Yesterday I watched in awe as a group of men and women covered from head to toe with traditional checked khromars wrapped around their heads for sun protection and dressed in pyjamas (women) or shirts and jeans (men), worked with a heavy wheelbarrow, carting wet concrete from the mixer about fifty metres away, to a track being cemented into a single lane roadway. With a “driver” leading the way, pulling the barrow handles from behind and four people pushing the back of the barrow, they built into a run from the mixer up the slight incline, over a pathway of planks laid for the journey. Upon reaching the section being cemented, the team repositioned to push the barrow over, pouring the cement out. A man using a long stick of wood then smoothed the concrete while the barrow team returned to the mixer for the next barrow load. As we watched from our office doorway, a local colleague told me that they would probably earn around $2 each for the day but that many labourers earn only food, not cash. It would be interesting to know how many calories their bodies burned – no doubt a much bigger benefit than the paltry financial gain being earned, but probably also at risk of long term complications which are likely the reason I see so many older people bent over themselves with bone and spine deformities.
My colleagues talk about their involvement a few years ago in a response to a Cholera outbreak which occurred here. According to media reports, in 2010 at least 60 Cambodians died of Cholera during an outbreak which spread across 20 of the country’s 24 provinces. One of the reasons for the outbreak is cited as being that people do not have access to clean water and, especially in the Dry Season, will drink whatever water is available. I guess this is the reason that bottled water is heavily marketed here, selling to locals for around 500 Riel (US12c) per 500ml bottle, which seems cheap but is nevertheless unaffordable if you have no money.
It’s easy to imagine, watching these teams of thin bodies push themselves in the hot sunshine, how vulnerable people are to infections. When the environment is conducive to bacteria, viruses and parasites anyway, bodies with no reserve will surrender so much easier to infection. The level of chronic malnutrition in Cambodia is a reason that TB has such a strong hold over the population, but TB is not the only organism able to thrive here. Dengue and Japanese Encephalitis viruses and Malaria parasites are the most common mosquito borne diseases; diarrhoeal diseases including Giardia and Cryptosporidium (parasites), Rotavirus (especially in children under 2yo) and bacteria such as Salmonella and Campylobacter contribute significantly to the issue of childhood malnutrition, which cycles well with diarrhoea, making the host more susceptible to illness, which in turn exacerbates malnutrition. Other respiratory diseases such as Streptococcus pneumoniae and Haemophilus influenzae are also very common causes of morbidity and mortality.
Throughout more than 20 years of nursing I have been trained about the risks of germs spreading in hospital settings, which are productive germ factories as people congregate in a single location with whatever ails them, searching for a cure. Infection Control is big business in the First World, where degrees and doctorates are earned by nurses and doctors who make specialised careers out of the subject. In contrast, the Third World have very few resources for the purposes of Infection Control, which is a large part of my role in the hospital setting here but on a very basic scale as hospital acquired infections are not monitored, let alone identified and acted upon as they would be in the Western World. I am on a very steep learning curve, coming from a country with many resources and having spent many years away from the hospital setting.
Toys in a paediatric setting are very important for the psychological well being of patients, but have to be carefully managed to ensure they don’t contribute to the spread of hospital acquired infections. As they are much easier to clean, hard toys are the only acceptable option in hospital settings where Infection Control is a primary concern, particularly in difficult circumstances such as the Third World where water supply, sewerage maintenance, hygiene standards and living conditions are all a constant struggle. Almost daily I am confronted with blocked toilets, leaking pipes, shortage of cleaning or waste disposal products and various other challenges to our attempts to maintain good Infection Control practices.
A good summary of the problems relating to soft toys and the spread of infection in health care settings can be found here:
In case the link doesn’t work, the text from this article is pasted below.
After mentioning on Facebook that certain specific toys would be of great value here, I had an astoundingly generous response with untold parcels received from as far away as Australia, NZ, UK and America, all of which I have not yet been able to distribute due to the sheer volume. It was on the whole a very fun and happy exchange with many thoughtful friends. I received a volume of parcels almost daily for a period of time, all of which required payment to the postal service upon receipt which involved some organisation as colleagues in Phnom Penh were paying out of their own pockets on my behalf. I managed to offend a tiny minority of donors by stating that some parcels were directed away from the hospital, which was done for practical reasons as described herein. Unrealistic and impractical stipulations were attached to two or three parcels which were not expressed until it was too late and which I could not have complied with even if I had known. It was a lesson for me that not everyone gives without strings attached or with reasonable scrutiny and expectation.
