Colonial War Memorial Hospital Research Articles

Environmental contamination with carbapenem resistant Acinetobacter baumannii in healthcare settings in Fiji: a potential source of infection.

There are multiple ongoing outbreaks of carbapenem resistant Acinetobacter baumannii (CRAb) infection in Fiji's hospitals. CRAb is able to colonize and persist on various hospital surfaces for extended periods. We conducted a study to understand the extent of hospital environmental contamination and phylogenetic links with clinical isolates. Swabs were collected from high-touch surfaces at Colonial War Memorial Hospital (CWMH) September 2021 and December 2022; Lautoka Hospital (LTKH) August 2022; and Labasa Hospital (LBSH) November 2022. All bacterial isolates were identified, and antimicrobial susceptibility testing (AST) performed; isolates resistant to carbapenems and producing a carbapenemase underwent whole genome sequencing. Comparison was made to clinical isolates obtained from CWMH in 2016-2017 and 2019-2021 and from LTKH and LBSH from 2020-2021. From the 180 environmental samples collected, ten (5.6%) CRAb were isolated; no other carbapenem-resistant gram-negative organisms were isolated. Seven (70%) of the CRAb were isolated from CWMH and three (30%) from LTKH; no CRAb were isolated from LBSH. Of the seven CWMH CRAb, two were sequence type 2 (ST2), three ST25, and two ST499. All LTKH isolates were ST499. The two environmental CRAb ST2 isolates were closely genetically linked to isolates obtained from patients in CWMH, LTKH, and LBSH 2020-2021. Similarly, the three environmental CRAb ST25 isolates were closely genetically linked to isolates obtained from patients admitted to CWMH in 2019-2021 and LBSH in 2020. The environmental CRAb ST499 isolates represented two distinct clones, with clone 1 comprising two genetically identical isolates from CWMH and clone 2 the three isolates from LTKH. Although no genetic linkages were observed when comparing environmental ST499 isolates to those from CWMH patients in 2020-2021, both clone 1 isolates were genetically identical to an isolate obtained from a patient admitted during the sampling period. Our study highlights the contamination of high-touch surfaces within Fiji hospitals with CRAb, suggesting that these may serve as important sources for CRAb. Phylogenetic linkages to CRAb isolated from patients since 2019 underscores the persistence of this resistant pathogen in hospital settings and the ongoing risk for hospital-acquired infections.

Knowledge, attitudes, and readiness about critical antimicrobial resistant organisms among healthcare workers at colonial war memorial hospital in Fiji: a pre and post intervention study

BackgroundGram-negative bacteria resistant to carbapenems are also known as critical antimicrobial resistant organisms. Their emergence at Colonial War Memorial Hospital (CWMH), the largest hospital in Fiji, is a major clinical concern. This study was conducted to determine the knowledge, attitudes, and readiness of healthcare workers (HCW) at CWMH regarding management of patients with infections caused by critical antimicrobial resistant organisms.MethodsA questionnaire was designed using a Likert scale to assess knowledge, attitudes, and readiness. Two cross-sectional studies were conducted, before and after the implementation of targeted educational activities which were informed by the pre-intervention study findings.ResultsA total of 393 and 420 HCW participated in the pre- and post-intervention studies, respectively. The majority of respondents were female (77.3%) and 18–34 years of age (67%). HCW professional roles included nurses (56.3%), doctors (31.6%), and laboratory personnel (12.2%). In the post-intervention study, significantly more HCW reported having received infection prevention and control (IPC) and antimicrobial resistance education and training (26.8% in pre to 45.5% in post intervention, p < 0.001). The majority of nurses and doctors (> 85% to ≥ 95%) were aware of how AMR organisms spread in healthcare settings and knew the IPC measures to prevent transmission of AMR infections including hand hygiene, standard and transmission-based precautions. Attitudes towards AMR were positive, with 84.2% pre intervention and 84.8% of HCW post intervention expressing their willingness to change their work environment to assist with AMR prevention. Perceived readiness to address the problem showed mixed results. Improvements in laboratory AMR surveillance data availability were noted (29.4–52.4%, p < 0001). Modest improvement in the hospital’s capacity for outbreak response (44–51.9%, p = 0.01), and treatment of AMR infections (38.9–44.4%, p = 0.01) was reported.ConclusionsOur data revealed high levels of staff awareness and knowledge about AMR and IPC. However, readiness for outbreak response and treatment of critical AMR infections requires more attention. Improving AMR prevention and containment in CWMH will likely require sustained and multisectoral interventions with strong administrative commitment.

