Infrastructure and Contamination of the Physical
Environment in Three Bangladeshi Hospitals: Putting
Infection Control into Context
Nadia Ali Rimi1*, Rebeca Sultana1, Stephen P. Luby1,2, Mohammed Saiful Islam1, Main Uddin1,
Mohammad Jahangir Hossain1, Rashid Uz Zaman1, Nazmun Nahar1, Emily S. Gurley1
1Centre for Communicable Diseases, icddr, b, Dhaka, Bangladesh, 2Global Disease Detection Program, Centers for Disease Control and Prevention (CDC), Atlanta,
Georgia, United States of America
Objective: This paper describes the physical structure and environmental contamination in selected hospital wards in three
government hospitals in Bangladesh.
Methods: The qualitative research team conducted 48 hours of observation in six wards from three Bangladeshi tertiary
hospitals in 2007. They recorded environmental contamination with body secretions and excretions and medical waste and
observed ward occupant handwashing and use of personal protective equipment. They recorded number of persons,
number of open doors and windows, and use of fans. They measured the ward area and informally observed waste disposal
outside the wards. They conducted nine focus group discussions with doctors, nurses and support staff.
Results: A median of 3.7 persons were present per 10 m2of floor space in the wards. A median of 4.9 uncovered coughs or
sneezes were recorded per 10 m2per hour per ward. Floors in the wards were soiled with saliva, spit, mucous, vomitus,
feces and blood 125 times in 48 hours. Only two of the 12 patient handwashing stations had running water and none had
soap. No disinfection was observed before or after using medical instruments. Used medical supplies were often discarded
in open containers under the beds. Handwashing with soap was observed in only 32 of 3,373 handwashing opportunities
noted during 48 hours. Mosquitoes and feral cats were commonly observed in the wards.
Conclusions: The physical structure and environment of our study hospitals are conducive to the spread of infection to
people in the wards. Low-cost interventions on hand hygiene and cleaning procedures for rooms and medical equipment
should be developed and evaluated for their practicality and effectiveness.
Citation: Rimi NA, Sultana R, Luby SP, Islam MS, Uddin M, et al. (2014) Infrastructure and Contamination of the Physical Environment in Three Bangladeshi
Hospitals: Putting Infection Control into Context. PLoS ONE 9(2): e89085. doi:10.1371/journal.pone.0089085
Editor: Li Wang, Peking Union Medical College, China
Received June 27, 2013; Accepted January 18, 2014; Published February 19, 2014
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for
any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Funding: This research was funded by the Centers for Disease Control and Prevention (CDC) under the cooperative agreement grant I-U01-C1000298 (website:
http://www.cdc.gov/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: firstname.lastname@example.org
Hospital-acquired infection represents a major public health
concern worldwide. Hospitals have played a significant role in the
spread of emerging infections. In Toronto, 77% of case patients
were exposed to severe acute respiratory syndrome (SARS) in
hospital settings in 2003 . Hospitals in South Asia can be at
particular risk for transmission of emerging infections, specifically
Nipah virus [2–4]. For example, a large outbreak of Nipah virus
was reported among healthcare workers and patients at hospitals
in Siliguri, India in 2001 and evidence of Nipah virus transmission
in Bangladesh has recently been reported . In addition, patients
in Bangladeshi hospitals face substantial risks from endemic
infections; studies have shown that hospital-acquired respiratory
infections occur at an incidence rate of 6.1 cases per 1000 patient-
days , and diarrhea with an incidence rate of 3.9 cases among
pediatric patients and 2.7 cases among adults per 1000 patient-
Pathogens in hospital environments can be transmitted through
airborne particles, fomites, respiratory droplets or direct contact
with bodily fluids [7–9]. International infection control guidelines
exist [7,9], but assume a level of basic infrastructure, which may
not be available in many low-income settings. Understanding the
context of environmental contamination in low-income hospital
settings is essential to inform interventions to control the spread of
hospital-acquired infection. Using data from a larger study that
explored hospital-acquired respiratory illness, this paper describes
the physical structure and contamination of the environment in
three Bangladeshi hospitals.
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The study protocol was approved by the Ethical Review
Committee of the International Centre for Diarrhoeal Disease
Research, Bangladesh (FWA # 00001468, Human Welfare
Assurance # 00001822). The team obtained informed consent
from hospital authorities for data collection and secured written
consent from participants before conducting discussions. They
observed public behavior and individuals were not identified.