Today I visited some patients and Home Based Care Nurses in their communities. At one location we sat on a bamboo day bed underneath a small wooden stilt house in the countryside, surrounded entirely by newly planted rice fields with just a narrow dirt lane leading through the rice fields to the house. An elderly man joined us, thin and wasted by Tuberculosis, while his son lay in a hammock nearby and his wife joined us to talk about the side effects of the treatment her husband is receiving for Drug Resistant TB. In a nutshell, her husband is experiencing some psychiatric problems related to one of the TB medications, as well as headaches, joint pain, back pain and decreased appetite. She has hypertension treated with medication she has to pay for, her son has pre-existing psychiatric problems, one daughter collapsed in a factory where she works recently and was unconscious for three days, leaving them with a hospital bill which they cannot afford and another daughter works on a construction site in Phnom Penh.
Cambodia’s Ministry of Planning coordinates an “ID Poor Card” scheme which is supposed to identify the most destitute families in each community, who upon receipt of this card become eligible for free health care at the local Health Centre and exemption from teacher payments at school. Village Chiefs are responsible for distributing these cards in their community and my colleagues all say that in reality, the families of Village Chiefs are the primary beneficiaries of ID Poor Cards, which is just another example of the pervasive corruption in Cambodian society. Despite being eligible for an ID Poor Card, this family do not have one. They have debts related to their ill health and no way of paying them. When I asked what amount the debt was, assuming it to be many hundreds of dollars to be causing such stress, the answer was 300,000 Riel, which converts to US$75. I returned to the car and got as much money as I had with me, and brought it to her, having my colleague translate for me that this was from me personally and not from our employer, to go towards paying their debt. Having received cash from other friends who did not want to send parcels I explained that this was a gift from overseas friends who wanted to contribute to Cambodia and that I felt their plight was deserving. As I passed the money (which did not cover the full debt) to her she began to cry, repeating “Oor kun jirian” (thank you very much) over and over, with her hands in sampiah gesture against her forehead. She then hugged me, followed us up the laneway to our car, thanking me tearfully all the way and hugging me again. To have such extreme stress by such a small amount of money truly astonishes me. But debt caused by hospital bills seems to be a crippling experience of many Cambodians. It was gratifying to be able to help one family in a small way.
To end on a slightly lighter note, the other night we were out for dinner and parked our bicycles up outside the restaurant, then took our seats at an outdoor table overlooking the river. We ordered drinks and after a few moments, the waiter approached us and said “Excuse me, please can we ride your bicycle?”. Excuse me? “Please can we ride your bicycle?”. Yes sure, you can take that one, it’s closest. The waitress came out and boarded an MSF bicycle and cycled off into the night skies. A few moments later she returned with the basket filled with a huge bag of ice, and our chilled drinks were served a few moments later. How can anywhere match the character of this place?! Now, the next time I’m told that they are out of wine or gin, I hope the offer of a bicycle loan may offer a practical solution, as the nearest liquor store is around the corner and there was an occasion some time back when we could not order wine for about three weeks!
Evidence-Based Practice: Examining the Risk of Toys in the Microenvironment of Infants in the Neonatal Intensive Care Unit
Review of the literature on toys included both clinical inpatient and outpatient settings (see Table 4 ). Two studies were identified that compared hard and soft toys in the waiting rooms of general practitioners. The first, a descriptive study from Edinburgh, reported cultures from 50 toys shared by children in the waiting and consultation rooms of a busy, inner-city practice. Investigators found organisms on 60% of the hard toys and 100% of soft toys. Organisms judged as “potentially pathogenic” were found more frequently on soft toys (30%) than on hard toys (5%) (odds ratio, 8.14; 95% confidence range, ). The authors cite a 1 in 10 chance of exposure to a pathogen from communal toys as an unacceptable risk. The study was limited by differences in culture techniques; swabs were used to culture hard toys, whereas direct cultures were obtained from the soft toys.