The epidemiology of enterococci in a tertiary hospital and primary healthcare facilities in Fiji (2019–2022)

ObjectivesWe analysed 4 y of laboratory data to characterise the species and determine the antimicrobial susceptibility profiles of enterococci as human pathogens in Fiji. The study also investigated the molecular epidemiology amongst the subset of vancomycin-resistant enterococci (VRE). MethodsThis retrospective study reviewed bacteriological data from Colonial War Memorial Hospital (CWMH) and other healthcare facilities in the Central and Eastern divisions of Fiji. Phenotypic, antimicrobial susceptibility and vanA and vanB PCR testing were performed using locally approved protocols. The first clinical isolates per patient with antimicrobial susceptibility testing results in a single year were included in the analysis. Data was analysed using WHONET software and Microsoft Excel. ResultsA total of 1817 enterococcal isolates were reported, 1415 from CWMH and 402 from other healthcare facilities. The majority of isolates, 75% (n = 1362) were reported as undifferentiated Enterococcus spp., 17.8% (n = 324) were specifically identified as Enterococcus faecalis and 6.7% (n = 122) as E. faecium. Overall, 10% of the enterococci isolates were from blood cultures. Among isolates from CWMH, <15% of E. faecium were susceptible to ampicillin, and 17.2% were vancomycin resistant. Overall, 874 enterococcal isolates (including the undifferentiated species) were tested against vancomycin, of which 4.8% (n = 42) were resistance. All of the VRE isolates tested (n = 15) expressed vanA genes. ConclusionsThis study demonstrates the clinical importance of VRE, particularly van A E. faecium in the national referral hospital in Fiji. Enhanced phenotypic and molecular surveillance data are needed to better understand enterococci epidemiology and help guide specific infection prevention and control measures and antibiotic prescribing guidelines.

Clinical practice guidelines: Their utility, dissemination and monitoring at Colonial War Memorial Hospital: A mixed methods study from Fiji.

Clinical practice guidelines (CPGs) improve patient care by standardising medical practice. However, little is known about their applicability in low-resource settings. Since 2010, Fiji has introduced guidelines to increase the application of evidence-based practice. We describe the dissemination, utility and monitoring of guideline implementation in Fiji, a low-resource setting in the Pacific. A mixed-methods design included a survey and focus groups. All 178 doctors in five departments at Fiji's largest tertiary hospital were invited to participate. Subsequently, two focus group interviews explored clinicians' perspectives in more detail. Analysis included data description, multi-variable logistic, multinomial regression and manifest content analyses. The response rate was 74%. Most doctors agreed that CPGs were good for patient management (100%), doctors continuing medical education (CME) (96%), patient education (73%), supported by systematic reviews (91%) and consistent with existing norms/values (83%). Ninety-five per cent stated that CPGs increased the quality of care, and 80% stated that CPGs increased physician satisfaction. Approximately two-thirds stated that CPGs decreased medical-legal problems (63%) and malpractice suits (68%). Sixty to 90% of doctors disagreed that CPGs were oversimplified/cookbook medicine (60%), too rigid to apply individually (65%), challenged physician autonomy (60%) or were ambiguous/unclear (86%) or not practical (89%). The preferred method of dissemination was CME, and quick reference guides were best for implementation. No formal CPG monitoring existed in any department. Most physicians found CPGs to be valuable for improving the consistency of care. In low-resource settings, dissemination of guidelines should be paired with CME to improve their uptake. Increased monitoring of guideline use appears necessary.

Molecular and clinical epidemiology of carbapenem resistant Acinetobacter baumannii ST2 in Oceania: a multicountry cohort study