Study Site and Data Collection
The main methods of data collection for this exploratory
qualitative study were structured and semi-structured direct
observation. A team of three anthropologists and two sociologists,
trained in qualitative research methods, collected data from March
through September 2007 from one pediatric and one adult male
medicine ward from each of three public tertiary teaching
hospitals. They mapped the wards to describe physical layout
and calculated the floor area. Next, they conducted 48 hours of
observation in 22 sessions: three to four sessions in each ward. To
capture variation in activities at different times of day, sessions
were held during three non-overlapping periods; three hours from
9:00 am–2:30 pm, three hours from 3:30 pm–9:00 pm and one
hour from 10:00 pm–12:30 am. Through structured direct
observation, they recorded number of ward occupants-including
patients, family caregivers, visitors and healthcare workers, use of
fans, and number of open doors and windows at the beginning and
end of each session. They also recorded frequencies of coughing
and sneezing on the wards, use of personal protective equipment
and handwashing. They recorded handwashing opportunities,
defined as events during which ward occupant hands were
contaminated with body secretions or excretions. Handwashing
opportunities included points at which hands should have been
washed before an activity, such as providing patient care  or
after an activity, such as coughing or sneezing into hands .
Through semi-structured direct observation, the team took
detailed field notes while observing the disposal of waste, the
reuse of medical equipment, and the soiling with body secretions
and excretions of surfaces such as floors, walls, bedding, tabletops,
verandas and window grills. They also noted the presence of
animals inside wards and waste disposal outside wards.
To complement observation findings, the team conducted nine
focus group discussions; one with each of the groups of doctors,
nurses and support staff in each hospital. They approached all the
staff working in the study wards and some staff from other wards
and enrolled those who consented to participate in the discussions.
Each discussion included six to 11 participants and lasted for 45 to
80 minutes. The discussions were facilitated at the hospitals by
NAR, RS and MSI and audio recorded.
The team expanded the observation field notes and transcribed
the recorded data verbatim from discussions. NAR and RS
reviewed data from observations to identify emerging themes
relevant to the study objective and summarized the data according
to those themes. They also reviewed focus group discussions to
identify relevant data to further cross-check and complement the
Physical Environment of the Wards
The wards had either an open floor plan or
cubicles with four-foot high walls. The floor areas ranged from 101
to 317 m2(Table 1). Most of the windows in Hospital A could not
be opened, while Hospitals B and C were ventilated with ceiling
fans, windows that could be opened and doors on opposite sides of
the rooms to allow cross-ventilation.
The condition of and accessibility to
sanitation facilities varied for different categories of ward
occupants (Table 1). Senior doctors usually had toilets or
handwashing stations with running water and soap inside their
offices. Only Hospital C had toilets and handwashing stations for
junior doctors. Nurses had separate toilets and handwashing
stations and usually bought their own soap. In Hospital A, toilets
and handwashing stations for doctors were located outside and
away from the wards. In the pediatric ward of Hospital B, there
was only one toilet with a handwashing station shared by nurses
and junior doctors from adult and pediatric wards.
Patients, family caregivers, visitors and support staff all used
patient toilets and handwashing stations. Only two of 12 patient
handwashing stations had running water and the team did not
observe any water stored by the handwashing stations. There was
no soap at any of these stations, though some patients and
caregivers brought their own soap. Patients and family caregivers
used bathroom facilities for bathing, and washing clothes and
utensils. They used urinals only for urinating. Non-functioning
toilets, bathrooms, urinals and handwashing stations were used as
Density on wards.
The hospital wards were crowded with
patients, caregivers, visitors and staff, especially from morning to
afternoon, when doctors made their rounds and patients were
admitted and discharged. An overall median of 3.7 (interquartile
range [IQR]: 2.0–5.3) ward occupants were present per 10 m2of
floor space (Table 2). Wards in Hospitals B and C had an average
of 1.2 times more patients than beds, whereas in Hospital A, the
patient-to-bed ratio was approximately 0.7. When beds were
unavailable, patients were cared for on mattresses or blankets on
the floor near patient beds or on adjacent verandas. Pediatric
wards were more crowded than adult wards (Figure 1). On a few
occasions in the pediatric wards in Hospitals B and C, two or three
patients shared one bed. In Hospital B, newborn babies were kept
in the same ward with older children. Patients with potentially
infectious diseases, such as diarrhea and encephalitis, were
hospitalized in the same ward with newborn babies and patients
Since the hospitals were also teaching facilities, medical students
accompanied senior physicians on their rounds. On one ward, 37
students accompanied two doctors for almost an hour. Students
stood nearby or sat on patient beds. Below is the description of a
pediatric ward from the observation notes.
