- Email: [email protected]
Clostridium difficile, ethnicity and religion
Journal of Hospital Infection (2008) 68, 90e99
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
LETTERS TO THE EDITOR Clostridium difficile, ethnicity and religion
Madam, Historically, hand-washing initiatives have focused on healthcare workers, but more recently interest has turned to patient hand-washing behaviours. We were interested to observe if religious hygiene practices such as ‘wudu’ made a difference. Wudu is a religious observance of Muslims who wash their hands under running water in a ritualised manner, after such activities as defaecation, urinating, sleeping and before prayer. We wondered whether practising Muslims performing wudu had superior hand hygiene, and therefore lower rates of infections transferred through contact or the faecaleoral route. A quick perusal of names of inpatients diagnosed with Clostridium difficile-associated diarrhoea (CDAD) at University Hospitals of Leicester showed a marked absence of Muslim and Asian names. This was surprising as in 2001 at least 30% of Leicester’s population were of Asian origin and 11% gave their religion as Muslim.1 Although this is a relatively young segment of the population because of recent migration, we would have expected a greater representation among hospital inpatients from these groups. This initial observation led us to investigate the phenomenon further. We considered two hypotheses to explain the low level of CDAD among Muslim and Asian patients. These related to religion and ethnicity. Our first hypothesis was that Muslim patients practising wudu had superior hand hygiene which prevented the transmission of C. difficile and led to fewer C. difficile infections. Our second hypothesis was that ethnic factors, namely lifestyle and genetics, were responsible. For example, perhaps certain food spices were providing gastrointestinal protection, or a culture of caring for relatives at home rather than in nursing homes meant that elderly Asians were less likely to have CDAD than their White contemporaries. Another suggestion was that genetics caused Asians to have a different gut colonisation.
The possibility of a relationship between CDAD and ethnicity was not considered to be unreasonable as there are several infections which appear to be affected by ethnicity. For example: e Pneumococcal infections have been found to be more common in Alaskan natives than non-natives.2 e Human immunodeficiency virus seroconversion rates were higher in African-American intravenous drug users than white intravenous drug users.3 e White females were more susceptible to rubella than black females.4 e Community-acquired meticillin-resistant Staphylococcus aureus infections were more likely to affect Aboriginals than non-Aboriginals.5 e In Israel, catheter-acquired bacteriuria was more prevalent among Arabs than Jews.6 After approaching the Local Research Ethics Committee we acquired the following patient data from the Hospital Information Support System: unique identifier, date of admission, date of discharge, CDAD status, age, diagnosis, ethnic group (self-identified) and religion. We included all hospital inpatients retrospectively from 1 July 2005 to 31 August 2006. This gave us 208 604 patients, 2476 of whom were diagnosed with CDAD during their stay. In the analysis, Asian patients were found to have a significantly lower incidence of CDAD compared with white patients, and Hindu, Sikh and Muslim patients had significantly lower incidences of CDAD compared with Christian patients (Chisquared test: P < 0.001). This seemed to confirm the possibility of a relationship between ethnicity and religion. However, when age was included in the analysis as an independent variable the previously apparent statistical association disappeared. It transpired that the majority (79%) of CDAD cases were inpatients aged >65 years. Although Asian patients make up 13% of the hospital’s patients, only 7% of patients aged >65 years are Asian. The hospital’s Asian population (mean: 40.2; SD: 22.7) is significantly younger (Student’s
Letters to the Editor t-test for independent samples: P < 0.001) than the hospital’s White population (mean: 52.2; SD: 24.0). This study confirms age as a risk factor for CDAD and appears to rule out a direct link between CDAD and membership of a minority ethnic group or religion. It also identifies the need for thorough statistical analysis. Conflict of interest statement None declared. Funding sources None.
References 1. Office for National Statistics. Census 2001: National Report for England and Wales. London: Office for National Statistics; 2003. 2. Davidson MAJ, Parkinson AJ, Bulkow LR, Fitzgerald MA, Peters HV, Parks DJ. The epidemiology of invasive pneumococcal disease in Alaska. J Infect Dis 1994;170:368e376. 3. Moss AR, Vranizan K, Gorter R, Bacchetti P, Watters J, Osmond D. HIV seroconversion in intravenous drug users in San Francisco, 1985e1990. AIDS 1994;8:223e231. 4. Kotzen II, Mets JT. Rubella sensitivity in young womendan occupational hazard in hospitals. S Afr Med J 1988;74: 62e65. 5. Maguire GP, Arthur AD, Bousted PJ, Dwyer B, Currie BJ. Emerging epidemic of community-acquired methicillinresistant Staphylococcus aureus infection in the Northern Territory. Med J Aust 1996;164:721e723. 6. Shapiro M, Simchen E, Izraeli S, Sacks TG. A multivariate analysis of risk factors for acquiring bacteriuria in patients with indwelling urinary catheters for longer than 24 hours. Infect Control 1984;5:525e532.