Carbapenem resistant Acinetobacter baumannii (CRAb) is categorised by the World Health Organization (WHO) as a pathogen of critical concern. However, little is known about CRAb transmission within the Oceania region. This study addresses this knowledge gap by using molecular epidemiology to characterise the phylogenetic relationships of CRAb isolated in hospitals in Fiji, Samoa, and other countries within the Oceania region including Australia and New Zealand, and India from South Asia. In this multicountry cohort study, we analysed clinical isolates of CRAb collected from the Colonial War Memorial Hospital (CWMH) in Fiji from January through December 2019 (n=64) and Tupua Tamasese Mea'ole Hospital (TTMH) in Samoa from November 2017 through June 2021 (n=32). All isolates were characterised using mass spectrometry, antimicrobial susceptibility testing, and whole-genome sequencing. For CWMH, data were collected on clinical and demographic characteristics of patients with CRAb, duration of hospital stay, mortality and assessing the appropriateness of meropenem use from the treated patients who had CRAb infections. To provide a broader geographical context, CRAb strains from Fiji and Samoa were compared with CRAb sequences from Australia collected in 2016-2018 (n=22), New Zealand in 2018-2021 (n=13), and India in 2019 (n=58), a country which has close medical links with Fiji. Phylogenetic relationships of all these CRAb isolates were determined using differences in core genome SNPs. Of CRAb isolates, 49 (77%) of 64 from Fiji and all 32 (100%) from Samoa belonged to CRAb sequence type 2 (ST2). All ST2 isolates from both countries harboured blaOXA-23, blaOXA-66 and ampC-2 genes, mediating resistance to β-lactam antimicrobials, including cephalosporins and carbapenems. The blaOXA-23 gene was associated with two copies of ISAba1 insertion element, forming the composite transposon Tn2006, on the chromosome. Two distinct clusters (group 1 and group 2) of CRAb ST2 were detected in Fiji. The first group shared common ancestral linkage to all CRAb ST2 collected from Fiji's historic outbreak in 2016/2017, Samoa, Australia and 54% of total New Zealand isolates; they formed a single cluster with a median (range) SNP difference of 13 (0-102). The second group shared common ancestral linkage to 3% of the total CRAb ST2 isolated from India. Fifty eight of the 64 patients with CRAb infections at the CWMH had their first positive CRAb sample collected 72h or more following admission. Meropenem use was deemed inappropriate in 15 (48%) of the 31 patients that received treatment with meropenem in Fiji. Other strains of CRAb ST1, ST25, ST107, and ST1112 were also detected in Fiji. We identified unrecognised outbreaks of CRAb ST2 in Fiji and Samoa that linked to strains in other parts of Oceania and South Asia. The existence of Tn2006, containing the blaOXA-23 and ISAba1 insertion element, within CRAb ST2 from Fiji and Samoa indicates the potential for high mobility and dissemination. This raises concerns about unmitigated prolonged outbreaks of CRAb ST2 in the two major hospitals in Fiji and Samoa. Given the magnitude of this problem, there is a need to re-evaluate the current strategies used for infection prevention and control, antimicrobial stewardship, and public health measures locally and internationally. Moreover, a collaborative approach to AMR surveillance within the Oceania region with technical, management and budgetary support systems is required to prevent introduction and control transmission of these highly problematic strains within the island nation health systems. This project was funded by an Otago Global Health Institute seed grant and Maurice Wilkins Centre of Research Excellence (CoREs) grant (SC0000169653, RO0000002300).

Assessment of knowledge, attitude and practice for oxygen therapy among medical staff at the Colonial War Memorial Hospital in Fiji.

Oxygen therapy (OT) is a commonly prescribed essential medicine for people of all ages in the management of hypoxia. The adverse effects of inappropriate OT supplementation may be underestimated by health professionals and lead to poor health outcomes among hospitalised patients. Knowledge, attitude and practice (KAP) assessments of medical staff members to OT guidelines are essential to ensure optimal patient care. To perform a KAP assessment of OT administration among doctors and nurses employed at the national hospital of Fiji in 2021. Prospective cross-sectional study design. KAP assessment was performed with an online questionnaire and clinical observation. The study population (N = 116) consisted of doctors (20.7%) and nurses (79.3%) representing the acute medical, burns, cardiac care, intensive care, surgical and postanaesthetic recovery units. Overall, the proportion of participants who obtained a good score (>70%) was 87% for knowledge, 87.93% for attitudes and 84% for practice. Best knowledge scores were obtained for general OT indications (71%) and scenarios where immediate oxygen application is required (70%). Lowest knowledge scores were for OT contraindications (14%) and oxygen saturation for acute myocardial infarction (32%), asthma (36%) and healthy newborns (43%). The most positive attitudes were in response to the statement that OT guidelines are essential (96%). A total of 78 (80.4%) patients were being cared for with good OT practice. Good KAP scores were obtained for medical staff in Fiji regarding OT administration. Ongoing professional education activities should include updated training of OT contraindications and optimal oxygen saturation levels for special patient groups.

Incidence, treatment patterns and clinical outcomes associated with acute kidney injury in Fiji: a retrospective cohort study.

