Household Animal and Human Medicine Use and Animal Husbandry Practices in Rural Bangladesh: Risk Factors for Emerging Zoonotic Disease and Antibiotic Resistance

Potential pathogens and antimicrobial resistance genes in household environments: a study of soil floors and cow dung in rural Bangladesh

In low- and middle-income countries, living in homes with soil floors and animal cohabitation may expose children to fecal organisms, increasing the risk of enteric and antimicrobial-resistant infections. Our objective was to understand whether cow cohabitation in homes with soil floors in rural Bangladesh contributed to the presence and diversity of potential pathogens and antimicrobial resistance genes (ARGs) in the home. In 10 randomly selected households in rural Sirajganj District, we sampled floor soil and cow dung, which is commonly used as sealant in soil floors. We extracted DNA and performed shotgun metagenomic sequencing to explore potential pathogens and ARGs in each sample type. We detected 7 potential pathogens in soil only, 38 pathogens in cow dung only, and 182 pathogens in both soil and cow dung. Cow dung exhibited modestly higher potential pathogen genus richness compared to soil floors (Wilcoxon signed-rank test, P = 0.002). Using Bray-Curtis dissimilarity, potential pathogen species community composition differed between floors and cow dung (permutational multivariate analysis of variance, P < 0.001). All soil floor and cow dung samples contained ARGs; detected ARGs confer resistance to antibiotic classes including sulfonamides, rifamycin, aminoglycosides, lincosamides, and tetracycline. Paired floor and cow dung samples shared ARGs against rifamycin and glycopeptides, but otherwise, there was little overlap in resistomes between sample types. Our findings contribute to the growing literature on household soil and domestic animals as potentially important contributors to disease transmission and as reservoirs of antimicrobial resistance in low-income country settings.IMPORTANCEIn low-income countries, inadequate housing materials and animal cohabitation can lead to fecal contamination of rural homes. Contaminated soil floors are difficult to clean and may harbor organisms causing illness and antibiotic resistance, especially in young children, who frequently ingest soil. We sequenced soil floor and cow dung samples from households in Sirajganj district, Bangladesh, and identified potential pathogens and antibiotic resistance genes. We detected 182 potential pathogens in both soil and cow dung; organisms present in both sample types at the highest relative abundances were Escherichia coli, Klebsiella pneumoniae, Salmonella enterica, and Pseudomonas aeruginosa. Antibiotic resistance genes were found in all samples. In cow dung, the most common genes conferred resistance to the antibiotics lincosamide, rifamycin, cephamycin, tetracycline, and multiple antibiotics. In soil floors, the most common genes conferred resistance to rifamycin, sulfonamides, and multiple antibiotics. Household soil and cow dung may be important reservoirs of pathogens and antimicrobial resistance in low-income country settings with high levels of animal cohabitation compared to settings with finished household floors and minimal animal cohabitation.

Dirt floors and domestic animals are associated with soilborne exposure to antimicrobial resistant E. coli in rural Bangladeshi households

Soil can harbor enteropathogens and antimicrobial-resistant organisms in settings with domestic animals. We enrolled 49 households with young children (28 soil floors, 21 concrete floors) in Bangladesh and recorded animal ownership/management. Staff swabbed the floor of children's sleeping area with a sterile sponge and collected floor dust and a child hand rinse. We used IDEXX QuantiTray/2000 with and without cefotaxime supplementation to enumerate cefotaxime-resistant and generic E. coli . There was 8.0 g/m 2 of dust on soil floors vs. 0.2 g/m 2 on concrete floors (p-value=0.005). We detected E. coli on 100% of soil vs. 86% of concrete floors and cefotaxime-resistant E. coli on 89% of soil vs. 43% of concrete floors (p-values<0.05). Cefotaxime-resistant E. coli prevalence on floors was 36% in compounds without animals, 79% in compounds with animals and 100% if animals stayed indoors overnight or the floor had animal feces; associations were strongest for chickens. In multivariable models, generic and cefotaxime-resistant E. coli counts were 1.5-2 log higher on soil vs. concrete floors, and counts on floors and child hands were 0.17-0.24 log higher for every 10 additional chickens owned (p-values<0.05). Efforts to mitigate infections and antimicrobial resistance in low-income countries should test flooring improvements and hygienic animal management.

Synopsis

In rural Bangladeshi households, generic and cefotaxime-resistant E. coli were more common on soil floors than concrete floors and among households with higher cohabitation intensity with domestic animals, especially chickens.

Prevalence and factors associated with multidrug resistant Escherichia coli carriage on chicken farms in west Nile region in Uganda: A cross-sectional survey

Infections with multi-drug-resistant (MDR) pathogens in food-animals threaten public health and food security. However, the epidemiology and factors associated with MDR Escherichia coli (MDR E. coli) on Ugandan farms are not well known. This study investigated the prevalence, resistance patterns and factors associated with MDR E. coli carriage on chicken farms. Escherichia coli was isolated from each of the 158 chicken farms sampled. The disc diffusion method for susceptibility testing was performed. Clinical breakpoints were interpreted according to Clinical and Laboratory Standards Institute guidelines. MDR was defined as resistance to three or more classes of antibiotics. MDR E. coli prevalence on chicken farms was 62.7% (95% CI: 55.0-70.3). High resistance was observed against ampicillin 79.8% (95% CI: 72.7-85.4), tetracycline 72.8% (95% CI: 65.2-79.2), cotrimoxazole 55.7% (95% CI: 47.8-63.3), and ciprofloxacin 38% (95% CI: 30.7-45.9). Male farm managers (Adjusted prevalence ratio [APR] = 0.72, CI: 0.55-0.93), attainence of at least secondary education (APR = 0.64, CI: 0.46-0.88) and administration of recommended antibiotic doses (APR = 0.76, CI: 0.59-0.96) posed a lower risk of MDR E. coli carriage while farms without footbaths posed a heighten risk (APR = 1.48, CI: 1.16-1.88). MDR E. coli carriage was highly prevalent on chicken farms in Uganda. This study underscores the urgent need for antimicrobial stewardship and improved infection prevention strategies on chicken farms.