The ward became crowded, even the verandas were filled
with patients and caregivers. Some of the patients’ mothers
had another healthy child staying in the ward. On the
examination bed and nursing table, doctors and nurses
quickly examined two or three patients at a time, gave
medicines, injections and/or nebulizers, placed and re-
moved canula and drew blood.
Overall, family caregivers were most the numerous on our study
wards in each hospital (Figure 2); a median of 2.1 caregivers per
Hospital Environment Contamination
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10 m2, compared to 1.3 patients and 0.2 healthcare workers.
Although these hospitals had fixed visiting hours, visitors entered
wards at all times. In Hospitals A and C, vendors moved from
ward to ward selling tea, water or snacks or offering haircutting
Open bowls or buckets under patient beds
for disposing waste (used medical supplies, patient body fluids,
discarded food) were emptied into larger drums once daily by the
hospital cleaners. A cleaner stated,
‘‘We have to carry the waste [in a bucket] from the third floor
on our shoulder to dump on the ground (i.e., ground floor
deposited directly on the ground). There is nothing [like a trolley]
to help carry the bucket… Sometimes there are holes in the bucket
and waste drops down on our bodies.’’
The team observed children crawling on the floor and playing
with used syringes with needles. Only Hospital C had separate
cardboard boxes beside the nursing stations to discard used sharps;
it also had a functioning incinerator. Cleaners discarded waste on
open grounds adjacent to the hospital building. City corporation
vehicles removed waste from these grounds once a week. The
team observed young boys and women collecting used syringes
and saline bags from hospital grounds. They reported they
planned to resell them.
Animals and insects.
Feral cats were commonly observed in
all wards, scavenging for food in cabinets and waste bins, climbing
on patient beds and sleeping on patient bedding. The team also
observed mosquitoes in the wards. All patients used mosquito nets
at night in Hospitals A and C, but not in Hospital B.
Contamination of the Environment
Many windows and doors remained fully or partially
closed. Some ceiling fans remained off every day due to electrical
outages. Below is a description of ventilation in a pediatric ward.
All fans remained off, except the one in the nursing station,
and most of the windows remained closed most of the time.
Family caregivers explained that the children had colds,
Table 1. Characteristics of six wards in three hospitals, 2007.
Hospital A Hospital BHospital C
Adult PediatricAdult PediatricAdult Pediatric
Ward area for patients (m2)* 317241 260 101205175
Number of beds3531 30 153033
Mean distance between beds (m)0.8 0.71.10.6 0.80.6
Number of toilets
For doctors and nurses101228
For patients, visitors and support staff414242
Number of functioning toilets
For doctors and nurses101228
For patients, visitors and support staff314242
Number of bathrooms
For patients, visitors and support staff313222
Number of functioning bathrooms
For patients, visitors and support staff203112
Number of urinals
For patients, visitors and support staff222020
Number of functioning urinals
For patients, visitors and support staff222020
Number of handwashing stations
For doctors and nurses101246
For patients, visitors and support staff222220
Number of functioning handwashing stations
For doctors and nurses101246
For patients, visitors and support staff000020
Average number of persons per functioning toilet
Doctors and nurses5–5231
Patients, visitors and support staff17 48252714 63
Average number of persons per functioning handwashing station
Doctors and nurses5–5211
Patients, visitors and support staff––––28–
*Ward area included patient beds and nursing stations.
Hospital Environment Contamination
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fever, breathing difficulty and pneumonia and that airflow
was harmful to patients with such illnesses.
The team observed a total of 6,033 coughs and 75 sneezes in 48
hours of observation; a median of 4.9 (IQR: 4.1–7.4) uncovered
coughs or sneezes per 10 m2per hour per ward. Only 60 coughs
and 20 sneezes were covered; four coughs were covered by a cloth
and the rest by the cougher’s or sneezer’s hands. No persons were
observed to wash hands after coughing or sneezing. Only one
family caregiver used a cloth mask while caring for the patient.