J. Tannera,b,* D. Anthonya M. Johnsona D. Khana C. Trevithickb a De Montfort University, Leicester, UK b University Hospitals Leicester, Leicester, UK E-mail address: [email protected] Available online 17 December 2007 * Corresponding author. Address: Faculty of Health and Life Sciences De Montfort University, Hawthorn Building, The Gateway Leicester, LE1 9BH UK. Tel.: þ44 (0)116 201 3885; fax þ44 (0)116 201 3821. ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2007.10.019
91 Nasal carriage of meticillin-resistant Staphylococcus aureus in medical students
Madam, Meticillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen in hospitals and long-term care facilities.1 In hospitals, the areas of highest risk are intensive care units (ICUs), operating theatres and cancer chemotherapy wards. MRSA is generally introduced by a colonised or infected patient or healthcare worker. Medical students come into contact not only with patients but also with different people in the community. Recent evidence suggests that some MRSA infections may be community acquired. A study was conducted to ascertain the nasal carriage of MRSA among medical students in Kasturba Medical College, Mangalore. Fifty medical students were randomly selected and screened for colonisation with MRSA in anterior nares. Students posted in surgical wards, medical wards, ICU, postoperative wards and the microbiology laboratory were selected for the study. The study was approved by the institutional ethics committee. Written informed consent was obtained from all those who enrolled for the study. Nasal swabs were obtained from anterior nares of students included in the study. Swabs were cultured on mannitol salt agar. Staphylococcus aureus was identified by the coagulase test. Oxacillin screen test (MuellereHinton agar with 6 mg/mL oxacillin plus 4% NaCl) was used to detect MRSA.2 Twenty-four undergraduates and 26 postgraduates were included in the study. All 26 postgraduates (100%) and 18 undergraduates (75%) were colonised with S. aureus. Of these, only one undergraduate (4.16%) and 11 postgraduates (42.3%) were colonised with MRSA (Table I). The one undergraduate colonised with MRSA was posted to the surgical unit. Among the postgraduates, all surgical postgraduates were colonised with MRSA. Fifty percent of medical postgraduates and 33.33% of postgraduates posted to ICU were colonised with MRSA. No postgraduate posted to microbiology was colonised with MRSA though all were colonised by S. aureus. It was observed that the rate of colonisation of both postgraduates and undergraduates with Staphylococcus aureus was high, 100% and 75% respectively. However, the rate of colonisation of postgraduates with MRSA was much higher than that of undergraduates, 42.3% and 4.16% respectively. The higher carriage among postgraduates
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
LETTERS TO THE EDITOR Clostridium difficile, ethnicity and religion
Madam, Historically, hand-washing initiatives have focused on healthcare workers, but more recently interest has turned to patient hand-washing behaviours. We were interested to observe if religious hygiene practices such as ‘wudu’ made a difference. Wudu is a religious observance of Muslims who wash their hands under running water in a ritualised manner, after such activities as defaecation, urinating, sleeping and before prayer. We wondered whether practising Muslims performing wudu had superior hand hygiene, and therefore lower rates of infections transferred through contact or the faecaleoral route. A quick perusal of names of inpatients diagnosed with Clostridium difficile-associated diarrhoea (CDAD) at University Hospitals of Leicester showed a marked absence of Muslim and Asian names. This was surprising as in 2001 at least 30% of Leicester’s population were of Asian origin and 11% gave their religion as Muslim.1 Although this is a relatively young segment of the population because of recent migration, we would have expected a greater representation among hospital inpatients from these groups. This initial observation led us to investigate the phenomenon further. We considered two hypotheses to explain the low level of CDAD among Muslim and Asian patients. These related to religion and ethnicity. Our first hypothesis was that Muslim patients practising wudu had superior hand hygiene which prevented the transmission of C. difficile and led to fewer C. difficile infections. Our second hypothesis was that ethnic factors, namely lifestyle and genetics, were responsible. For example, perhaps certain food spices were providing gastrointestinal protection, or a culture of caring for relatives at home rather than in nursing homes meant that elderly Asians were less likely to have CDAD than their White contemporaries. Another suggestion was that genetics caused Asians to have a different gut colonisation.