Pathogens and Antimicrobial Resistance Genes in Household Environments: A Study of Soil Floors and Cow Dung in Rural Bangladesh

In low- and middle-income countries, living in homes with soil floors and animal cohabitation may expose children to fecal organisms, increasing risk of enteric and antimicrobial-resistant infections. Our objective was to understand whether cow cohabitation in homes with soil floors in rural Bangladesh contributed to the presence and diversity of potential pathogens and antimicrobial resistance genes (ARGs) in the home. In 10 randomly selected households in rural Sirajganj District, we sampled floor soil and cow dung, which is commonly used as sealant in soil floors. We extracted DNA and performed shotgun metagenomic sequencing to explore potential pathogens and ARGs in each sample type. We detected 6 potential pathogens in soil only, 49 pathogens in cow dung only, and 167 pathogens in both soil and cow dung. Pathogen species with relative abundances >5% in both soil floors and cow dung from the same households included E. coli (N=8 households), Salmonella enterica (N=6), Klebsiella pneumoniae (N=2), and Pseudomonas aeruginosa (N=1). Cow dung exhibited modestly higher pathogen genus richness compared to soil floors (Wilcoxon signed-rank test p=0.002). Using Bray-Curtis dissimilarity, pathogen species community composition differed between floors and cow dung (PERMANOVA p<0.001). All soil floors and cow dung samples contained ARGs against antibiotic classes including sulfonamides, rifamycin, aminoglycosides, lincosamides, and tetracycline. Paired floor and cow dung samples shared ARGs against rifamycin. Our findings support the development of interventions to reduce soil and animal feces exposure in rural, low-income settings.

Understanding antibiotic purchasing practices in community pharmacies: A potential driver of emerging antimicrobial resistance

Introduction

Antimicrobial resistance (AMR), a transboundary health issue, critically impacting low- and middle-income countries (LMICs) where 80% of antibiotics are used in the community, with 20-50% being inappropriate. Southeast-Asia, including Bangladesh, faces heightened AMR risk due to suboptimal healthcare standard and unregulated antibiotic sales. This study aimed to audit antibiotic dispensing patterns from community pharmacies, identifying factors influencing purchasing behaviors.

Methods

A cross-sectional survey of 385 antibiotic customers and structured observations of 1000 pharmacy dispensing events were conducted in four urban and rural areas in Bangladesh. Descriptive analysis defined antibiotic use, while Poisson regression examined how patients' demographics and health symptoms influenced prescription behaviors.

Results

Among 1000 observed medicine dispensing events, 25.9% were antibiotics. Commonly purchased antibiotics included macrolides (22.8%), third-generation-cephalosporins (20.8%), and second-generation-cephalosporins (16.9%). Following WHO-AWaRe classifications, 73.5% of antibiotics were categorized as Watch, and 23.1% as Access. From the survey, 56.6% antibiotics were purchased without a prescription from drug-sellers and informal healthcare providers, primarily for "non-severe" health-symptoms such as upper-respiratory-tract infections (37.4%), fever (31.7%), uncomplicated skin infections (20%), gastrointestinal-infections (11.2%), and urinary-tract infections (7.9%). The likelihood of presenting a prescription while purchasing antibiotics was 27% lower for individuals aged 6-59 compared to those ≤5 or ≥ 60. Lower-respiratory-tract infections and enteric-fever had higher prescription rates, with adjusted prevalence ratios of 1.78 (95% CI: 1.04, 3.03) and 1.87 (95% CI: 1.07, 3.29), respectively. After adjusting for confounders, sex, urban-rural locations, income, education, and number of health-symptoms exhibited no significant influence on prescription likelihood.

Conclusion

This study underscores unregulated antibiotic sales without prescriptions, urging tailored interventions considering prevailing health-seeking practices in diverse healthcare settings in LMICs. Enforcing prescription-only regulations is hindered by easy access through community pharmacies and conflicts of interest. Future strategies should consider how stewardship impacts the financial interests of pharmacy personnel in settings lacking clear authority to ensure optimal compliance.

Association between antimicrobial usage and resistance on commercial broiler and layer farms in Bangladesh

Antimicrobial resistance has emerged as a significant health problem worldwide, including in Bangladesh, where chickens are an important protein source for human nutrition. One of the factors accelerating the development of antimicrobial resistance is the inappropriate use of antimicrobials on commercial chicken farms. A cross-sectional study was conducted in 2019 on 140 commercial chicken farms in the Chattogram district of Bangladesh to investigate the association between antimicrobial use and resistance in Escherichia coli and Salmonella spp. cultured from cloacal swabs of chickens and from the poultry shed environment. All E. coli and Salmonella spp. isolates were resistant to multiple antimicrobial classes, including those categorized as "Highest Priority Critically Important Antimicrobials" for human medicine. Notably, resistance was observed in E. coli isolates from farms that did not use these antimicrobial classes in the current production cycle. For example, although quinolones were not used on 43.9% of E. coli positive farms, 95.7% of these farms had quinolone-resistant E. coli isolates. The results of the path analysis revealed that there was a "direct effect" of the frequency of antimicrobial usage on "high" resistance, with resistance increasing when antimicrobials were administered more frequently (β = 0.28, p = 0.002). There was a "direct effect" of the purpose of antimicrobial use on "low" resistance, with resistance marginally decreasing when antimicrobials were administered solely for therapeutic use (β = -0.17, p = 0.062), but increasing when they were used prophylactically. Overall, the study results could be used to educate farmers on better practices for antimicrobial administration, and to guide government agencies to update policies on antimicrobial use and resistance surveillance in the poultry sector of Bangladesh.

