Global Programs to prevent post- surgical infections in LMICs: Meet Dr. Maia Nofal

The right to access safe, equitable surgical care is unfortunately out of reach for millions of people around the world. Lifebox, a nonprofit focused on improving surgery and anesthesia globally, has been working to tackle these inequities. Lifebox has implemented numerous projects, including the distribution of low-cost pulse oximetry devices and a program to improve surgical infection prevention, among others.

We met with Dr. Maia Nofal, a General Surgery resident at Boston Medical Center who is currently completing a Fogarty Fellowship through the Center for Innovation in Global Health at Stanford while working with Stanford Surgery’s Global Engagement group under the mentorship of Dr. Tom Weiser. Dr Nofal was recently awarded a Seed Grant through CIGH for her study “Antibiotic Timeout” to reduce unnecessary perioperative antibiotic use in Ethiopia, Malawi, and Rwanda: a prospective quality improvement. Dr. Nofal is also part of the team implementing the Clean Cut program in Ethiopia.

Q: Maia, congratulations on winning the Department’s Seed Grant Award. When did your passion for global surgery first begin?

I was first introduced to Lifebox and the Clean Cut program when I was a medical student, when I went to Ethiopia in February and March of 2020. I worked on the clean cut program sustainability program with Dr. Nichole Starr who was a fellow there, at that time.

I worked closely with Dr. Starr and got involved in the program together with our Ethiopian colleagues. When I returned to the US, and I continued working on the program remotely. I truly valued the work that Lifebox was doing and started to become more and more focused on the Clean Cut program and its potential impact. I decided that this is what I want to do during my professional development time, and I aim to build off the work that Dr. Nicole and her colleagues started.

Q: Can you give us examples in which Lifebox recruited fellows from other countries to work side by side with their local colleagues on execute their programs in low- and middle-income countries (LMIC)s?

The first American fellow who implemented Clean-Cut in Ethiopia was Dr. Jared Forrester in 2020, who worked in partnership with Ethiopian clinicians, like Dr. Tihitena Negussie Mammo, who is now the global clinical director at Lifebox. He then handed it over to Dr. Nicole Starr.  During that time, the Ethiopian team also grew, with a number of Ethiopian fellows as well as program leadership who became experts at implementing the Clean Cut program throughout Ethiopia. That group eventually took the program globally. Today we have fellows working in Liberia, Madagascar, Ivory Coast, and Malawi, all of whom are from those countries. It is a team effort, and each side brings a unique set of skills to the work. Local healthcare professionals at partner hospitals have the best understanding of their country’s healthcare system: they know the day-to-day challenges and can provide creative solutions. But they receive the support of an experienced global Clean Cut team that has lots of experience implementing and evaluating the program, and that’s where our role becomes essential.

Q: What’s your regular routine in Ethiopia, and what did you learn from the Ethiopian culture?

There’s a Lifebox office in Addis Ababa. I go to the office several times a week to attend meetings and connect with the team. I also visit hospital partner sites a couple times a week to meet with hospital staff, some of whom are Lifebox affiliated. We visit the ORs or the wards and see how our program implementation is going. I also try to spend a day in the OR once a week to better understand the system. They deliver all kinds of surgeries working around supply shortages or infrastructure needs. I am amazed to see how much the surgeons can accomplish with limited resources. It certainly reflects how skilled and dedicated they are.

I am taking lessons to learn Amharic and that makes a huge difference in connecting with locals. Although I won’t be speaking Amharic fluently, I think my colleagues appreciate that I’m making the effort to learn their language.

Q: Can you tell us about the Clean Cut program?