The second study described contamination of hard versus soft toys. Twenty-two hard toys and 10 soft toys were gathered from 6 general practice offices in New Zealand. The toys were soaked in a broth media, which was then cultured for coliforms and total bacteria. Ninety percent of soft toys showed coliform contamination compared to 13.5% of hard toys (P < 0.001). Soft toys were more often contaminated (100% v 91%) and were more likely to have moderate to high bacterial counts (90%) when compared to hard toys (27%; P = 0.002). Although useful information is provided about the ineffectiveness of decontaminating toys (particularly soft toys) by soaking, machine washing, or autoclaving, data are not provided to support these conclusions.
Together, these 2 studies provide consistent and moderate (level IV) evidence that toys in the waiting rooms of general practitioners are quickly colonized with bacteria. Soft toys colonize at higher rates and present the greatest risk of contamination. Procedures for cleaning are generally more effective for hard toys.
A number of case reports in hospital settings describe toys as probable reservoirs for pathogenic organisms. A report from an ICU in the United Kingdom describes a 79-year-old woman who was given a cuddly toy dog by her family. Knowing the patient previously had MRSA, a culture of the toy was obtained and promptly grew MRSA. In this case, it appears the patient contaminated the toy. The toy was removed from the ICU at the advice of the infection control team. The clinicians advocate a ban on cuddly toys.
An outbreak (8 cases) of rotavirus was reported in a 42-bed cancer center. After weeks of aggressive infection control measures with no decrease in incidence, a pediatric epidemiology investigation revealed that toys in the playroom had not been cleaned according to the weekly protocol. Cleaning procedures were enforced; although no further clinical cases occurred, this finding may be related to seasonal patterns of this infection. The toys were not tested for rotavirus. Investigators hypothesized that shared toys were likely serving as fomites transmitting rotavirus.
One practitioner reports a case of a toddler from his neighborhood who presented with diarrhea caused by a Giardia infection after having swallowed several gulps of water from a toy left in a stagnant pool of water. Although no evidence of cause is presented, the author warns clinicians not to overlook water toys as a source of infection.
These cases individually provide low levels of evidence (level V) linking toys and infection. When reviewed together, however, they reflect reports in the more general fomite literature and offer stronger and more consistent evidence. Use of molecular technologies to link organisms at a highly discriminate level will provide stronger evidence in case reports as the following study demonstrates.
A report of 9 cases of multiresistant P. aeruginosa in a pediatric oncology unit compared isolates from infected immunocompromised patients to environmental cultures taken from wet surfaces. Using molecular DNA analysis, researchers found that isolates from 8 infected cases had identical banding patterns that matched isolates from 3 bath toys and a box for water toys. A case-control study compared the 8 infection cases to controls that matched the disease. It showed a significant association between infection and use of bath toys (P = 0.004), use of bubble bath (P = 0.014), duration of stay (P = 0.007), and previous antibiotic exposure (P = 0.026). The authors caution against the use of water-retaining toys with immunosuppressed patients. This study provides good evidence (level III) linking toys to infection by using molecular technologies and case-control risk analysis.
In a descriptive study, random selection and culture of an unspecified number of toys from a pediatric ward communal playroom were undertaken. Sterile swabs were used on hard toys and contact plates were used on soft toys to culture organisms. The results showed no growth from the contact plates taken from the soft toys. Swabs on agar plates from the hard toys grew Staphylococcus albus and Bacillus species. The author suggests that although only environmental organisms were found, these pose a risk for immunocompromised children and those with invasive devices. Lack of data to support findings, an unknown sample size, and varied sampling techniques are limitations of this study. The evidence (level IV) presented shows weak support for the presence of organisms on hard toys.
A prospective study in a hematology/oncology unit showed positive cultures of 39 stuffed animals. The “T. Bears,” sponsored by the Department of Health and Human Services (HHS), were a mascot to promote handwashing and were given to hospitalized children ages 9 months to 15 years. All of the toys were colonized with at least 1 organism within the patient’s first week of admission to the hospital. The organisms represented human skin flora, although not necessarily flora from the cohort patient. Five of the 39 patients became bacteremic 1 to 30 days after receiving the T. Bear. The toys could neither be implicated nor excluded as the source of infection. No effect was noted on monthly NI rates. Of clinical significance were the rapid colonization rate of the T. Bears and the presence of organisms known to cause severe infections in the study hospital. The authors concluded that the colonized toys could provide an unnecessary means of nosocomial transfer and spread of organisms. This study provides some evidence (level IV) of the presence of pathogens on soft toys; however, the effect on NI rate or bacteremia is not demonstrated.
