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The COVID-19 pandemic has profoundly disrupted the provision of health services across the globe. Travel to hospitals is restricted and many health facilities have limited services, deepening financial problems for some clinics and hospitals.1 Vulnerable groups who are already marginalised by their gender, race or nationality have been disproportionately affected by COVID-19.2 In response, social innovations have been developed to protect vulnerable groups and rapidly pivot health systems towards COVID-19. Social innovations in health are inclusive solutions that meet the needs of end users through a multistakeholder, community-engaged process to address the healthcare delivery gap.3 Social innovation is particularly well suited for the COVID-19 response because it focuses on local needs, develops low-cost solutions and builds on community strengths (figure 1). In partnership with partner academic institutions, the Special Programme for Research and Training in Tropical Diseases launched the Social Innovation in Health Initiative (SIHI) in 2014. SIHI focuses on research, training and advocacy related to social innovation in health. In collaboration with partners, the network organised an online open event to discuss social innovation responses to emergencies.4 This piece highlights how social innovation has contributed to the COVID-19 response and presents three examples of social innovation projects that have adapted to the pandemic. These examples demonstrate how social innovation during COVID-19 has mobilised local communities, swiftly adapted existing health services and built strong partnerships. Figure 1 Characteristics of social innovation that have facilitated its use during the COVID-19 pandemic. COVID-19 responses suggest the importance of local community mobilisation and the flexibility of projects that may already be operating in the field to improve other health outcomes. Mamas Del Rio is a community-based maternal and neonatal …

BackgroundMany low-and middle-income country (LMIC) researchers have disadvantages when applying for research grants. Crowdfunding may help LMIC researchers to fund their research. Crowdfunding organizes large groups of people to make small contributions to support a research study. This manuscript synthesizes global qualitative evidence and describes a TDR crowdfunding pilot for LMIC-based researchers.MethodsOur global systematic review and qualitative evidence synthesis searched six databases for qualitative data. We used a thematic synthesis approach and assessed our findings using the GRADE-CERQual approach. Building on the review findings, we organized a crowdfunding pilot to support LMIC researchers and use crowdfunding. The pilot provided an opportunity to assess the feasibility of crowdfunding for infectious diseases of poverty research in resource-constrained settings.ResultsNine studies were included in the qualitative evidence synthesis and we identified seven themes. Seven studies demonstrated that strong public engagement facilitated crowdfunding for research. Other themes included the correlates of crowdfunding success, risks of crowdfunding, and risk mitigation strategies. Our pilot data suggest that crowdfunding is feasible in diverse LMIC settings. Three researchers launched crowdfunding campaigns, met their goals and received substantial monetary (raising a total of $26,546 across all five campaigns) and non-monetary contributions. Two researchers are still preparing for campaign launch due to COVID-19 related difficulties.ConclusionPublic engagement provides a foundation for effective crowdfunding for health research. Our evidence synthesis and pilot data provide practical strategies for LMIC researchers to engage the public and use crowdfunding. A practical guide was created alongside to facilitate these activities across multiple settings.What is already known?Crowdfunding has been used to fund health causes, technology start-ups, creative projects, and more recently, scientific research. Although crowdfunding has been used for research funding in high-income settings, there is less evidence from LMIC settings. In addition, previous reviews of crowdfunding have not focused on public engagement strategies that may be important for developing effective crowdfunding campaigns.What are the new findings?-Our qualitative evidence synthesis finds that crowdfunding research focuses on creators and backers in high-income settings, neglecting LMIC researchers.-The TDR pilot programme suggests that crowdfunding is feasible for LMIC researchers. Three of the five pilot finalists exceeded their crowdfunding goals and received substantial non-monetary contributions.