The floors, walls, grills of windows and verandas,
bedrails, nursing tabletops, bedcovers, mattresses and blankets
were soiled with ward occupant body secretions and excretions.
The team observed floors being soiled 125 times in 48 hours. The
following excerpts illustrate the soiling of surfaces.
While setting a blood transfusion bag in a patient’s hand, the
doctor accidentally dripped blood on the bed and floor. No
staff cleaned it during observation hours.
While drawing gastric fluid from a patient’s stomach, fluid
dripped on the bedcover and the stain remained visible two
days later when the bed with the unchanged bedcover was
occupied by another patient.
Cleaners swept the ward floors daily with dry brooms. Although
cleaners in all hospitals reported wet mopping wards two to three
times daily, the team observed daily wet mopping only in Hospital
A and weekly sweeping with water in Hospital B. Cleaners also
reported using disinfectant while mopping if disinfectants were
available. Soiled blankets or mattresses were only shaken to
remove dust after being used by one patient and then provided to
another. No cleaning of window grills, bedrails, cabinets or walls
The floors of the patient toilet areas were wet, slippery and
soiled with body secretions and excretions and food remnants. In
one hour, the team observed seven pediatric patients urinate on
the floor near the entrance of the toilet area at night since there
was no light inside the toilet area.
Doctors and nurses used the same
medical instruments, such as stethoscopes, sphygmomanometers
and clinical hammers, for all patients in the ward without
disinfecting them between patients. Nebulizers were used 14 times
and no disinfectant was observed before or after use. A doctor
‘‘The same oxygen tube is used for almost all the patients. There
is only one oxygen cylinder and one mask in the ward and that
mask is used for every patient.’’
Thermometers, used in the mouth, were partially dipped in
bottles half-filled with disinfectant after each patient use.
A total of 3,373 handwashing opportunities were
noted during 48 hours, and occurred before or after family
caregivers and healthcare workers cared for patients, after ward
occupants blew their noses, coughed, sneezed, or vomited, and
before ward occupants consumed food (Table 3). The most
frequently observed opportunities occurred during patient feeding
and physical examination (Table 3). Handwashing with soap was
observed on only 32 (1% of the 273 observed handwashing events)
occasions. Rinsing fingers with water before and after eating was
common. Caregivers frequently touched patients and use of
disposable gloves was observed only three times. The team
Figure 1. Median people present per 10 m2by type of ward in three hospitals, 2007. Detailed legend: Median number of people
present per 10 m2by type of ward of the three hospitals, 2007.
Table 2. Median number of people present per 10 m2in
three hospitals, 2007.
Time slot of
Median number of people (IQR*)
Hospital A Hospital BHospital C Overall
9:00 am to 2:30 pm2.1 (1.6–2.5) 5.0 (4.4–7.9) 5.8 (4.6–8.9) 4.6 (2.6–8.2)
3:30 pm to 9:00 pm 1.7 (1.2–2.1) 3.6 (2.8–3.9)4.2 (1.8–6.4) 2.4 (1.8–3.9)
10:00 pm to 12:30 am 1.9 (1.3–2.4) 4.1 (3.7–4.4)3.7 (1.6–5.8) 3.1 (1.6–4.4)
Irrespective of time slot 1.9 (1.4–2.4) 4.1 (3.7–4.5)5.2 (2.2, 6.8) 3.7 (2.0–5.3)
*IQR indicates interquartile range.
Hospital Environment Contamination
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Figure 2. Median people present per 10 m2by category of person in three hospitals, 2007. Detailed legend: Median number of people
present per 10 m2by category of person in the three hospitals, 2007.
Table 3. Handwashing opportunities observed in three hospitals, 2007.
