Pham Thi Lan

Reproductive tract infections including sexually transmitted infections: a population-based study of women of reproductive age in a rural district of Vietnam

Objectives: To investigate the prevalences of reproductive tract infections (RTI)/sexually transmitted infections (STI) among married women in a rural district of Vietnam, and analyse the influence of socioeconomic, sociodemographic, and other determinants possibly related to RTI/STI. Methods: A community-based cross-sectional study. Married women aged 18–49 years (n  =  1012) were interviewed and underwent a gynaecological examination. Specimens were collected for laboratory diagnosis of chlamydia, gonorrhoea, trichomonas, bacterial vaginosis (BV), candidiasis, hepatitis B, HIV, and syphilis. Results: In total, 37% of the women were clinically diagnosed with an RTI/STI. Aetiologically confirmed RTI/STI was identified in 39% of the women (including 6% with STI). Endogenous infections were most prevalent (candidiasis 26%, BV 11%) followed by hepatitis B 8.3%, Chlamydia trachomatis 4.3%, Trichomonas vaginalis 1%, Neisseria gonorrhoeae 0.7%, genital warts 0.2%, and HIV and syphilis 0%. Fifty per cent of the STI cases were asymptomatic. Younger age and intrauterine devices were significantly associated with an increased risk of BV. Determinants of candidiasis were vaginal douching, high education level and low economic status, whereas a determinant of chlamydia was high economic status. Outmigration of the husband was associated with an increased risk of hepatitis B surface antigen seroposivity among women. Conclusions: RTI/STI were prevalent among married women in a rural population of Vietnam. Syndromic algorithms should be consistently supplemented by risk assessment in order to reduce under and overtreatment. Microscopic diagnosis could be applied in primary care settings to achieve more accurate diagnoses. The promotion of health education aimed at reducing RTI/STI prevalences is an important tool in STI/HIV control programmes. Vaccination to prevent hepatitis B for migrants should be considered.

Antimicrobial susceptibility and genetic characteristics of Neisseria gonorrhoeae isolates from Vietnam, 2011

BackgroundAntimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major public health concern worldwide. In Vietnam, knowledge regarding N. gonorrhoeae prevalence and AMR is limited, and data concerning genetic characteristics of N. gonorrhoeae is totally lacking. Herein, we investigated the phenotypic AMR (previous, current and possible future treatment options), genetic resistance determinants for extended-spectrum cephalosporins (ESCs), and genotypic distribution of N. gonorrhoeae isolated in 2011 in Hanoi, Vietnam.MethodsN. gonorrhoeae isolates from Hanoi, Vietnam isolated in 2011 (n = 108) were examined using antibiograms (Etest for 10 antimicrobials), Neisseria gonorrhoeae multi-antigen sequence typing (NG-MAST), and sequencing of ESC resistance determinants (penA, mtrR and penB).ResultsThe levels of in vitro resistance were as follows: ciprofloxacin 98%, tetracycline 82%, penicillin G 48%, azithromycin 11%, ceftriaxone 5%, cefixime 1%, and spectinomycin 0%. The MICs of gentamicin (0.023-6 mg/L), ertapenem (0.002-0.125 mg/L) and solithromycin (<0.016-0.25 mg/L) were relatively low. No penA mosaic alleles were found, however, 78% of the isolates contained an alteration of amino acid A501 (A501V (44%) and A501T (34%)) in the encoded penicillin-binding protein 2. A single nucleotide (A) deletion in the inverted repeat of the promoter region of the mtrR gene and amino acid alterations in MtrR was observed in 91% and 94% of the isolates, respectively. penB resistance determinants were detected in 87% of the isolates. Seventy-five different NG-MAST STs were identified, of which 59 STs have not been previously described.ConclusionsIn Vietnam, the highly diversified gonococcal population displayed high in vitro resistance to antimicrobials previously recommended for gonorrhoea treatment (with exception of spectinomycin), but resistance also to the currently recommended ESCs were found. Nevertheless, the MICs of three potential future treatment options were low. It is essential to strengthen the diagnostics, case reporting, and epidemiologic surveillance of gonorrhoea in Vietnam. Furthermore, the surveillance of gonococcal AMR and gonorrhoea treatment failures is imperative to reinforce. Research regarding novel antimicrobial treatment strategies (e.g., combination therapy) and new antimicrobials is crucial for future treatment of gonorrhoea.