Objectives. The authors considered the community-based on-site water sampling-surveys case-study in Angono, Rizal, in the Republic of the Philippines. The study was designed to determine whether individual citizens within the community could successfully collaborate in order to develop a method for quantification of E. coli levels in water (especially underground water) for domestic use. Methods. We used techniques that had been validated in Japan for on-site evaluation of E. coli. These simple techniques enabled the on-site quantification of E. coli levels in multiple water sources, including underground water. Results. The techniques used in Japan were successfully adopted in the Philippines, and we cooperated with regional medical technicians, scientists, and citizens, in order to develop a system where ultimately, the people in Angono can perform all the tasks related to on-site water quality evaluation. From societal and economic perspectives, we were able to reduce the traditionally high laboratory cost (including testing cost and samples transit cost) of coliform bacteria and E. coli evaluation to a lower, fixed cost level that is affordable for regional health centers and other sites. Conclusion. The transfer of a simple inspection method technology, under the supervision of an experienced Japanese research team, allowed us to validate the E. coli on-site quantification strategy at a regional level as ”cocreation of science and society”. In addition, beyond technology transfer, our collaborative efforts with scientists, regional medical engineers, and citizens, led to the creation of an NGO (non-governmental organization) that serves citizens in the town of Angono with regard to water quality assessment and certification activities.

Setting The 3rd national tuberculosis (TB) survey in the Philippines in 2007 reported a significant decline in the prevalence of TB. Since then, more significant investments for TB control have been made, yet TB burden estimates from routine surveillance data remain relatively stable. Objective To estimate the prevalence of bacteriologically confirmed pulmonary TB in the Philippines amongst individuals aged ≥15 years in 2016. Design In March–December 2016, we conducted a population-based survey with stratified, multi-stage cluster sampling of residents in 106 clusters aged ≥15 years. Survey participants were screened for TB by symptom-based interview and digital chest X-ray. Those with cough ≥2 weeks and/or haemoptysis and/or chest X-ray suggestive of TB were requested to submit 2 sputum specimens for Xpert MTB/RIF, direct sputum smear microscopy using LED fluorescent microscopy, and mycobacterial solid culture (Ogawa method). Bacteriologically confirmed pulmonary TB was defined as MTB culture positive and/or Xpert positive. Results There were 46,689 individuals interviewed, and 41,444 (88.8%) consented to a chest X-ray. There were 18,597 (39.8%) eligible for sputum examination and 16,242 (87.3%) submitted at least one specimen. Out of 16,058 sputum-eligible participants, 183 (1.1%) were smear-positive. There were 466 bacteriologically confirmed TB cases: 238 (51.1%) Xpert positive, 69 (14.8%) culture positive, and 159 (34.1%) positive by both Xpert and culture. The estimated TB prevalence per 100,000 population aged ≥15 years was 434 (95% CI: 350−518) for smear-positive TB, and 1,159 (95% CI: 1,016−1,301) for bacteriologically confirmed TB. Conclusion This nationally representative survey found that the TB burden in the Philippines in 2016 was higher than estimated from routine TB surveillance data. There was no evidence of a decline in smear and culture positive TB from the 2007 survey despite significant investments in TB control. New strategies for case-finding and patient-centered care must be intensified and expanded.

Background and Introduction. The RxBox is a telemedicine device that measures and transmits vital signs to remote experts. It has been deployed to primary care health centers (PCHC) in the Philippines serving disadvantaged populations, to decrease morbidity and mortality due to common diseases and poor access to care. Factors affecting its adoption by healthcare workers is unknown. Materials and Methods. The study determined social and behavioral factors that affect adoption of a telemedicine device into the clinical workflow using the Unified Theory of Acceptance and Use of Technology (UTAUT) framework. This is a mixed methods research using review of records, survey and focused group discussions. Results and Discussion. RxBox telemedicine devices were installed in 79 primary care health centers (PCHC) and were used a total of 15,705 times within the study period. An ordinary least squares regression analysis using the combined site and individual-level data showed that among the UTAUT parameters, only compatibility, facilitating conditions, and social factors have significant relationships with intent-to-use of the RxBox. The innovation assisted primary care health workers in their clinical responsibilities, improved the stature of their PCHC in the community, and helped in the care for patients. Training and technology support after deployment as well as encouragement by peer and champions (the PCHC physician, local government leaders) reinforced continuous use after training. Users described the experienced improvements in quality of services provided by the PCHC and the consequent benefits to their patients. Conclusions. These factors should be accounted for in designing strategies to reinforce health workers' attitudes and enhance support towards acceptance and use of novel telemedicine devices into clinical routine in local health centers. Lessons are immediately useful for local leaders in low- and lower middle-income countries that suffer disproportionately from unnecessary maternal deaths and mortality due to non-communicable diseases. This contributes to the body of knowledge and should bolster national-level advocacy to institute an enabling policy on telehealth Information Communication Technology (ICT) and use of Filipino innovations towards health systems strengthening. Results can be used by implementers, evaluators, and regulators of health ICT, especially in resource-poor settings. Likewise, the study can encourage more research in the field to spur more dynamic local health ICT and biomedical device industries.