This study aims to describe the incidence and outcomes of acute kidney injury at Fiji's tertiary referral hospital. A retrospective study of adults aged ≥ 18years hospitalised at the Colonial War Memorial Hospital between 1 January and 30 June, 2015 was conducted. Acute kidney injury was defined using the 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines by medical record review. One hundred ten (2.1%) of 5140 hospitalised patients met the diagnostic criteria for acute kidney injury. Fifty-two cases (47%) of acute kidney injury were stage 1, 11 (10%) cases were stage 2, and 47 (43%) cases were stage 3. Acute sepsis (n = 68) and dehydrating illness (n = 52) were the most common causes. Thirty-nine patients had urinalysis and 36 received imaging; none underwent kidney biopsy. Treatment included antibiotics (n = 91), intravenous fluids (n = 84) and vasopressors (n = 25). Twenty-one (19%) patients were treated with intermittent haemodialysis. Forty-seven patients (43%) with acute kidney injury died including 16 (76%) dialysed patients. Crude mortality at 7days was 19 (40%). Of the 63 patients who survived their primary illness, 29 (46%) had a follow-up assessment at 3months. In patients needing hospitalisation for acute kidney injury in Fiji, the most common causes were sepsis and dehydration. Mortality was high, in particular in those who received dialysis. Follow-up after acute kidney injury is incomplete.

SG-APSIC1157: The attributable mortality and excess length of stay associated with third-generation cephalosporin-resistant Enterobacterales bloodstream infections—A prospective cohort study in Suva, Fiji

Objectives: Although antimicrobial resistance (AMR) disproportionately affects low- and middle-income countries (LMICs), primary clinical data on AMR burden from LMICs are lacking, particularly from the Pacific Islands. We adapted recent World Health Organization methodology to measure the impact of third-generation cephalosporin (3GC) resistance on mortality and excess length of hospital stay among inpatients with Enterobacterales bloodstream infection (BSI) in Fiji. Methods: We conducted a prospective cohort study of inpatients with Enterobacterales BSIs at Colonial War Memorial Hospital in Suva. We collected demographic, clinical, and microbiological data, and we stored bacterial isolates for confirmatory testing and molecular genomics in Melbourne, Australia. We employed cause-specific Cox proportional hazards models to estimate the effect of 3GC-resistance on hazard of in-hospital mortality and discharge alive (competing outcomes), and we used multistate modelling to estimate the excess length of hospital stay associated with 3GCR. Results: From July 2020 to February 2021, we identified 162 consecutive Enterobacterales BSIs, and 66 (40.7%) were 3GC resistant. The crude mortality rates for patients with 3GC-susecptible and 3GC-resistant BSIs were 16.7% (16 of 96) and 30.3% (20 of 66), respectively. Also, 3GC resistance was not associated with either in-hospital mortality (aHR, 1.67; 95% CI, 0.80–3.49) or discharge alive (aHR, 0.75; 95% CI, 0.50–1.12). However, patient comorbidities and acuity of illness were associated with in-hospital mortality. Furthermore, 3GC-resistance was associated with an increased length of stay of 2.6 days (95% CI, 2.5–2.8). Overall, 3GC-resistance was more common among patients with hospital-associated than community-acquired infection, but genomics did not identify clonal transmission. Conclusions: Among patients with Enterobacterales BSIs, mortality was relatively high, and 3GC resistance was common. Also, 3GC resistance was associated with increased hospital length of stay but not with in-hospital mortality after adjusting for potential confounders. Accurate estimates of the burden of AMR are important, especially from LMICs. Such knowledge can inform policy decisions, guide allocation of limited resources, and assist the evaluation of future interventions to address AMR.

What Helped Support Nurses in the ED at CWM during the COVID-19 Outbreak in Fiji in 2021?

Background/Introduction:Following a quarantine breach in April 2021, Fiji went from no cases of COVID-19 to having the highest number per capita in the world. Fiji was relatively well-prepared to respond to COVID-19 as it has strong emergency management response systems. Nevertheless, due to the rapid increase, the public health system was quickly overwhelmed. The problem was particularly acute at the main tertiary hospital in Suva.Objectives:To describe the effects of an overwhelming COVID-19 outbreak on nurses working in the Emergency Department of Colonial War Memorial Hospital in Fiji, in 2021.To describe the lessons learned and recommendations for the future.Method/Description:Focus Group Discussion with two groups of nurses: (1) ED nurse and (2) nurses seconded to provide a surge workforce in the most acute phase.Results/Outcomes:Preliminary findings show that nurses were lacking in confidence and frightened about the growing epidemic. Resources, material and human, were initially in short supply. The agency of the nurses as result of their post-graduate study and due to the collegial environment in ED resulted in increased supplies of PPE and changes to nursing practice (eg, web-based handover). Final results pending.Conclusion:The preliminary findings of this research illustrate that even in low-resource settings, with the right support and effective nursing leadership, nurses can provide safe and effective care to patients. The research illustrates the benefits of sound, relevant education, the crucial importance of teamwork, the importance of networks, the important benefits of early deployment of the MET, and the need for effective nursing leadership.