Lack of knowledge about sexually transmitted infections among women in North rural Vietnam

BackgroundThe serious long-term complications of sexually transmitted infections (STI) in women and newborns are well-documented. Particularly, STI imply considerable social consequences for women. Low STI knowledge has been shown to be associated with unsafe sex. In Vietnam, misconceptions regarding STI exist, and rural women delay seeking care for STI. The aim of the study was to investigate knowledge of STI among women aged 15 to 49 years in a rural district of Vietnam and to evaluate possible associations between socioeconomic factors and STI knowledge.MethodsA cross-sectional population-based study using face-to-face interviews was carried out between March and May 2006 in a demographic surveillance site in rural Vietnam. In total, 1805 women aged 15–49 years were randomly selected to participate in the study. The interviews were based on a structured questionnaire including questions on sociodemographic characteristics of the women and their knowledge about STI. Each correct answer was scored 1, incorrect or do not know answer was scored 0. Multivariate analyses were applied to examine associations between socio-economic conditions and STI knowledge. Intra-cluster correlation was calculated to examine similarities of STI knowledge within clusters.ResultsOf the 1,805 respondents, 78% (73% married vs. 93% unmarried, p < 0.001) did not know any symptoms of STI, 50% could not identify any cause of STI, 59% (54% married vs. 76% unmarried, p < 0.001) did not know that STI can be prevented. Only 31% of the respondents (36% married vs. 14% unmarried, p < 0.001) answered that condom use could protect against STI, and 56% considered partner treatment necessary. Of 40 possible correct answers, the mean knowledge score was 6.5 (range 0–26, median 6). Young, unmarried women and women who lived in the highlands or mountainous areas demonstrated very low levels of STI knowledge (regression coefficients -1.3 and -2.5, respectively, p < 0.001). Experience of an induced abortion was significantly associated with a higher level of knowledge.ConclusionThe low levels of STI knowledge found among women of reproductive age in a rural district of Vietnam indicate an urgent need of health education interventions, of which, young and unmarried women should be specifically targeted.

Population-based assessment of Mycoplasma genitalium in Vietnam – low prevalence among married women of reproductive age in a rural area

Objective  To analyse the prevalence of Mycoplasma genitalium infection in a population‐based study among married women from a demographic surveillance site in a rural geographical area of Vietnam.

Knowledge and practice among healthcare providers in rural Vietnam regarding sexually transmitted infections.

Objectives: To assess knowledge and reported practice regarding sexually transmitted infections (STI) among healthcare providers in rural Vietnam and to examine background characteristics possibly associated with knowledge and practice. Methods: A cross-sectional study using a self-completed questionnaire was carried out in 2006 among 465 healthcare providers in rural Vietnam. The questionnaire included questions on providers’ characteristics, STI knowledge, and case scenarios of 4 common STI syndromes. Correct answer was scored 1, “do not know” or incorrect answer was scored 0. Linear and logistic regressions were applied. Results: Diseases considered as STI were gonorrhea and syphilis by 83% of the respondents, 70% believed partner treatment necessary for bacterial vaginosis or candidiasis cases. Sharing clothes/food or kissing was commonly mentioned as transmission routes (60%). Median scores of knowledge and reported practice were 29 (range: 0–50) and 2 (range: 0–20), respectively. Among the respondents, 34% had a knowledge score of less than 25 and 78% had a practice score of less than 10. Characteristics predicting higher level of knowledge were being a medical doctor, assistant medical doctor, midwife, or serving STI patients. Characteristics predicting higher level of practice were serving STI patients, being a midwife or female provider, and having participated in STI or reproductive tract infection training courses. Respondents who reported treating STI patients had a higher level of knowledge and reported practice than the others. Conclusion: Suboptimal STI knowledge and reported practice found among healthcare providers in rural Vietnam imply the urgent need of interventions to improve STI knowledge and practice for providers at grassroots healthcare levels.

