing and subdividing genotypes. Investigation of JCV variation in Papua New Guinea (PNG) revealed three distinct variants called PNG- 1, PNG-2, and PNG-3. These variants exhibited consistent coding region and regulatory region mutations. Evolutionary analysis of 32 complete JCV genomes including six new viral genomes from the western Pacific suggests that the new PNG JCV variants are closely associated with the broad group of Type 2 strains of JCV found throughout Asia, forming a monophyletic group with the Northeast Asian strains (Type 2A). Within the Type 2 clade, however, the PNG JCV variants cluster as two distinct groups and are therefore described here as new JCV genotypes designated Type 2E and Type 8.

JC virus as a marker of human migration to the Americas

JC virus is a ubiquitous human polyomavirus present in populations worldwide. Seven genotypes differing in DNA sequence by approximately 1-3% characterize three Old World population groups (African, European and Asian) as well as Oceania. It is possible to follow Old World populations into the New World by the JC virus genotypes they carried. The first population to settle in the Americas, the Native Americans, brought with them type 2A from northeast Asia. European settlers arriving after Columbus carried primarily type 1 and type 4. Africans brought by the slave trade carried type 3 and type 6.

Polyomavirus JC genotypes in an urban United States population reflect the history of African origin and genetic admixture in modern African Americans

The human polyomavirus JC (JC virus), a small, circular, double-stranded DNA virus, has a worldwide distribution and is excreted harmlessly in urine by 20% to 70% of adults. DNA sequence analysis has identified seven distinct genotypes that likely coevolved with modern humans, although the mode of virus transmission is unknown. Type 1 is European in its distribution. Types 2 and 7 are Asian, while Types 3 and 6 are African. Type 4, closely related to Type 1, is of uncertain origin, having been found in population groups in parts of Europe and in the United States, but not in Africa. Here we have studied the JCV partial genomic DNA sequences amplified by polymerase chain reaction techniques from urines of an urban, mainly African American population cohort from Washington, D.C. The predominant genotype identified was Type 4 (32/78 JCV strains, 41%). Type 1 strain was found in 32% of African Americans, while JCV Type 3 strain was found in 18% of African Americans. These African strains have persisted in modern African Americans after 200 to 400 years of minority existence and genetic admixture in the New World. An ancient West African genotype, Type 6, was absent in this African American cohort. However, one Type 6 strain was found in a patient from Sierra Leone (West Africa), domiciled in the United States for 20 years. Type 2A, the most common subtype in Native Americans, was seen in only two African-Americans (3%). A Type 7 strain, previously reported only in Taiwan and South China, was identified in a Vietnamese immigrant. These data support the history of African origin, migration, and genetic admixture of modern African Americans. Analysis of JCV strains in the present American populations provides a novel tool for reconstructing human migrations and genetic admixture in the New World.

Human polyomavirus JC variants in Papua New Guinea and Guam reflect ancient population settlement and viral evolution

The peopling of the Pacific was a complex sequence of events that is best reconstructed by reconciling insights from various disciplines. Here we analyze the human polyomavirus JC (JCV) in Highlanders of Papua New Guinea (PNG), in Austronesian-speaking Tolai people on the island of New Britain, and in nearby non-Austronesian-speaking Baining people. We also characterize JCV from the Chamorro of Guam, a Micronesian population. All JCV strains from PNG and Guam fall within the broad Asian group previously defined in the VP1 gene as Type 2 or Type 7, but the PNG strains were distinct from both genotypes. Among the Chamorro JCV samples, 8 strains (Guam-1) were like the Type 7 strains found in Southeast Asia, while nine strains (Guam-2) were distinct from both the mainland strains and most PNG strains. We identified three JCV variants within Papua New Guinea (PNG-1, PNG-2 and PNG-3), but none of the Southeast Asian (Type 7) strains. PNG-1 strains were present in all three populations (Highlanders and the Baining and Tolai of New Britain), but PNG-2 strains were restricted to the Highlanders. Their relative lack of DNA sequence variation suggests that they arose comparatively recently. The single PNG-3 strain, identified in an Austronesian-speaking Tolai individual, was closely related to the Chamorro variants (Guam-2), consistent with a common Austronesian ancestor. In PNG-2 variants a complex regulatory region mutation inserts a duplication into a nearby deletion, a change reminiscent of those seen in the brains of progressive multifocal leukoencephalopathy patients. This is the first instance of a complex JCV rearrangement circulating in a human population.

Progressive multifocal leukoencephalopathy and JC virus genotypes in West African patients with acquired immunodeficiency syndrome: a pathologic and DNA sequence analysis of 4 cases

OBJECTIVE

Progressive multifocal leukoencephalopathy is caused by polyomavirus JC in immunosuppressed patients. JC virus genotypes are identified by sequence analysis of the viral genome. Despite the prevalence of acquired immunodeficiency syndrome in sub-Saharan Africa, few cases of progressive multifocal leukoencephalopathy have been reported from this region. Here we describe 4 African cases and provide an analysis of viral genotypes.