Multi-drug resistant (MDR) Gram-negative pathogenic bacteria isolated from poultry in the Noakhali region of Bangladesh

Rapidly increasing antibiotic-resistant bacterial strains in Bangladesh's food and farm animals stem from the excessive and inappropriate use of antibiotics. To assess the prevalence of multi-drug resistant (MDR) Gram-negative bacteria in poultry chicks, we sought to isolate and identify strains carrying antimicrobial resistance genes. Isolation and identification involved biochemical tests, 16S rRNA sequencing, and PCR screening of species-specific genes. MDR patterns were evaluated using CLSI guidelines with seventeen antibiotics across twelve classes. Targeted gene sequences were amplified for the detection of Extended-spectrum β-Lactamase (ESBL), carbapenem, tetracycline, sulfonamide, and colistin resistance genes. Common isolates, such as Escherichia coli, Klebsiella pneumoniae, Proteus penneri, and Enterobacter hormaechei, exhibited average Multiple Antimicrobial Resistance (MAR) indices of 0.66, 0.76, 0.8, 0.84, and 0.81, 0.76, 0.84, 0.41 for broiler and layer chicken, respectively. Providencia stuartii and Salmonella enterica, exclusive to broiler samples, had MAR indices of 0.82 and 0.84, respectively. Additional isolates Morganella morganii, Aeromonas spp., and Wohlfahrtiimonas chitiniclastica were found in layers (Average MAR indices: 0.73, 0.71, and 0.91). Notably, M. morganii, E. hormaechei and W. chitiniclastica were identified for the first time in Bangladeshi poultry chicken, although their evolution is yet to be understood. In this study, Pan-drug resistance was observed in one P. stuartii (broiler) and one Aeromonas spp. (layer) with a MAR index 1, while all isolates exhibited MAR indices >0.2, indicating MDR. Antimicrobial resistance (AMR) gene screening identified blaTEM, blaSHV, tetA, and sul1 in a majority of the MDR strains. Interestingly, E. coli (lactose positive and negative) and E. hormaechei were exclusively found to possess the tetB gene. In addition, E. coli (lactose negative), Klebsiella pneumoniae, Enterobacter hormaechei, M. morganii, and P. stuartii were observed to carry the colistin-resistant mcr-1 gene, whereas sul2 was detected in E. coli (lactose positive and negative), E. hormaechei, P. stuartii, and P. penneri. These findings emphasize the health risk of our consumers of both broiler and layer chickens as they have turned into a potent reservoir of various AMR gene carrying MDR and Pan-drug resistant bacteria.

A one health approach to tackling AMR and why gender matters: findings from pastoralist communities in Tanzania

Introduction

Inappropriate use of antimicrobials is a major driver of AMR in low-resource settings, where the regulation of supply for pharmaceuticals is limited. In pastoralist settings in Tanzania, men and women face varying degrees of exposure to antibiotics due to gender relations that shape access and use of antimicrobials. For example, critical limitations in healthcare systems in these settings, including inadequate coverage of health services put people at risk of AMR, as families routinely administer self-treatment at home with antimicrobials. However, approaches to understanding AMR drivers and risk distribution, including the One Health approach, have paid little attention to these gender considerations. Understanding differences in access and use of antimicrobials can inform interventions to reduce AMR risk in community settings. This paper focuses on the gendered risk of AMR through a study of gender and social determinants of access to and use of antimicrobials in low-resource pastoralist settings in Tanzania.

Methods

A mixed methods approach involving household surveys, interviews and ethnographic participant observation in homes and sites of healthcare provision was used, to investigate access and administration of antibiotics in 379 adults in Naiti, Monduli district in northern Tanzania. A purposive sampling technique was used to recruit study participants and all data was disaggregated by sex, age and gender.

Results

Gender and age are significantly associated with the use of antibiotics without a prescription in the study population. Young people aged 18-24 are more likely to use unprescribed antibiotics than older people and may be at a higher risk of AMR. Meanwhile, although more men purchase unprescribed antibiotics than women, the administration of these drugs is more common among women. This is because men control how women use drugs at the household level.

Discussion

AMR interventions must consider the critical importance of adopting and implementing a gender-sensitive One Health approach, as gender interacts with other social determinants of health to shape AMR risk through access to and use of antimicrobials, particularly in resource-limited pastoralist settings.

Knowledge, Attitudes, and Practices of Antibiotic Use among Small-, Medium-, and Large-Scale Fish Farmers of the Stratum II of the Volta Lake of Ghana

BACKGROUND

Antibiotic residue in food products and the resulting antibiotic-resistant bacteria represent a significant global public health threat. The misuse of antibiotics is a primary contributor to this issue. This study investigated the knowledge, attitudes, and practices (KAP) regarding antibiotic use among cage fish farmers on Ghana's Volta Lake.

METHOD

We conducted a cross-sectional survey with 91 cage fish farmers across three scales: small, medium, and large. A semi-structured questionnaire complemented by personal observations provided comprehensive data. We used several statistical methods for analysis: Pearson Chi-Square and Spearman correlation tests to examine relationships and trends among variables, logistic regression to analyze variable interactions, and Cronbach's alpha to check internal consistency. Additionally, Kendall's coefficient was used to rank challenges, utilizing STATA and SPSS for these calculations.

RESULTS

The survey revealed that 58.55% of cage fish farmers earn an average of 10,000 USD annually, with 35.16% having over 16 years of experience. From the survey, all sampled populations admitted to antibiotic applications in their farming operation. Knowledge of antibiotic types was mainly influenced by peers (46.15%), with tetracycline being the most recognized and used. There was a significant reliance on the empirical use of antibiotics, with 52.75% of farmers using them based on personal experience and 40.66% without a prescription. When initial treatments failed, 41.76% of the farmers would change or combine drugs. Older farmers (over 51 years) and those with tertiary education demonstrated significantly better KAP scores regarding antibiotic use. Strong correlations were also found among knowledge, attitudes, and practices in antibiotic usage.

CONCLUSIONS

The findings indicate a need for improved education on antibiotic use among fish farmers to reduce misuse and enhance awareness of the potential consequences. This study provides foundational data for designing interventions to address these issues in the context of cage fish farming on Volta Lake.