During patient care
Before giving food, drinks, or medicine either orally or through a nasogastric tube, before administering
eye or ear drops, or before breastfeeding
Before and after conducting physical examination550
Before and after giving injections, placing or removing canula or IV, drawing blood or other body fluids458
After sponging, wiping, or massaging the body, face or head389
After touching patient to provide support 164
After changing clothes or spreading or arranging bed sheet or oilcloth under patient’s body144
Before and after placing or removing nasogastric tube, oxygen, nebulizer, Ambu bag88
After cleaning sputum, vomit, feces, urine, anus or inserting suppository74
After cleaning waste bin or emptying catheter bag64
After checking temperature or pulse61
Before and after cleaning patient’s mouth, ear, nose or eye 56
Before and after placing urinary catheter46
Before and after dressing or touching wound40
After holding or carrying biological specimens or blood bag22
After blowing nose, coughing, sneezing and vomiting
Blowing nose using hand79
Coughing into hands56
Sneezing into hands20
Vomiting into hands4
Hospital Environment Contamination
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observed only one doctor wearing gloves and a mask during
rounds in Hospital C. They observed a staff member cleaning bins
wearing disposable latex gloves, which he later hung on the
window grill of the toilet to reuse.
Infection Control Policies and Logistics
No staff mentioned knowledge of any policy or written rule on
infection control. All categories of staff reported inadequate
supplies of cleaning and disinfection products, bed sheets, soap and
hand sanitizer. Support staff reported,
‘‘They gave us three Harpics [a brand of toilet cleaning
product] last month. We must use Harpic for professors’
handwashing station daily. There are also doctors’ handwashing
stations and toilets which have to be cleaned. Two of three
Harpics are used for cleaning these toilets. We have to manage
cleaning the five to six patient toilets with the remaining one.’’
There was no autoclave in the wards and nurses reported
disinfecting medical instruments by boiling, which the team also
observed, or immersing in chlorine-water solution for 10 minutes.
A doctor stated,
‘‘An instrument should be boiled for at least 30 minutes. We are
so loaded with patients that nurses are only dipping instruments in
Nurses and support staff reported using antiseptic liquid or
saline to wash hands on some occasions when soap was not
available. Nurses reported using surgical masks while making
patient beds, which the team never observed. Nurses also reported
that they could change bed sheets only every one to two weeks due
to inadequate supply. They mentioned family caregivers some-
times took linens soiled with patient body secretions and excretions
to wash at home because water was often unavailable in the
hospital. Support staff reported using gloves when caring for
patients with infectious diseases like hepatitis B, but the team never
observed this. Staff also reported that supplies could not be
accessed in the evening or at night when the nurse-in-charge was
not on ward duty.
Overcrowding, inadequate sanitary facilities, lack of routine
cleaning, lack of basic infection control measures and improper
waste management combined to create numerous opportunities
for transmission of infection in the study wards. This environment
posed a threat of infection to all ward occupants.
Crowding in hospitals facilitates the spread of many diseases
[12,13]. The observed crowded environment could facilitate
transmission of infectious microorganisms through coughing,
sneezing, talking and contact with materials and surfaces. A study
conducted in a hospital in Singapore reported higher concentra-
tions of airborne bacteria in the most densely occupied locations,
such as the pharmacy and lobby, and an occupant density of 0.5 to
one person per 10 m2ward area  compared to our reported
overall median of 3.7 persons per 10 m2. The uncontrolled flow of
visitors in our study wards may influence prevalence of hospital-
acquired infection, as was noted in a cross-sectional study in
surgical wards in a Bangladeshi tertiary hospital . Sharing beds
may also facilitate disease transmission; a study reported trans-
mission of Nipah encephalitis from a patient to a caregiver while
sharing a bed . A number of diseases, such as SARS, Nipah
virus, tuberculosis, measles, influenza, chickenpox, meningitis,
mumps and aspergillosis can be spread by airborne or droplet
transmission from coughing, sneezing or inadequate ventilation
[7,8,15,16]. Exposure to cold air is commonly perceived to be one
reason behind acute respiratory diseases in Bangladeshi children
, hence the restricted airflow in pediatric wards, which led to
inadequate ventilation. Frequent uncovered coughing and sneez-
ing occurred among people in close physical proximity in the study
wards with suboptimal ventilation, posing a risk to all ward
Hospital surfaces could be potential reservoirs of nosocomial
pathogens that can survive for a few days to several months [8,18].
Contaminated floors, taps, door handles and walls in toilets could
be potential sites for colonization of pathogens and transmission
through hand contact of diseases such as cholera , hepatitis A
, vancomycin-resistant enterococci  and puerperal fever
. The practice of dry sweeping is strongly discouraged in
global infection control recommendations, since it can aerosolize
particles that may contain microorganisms [7,9]. Medical equip-
ment such as nebulizers , stethoscopes  and sphygmoma-
nometers  that have been used on multiple patients without
disinfection can also act as fomites for pathogens such as gram-
negative bacilli, coagulase-negative staphylococci and methicillin-
resistant Staphylococcus aureus (MRSA).