“It’s a waste of time coming here, better go to private clinics with wider options for treatment”: patient’s perception on dental services provided in Fiji

BackgroundOral health can influence the quality of an individual’s life. Patient’s perception of the service plays a vital role in understanding the reasons as to why a patient may be satisfied or dissatisfied with the service that they accessed at a dental setting. As no studies have been done in Fiji until now, this study aimed to explore the perceptions of patients on services provided by the largest dental clinic in the Central/Eastern division in Fiji.MethodA qualitative study was used to collect data from patients who visited the Colonial War Memorial Hospital (CWMH) dental clinic in Suva Fiji from 5th August to 31st October, 2020. All patients above the age of 18 of both genders and from any ethnicity who visited the CWMH dental clinic during the period of data collection were included the study. A total of 25 participants were interviewed for this study using the in-depth interview method till data saturation occurred. A semi-structured open-ended questionnaire was used to collect data using face-to-face in-depth interviews. The data were transcribed and analyzed using manual thematic analysis process to gather the themes and sub-themes for the results.ResultsA total of 25 patients were interviewed, with a majority (n = 14) being men and 15 were of I-Taukei background. Five themes emerging from data analysis include: Waiting time before treatment, Cost of Treatment, Accessibility of services, Privacy and confidentiality and Range of treatment options. The patients had an expectation to get the best treatment but face many hurdles while trying to get the treatment that they expect. The shortfalls on the part of this dental clinic caused an onset of negative perception among its users.ConclusionThis study shows an overall dissatisfaction with regards to services delivery among the patients who use the CWMH dental clinic for dental care purposes. The decision makers need to look into the genuine concerns that have been raised by patients in order to create improvements in services delivery and create an array of satisfaction for its patients.

Frontline Health Care Workers' (HCWs) perception of barriers to managing COVID-19 in Fiji.

BackgroundHealth Care Workers (HCWs) are at higher risk of COVID-19 infection with their efforts while protecting the greater community and also exposed to hazards, such as psychological distress, fatigue, and stigma. This study aimed to explore the perception of frontline HCWs on barriers of managing COVID-19 in Fiji.MethodsA qualitative study method was approached to conduct this study among the HCWs who worked on the frontline during the COVID-19 pandemic based at ten purposively selected health facilities in the Suva subdivision in the Central Division of Fiji. The Colonial War Memorial Hospital (CWMH), the Fiji Centre for Communicable Diseases (Fiji CDC), Twomey hospital laboratory, and CWMH laboratory did the main control and most of the operations of other divisions were monitored from these settings. A semi-structured open-ended questionnaire was used to collect data using in-depth interviews. The participants' responses were audio-recorded and were later transcribed and analyzed using thematic analysis.ResultsA total of twenty-nine HCWs took part in the in-depth interview and the responses were grouped into four themes, which include: workload, poor communication, lack of resources, and hindrance to education. It was also found through this study that some of the HCWs felt tired, frustrated, got rude to patients, and found it difficult to handle situations, which affected them mentally and physically stressed.ConclusionManaging the COVID-19 cases has been attributed to the presence of many barriers, such as workload, tiredness, frustration, and sometimes difficult-to-handle situations, and the HCWs were indeed affected mentally and physically. Regular training for HCWs and more awareness programs would help the general public to follow the preventive measures, which reduces the cases and would help the HCWs manage COVID-19 well.

Attributable mortality and excess length of stay associated with third-generation cephalosporin-resistant Enterobacterales bloodstream infections: a prospective cohort study in Suva, Fiji

There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the effect of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji. We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and we used multistate modelling to estimate the excess length of hospital stay. From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs; 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio [aHR] 1.13, 95% confidence interval [CI] 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission. Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.

Epidemiology, antimicrobial resistance and outcomes of Staphylococcus aureus bacteraemia in a tertiary hospital in Fiji: A prospective cohort study

SummaryBackgroundStaphylococcus aureus bacteraemia (SAB) is one of the commonest bloodstream infections globally and is associated with a high mortality rate. Most published data comes from temperate, high-income countries. We describe the clinical epidemiology, microbiology, management and outcomes of patients with SAB treated in a tropical, middle-income setting at Fiji's largest hospital.MethodsA prospective, observational study was performed of consecutive SAB cases admitted to Colonial War Memorial Hospital (CWMH) in Suva, between July 2020 and February 2021. Detailed demographic, clinical and microbiological data were collected, including the key outcome of in-patient mortality. To estimate the population incidence, all SAB cases diagnosed at the CWMH laboratory were included – even if not admitted to CWMH – with the population of Fiji's Central Division used as the denominator.FindingsA total of 176 cases of SAB were detected over eight-months, which equated to an incidence of 68.8 cases per 100,000 population per year. Of these, 95 cases were admitted to CWMH within 48 h of index culture. Approximately 8.4% (8/95) of admitted cases were caused by methicillin-resistant Staphylococcus aureus (MRSA). All cause in-patient mortality was 25.3%, increasing to 55% among patients aged 60 or older.InterpretationThis reported incidence of SAB in central Fiji is one of the highest in the world. SAB was associated with significant mortality, especially in those over 60 years of age, despite a relatively low frequency of methicillin resistance.FundingSupported by the National Health and Medical Research Council (Australia) and the GRAM (Global Research on Antimicrobial Resistance) Project, Oxford University (United Kingdom).