Characteristics of Nontyphoid Salmonella Isolated from Human, Environmental, Animal, and Food Samples in Burkina Faso: A Systematic Review and Meta-Analysis

Salmonella is one of the world's leading causes of zoonotic and foodborne illnesses. Recently, antimicrobial resistance (AMR) has become one of the most critical challenges to public health and food safety. Herein, we employed a meta-analysis to determine the pooled prevalence and spatiotemporal distribution of serovars and antimicrobial resistance in NTS in Burkina Faso. To find eligible articles, a comprehensive literature search of PubMed, African Journals Online, ScienceDirect, Google Scholar, and the gray literature (university libraries) in Burkina was conducted for the period from 2008 to 2020. Studies meeting the inclusion criteria were selected and assessed for risk of bias. To assess the temporal and spatial relationships between serotypes and resistant strains from humans, animals, food, and the environment, a random-effects statistical model meta-analysis was carried out using the Comprehensive Meta-Analysis Version 3.0 program. The NTS prevalence rates were 4.6% (95% CI: 3-7) and 20.1% (95% CI: 6.6-47.4) in humans and animals, respectively, and 16.8% (95% CI: 10.5-25.8) and 15.6% (95% CI: 8.2-27.5) in food and the environment, respectively. Most NTS serovars were S. Derby, reported both in food and animals, and S. Typhimurium, reported in humans, while S. Croft II, S. Jodpur II, and S. Kentucky were the most prevalent in the environment. NTS isolates were highly resistant to erythromycin, amoxicillin, cefixime, and cephalothin, with a pooled prevalence of multidrug resistance of 29% (95% CI: 14.5-49.5). The results of this review show a high diversity of Salmonella serotypes, as well as high antibiotic resistance in Salmonella isolates from animal, human, food, and environmental samples in Burkina, calling for a consolidated "One Health" approach to better understand the drivers of pathogen emergence, spread, and antimicrobial resistance, as well as the formulation of intervention measures needed to limit the risk associated with the disease.

Prevalence and Antimicrobial Resistance Profile of Salmonella Isolated from Human, Animal and Environment Samples in South Asia: A 10-Year Meta-analysis

Salmonella is a foodborne zoonotic bacterium, and the antimicrobial-resistant strains of Salmonella are a worldwide health concern. Herein, we employed a meta-analysis to determine the pooled prevalence of Salmonella and its antimicrobial resistance status in human, animal, and environmental isolates in South Asia. To this end, we followed the standard guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements for searching literature in three databases namely PubMed, Google Scholar, and CAB abstracts, and a total of 100 eligible datasets were finally included which were published from January 2010 to June 2021. In the pooled prevalence of Salmonella in South Asia, the random model effect was 14.47% (95% CI: 10.17-20.19) with a high degree of heterogeneity (I2, 99.8%) and overall antimicrobial resistance was 70% (95% CI: 63.0-76.0) with a heterogeneity of 23.6%. The temporal distribution of the overall antimicrobial resistance (%) against Salmonella was increased from 53 to 77% within 10 years. Out of 18 distinct Salmonella serotypes, S. enterica was highly prevalent (14.22%, 95% CI: 4.02-39.64) followed by S. pullorum (13.50%, 95% CI: 5.64-29.93) with antimicrobial resistance (%) were 86.26 and 90.06, respectively. Noteworthy, nalidixic acid (74.25%) and tetracycline (37.64%) were found mostly resistant to Salmonella whereas ceftriaxone (1.07%) and cefixime (1.24%) were sensitive. This systematic review demonstrated that overall antibiotic resistance profiles of Salmonella are increasing over time in South Asia. Thus, adequate hygienic practices, proper use of antimicrobials, and implementation of antibiotic stewardship are imperative for halting the Salmonella spread and its antimicrobial resistance.

Characterization and epidemiology of antimicrobial resistance patterns of Salmonella spp. and Staphylococcus spp. in free-ranging rhesus macaque (Macaca mulatta) at high-risk interfaces with people and livestock in Bangladesh

Introduction

Antimicrobial resistance (AMR) is a growing global health threat for humans and animals. Environmental contamination of antimicrobials from human and domestic animal feces has been linked to AMR in wildlife populations, including rhesus macaques. This study aimed to describe the eco-epidemiology of AMR within Salmonella and Staphylococcus species isolated from rhesus macaques.

Methods

We followed macaque groups for 4 h per day (2 days) to observe the direct and indirect contact rate and type between macaques and people and livestock. We collected 399 freshly defecated, non-invasive fecal samples from macaques at seven sites in Bangladesh in January-June 2017. Bacterial isolation and identification were conducted using culture, biochemical characteristics, and polymerase chain reaction (PCR). An antimicrobial susceptibility test (AST) for 12 antimicrobials for each organism was conducted using the Kirby-Bauer disc diffusion method.

Results

The overall prevalence of Salmonella spp. and Staphylococcus spp. in rhesus macaques was 5% (n = 18; 95% CI: 3-7%) and 16% (n = 64; 95% CI: 13-20%), respectively. All the isolated Salmonella spp. and most of the Staphylococcus spp. (95%; 61/64; 95% CI: 86.9-99%) were resistant to at least one antimicrobial. The odds of a fecal sample having antimicrobial-resistant Salmonella spp (OR = 6.6; CI: 0.9-45.8, P = 0.05) and Staphylococcus spp. (OR = 5.6; CI: 1.2-26, P = 0.02) were significantly higher in samples collected at peri-urban sites than those collected at rural and urban sites. Salmonella spp. were most frequently resistant to tetracycline (89%), azithromycin (83%), sulfamethoxazole-trimethoprim (50%), and nalidixic acid (44%). Staphylococcus spp. were found to be highly resistant to ampicillin (93%), methicillin (31%), clindamycin (26%), and rifampicin (18%). Both bacterial species produced colonies with multidrug resistance to up to seven antimicrobials. Direct and indirect contact rates (within 20 m for at least 15 min) and resource sharing between macaques and people were higher in urban sites, while macaque-livestock contact rates were higher in rural sites.

