Surgical Site Infection Rates following Cesarean Section in Sub-Saharan Africa: A Focus Point for Guideline-Based Intervention Joseph S. Solomkin, M.D. Professor of Surgery (Emeritus) University of Cincinnati College of Medicine for

OASIS Global A non-profit started to support development of a WHO guideline to prevent surgical infections Now working to implement guidelines in low and middle income countries We have developed an important tool for measuring infection rates in low and middle income countries

The Problem: Complications of surgical care have become a major cause of death and disability worldwide and a public health threat The annual volume of major surgery globally was an estimated 187 million–281 million operations, or approximately one operation annually for every 25 human beings alive Of these, 3% (7,000,000 people) suffered a serious adverse event and 200,000 die Weiser TG, Regenbogen SE, Thompson KD, et al An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372(9633):139-44

Problems are in Low and Middle Income Countries

Dollars Spent on Health Care vs. Procedures/100,000 An estimation of the global volume of surgery: a modelling strategy based on available data Weiser TG, Regenbogen SE, Thompson KD, et al Lancet. 2008;372(9633):139-44

Effect of Economic Status on Surgical Volume ExpenditureEstimated surgical rate per 100,000 Estimated volume of surgery in millions Share of global population Poor-expenditure countries (N=47) % Low-expenditure countries % Middle- expenditure countries % High-expenditure countries %

J Hosp Infect.J Hosp Infect Apr;68(4): Epub 2008 Mar 10.

SSI Prevention Guidelines – WHO Perspectives  Lessons learned from the WHO Hand Hygiene guidelines: need for global approach  Lessons learned from checklists and other programs  Valid for any country, but including specific issues relating to regional differences and/or peculiar to low-/middle-income countries  Strong component on implementation strategies and tools

Surgical Procedures Performed in Low Income Countries Most procedures are emergencies – Caesarean sections – Trauma – Appendicitis – Strangled hernia Risk factors in this younger population are greatly different: – HIV, other chronic infections – Malnutrition – Malaria

Number of Operating Rooms/Hospital COSECSA Poll * * : 56 Respondents

Common Surgical Procedures in Kenya

Indications for C/section in a Systematic Review of Surgical Site Infection Following Cesarean Section in sub-Saharan Africa ROM Repeat CS CPD Fetal Distress Hemorrhage Breech Preeclampsia/ HTN

Perinatal Deaths SSI (CDC Criteria) Wound Infection Endometritis Other (Sepsis, Fever, Etc.) Results of a Systematic Review of Surgical Site Infection Following Cesarean Section in sub-Saharan Africa

The Lucina Project: Prevalence Survey of C/section SSI in Kenya Kenya selected because of outstanding and interested physician and nursing partners and progressive economic improvement Done in partnership with Kenyatta University School of Medicine through the Department of Ob/Gyn First patient in 15 May 2015 Planned for six month study at three district level government hospitals

Goals of the Project Validate a standardized protocol and data collection tool that can be used widely for multiple purposes – Evaluate microbiology of SSI – Create a validated risk adjustment model – Pre/Post or Cluster-Randomized Evaluation of WHO SSIP Guideline (implementation tools) – Evaluation platform for innovative approaches to reducing burden of infection