Introduction. We analyzed the concentrations of the trace elements [chromium (Cr), arsenic (As), cadmium (Cd),cesium (Cs), lead (Pb), thorium (Th), and uranium (U)] in commercial bottled water consumed in the town of Angono,Rizal province, Luzon island, Philippines to evaluate the health risks of the trace elements in drinking water. Thereare some arguments that water resources available in the Philippines are heavily polluted by various materials, inparticular heavy metal elements. Method. The concentrations of seven trace elements in commercial bottled water produced and consumed in thePhilippines were analyzed using a solution nebulization inductively coupled plasma mass spectrometry (SN−ICP−MS). Result. The concentrations of the trace elements except for Cs, which does not yet have a WHO guideline value,in the locally produced bottled water were below the WHO guideline values. The Cs concentrations (

Background Crowdsourcing is a distributed problem-solving and production mechanism that leverages the collective intelligence of non-expert individuals and networked communities for specific goals. Social innovation (SI) initiatives aim to address health challenges in a sustainable manner, with a potential to strengthen health systems. They are developed by actors from different backgrounds and disciplines. This paper describes the application of crowdsourcing as a research method to explore SI initiatives in health. Methods The study explored crowdsourcing as a method to identify SI initiatives implemented in Africa, Asia and Latin America. While crowdsourcing has been used in high-income country settings, there is limited knowledge on its use, benefits and challenges in low- and middle-income country (LMIC) settings. From 2014 to 2018, six crowdsourcing contests were conducted at global, regional and national levels. Results A total of 305 eligible projects were identified; of these 38 SI initiatives in health were identified. We describe the process used to perform a crowdsourcing contest for SI, the outcome of the contests, and the challenges and opportunities when using this mechanism in LMICs. Conclusions We demonstrate that crowdsourcing is a participatory method, that is able to identify bottom-up or grassroots SI initiatives developed by non-traditional actors.

Background The social-ecological systems theory, with its unique conception of resilience (social-ecological systems & resilience, SESR), provides an operational framework that currently best meets the need for integration and adaptive governance as encouraged by the Sustainable Development Goals. SESR accounts for the complex dynamics of social-ecological systems and operationalizes transdisciplinarity by focusing on community engagement, value co-creation, decentralized leadership and social innovation. Targeting Social Innovation (SI) in the context of implementation research for vector-borne diseases (VBD) control offers a low-cost strategy to contribute to lasting and contextualized community engagement in disease control and health development in low and middle income countries of the global south. In this article we describe the processes of community engagement and transdisciplinary collaboration underpinning community-based dengue management in rural primary schools and households in two districts in Cambodia. Methods Multiple student-led and community-based interventions have been implemented focusing on empowering education, communication for behavioral change and participatory epidemiology mapping in order to engage Cambodian communities in dengue control. We describe in particular the significance of the participatory processes that have contributed to the design of SI products that emerged following iterative consultations with community stakeholders to address the dengue problem. Results The SI products that emerged following our interaction with community members are 1) adult mosquito traps made locally from solid waste collections, 2) revised dengue curriculum with hands-on activities for transformative learning, 3) guppy distribution systems led by community members, 4) co-design of dengue prevention communication material by students and community members, 5) community mapping. Conclusions The initiative described in this article put in motion processes of community engagement towards creating ownership of dengue control interventions tools by community stakeholders, including school children. While the project is ongoing, the project’s interventions so far implemented have contributed to the emergence of culturally relevant SI products and provided initial clues regarding 1) the conditions allowing SI to emerge, 2) specific mechanisms by which it happens and 3) how external parties can facilitate SI emergence. Overall there seems to be a strong argument to be made in supporting SI as a desirable outcome of project implementation towards building adaptive capacity and resilience and to use the protocol supporting this project implementation as an operational guiding document for other VBD adaptive management in the region.