Antibiotic Resistance and Antibiotic Resistance Genes in Escherichia coli Isolates from Hospital Wastewater in Vietnam

The environmental spread of antibiotic-resistant bacteria has been recognised as a growing public health threat for which hospitals play a significant role. The aims of this study were to investigate the prevalence of antibiotic resistance and antibiotic resistance genes (ARGs) in Escherichia coli isolates from hospital wastewater in Vietnam. Wastewater samples before and after treatment were collected using continuous sampling every month over a year. Standard disk diffusion and E-test were used for antibiotic susceptibility testing. Extended-spectrum beta-lactamase (ESBL) production was tested using combined disk diffusion. ARGs were detected by polymerase chain reactions. Resistance to at least one antibiotic was detected in 83% of isolates; multidrug resistance was found in 32%. The highest resistance prevalence was found for co-trimoxazole (70%) and the lowest for imipenem (1%). Forty-three percent of isolates were ESBL-producing, with the blaTEM gene being more common than blaCTX-M. Co-harbouring of the blaCTX-M, blaTEM and qepA genes was found in 46% of isolates resistant to ciprofloxacin. The large presence of antibiotic-resistant E. coli isolates combined with ARGs in hospital wastewater, even post-treatment, poses a threat to public health. It highlights the need to develop effective processes for hospital wastewater treatment plants to eliminate antibiotic resistant bacteria and ARGs.

Antibiotic prescribing and dispensing for acute respiratory infections in children: effectiveness of a multi-faceted intervention for health-care providers in Vietnam

ABSTRACT Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries. Objective: To evaluate a multi-faceted intervention targeting health-care-providers’ (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs. Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010–2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively. Results: Knowledge improved in the intervention group for ARI aetiology by 28% (ΔDecrement control arm 10%), antibiotic use for mild ARIs by 15% (ΔDecrement control arm 13%) and for severe ARIs by 14% (ΔImprovement control arm 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δmean improvement 1.17); less so in the control group (Δmean improvement 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (ΔDecrement control arm 3%). Conclusions: The intervention significantly improved HCPs’ knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

Knowledge and self-reported practices of infection control among various occupational groups in a rural and an urban hospital in Vietnam

Staff practice, driven by knowledge, plays a decisive role in hospital infection control. This study aimed to assess and compare knowledge and self-reported practices of infection control among various occupational groups in a rural and an urban hospital in Vietnam. Questionnaires consisting of items on knowledge and practices were collected from 339 hospital staff with varying occupations. For analysis, total knowledge or practice score ranged from 0–15. Mood’s median test was performed to compare median scores. Post-hoc analysis of ordinal logistic regression models was applied to test differences in scores among occupational groups. The majority of hospital staff had good or adequate knowledge (median score: rural = 11.8; urban = 12), but the score range was wide (1.4–14.5). Self-reported practices in the urban hospital were likely to be better than in the rural one (p = 0.003). Self-reported practices yet not completely satisfactory, indicating the need for continuing professional development in both settings. Overall, cleaners had lower scores than both physicians and nurses, highlighting the need for tailored education in this topic. Future infection control strategies within the hospitals might want to assess the difference between the staff’s self-reported practice and their actual real practice. These findings can be of value in many other similar settings.

Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives’ experiences and views of obstetric ultrasound

ABSTRACT Background: Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed. Objectives: To explore Rwandan midwives’ experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects. Methods: A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS). Results: Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed. Conclusions: Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda. RESPONSIBLE EDITOR Virgilio Mariano Salazar Torres, Karolinska Institute, Sweden

A Potential Way to Decrease the Know-Do Gap in Hospital Infection Control in Vietnam: “Providing Specific Figures on Healthcare-Associated Infections to the Hospital Staff Can ‘Wake Them Up’ to Change Their Behaviour”

Adequate infection control plays a key role in preventing healthcare-associated infections (HAIs). This study aimed to explore staff perceptions of hospital infection control in a rural and an urban hospital in Vietnam. Individual interviews were conducted with hospital managers, and focus group discussions were conducted with doctors, nurses and cleaning workers separately. Content analysis was applied. An interview guide including discussion points on HAIs, hand hygiene and healthcare waste management was used. Generally, the staff were knowledgeable of hospital infection control, but they were not aware of the situation in their own hospital, and infection control practices in the hospitals remained poor. Reported difficulties in infection control included lack of resources, poor awareness and patient overload. A main theme emerged: ‘Making data on HAIs available for health workers can improve their awareness and motivate them to put their existing knowledge into practice, thus decreasing the know-do gap in infection control’. This could be a feasible intervention to improve infection control practice in the hospitals with limited resources, high workload and patient overload.