Surgical site infections are a common and devastating complication of surgery. In low- and middle-income countries, surgical patients are twice as likely to suffer from an infection than patients undergoing surgery in the United States. A surgical site infection is an infection that occurs in the part of the body where surgery took place and can lead to serious complications and death. The Lifebox Clean Cut program reduces infection by strengthening adherence to six key infection prevention practices: appropriate skin preparation, antibiotic administration, sterile field maintenance, instrument sterility, gauze counting, and the use of surgical safety checklist.  Partner hospitals complete a process mapping exercise to identify gaps in infection prevention processes. Then they hold regular sessions to brainstorm solutions to achieve adherence with each one of these six practices. Lifebox also delivers educational sessions to multidisciplinary staff at each hospital.

Clean Cut has demonstrated a 35% infection reduction in all surgical patients – with results published in the British Journal of Surgery. Data showing the lasting impact of Clean Cut were recently published in The Journal of the American Medical Association (JAMA) Surgery. In that study, hospitals were able to maintain compliance with all six program infection prevention standards above their levels prior to the initiation of the program, and in some cases continued to improve, demonstrating the program’s impact and sustainability. Most importantly, for scalability across low- and middle-income countries, Clean Cut requires no major investments in new infrastructure or resources.

Some of these things we take for granted in the US, but these practices are not necessarily easy or obvious in LMIC countries. For example, you wouldn’t worry that instruments are not sterilized before surgery in the US, but in resource-constrained settings you can’t always guarantee that. There should be a process in place that can ensure the autoclave is functioning, for example, which is needed to make sure equipment is sterile in the OR. Such processes directly contribute to reducing surgery related infections.

Q: Do you think that these measures might better be enforced through government policies?

Policies might be helpful, but policy isn’t always carried out exactly how you want it to be. For example, in many countries a surgical safety checklist is mandatory, but we work in those countries and see that it’s sometimes carried out more like checking a box and rather than really engaging with the checklist as intended. Policies promoting these practices could be helpful but not necessarily sufficient—unless they are associated with a concrete foundation of understanding on how to implement these practice changes.

Q: Can you tell us more about the specific study you are focusing on right now?

We learned from Clean Cut data that a large number of patients get antibiotics after surgery as an “infection prevention” measure, but according to the WHO guidelines, giving antibiotics after surgery does not prevent infections and can contributes to antibiotic resistance, which disproportionately affects countries in Sub-Saharan Africa.

In LMIC countries like Ethiopia, healthcare providers are aware that the sterility practices are poor and compensate for that by prescribing antibiotics after surgery. Also, the data that support these WHO recommendations mostly come from high income countries, so they are rightfully a little bit skeptical about how it applies in their setting.

We did two things to address these doubts: first we did a study using our Clean Cut data on the risk of infection after surgery in patients who got antibiotics for more than 24 hours and those that didn’t, and we didn’t find any difference. That is consistent with the data derived from other countries that might have stronger sterility practices and lower infection rates.

This study gave us confidence that surgeons working in these environments should not give long courses of antibiotics after surgery because it doesn’t prevent infections, it’s costly, and it worsens antibiotic resistance. We are now trying to translate our findings into practice. We are running a pilot program in one of the sites in Ethiopia to address some of the barriers to reducing unnecessary antibiotics after surgery.

Q: What are other challenges you confronted while you were advocating for that new approach? How are you addressing those challenges?

One challenge is that the guidelines, including the national guidelines in Ethiopia, don’t account for the challenges in that context. For example, sometimes these guidelines recommend antibiotics that are not available in the country, and they don’t really address some of the main barriers, like the differences in infection rates after surgery. Most hospitals don’t have local antibiotic stewardship systems or know their resistance patterns. We are trying address questions around resistance patterns by improving processes for culture collection, so they can understand their resistance patterns which can help inform treatment choices. We are trying to improve engagement from pharmacists and microbiologists to improve evidence-based prescribing and help them make decisions around de-escalating antibiotics earlier.

Q: How would you conclude this effort in a few words?

This pilot is only one of the six pillars of preventing post-surgery infections that we mentioned earlier, but if we are able to make progress on better antibiotic stewardship practices it could work synergistically with other infection prevention programs such as Clean Cut, which would be a further step in the right direction.