Drug Shortages and Its Effects on Service Delivery among Key Informants (KIs) in Fiji

BACKGROUND: Drug shortage is a global problem that adds extra burden to health systems with additional costs and posing risks to patients who fail to receive the medicines they need. Aim This study aimed to describe drug shortage and its effects on service delivery among Key Informants (KIs) in Fiji. &#x0D; &#x0D; MATERIALS AND METHODS: In this quantitative cross-sectional study, the information on drug shortage per month was collected through the stock status report and pharmacy records of the main referral hospital in Fiji, the Colonial War Memorial hospital (CWMH) from 1st June to 30th November 2015. Purposive sampling was applied to reach 50 KIs who met the study crietria. A pilot tested structured questionniare was used to collect data and descriptive statistic was used to analyze data. &#x0D; &#x0D; RESULTS: The results showed the most frequent out of stock items were antibiotics (49) followed by vitamins (18) and antihypertensive (17). The frequency of total drugs on shortage ranged from 29 to 50 items per month with an average rate 10% (n=40) drug shortages per month. Additinally, 98% (n=49) of the KIs indicated that drug shortage increased workload of staff and 90% (n=45) indicated that the standard treatment was deviated or alternatives were sought due to shortage of drugs.&#x0D; &#x0D; CONCLUSIONS: The findings of this study revealed that drug shortage was experienced in CWMH during the study period and had an impact on the clinical service delivery. There is a needed to focus on the use, selection, procurement and storage and distribution of medicines at CWMH.

Prevalence and Characteristics of Oral Squamous Cell Carcinoma in Fiji: A Retrospective Study

BACKGROUND: Oral squamous cell carcinoma (OSCC) is malignant epithelial neoplasm that affects the oral cavity. Despite the large number of studies on OSCC in the literature, details on the demographic profile of these lesions in different populations are limited, especially amongst the Fijian population, thus this study aimed to determine the prevalence and characteristics of OSCC cases diagnosed from 2011 to 2015 at the Colonial War Memorial Hospital (CWMH), Suva, Fiji Islands. &#x0D; &#x0D; MATERIALS &amp;amp; METHODS: A retrospective quantitative study was carried out at the CWMH Histology department looking at OSCC cases diagnosed from 2011&amp;ndash;2015. All confirmed cases were included in the study and excluded cases were suspected cases that were pending diagnosis and children. An extraction sheet was used for data collection which was designed to meet the requirements of study finding. This data was entered in SPSS software and then analyzed using the simple analytical tool as bar graphs and tables.&amp;nbsp; &#x0D; &#x0D; RESULTS: There were 74 OSCC cases diagnosed in the study period. The occurrence of OSCC cases over the 5-year period was fluctuant with the year 2013 recording the highest number of cases (24 cases, 32%). During the reported period, more men suffered (53 cases, 72%) from this condition with the tongue (40%) being the commonest oral cancer site followed by the lip and vermillion border (28%). Individuals in the 40 to 60 years&amp;rsquo; age group (35 cases, 47.3%) were mostly affected with the I-taukei population (38 cases, 51.4%) recording the highest occurrence of OSCC. The results show that, the common occurrence is the tongue (40.5%) while the least presentation sight is Buccal mucosa/buccal sulcus area (8.1%). &#x0D; &#x0D; CONCLUSION: The study concluded that more men suffer from oral squamous cell carcinoma compared to woman and the ethnicity that was most affected was I-taukei population. More detailed record keeping and reporting of oral cancer is needed to help evaluate progress in controlling oral cancer in the Fiji Islands. This availability of geographic data would further assist the Ministry of Health of Fiji in data collection and planning of preventative activities