Discussion

The study shows that resistant microorganisms are circulating in rhesus macaque, and direct and indirect contact with humans and livestock might expand the resistant organisms.

A review of antibiotic resistance among Campylobacter species in human, animal, and water sources in South Africa: a One Health Approach

Campylobacter species are among the aetiological agents responsible for 400-500 million human diarrhoea cases per annum. The risk of dissemination of antibiotic-resistant Campylobacter species between humans, animals, and the environment is anticipated, given its transmissibility through these sources. The objective of this paper is to present a situation analysis that reports the current patterns and determinants of Campylobacter antibiotic resistance in South Africa. This review applies the One Health (OH) Approach to systematically review and collate the current antibiotic resistance status among Campylobacter spp. in South Africa. The highest level of resistance of Campylobacter in humans is to azithromycin (69.7%), whereas the lowest level of resistance of Campylobacter is to gatifloxacin (8.3%). In animals, high resistance to common antibiotics erythromycin (95.06%), clindamycin (95.68%), doxycycline (87.65%), erythromycin (90%), tetracycline (84.3%), streptomycin (88%), and ampicillin (73%) while 100% resistance of Campylobacter from water samples to tetracycline, imipenem, is recorded. Furthermore, resistance to clarithromycin (95%), azithromycin (92%), clindamycin (84.2%), doxycycline (80%), and ciprofloxacin (77.8%) is reported among Campylobacter spp. from water samples. The genetic similarity results suggest the movement of antibiotic-resistant Campylobacter spp. between humans and the environment. More research on antibiotic resistance among Campylobacter from other sources, outside clinical isolates, is recommended.

A scoping review of antibiotic use practices and drivers of inappropriate antibiotic use in animal farms in WHO Southeast Asia region

Antibiotic use (ABU) plays an important role in the proliferation of antimicrobial resistance (AMR). Global antimicrobial consumption in food production is projected to rise by 67% from 2010 to 2030, but available estimates are limited by the scarcity of ABU data and absence of global surveillance systems. The WHO South-East Asia (WHO SEA) region is at high risk of emergence of AMR, likely driven by intensifying farm operations and worsening ABU hotspots. However, little is known about farm-level ABU practices in the region. To summarize emerging evidence and research gaps, we conducted a scoping review of ABU practices following the Arksey and O'Malley methodological framework. We included studies published between 2010 and 2021 on farm-level ABU/AMR in the 11 WHO SEA member states, and databases were last searched on 31 October 2021. Our search strategy identified 184 unique articles, and 25 publications underwent full-text eligibility assessment. Seventeen studies, reported in 18 publications, were included in the scoping review. We found heterogeneity in the categorizations, definitions, and ABU characterization methods used across studies and farm types. Most studies involved poultry, pig, and cattle farms, and only one study examined aquaculture. Most studies evaluated ABU prevalence by asking respondents about the presence or absence of ABU in the farm. Only two studies quantified antibiotic consumption, and sampling bias and lack of standardized data collection methods were identified as key limitations. Emerging evidence that farm workers had difficulty differentiating antibiotics from other substances contributed to the uncertainty about the reliability of self-reported data without other validation techniques. ABU for growth promotion and treatment were prevalent. We found a large overlap in the critically important antibiotics used in farm animals and humans. The ease of access to antibiotics compounded by the difficulties in accessing quality veterinary care and preventive services likely drive inappropriate ABU in complex ways.

One Health: a holistic approach for food safety in livestock

The food safety of livestock is a critical issue between animals and humans due to their complex interactions. Pathogens have the potential to spread at every stage of the animal food handling process, including breeding, processing, packaging, storage, transportation, marketing and consumption. In addition, application of the antibiotic usage in domestic animals is a controversial issue because, while they can combat food-borne zoonotic pathogens and promote animal growth and productivity, they can also lead to the transmission of antibiotic-resistant microorganisms and antibiotic-resistant genes across species and habitats. Coevolution of microbiomes may occur in humans and animals as well which may alter the structure of the human microbiome through animal food consumption. One Health is a holistic approach to systematically understand the complex relationships among humans, animals and environments which may provide effective countermeasures to solve food safety problems aforementioned. This paper depicts the main pathogen spectrum of livestock and animal products, summarizes the flow of antibiotic-resistant bacteria and genes between humans and livestock along the food-chain production, and the correlation of their microbiome is reviewed as well to advocate for deeper interdisciplinary communication and collaboration among researchers in medicine, epidemiology, veterinary medicine and ecology to promote One Health approaches to address the global food safety challenges.

A Survey on Knowledge, Attitude, and Practices of Large-Animal Farmers towards Antimicrobial Use, Resistance, and Residues in Mymensingh Division of Bangladesh

The widespread and indiscriminate use of antimicrobials in food animals is a key contributor to antimicrobial resistance and antimicrobial residue, which have become a growing public and animal health concern in developing countries such as Bangladesh. This study was aimed to assess the knowledge, attitude, and practices (KAP) of large-animal farmers towards antimicrobial use (AMU), antimicrobial resistance (AMR), and antimicrobial residue (AR) with their correlation. A cross-sectional survey was conducted with a structured and pretested questionnaire in the Mymensingh division of Bangladesh. A total of 212 large-animal farmers (dairy, beef fattening, buffalo, sheep, and goat farmers) were surveyed. Results showed that most of the farmers are male (85.8%) and belong to the 18-30 age group (37.3%). About 20.3% had no formal education, and nearly half of the participants (48.1%) received training regarding antibiotic use and resistance. Penicillin is the most common class of antibiotic used (61.8%) in the study area, followed by other antimicrobials. Only 37.7% of the farmers used antimicrobials on the recommendation of their veterinarian. Overall, 41.5%, 42.5%, and 21.7% of farmers possess adequate knowledge and a satisfactory attitude and perform desirable practices, respectively. Farmers in the 31-40 age group have adequate knowledge, attitude, and ability to implement desired practices compared to farmers in the 18-30 age group. Farmers having a graduate or post-graduate degree scored better in relation to knowledge, attitude, and practice than other farmers. Analysis revealed that farmers who received training on AMU and AMR had 10.014 times (OR = 10.014, 95% CIs: 5.252-19.094), 9.409 times (OR = 9.409, 95% CIs: 4.972-17.806), and 25.994 times (OR = 25.994, 95% CIs: 7.73-87.414) better knowledge, attitude, and performance, respectively, compared to their counterparts. A significant proportion of farmers (97.2%) dispose of leftover antibiotics inappropriately. The findings of the present study will be used to intervene in the education and training of the farmers, which will help to limit the indiscriminate and irrational use of antimicrobials, leading to reducing the chances of developing AMR.