Background Social innovation (SI) in health holds potential to contribute to health systems strengthening and universal health coverage (UHC). The role of universities in SI has been well described in the context of high-income countries. An evidence gap exits on SI in healthcare delivery in the context of low- and middle-income countries (LMICs) as well as on the engagement of universities from these contexts. There is thus a need to build capacity for research and engagement in SI in healthcare delivery within these universities. The aim of this study was to examine the adoption and implementation of network of university hubs focused on SI in healthcare delivery within five countries across Africa, Asia and Latin America. The objectives were to describe the model, components and implementation process of the hubs; identify the enablers and barriers experienced and draw implications that could be relevant to other LMIC universities interested in SI. Methods A case study design was adopted to study the implementation process of a network of university hubs. Data from documentation, team discussions and post-implementation surveys were collected from 2013 to 2018 and analysed with aid of a modified policy analysis framework. Results/discussion SI university-based hubs serve as cross-disciplinary and cross-sectoral platforms, established to catalyse SI within the local health system through four core activities: research, community-building, storytelling and institutional embedding, and adhering to values of inclusion, assets, co-creation and hope. Hubs were implemented as informal structures, managed by a small core team, in existing department. Enablers of hub implementation and functioning were the availability of strong in-country social networks, legitimacy attained from being part of a global network on SI in health and receiving a capacity building package in the initial stages. Barriers encountered were internal institutional resistance, administrative challenges associated with university bureaucracy and annual funding cycles. Conclusions This case study shows the opportunity that reside within LMIC universities to act as eco-system enablers of SI in healthcare delivery in order to fill the evidence gap on SI and enhance cross-sectoral participation in support of achieving UHC.

Background Traumatic brachial plexus injuries are devastating injuries with lifelong disability and pain. The objective of this paper was to determine the functional disability of adult patients with traumatic brachial plexus injuries. Patients and methods A cross-sectional study was done to determine the functional disability of patients using the FIL-DASH (Filipino Disability of the Arm, Shoulder and Hand) and the BPI (Brief Pain Inventory) Severity Pain Score (Tagalog version) questionnaires to determine the functional disability and quality of life of patients with traumatic brachial plexus injuries. A regression analysis was done to determine the factors associated with the FIL-DASH score with the level of significance set at p Results A total of 126 adult patients with traumatic brachial plexus injuries were evaluated with a mean age of 30.1(standard deviation [SD], 9.1; range, 17-69). There were 123 males and three females. The mean quality of life (FIL-DASH Score) of the 126 patients was 45.6 (95% CI: 42.5 – 48.7), (SD, 17.4), (range, 2.5 – 89.2), the mean BPI Severity Pain Score was 16.1 (95% CI: 14.6-17.8; SD, 8.9; range, 0-36) among 126 patients. On multivariate analysis using the hierarchical method of model building, higher range of elbow flexion, lower Brief Pain Inventory Severity Score, and longer months from injury were found to be associated with a better FIL-DASH score. Conclusion The study showed that elbow flexion recovery, pain and duration of the injury were significantly associated with the FIL-DASH scores.

Objective. The present study aims to determine the concentrations of seven trace elements [chromium (Cr), arsenic (As), cadmium (Cd), cesium (Cs), lead (Pb), thorium (Th), and uranium (U)] in tap, well, spring, river, and lake waters in the town of Angono, Rizal in the Philippines, consumed for drinking, cooking, bathing, and washing. In the town of Angono, both of the tap and purified tap waters produced in the refilling station are consumed as the water for drinking.Methods. Water samples from six unpurified tap, six purified taps, 10 wells, two springs, two rivers, and one lake water were obtained in October 2015. Samples were analyzed using solution nebulization inductively coupled plasma mass spectrometry. Results were evaluated for health risks of the trace elements in the water samples using WHO guideline values. The provisional WHO guideline values are as follows: Cr: 50 µg/L, As: 10 µg/L, Cd: 3 µg/L, Pb: 10 µg/L, and U: 30 µg/L. That of Cs has not been proposed yet. The WHO guideline value for the naturally occurring radioactive isotope 232Th in drinking water is 1 Bq/L, which is equivalent to 250 μg/L.Results. The concentrations of the trace elements in the tap water samples were