The possibility of a relationship between CDAD and ethnicity was not considered to be unreasonable as there are several infections which appear to be affected by ethnicity. For example: e Pneumococcal infections have been found to be more common in Alaskan natives than non-natives.2 e Human immunodeficiency virus seroconversion rates were higher in African-American intravenous drug users than white intravenous drug users.3 e White females were more susceptible to rubella than black females.4 e Community-acquired meticillin-resistant Staphylococcus aureus infections were more likely to affect Aboriginals than non-Aboriginals.5 e In Israel, catheter-acquired bacteriuria was more prevalent among Arabs than Jews.6 After approaching the Local Research Ethics Committee we acquired the following patient data from the Hospital Information Support System: unique identifier, date of admission, date of discharge, CDAD status, age, diagnosis, ethnic group (self-identified) and religion. We included all hospital inpatients retrospectively from 1 July 2005 to 31 August 2006. This gave us 208 604 patients, 2476 of whom were diagnosed with CDAD during their stay. In the analysis, Asian patients were found to have a significantly lower incidence of CDAD compared with white patients, and Hindu, Sikh and Muslim patients had significantly lower incidences of CDAD compared with Christian patients (Chisquared test: P < 0.001). This seemed to confirm the possibility of a relationship between ethnicity and religion. However, when age was included in the analysis as an independent variable the previously apparent statistical association disappeared. It transpired that the majority (79%) of CDAD cases were inpatients aged >65 years. Although Asian patients make up 13% of the hospital’s patients, only 7% of patients aged >65 years are Asian. The hospital’s Asian population (mean: 40.2; SD: 22.7) is significantly younger (Student’s
Letters to the Editor t-test for independent samples: P < 0.001) than the hospital’s White population (mean: 52.2; SD: 24.0). This study confirms age as a risk factor for CDAD and appears to rule out a direct link between CDAD and membership of a minority ethnic group or religion. It also identifies the need for thorough statistical analysis. Conflict of interest statement None declared. Funding sources None.
References 1. Office for National Statistics. Census 2001: National Report for England and Wales. London: Office for National Statistics; 2003. 2. Davidson MAJ, Parkinson AJ, Bulkow LR, Fitzgerald MA, Peters HV, Parks DJ. The epidemiology of invasive pneumococcal disease in Alaska. J Infect Dis 1994;170:368e376. 3. Moss AR, Vranizan K, Gorter R, Bacchetti P, Watters J, Osmond D. HIV seroconversion in intravenous drug users in San Francisco, 1985e1990. AIDS 1994;8:223e231. 4. Kotzen II, Mets JT. Rubella sensitivity in young womendan occupational hazard in hospitals. S Afr Med J 1988;74: 62e65. 5. Maguire GP, Arthur AD, Bousted PJ, Dwyer B, Currie BJ. Emerging epidemic of community-acquired methicillinresistant Staphylococcus aureus infection in the Northern Territory. Med J Aust 1996;164:721e723. 6. Shapiro M, Simchen E, Izraeli S, Sacks TG. A multivariate analysis of risk factors for acquiring bacteriuria in patients with indwelling urinary catheters for longer than 24 hours. Infect Control 1984;5:525e532.
J. Tannera,b,* D. Anthonya M. Johnsona D. Khana C. Trevithickb a De Montfort University, Leicester, UK b University Hospitals Leicester, Leicester, UK E-mail address: [email protected] Available online 17 December 2007 * Corresponding author. Address: Faculty of Health and Life Sciences De Montfort University, Hawthorn Building, The Gateway Leicester, LE1 9BH UK. Tel.: þ44 (0)116 201 3885; fax þ44 (0)116 201 3821. ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2007.10.019
91 Nasal carriage of meticillin-resistant Staphylococcus aureus in medical students
Madam, Meticillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen in hospitals and long-term care facilities.1 In hospitals, the areas of highest risk are intensive care units (ICUs), operating theatres and cancer chemotherapy wards. MRSA is generally introduced by a colonised or infected patient or healthcare worker. Medical students come into contact not only with patients but also with different people in the community. Recent evidence suggests that some MRSA infections may be community acquired. A study was conducted to ascertain the nasal carriage of MRSA among medical students in Kasturba Medical College, Mangalore. Fifty medical students were randomly selected and screened for colonisation with MRSA in anterior nares. Students posted in surgical wards, medical wards, ICU, postoperative wards and the microbiology laboratory were selected for the study. The study was approved by the institutional ethics committee. Written informed consent was obtained from all those who enrolled for the study. Nasal swabs were obtained from anterior nares of students included in the study. Swabs were cultured on mannitol salt agar. Staphylococcus aureus was identified by the coagulase test. Oxacillin screen test (MuellereHinton agar with 6 mg/mL oxacillin plus 4% NaCl) was used to detect MRSA.2 Twenty-four undergraduates and 26 postgraduates were included in the study. All 26 postgraduates (100%) and 18 undergraduates (75%) were colonised with S. aureus. Of these, only one undergraduate (4.16%) and 11 postgraduates (42.3%) were colonised with MRSA (Table I). The one undergraduate colonised with MRSA was posted to the surgical unit. Among the postgraduates, all surgical postgraduates were colonised with MRSA. Fifty percent of medical postgraduates and 33.33% of postgraduates posted to ICU were colonised with MRSA. No postgraduate posted to microbiology was colonised with MRSA though all were colonised by S. aureus. It was observed that the rate of colonisation of both postgraduates and undergraduates with Staphylococcus aureus was high, 100% and 75% respectively. However, the rate of colonisation of postgraduates with MRSA was much higher than that of undergraduates, 42.3% and 4.16% respectively. The higher carriage among postgraduates