Drivers of zoonotic disease risk in the Indian subcontinent: A scoping review

Literature on potential anthropogenic drivers of zoonotic disease risk in the Indian subcontinent is sparse. We conducted a scoping review to identify primary sources, published 2000-2020, to clarify what research exists and on which areas future research should focus. We summarised findings thematically by disease. Of 80 sources included, 78 (98%) were original research articles and two were conference abstracts. Study designs and methods were not always clearly described, but 74 (93%) were quantitative (including one randomised trial), five (6%) were mixed-methods, and one was qualitative. Most sources reported research from India (39%) or Bangladesh (31%), followed by Pakistan (9%), Nepal (9%), Bhutan and Sri Lanka (6% each). Topically, most focused on rabies (18; 23%), Nipah virus (16; 20%) or leptospirosis (11; 14%), while 12 (15%) did not focus on a disease but instead on knowledge in communities. People generally did not seek post-exposure prophylaxis for rabies even when vaccination programmes were available and they understood that rabies was fatal, instead often relying on traditional medicines. Similarly, people did not take precautions to protect themselves from leptospirosis infection, even when they were aware of the link with rice cultivation. Nipah was correlated with presence of bats near human habitation. Official information on diseases, modes of transmission and prevention was lacking, or shared informally between friends, relatives, and neighbours. Behaviour did not correspond to disease knowledge. This review identifies various human behaviours which may drive zoonotic disease risk in the Indian subcontinent. Increasing community knowledge and awareness alone is unlikely to be sufficient to successfully change these behaviours. Further research, using interdisciplinary and participatory methods, would improve understanding of risks and risk perceptions and thus help in co-designing context-specific, relevant interventions.

"If It Works in People, Why Not Animals?": A Qualitative Investigation of Antibiotic Use in Smallholder Livestock Settings in Rural West Bengal, India

Smallholder farms are the predominant livestock system in India. Animals are often kept in close contact with household members, and access to veterinary services is limited. However, limited research exists on how antibiotics are used in smallholder livestock in India. We investigated antibiotic supply, usage, and their drivers in smallholder livestock production systems, including crossover-use of human and veterinary antibiotics in two rural sites in West Bengal. Qualitative interviews were conducted with key informants (n = 9), livestock keepers (n = 37), and formal and informal antibiotic providers from veterinary and human health sectors (n = 26). Data were analysed thematically and interpreted following a One Health approach. Livestock keepers and providers used antibiotics predominantly for treating individual animals, and for disease prevention in poultry but not for growth promotion. All providers used (highest priority) critically important antimicrobials for human health and engaged in crossover-use of human antibiotic formulations in livestock. Inadequate access to veterinary drugs and services, and a perceived efficacy and ease of dosing of human antibiotics in animals drove crossover-use. Veterinary antibiotics were not used for human health due to their perceived adverse effects. Given the extent of usage of protected antibiotics and crossover-use, interventions at the community level should adopt a One Health approach that considers all antibiotic providers and livestock keepers and prioritizes the development of evidence-based guidelines to promote responsible use of antibiotics in animals.

Toward a Feminist Agroecology

Agroecology is gaining ground as a movement, science, and set of practices designed to advance a food systems transformation which subverts the patterns of farmer exploitation currently entrenched in dominant agricultural models. In order for agroecology to achieve its espoused twin aims of social and ecological wellbeing, women and other historically marginalized stakeholders must be empowered and centered as the movement’s protagonists. The importance of gender and social considerations is not limited to patently social aspects of the agroecological agenda, but bears relevance in every dimension of agroecology. Yet, issues related to gender have commanded relatively little attention in the agroeocological literature. In this paper, we review HLPE’s 13 defining principles of agroecology through a feminist lens to demonstrate the ways in which human dimensions and power dynamics are interwoven in every principle. Through this analysis, we demonstrate that a feminist approach is instrumental to establish a socially just and ecologically sustainable agroecological transition.

Mapping the Antimicrobial Supply Chain in Bangladesh: A Scoping-Review-Based Ecological Assessment Approach

INTRODUCTION

Maintaining access to antimicrobials while preventing misuse is essential to combating the threat of antimicrobial resistance (AMR). The study objectives are to propose a framework of 16 indicators that can be used at the national level to assess the capacity to ensure access and curtail inappropriate use and to profile the antimicrobial supply chain for Bangladesh.

METHODS

Using a framework based on a rational construct, we assessed the antimicrobial supply chain of Bangladesh, with a focus on key players and products using a scoping review to obtain and describe information on 16 indicators. With players, we mapped linkages, manufacturers' production capacity, and ownership, among others, and demand point characteristics-pharmacy and pharmacist density, pharmacy/medicine outlets dispersion, veterinary clinic/hospitals, veterinarians' density, product quality, and regulation. We assessed product characteristics including listing on the World Health Organization (WHO) Model Essential Medicines List (EML) and WHO Access, Watch, and Reserve (AWaRe) classification of the major (top 10) antibiotics for human use; the proportion of medically important antimicrobials (MIAs) in veterinary use; and pricing. Production capacity and price controls were used to assess access and listing on the WHO EML, AWaRe/MIA classification, and a calculated pharmacy-to-pharmacist ratio to assess use.

RESULTS

Bangladesh has a high (98%) local antibiotic production capacity with pricing controls indicating the ability to ensure access. The presence of a high proportion of medicine outlets not under the control of pharmacists (4:1) and the high percentages of WHO Watch (54%) and MIAs (90%) of the major antibiotics are indicators of possible misuse.