Background: The objective of this paper was to determine the validity, reliability and internal consistency of the translated FILIPINO DASH (FIL-DASH) questionnaire in patients with traumatic brachial plexus injuries. Methods: Thirty-five adult patients with traumatic brachial plexus injury were enrolled in the validation stage. The same questionnaire was given to the patient between 7 to 14 days for the test-retest reliability. The validated Filipino version of the SF-36 was used as the gold standard to determine the construct validity of the translated DASH. We also compared the DASH score with the SF-36 total and subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Acuity Scale (VAS) for Pain. Results: The internal consistency was adequate, with Cronbach’s Alpha for the 30 items of 0.93 and an average inter-item covariance of 0.399. The test-retest reliability was 0.87 (p < 0.001). There was no significant difference in establising the validity of the translated DASH against SF-36 total and Subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Analogue Scale (VAS). Conclusions: The translated DASH (FIL-DASH) questionnaire was internally consistent and showed no difference in testing for test-retest reliability and validity against functional outcome measures and pain scales validated for adult Filipinos.

Objective. To determine the Disability Adjusted Life Year (DALY) weights of road traffic injuries and use the DALY weights in determining the total DALYs lost in Metro Manila using available data. Methods. Consensus on DALY weights for each of the 31 International Classification of Diseases (ICD)10 codes related to road traffic injuries was done using Delphi Process. Experts from different fields were invited to participate in 2 rounds of discussion-and-scoring were done to obtain consensus were obtained for each DALY weight. Philippine Health Insurance Corporation (PHIC) data on the counts of the 31 ICD 10 coded claims for the years 2011, 2012, and 2013 were obtained and used to calculate the total DALY lost due to vehicular injuries for Metro-Manila. Results. Road traffic related injuries affected mostly young people (mean 34 yo + 15) and affected mostly men (81%). There were a total of 3,199 injuries seen in 2,573 patients. 98.1% of the patients had a < 1 year type of injury with an average disability weight of 0.34154 and a total DALYs lost of 300.4. 0.5% of the patients had a ≥ 1 year type of injury with an average disability weight of 0.2726 and a total DALYs lost of 218.08.1.4% of the patients most likely died from their injuries earning a total DALYs lost of 1,440.The sum of DALYs lost is equivalent to a total of 1,958.12. Conclusion. The Metro Manila loses roughly Php 76.6 Million per year due to road traffic injuries and accidents. These events are highly preventable. Without proper interventions, road traffic injuries may lead to impoverishment of the young families who pick up the pieces, or are left behind.

Introduction The purpose of this study is to assess the effectiveness of diabetes self-management education (DSME) in a rural agricultural town. Methods In this prospective, education-intervention trial, 85 adults with type 2 diabetes mellitus from villages randomly assigned to DSME and 70 from villages assigned to standard care participated. The DSME group underwent a curriculum delivered by peer educators; those in the standard group received usual advice. Outcome measures were anthropometric, biochemical, health behaviors, and medication use data taken at baseline then after three and six months. Results DSME group had a lower median A1C after three and six months. After six months, there was a 0.5% median A1C reduction in DSME group and a 0.25% increase in the standard group. There were more participants in DSME group with A1C ⩽7.0% after three and six months. By the third month, there were more participants in DSME group performing foot examination. Conclusion DSME in this rural agricultural town improved glycemic control and promoted foot examination.

Aims: 1. To determine the knowledge, attitudes, and practices of persons with type 2 diabetes in the rural community of San Juan, Batangas, Philippines. 2. To determine the association between patient factors such as age, sex, duration of diabetes, and type of diabetes on knowledge, attitudes, and practices regarding diabetes. Methods: Cross-sectional analytic study done among persons with type 2 diabetes in the rural community. Participants were selected using stratified cluster sampling. Data were collected using two main methods: use of investigator-administered questionnaires and focus group discussions (FGDs). Results: 156 diabetic residents were included. The overall mean percentage score on knowledge was 43%. Less than half of the respondents strongly believed in the need for patient autonomy (38%). 35 respondents were included in the FGDs. Only 4 out of 35 diabetic respondents owned a glucose meter while only 16 out of the 35 consult their doctors on a regular basis. Conclusions: The study comprises Phase I of the proposed 5-year community-based DSME Program in the Philippines. It highlights the importance of evaluating knowledge, attitudes and practices as crucial means to understand observed behaviors and guide behavioral change.