Accuracy of radiographers in Fiji in interpreting adult chest X-ray images

IntroductionThe idea of radiographer image interpretation has not been fully explored in Fiji despite the great shortage of radiologists in the country. This is a feasibility study of radiographer image interpretation aimed at assessing the accuracy of radiographers in interpreting adult chest X-ray images at the Colonial War Memorial Hospital (CWMH) in Fiji. MethodsForty PA chest X-ray images were interpreted in terms of correctly commenting on the presence/ absence of pathology, the name of the pathology, and the location of the pathology on the data sheets by the CWMH diagnostic radiographers (n = 14). The radiographers were grouped according to their years of work experience (≤ 5 vs > 5) and the Mann Whitney U test on a two-tailed p-value of 0.05 was used to compare this grouping. ResultsThe data analysis was conducted using the Statistical Package for Social Sciences (SPSS) v.25 and Microsoft Excel. The diagnostic performance of all radiographers in terms of triaging normal and abnormal in the images shows sensitivity ranging from 71.4 to 100%, with specificity ranging from 47.4 to 100%. The mean sensitivity, specificity, and the overall accuracy of radiographers in triaging normal and abnormal on the images were 89.5%, 72.9%, and 81.6%, respectively. The mean accuracy in naming the pathology was 33.6% and the location sensitivity was 45.7%. There was no statistically significant difference in results between the radiographers’ years of experience. ConclusionWithout any formal qualification, training, and practice, the current results suggest that the cohort of radiographers can perform normal/abnormal triage of CXRs within a test setting. With a significant reduction in the radiographers’ accuracy in terms of naming and locating the abnormality, the study results do not support image interpretation by the radiographers at this stage. Implications for practiceThis feasibility study provides baseline information about the accuracy of image interpretation by diagnostic radiographers at CWMH and provides a platform for further research in image interpretation in Fiji.

Patterns and risk factors associated with index Lower Extremity Amputations (LEA) among Type 2 Diabetes Mellitus (T2DM) patients in Fiji

AimTo describe patterns of index (first ever) Lower Extremity Amputations (LEA) and to determine factors associated with their occurrence amongst Type 2 Diabetes Mellitus (T2DM) patients in Fiji. MethodsThis cross-sectional study was conducted that adheres to the STROBE check lists for observational research among T2DM patients who experienced index LEA at the Colonial War Memorial Hospital (CWMH) in Fiji between 2011 and 2015. Demographic and clinical variables were extracted from patient folders. Univariate and multivariate logistic regression were used to determine factors associated with Major LEA. A p-value < 0.05 was considered significant. ResultsA total of 649 study participants were studied with the average age of index amputation was 58.4 years (±9.6 years, range 30–91 years). The average duration of T2DM was 9.5 ± 5.7 years. LEAs were more common amongst males (55%) and indigenous Fijians (71.8%). One-third of index LEA (33%) were major amputations. Factors associated with occurrence of Major LEA were poor Random Blood Sugar (RBS) levels (OR = 1.68, 95% CI: 1.01, 2.81), midfoot lesion (OR = 9.38 95% CI: 4.95, 19.52), septicaemia (OR = 2.42, 95% CI: 1.28, 4.57), low haemoglobin level (OR = 0.78 95% CI: 0.72, 0.86), and history of hypertension (OR = 0.58, 95% CI: 0.40, 0. 84). ConclusionsResults indicate that diabetic patients with foot infections present late to tertiary level care. Our findings also show an urgent need to strengthen primary care interventions and surveillance of both diabetes and diabetic LEA.

Prevalence of healthcare-associated infections and antimicrobial use among inpatients in a tertiary hospital in Fiji: a point prevalence survey

BackgroundHealthcare-associated infections (HAIs) and antimicrobial use (AMU) are important drivers of antimicrobial resistance, yet there is minimal data from the Pacific region. We sought to determine the point prevalence of HAIs and AMU at Fiji’s largest hospital, the Colonial War Memorial Hospital (CWMH) in Suva. A secondary aim was to evaluate the performance of European Centre for Diseases Prevention and Control (ECDC) HAI criteria in a resource-limited setting.MethodsWe conducted a point prevalence survey of HAIs and AMU at CWMH in October 2019. Survey methodology was adapted from the ECDC protocol. To evaluate the suitability of ECDC HAI criteria in our setting, we augmented the survey to identify patients with a clinician diagnosis of a HAI where diagnostic testing criteria were not met. We also assessed infection prevention and control (IPC) infrastructure on each ward.ResultsWe surveyed 343 patients, with median (interquartile range) age 30 years (16–53), predominantly admitted under obstetrics/gynaecology (94, 27.4%) or paediatrics (83, 24.2%). Thirty patients had one or more HAIs, a point prevalence of 8.7% (95% CI 6.0% to 12.3%). The most common HAIs were surgical site infections (n = 13), skin and soft tissue infections (7) and neonatal clinical sepsis (6). Two additional patients were identified with physician-diagnosed HAIs that failed to meet ECDC criteria due to insufficient investigations. 206 (60.1%) patients were receiving at least one antimicrobial. Of the 325 antimicrobial prescriptions, the most common agents were ampicillin (58/325, 17.8%), cloxacillin (55/325, 16.9%) and metronidazole (53/325, 16.3%). Use of broad-spectrum agents such as piperacillin/tazobactam (n = 6) and meropenem (1) was low. The majority of prescriptions for surgical prophylaxis were for more than 1 day (45/76, 59.2%). Although the number of handwashing basins throughout the hospital exceeded World Health Organization recommendations, availability of alcohol-based handrub was limited and most concentrated within high-risk wards.ConclusionsThe prevalence of HAIs in Fiji was similar to neighbouring high-income countries, but may have been reduced by the high proportion of paediatric and obstetrics patients, or by lower rates of inpatient investigations. AMU was very high, with duration of surgical prophylaxis an important target for future antimicrobial stewardship initiatives.