DISCUSSION

Most of the data used in the framework were publicly available. Bangladesh has the capacity to ensure access but needs to strengthen its ability to regulate the quality of antimicrobials and prevent their inappropriate use through antimicrobial stewardship at the community (medicine outlet) levels to check AMR. There may also be a need for more regulations on licensing of MIAs.

Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel

BACKGROUND

South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics.

METHODS

We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings.

RESULTS

Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course.

CONCLUSIONS

We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Antibiotic use in animal husbandry: A mixed-methods study among general community in Boyolali, Indonesia

Background and Aim: Antibiotic resistance is one of the most serious problems worldwide. One predictive factor of increasing antibiotics resistance is the use of antibiotics in animals. This study aimed to explore the use of antibiotics for animal husbandry in a general community in Indonesia. Materials and Methods: A concurrent mixed-methods study was conducted. Data were collected from 407 respondents using a questionnaire, followed by an in-depth interview in 12 respondents. Data were analyzed both quantitatively and qualitatively. Results: Forty-two (10.32%) of 407 respondents used antibiotics for animal husbandry. Of these 42, >60% occasionally bought antibiotics from the pharmacy without prescription and 50% used their leftover antibiotics. Respondents also bought antibiotics from food stalls and animal feed shops. Tetracycline and amoxicillin were the most common antibiotics used for animal husbandry. The majority of respondents used antibiotics for therapeutic purposes and received information about using antibiotics for animal husbandry from friends and neighbors. Most of the respondents used antibiotics for animal husbandry incorrectly and had never heard of antibiotics resistance. Conclusion: Inappropriate antibiotic use in animal husbandry was common in the community. Education on the prudent use of antibiotics for animal husbandry is needed.

Poultry Ownership and Genetic Antibiotic Resistance Determinants in the Gut of Preschool Children

Zoonotic transmission is likely a pathway for antibiotic resistance. Data from a randomized trial of pediatric antibiotic administration were secondarily evaluated to determine if poultry ownership was significantly associated with the presence of gut genetic antibiotic resistance determinants among 118 children in Burkina Faso. Antimicrobial resistance (AMR) determinants were classified using DNA sequencing. We measured the relationship between genetic resistance determinants and chicken ownership using a logistic regression model adjusted for confounding variables. Children in households reporting poultry ownership had four times the odds of tetracycline resistance determinants in the gut compared with those without household poultry (odds ratio [OR]: 4.08, 95% CI: 1.08-15.44, P = 0.04). There was no statistically significant difference found for other antibiotic classes. Understanding the origins of antibiotic resistance may help spur the development of interventions to combat the global AMR crisis.

Antibiotic practices among household members and their domestic animals within rural communities in Cumilla district, Bangladesh: a cross-sectional survey

Background

Antibiotic resistance is a global threat to human health, and inappropriate use of antibiotics in humans and animals is widely considered to be a key driver of antibiotic resistant infections. Antibiotic use in humans and animals is growing rapidly in low- and, particularly, middle-income countries. However, there is little detailed understanding about practices related to the use of antibiotics in humans and animals within community settings in such countries. Here we aimed to understand the antibiotic practices of rural households across Cumilla district, Bangladesh, in relation to household members and their domestic animals.

Methods

In 2018 we conducted a cross-sectional survey using representative cluster sampling methods. We collected self-reported information from 682 female and 620 male household heads, with women also asked about their children’s antibiotic practices.

Results

Only 48% (95% CI: 40, 56%) of women and men had heard of antibiotics, and among those women and men who were aware of antibiotics and the children of those women 70% (95% CI: 64, 76%) reported having previously taken antibiotics, while among these individuals who reported previously taking antibiotics 21% (95% CI: 18, 25%) said they had done so most recently within the last month. Risky/inappropriate antibiotic practices in humans and animals were often reported. For example, among women and men who were aware of antibiotics and the children of those women 52% (95% CI: 40, 63%) reported previously taking antibiotics for a “cough/cold”, despite antibiotics being typically inappropriate for use against viral upper respiratory tract infections. Among poultry-owning respondents who were aware of antibiotics 11% (95% CI: 8, 15%) reported previously giving healthy poultry antibiotics, mainly for growth/prophylaxis, while among cattle-owning respondents who were aware of antibiotics and reported previously giving their cattle feed 20% (95% CI: 9, 37%) said the feed had contained antibiotics at least sometimes.

Conclusions

Our results highlight the need for context-adapted interventions at both the community level and the health systems level to reduce inappropriate antibiotic use among humans and domestic animals in rural Bangladesh. Successfully reducing inappropriate use of antibiotics among humans and animals is a required and critical step in tackling antimicrobial resistance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10457-w.

Bacterial resistance to antibiotics: access, excess, and awareness in Bangladesh

Introduction: Antibiotic resistance is a substantial cause of mortality, morbidity burden in Bangladesh. In this perspective piece, the problem of antibiotic resistance has been analyzed by critically evaluating literature data, and based on the author's experience.Areas covered: The underlying causes of this resistance are numerous including irrational and inappropriate use of antibiotics aggravated by aggressive marketing, over-the-counter dispensing, prescribing by the unqualified providers, lack of awareness in the general population, and inadequate implementation of relevant regulations.Expert opinion: Although Bangladesh is making some progress toward containing antibiotic resistance, the pace of this progress is insufficient. Public awareness is crucial for the full implementation of the regulations. Given that it is more a social than a medical problem, the health sector is unable to tackle the problem on its own. An integrated approach is required that identifies the roles and relative importance of each sector (human, animal, and environment). A set of recommendations has been provided for the government to act.