Most hospital infections are acquired via direct contact , and
hand contact is a major route of acquisition . Thus hand
hygiene is considered to be the single most effective measure of
infection control . Lack of functioning and accessible
handwashing stations in study wards is one reason that handwash-
ing with soap was infrequent. In other settings, hand hygiene
compliance improved after providing multiple conveniently
located handwashing stations [27–29]. Given the continuous hand
contamination during patient caregiving, waterless hand sanitizers
could also play a role in hand disinfection in addition to
handwashing with soap, particularly when hands are not soiled
with body secretions and excretions. This alternative is more costly
than soap and water and may be unacceptable to family caregivers
and staff who are unfamiliar with waterless cleaning agents.
However, given the logistical constraints to accessing water on
these wards, the acceptability and feasibility of waterless sanitizers
should be investigated as an alternative.
The presence of animals inside wards poses a threat of
transmission of zoonotic diseases. In a geriatric care center, a cat
was associated with an outbreak of epidemic MRSA .
Evidence of hospitalizations of dengue patients in Bangladesh
, coupled with an abundance of mosquitoes in wards, creates
an opportunity for nosocomial spread of dengue, a major public
health concern in Bangladesh .
Improper handling and unsafe disposal of hospital waste is a
public health concern globally  and in Bangladesh .
Particular risks include cleaning, packaging and reusing contam-
inated medical equipment. Disposing of used sharps in open
buckets and on open grounds at these hospitals could increase the
potential for transmitting HIV , hepatitis B  and hepatitis
C  to both healthcare workers who handle waste and the
general public who scavenge in open dumpsites.
This study was conducted in only three public tertiary hospitals
that were not randomly chosen; therefore the findings cannot be
generalized to other government tertiary hospitals, private clinics
or other non-government hospitals in Bangladesh. However, our
findings are consistent with other studies in Bangladeshi tertiary
hospitals that have reported crowding in wards , improper
waste disposal  and poor hygiene and sanitation facilities .
There are many hospitals in other low-income countries with
similar environments [39–41], particularly within South Asia .
Since each researcher was assigned to observe and take notes on
the activities of multiple persons, we assume that some events
could have been missed and the frequency of events reported here
could be underestimated.
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Public hospitals play a crucial role in ensuring healthcare
services for the poor in Bangladesh . Bangladesh has 17 public
tertiary hospitals and a population of 150.5 million, 31% of whom
are below the poverty line . Our findings indicate the physical
structure and environment of the three public hospitals are
conducive to spreading infections to all ward occupants. With
evidence of diseases like Nipah virus, avian influenza and H1N1 in
this country, this environment creates a regional and global risk for
wider transmission of emerging infections. Unlike hospitals in
high-income settings, hospitals in low-income settings cannot
follow many international infection control recommendations due
to resource constraints. Furthermore, it is possible that manage-
ment that extracts unofficial fees in exchange for services,
commodities and access may have a vested interest to maintain
such poor conditions in some of these public facilities .
Interventions focused solely on education or training are unlikely
to improve infection control in these hospitals; interventions
should also aim to improve infrastructure and to establish
administrative initiatives, such as developing and implementing
infection control guidelines, monitoring of routine cleaning and
providing incentives for infection control activities among
healthcare staff. Low-cost interventions on hand hygiene and
cleaning procedures for rooms and medical equipment should be
developed and evaluated for their practicality and effectiveness.
icddr, b acknowledges the commitment of the Government of the People’s
Republic of Bangladesh (GoB) to our research efforts with gratitude. We
acknowledge, with gratitude, the cooperation of the hospital faculty,
administrators and collaborators for their support of the study. We are
indebted to the study participants for their valuable time and information.
We thank Dorothy Southern and Meghan Scott for their support in
reviewing and editing this manuscript and Md. Jaynal Abedin for his
contribution in the calculation of the quantitative data.
Conceived and designed the experiments: RS SPL NN ESG. Performed
the experiments: NAR RS MSI MU. Analyzed the data: NAR RS. Wrote
the paper: NAR RS SPL MSI MU MJH RUZ NN ESG.
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