Further information is provided by a small prospective study that examined nonsterilized stuffed toy animals placed in the incubators of 12 NICU infants. The infants had a mean age of 30.6 weeks (±3.4) and a mean weight of 1419 grams (±743). Aerobic cultures of the toys, incubators, and infants’ skin were taken at 0 and 72 hours. The cultures (sites not specified) predominately revealed CONS. The authors concluded that the results “failed to implicate the stuffed animals as harboring pathogens.” This study was reported in a brief letter that provided no specific data. Other limitations of the study include the use of only aerobic cultures, cultures for no longer than 72 hours, and the small sample size. The presence of CONS, the most common cause of late-onset NI in the NICU,[12,54,55] is evidence contrary to the authors’ conclusions. The presence of these known potential pathogens may represent a risk for this population. The conclusion, that the practice of placing stuffed toys in incubators “may be safe and reassuring for both parents and neonates,” is an overstatement of the type, size, and scope of the study and, further, is inconsistent with the evidence (level IV) presented.
The trigger study that led to this evidence-based clinical project is a cross-sectional, longitudinal survey of the toys in the beds of NICU infants. The authors investigated the bacteria and fungi contaminating toys in a 20-bed, level III NICU in Melbourne, Australia. Infants’ mean age was 28.2 weeks (range, 23 to 41) and mean weight was 1114 grams (range, 480 to 2710). Toys resided in infants’ beds and were cultured weekly over a 4-week period. A total of 86 cultures from 34 toys of 19 infants were collected. Bacteria grew in 98% of cultures. The most common organisms were CONS (98%), Micrococcus species (58%), Bacillus species (24%), MRSA (15%), and diptheroids (14%). Colonization rate did not change with bed type, presence of humidity, toy size, toy fiber, or toy fluffiness. Eight (42%) of the infants had a positive blood culture, and 5 of those isolates (63%) were the same type as the corresponding toy. Unfortunately, molecular techniques were not used in this study. The authors concluded that toys might be reservoirs for potential nosocomial sepsis. This prospective, well-designed study provides good evidence (level III) of bacterial and pathogen colonization of toys and highlights the potential for fomite transmission to a neonatal population.
In summary, the evidence demonstrates that toys are reservoirs for infectious organisms in a variety of settings. This is supported by the breadth and depth of literature related to organisms present on fomites[20,22,23,25-41] and, more specifically, on toys.[10,42-46,49] Two studies (level IV) demonstrated higher colonization rates on soft toys.[42,43] Caution was raised (level III and V evidence) regarding colonization of water toys with pathogens.[46,47] Although randomized controlled studies are lacking, these level III, IV, and V studies show generally consistent findings. Colonization of the microenvironment with potential pathogens has clearly been established.
The evidence to link the colonization of toys to increased risk for NI is plausible but not proven. An association between NI and organisms on toys was evidenced by both well-designed studies (level III)[10,47] and a case report. The use of resistant organisms and DNA molecular technologies show discriminate evidence linking the organisms of sick infants to those on toys. Weaker evidence of linkage was provided by comparing organism species in the sick infant to those on toys.[10,49]
No prospective randomized controlled trials were identified with sufficient power to support the safety and efficacy of toys in the microenvironment nor, conversely, to demonstrate a cause and effect relationship between colonized toys and increased NIs. In the absence of randomized trials and clear causality, an attempt was made to determine if evidence about causing harm is valid.[56,57]
The scientific principles of fomite transmission and literature review support plausibility:
– Toys are potential reservoirs for pathogens and other organisms;
– The hands of health care workers and families transmit organisms between toys and infants;
– Infants exposed to pathogens and other organisms are at high risk for NIs and associated morbidities and mortalities
– Drug resistance patterns and DNA technologies have linked organisms in hospitalised patients to those on their toys
– A common theme throughout the literature suggests that NI outbreaks reliably declined when fomites were removed from patient contact.
| From Advances in Neonatal Care, 2004; 4(4)