Adverse Maternal Outcomes of Fijian Women with Gestational Diabetes Mellitus and the Associated Risk Factors.

The purpose of this study is to determine the factors associated with adverse maternal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM) in urban Fiji. This cross-sectional study used data from existing records of singleton pregnant women with GDM attending the Colonial War Memorial Hospital (CWMH) Suva Fiji between June 2013 and May 2014. Data retrieved included demographic data, antenatal and intrapartum care data, route of delivery, treatment modality, and maternal risk factors. The prevalence of GDM is 3.0%, n = 255/8698, and the most frequent maternal complications were induction of labor (66%), C-section (32%), and preeclampsia (19%), and 25% had babies with birthweight > 4kg. Older women (≥ 36years) and those treated with insulin were 5.2 times and 10.7 times, respectively, more likely to have labor induction during childbirth compared with younger women and those on dietary management. Family history of diabetes was associated with 2.4× and/or 2.5× higher odds of cesarean delivery and/or develop hypertension in pregnancy, respectively. Parity > 5 children and diagnoses of GDM after the first trimester reduced the odds of cesarean delivery. The odds of developing preeclampsia in GDM was 3.4 times higher (95% confidence interval (CI) of adjusted odds ratio (aOR): 1.03, 18.78) among obese women than normal-weight women, and married women were less likely to have babies with birthweight > 4kg. The prevalence of and adverse outcomes among women with GDM attending antenatal public health care in Suva Fiji were higher than previously reported from the hospital. Older and multiparous women with GDM, those insulin treated, and with a strong family history and high body mass index (BMI) need special attention and better monitoring by health care personnel to reduce adverse outcomes during pregnancy.

Factors associated with macrosomia, hypoglycaemia and low Apgar score among Fijian women with gestational diabetes mellitus

BackgroundGestational diabetes mellitus (GDM) in Fiji is a serious public health issue. However, there are no recent studies on GDM among pregnant women in Fiji. The aim of this study was to examine prevalence of, and sociodemographic factors associated with adverse neonatal outcomes among Fijian women with GDM.MethodsWe used cross-sectional data of 255 pregnant women with GDM who gave birth to singleton infants at Colonial War Memorial Hospital (CWMH) in Suva city. Women underwent testing for GDM during antenatal clinic visits and were diagnosed using modified International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Multivariable logistic regression analysis was used to investigate factors associated with neonatal outcomes.ResultsWomen with a previous baby weighing > 4 kg were 6.08 times more likely to experience neonatal macrosomia (Adjusted odds ratio (AOR) = 6.08; 95%CI: 2.46, 15.01). Compared to unmarried women, the odds of macrosomia among married women reduced by 71% (AOR = 0.29; 95%CI: 0.11, 0.77). Compared with delivery before 38 weeks of gestation, the infants of women who delivered between 38 and 41 weeks of gestation were 62 and 86% less likely to experience neonatal hypoglycaemia and Apgar score < 7 at 5 mins, respectively. The offspring of women who were overweight and obese had higher odds of neonatal hypoglycaemia. Late booking in gestation (≥28 weeks) was significantly associated with Apgar score < 7 at 5 min (AOR = 7.87; 95%CI: 1.11, 55.75). Maternal pre-eclampsia/pregnancy induced hypertension was another factor associated with low Apgar score in infants.ConclusionsThe study found high rates of adverse neonatal outcomes among off springs of Fijian women with GDM and showed that interventions targeting pregnant women who are overweight, had a previous baby weighing > 4 kg, had pre-eclampsia, delivered before 38 weeks of gestation, and those who booked later than 13 weeks in gestation, are needed to improve pregnancy outcomes.