Background The Integrated Management of Childhood Illness (IMCI) is used to address the most common yet preventable causes of child mortality worldwide. However, difficulties in the scale-up of IMCI led to the development of the IMCI Computerized Adaptation and Training Tool (ICATT). Objectives This paper describes the development of ICATT-based training configurations to be pilot-demonstrated in Davao City and Puerto Princesa City. Methods The design of training configurations was based on findings from scoping activities, which included literature review, and consultations with expert, stakeholders and end-users. Findings from scoping activities yielded (1) preference for a shorter training courses; (2) allocation of more training days for clinical practicum; (3) preference for blended learning approach; and (4) need to develop a complementation of tools to evaluate training performance. Result Two specific ICATT-based training configurations (i.e. a seven-day course and an eight-day course) were developed, with the main difference being on the number of classroom-based sessions allocated, and the mode of delivery of integration sessions. For both configurations, two days are allocated for distance learning, one day is allocated for integration, and two days are allocated for practicum. Conclusion Tools developed to measure changes in knowledge levels on IMCI consists of two written exams, while changes in levels of skills on IMCI is measured using two self-administered surveys and two observation checklists. Readiness to undertake ICATT-based training is assessed through a self-administered survey. User experience and performance is evaluated through key informant interviews and review of records in participating health facilities.

Due to a USAID-funded study on blood banks, a national policy was instituted in 1994 that set standards for Philippine blood services, promoted voluntary donation, and led to a ban on commercial blood banks. In this follow-up study, we assess the safety of the supply by determining the residual risk for transfusion-transmitted infections (syphilis, hepatitis B and C, HIV). We also identified unsafe facility practices and generated policy recommendations. A 1992 study found that transfusion-ready blood was not safe using the LQAS method (P > 0.05). We found that the 2012 residual risk became 0 to 0.9 percent attributable to the national policy. We noted poor to fair adherence to this policy. We identified unsafe practices such as use of rapid tests and lack of random blood retesting. Training and use of regional networks may improve safety. Despite improvement in safety, facilities complain of funding and logistical issues regarding compliance with the policy.

Vitamin A deficiency (VAD) is a serious and widespread public health problem in the Philippines. Initiated in 1993, the Philippines National Vitamin A Supplementation Program (NVASP) is one of the oldest, most mature and comprehensive of its kind. This paper presents a cost-effectiveness and efficiency analysis of the NVASP and of a hypothetical program of vitamin A fortification of wheat flour that was conducted to inform policymakers as to how to modify the program. Employing a proxy effectiveness indicator of VAD--the intake of70% of the recommended daily allowance of vitamin A--in a series of simulations using individual child consumption data, the analysis finds that fortification is more efficient in reducing inadequate vitamin A intake (IVAI) compared to the NVASP. Due to the nature of food consumption patterns, however, fortification alone, is not enough. At what is regarded as the maximum politically acceptable fortification level, there will still be 2.2 million (29%) Filipino children aged 12-59 months who will have IVAI. An investigation of the cost and efficiency of geographically targeted supplementation programs reveals that maintaining a universal supplementation program in urban areas and, in rural areas, introducing a targeted program to only the poorest municipalities (where the prevalence of VAD is the highest) will provide a more acceptable public health policy response than fortification alone. Such a policy will reduce incremental direct Government expenditures on vitamin A programs by nearly 20% and will reduce the number of children with IVAI to 900,000 (12%) Filipino children. The paper describes the fortification and supplementation programs, and how their costs were estimated. Lessons for program designers and policymakers in other countries in which vitamin A deficiency constitutes a public health problem are also discussed.

The purchase of antimicrobial agents in drugstores in a district in Manila. The Philippines was examined in order to determine how these agents might be used. Most antimicrobial agents are imported as bulk products and repackaged by a large number of small firms into 1491 different preparations including 206 marketed as combinations with other drugs. Antimicrobial agents accounted for 20.1% of all drug purchases. Purchases were made without prescription in 66.3% of 1608 transactions. Most of these were aminopenicillins or penicillins G or V (40.0%). The most common perceived indications were respiratory tract infections (20.2%), tuberculosis (8.8%), "prophylaxis" (8.6%) and gastrointestinal infection (8.3%). Almost 90% of purchases were for 10 or less capsules or tablets. The median number of units purchased was 3. Customers with written prescriptions purchased a mean of 8 while those who self-prescribed purchased a mean of 4 units (p = less than 0.05). We believe that these practices can provide only limited clinical efficacy and should favor emergence of resistant bacteria.