METHODS

Immunohistochemical staining by labeled streptavidin-biotin for capsid protein antigen was performed on all cases. Polymerase chain reaction amplification of viral genomic DNA was followed by direct cycle sequencing.

RESULTS

JC virus type 3 was identified in 2 cases, and type 6 was isolated in 1 case. The viral regulatory region from 1 case showed an uncommon rearrangement pattern.

CONCLUSIONS

Progressive multifocal leukoencephalopathy in West African patients with acquired immunodeficiency syndrome is caused by African genotypes of JC virus (types 3 and 6). The prevalence of disease in this autopsy series from sub-Saharan Africa (1.5%) was less than has been reported from Europe and the United States (4% to 10%) and may be partly due to biological differences in JC virus genotypes. Further studies will be needed to confirm this observation.

A cerebral primitive neuroectodermal tumor in a squirrel monkey (Saimiri sciureus)

An adult squirrel monkey with a history of long-term exposure to microwave radiation was found at necropsy to have a malignant tumor of the right cerebral cortex. Gross examination revealed a mass with expanding borders in the right frontoparietal cortex with compression of the adjacent lateral ventricle. Microscopy revealed a tumor composed of sheets of moderate-sized cells, resembling an oligodendroglioma, with clear cytoplasm and central nuclei interrupted by delicate vasculature. Malignant features were present in the form of marked nuclear pleomorphism, frequent mitotic figures, and focal necrosis. A neuronal cell origin for this tumor was supported by immunohistochemical analysis, which revealed immunopositivity for neurofilament proteins and neuron-specific enolase. Staining for vimentin and glial fibrillary acid protein was negative, except in reactive astrocytes at the tumor margins and adjacent to intra-tumoral blood vessels. Antibody activity against Ki-67 antigen, a marker of rapidly proliferating tumor cells, and p53 oncoprotein was strongly positive, indicative of the aggressive and malignant nature of this tumor. The tumor was diagnosed as a cerebral primitive neuroectodermal tumor.

Phylogenetic analysis of 22 complete genomes of the human polyomavirus JC virus

The polyomavirus JC (JCV) establishes a persistent infection in the kidneys, and is the virus agent that causes the demyelinating disease progressive multifocal leukoencephalopathy. PCR and DNA sequence analyses of partial JCV genomes have shown that there are at least four main JCV types, each associated with a specific geographical region. Type 1 is of European origin, Type 2 is Asian, Type 3 is found in individuals of African decent and Type 4 is a potential recombinant of Types 1 and 3, and is widely distributed throughout the population of the United States. A comprehensive phylogenetic analysis of 22 complete JCV genomes excluding part of the regulatory region was accomplished using neighbour-joining, UPGMA and maximum parsimony methods. The resulting UPGMA and parsimony phylogenies suggest that the European Type 1 strains diverged from the other types during the evolution of JCV and that each of the other genotypes (and subtypes) falls into well-supported clades. This is the first whole genome approach to phylogeny reconstruction for JCV and represents a significant improvement over earlier studies that were limited to partial JCV sequences and the neighbour-joining method.

Molecular epidemiology of human polyomavirus JC in the Biaka Pygmies and Bantu of Central Africa

Polyomavirus JC (JCV) is ubiquitous in humans and causes a chronic demyelinating disease of the central nervous system, progressive multifocal leukoencephalopathy which is common in AIDS. JCV is excreted in urine of 30-70% of adults worldwide. Based on sequence analysis of JCV complete genomes or fragments thereof, JCV can be classified into geographically derived genotypes. Types 1 and 2 are of European and Asian origin respectively while Types 3 and 6 are African in origin. Type 4, a possible recombinant of European and African genotypes (1 and 3) is common in the USA. To delineate the JCV genotypes in an aboriginal African population, random urine samples were collected from the Biaka Pygmies and Bantu from the Central African Republic. There were 43 males and 25 females aged 4-55 years, with an average age of 26 years. After PCR amplification of JCV in urine, products were directly cycle sequenced. Five of 23 Pygmy adults (22%) and four of 20 Bantu adults (20%) were positive for JC viruria. DNA sequence analysis revealed JCV Type 3 (two), Type 6 (two) and one Type 1 variant in Biaka Pygmies. All the Bantu strains were Type 6. Type 3 and 6 strains of JCV are the predominant strains in central Africa. The presence of multiple subtypes of JCV in Biaka Pygmies may be a result of extensive interactions of Pygmies with their African tribal neighbors during their itinerant movements in the equatorial forest.