Antimicrobial resistance situation in animal health of Bangladesh

Antimicrobial resistance (AMR) is a crucial multifactorial and complex global problem and Bangladesh poses a regional and global threat with a high degree of antibiotic resistance. Although the routine application of antimicrobials in the livestock industry has largely contributed to the health and productivity, it correspondingly plays a significant role in the evolution of different pathogenic bacterial strains having multidrug resistance (MDR) properties. Bangladesh is implementing the National Action Plan (NAP) for containing AMR in human, animal, and environment sectors through “One Health” approach where the Department of Livestock Services (DLS) is the mandated body to implement NAP strategies in the animal health sector of the country. This review presents a “snapshot” of the predisposing factors, and current situations of AMR along with the weakness and strength of DLS to contain the problem in animal farming practices in Bangladesh. In the present review, resistance monitoring data and risk assessment identified several direct and/or indirect predisposing factors to be potentially associated with AMR development in the animal health sector of Bangladesh. The predisposing factors are inadequate veterinary healthcare, monitoring and regulatory services, intervention of excessive informal animal health service providers, and farmers’ knowledge gap on drugs, and AMR which have resulted in the misuse and overuse of antibiotics, ultimate in the evolution of antibiotic-resistant bacteria and genes in all types of animal farming settings of Bangladesh. MDR bacteria with extreme resistance against antibiotics recommended to use in both animals and humans have been reported and been being a potential public health hazard in Bangladesh. Execution of extensive AMR surveillance in veterinary practices and awareness-building programs for stakeholders along with the strengthening of the capacity of DLS are recommended for effective containment of AMR emergence and dissemination in the animal health sector of Bangladesh.

Disease Outbreak, Health Scare, and Distance Decay: Evidence from HPAI Shocks in Chinese Meat Sector

Background: During zoonotic disease shocks (ZDSs), zoonotic disease outbreaks (ZDOs) can induce public health scares (PHSs), causing meat price risks (MPRs). Nevertheless, spatial spillovers of zoonotic disease shocks in meat markets remain unclear. We explore how zoonotic disease outbreaks and public health scares locally and spatially spill over to meat price risks, and whether spatial spillovers of public health scares decay with distance. Methods: (i) We construct a long panel covering 30 provinces and 121 months, using highly pathogenic avian influenza (HPAI) epidemics as exogenous shocks in Chinese meat sector. (ii) We decompose zoonotic disease shocks into zoonotic disease outbreaks (objective incident) and public health scares (subjective information) and examine their spillovers to meat price risks. (iii) We identify distance-decaying spatial spillovers of public health scares, by running our dynamic SAR models 147 times, from 80 km to 3000 km with 20 km as incremental value, in a setting with risk-level heterogeneity. Results: (i) Zoonotic disease outbreaks themselves only cause local and neighboring meat price risks for high-risk meat, not for low-risk or substitute meat. (ii) Public health scares exacerbate local and neighboring meat price risks for high-risk and low-risk meat, and local meat price risks for substitute meat. (iii) Spatial spillovers of public health scares are distance-decaying and U-shaped, with four spatial attenuation boundaries, and distance turning point is shorter for high-risk meat (500 km) than for low-risk meat (800 km). Conclusions: We complement the literature by arguing that health scares induced by disease outbreaks negatively spill over to meat prices, with U-shaped distance-decaying spatial effects. This suggests low interregional spatial market integration in meat products, due to distance decay of nonstandardized information and local government control effects, across provincial boundaries. To the best of our knowledge, we are the first to document nonmonotonic distance decay of health scare effects on food prices, previously not found by the literature.

Exposure pathways and ecological risk assessment of common veterinary antibiotics in the environment through poultry litter in Bangladesh

Veterinary antibiotics (VAs) have entered the ecosystem principally through the application of organic fertilizer. However, factors influencing the contributions made by the prescribers and users thereof with respect to VAs in poultry manure have not been investigated. The purpose of this paper, therefore, is to identify factors associated with the VA prescription and usage as well as to measure the residual concentration along with the ecological risk of common VAs in poultry litter in Bangladesh. Structured questionnaire surveys were conducted so as to provide an understanding the perspective of prescribers and farmers. Ciprofloxacin (CIP), enrofloxacin (ENR), oxytetracycline (OTC), and doxycycline (DOX) were screened through the use of thin-layer chromatography (TLC) and quantified through high-performance liquid chromatography (HPLC). Also, methods of risk quotient (RQ) were applied to assess ecotoxicity. Most VAs were prescribed without a confirmatory diagnosis. The residue of CIP was dominant with a high concentration, followed by OTC but with a low concentration. A high ecological risk was associated with the use of OTC and DOX whereas the risk associated with the use of CIP and ENR was insignificant to low. The study highlights prescriber and user factors along with the variable ecological risk of VAs in litter.

A Review of Antimicrobial Resistance in Poultry Farming within Low-Resource Settings

The emergence, spread, and persistence of antimicrobial resistance (AMR) remain a pressing global health issue. Animal husbandry, in particular poultry, makes up a substantial portion of the global antimicrobial use. Despite the growing body of research evaluating the AMR within industrial farming systems, there is a gap in understanding the emergence of bacterial resistance originating from poultry within resource-limited environments. As countries continue to transition from low- to middle income countries (LMICs), there will be an increased demand for quality sources of animal protein. Further promotion of intensive poultry farming could address issues of food security, but it may also increase risks of AMR exposure to poultry, other domestic animals, wildlife, and human populations. Given that intensively raised poultry can function as animal reservoirs for AMR, surveillance is needed to evaluate the impacts on humans, other animals, and the environment. Here, we provide a comprehensive review of poultry production within low-resource settings in order to inform future small-scale poultry farming development. Future research is needed in order to understand the full extent of the epidemiology and ecology of AMR in poultry within low-resource settings.

What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study

Background

Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh.

Methods

We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method.

Results

Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals.

Conclusions

Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs.

Drivers of Antibiotic Resistance Transmissionin Low- and Middle-Income Countriesfrom a "One Health" Perspective-A Review

Antibiotic resistance is an ecosystem problem threatening the interrelated human-animalenvironmenthealth under the "One Health" framework. Resistant bacteria arising in onegeographical area can spread via cross-reservoir transmission to other areas worldwide either bydirect exposure or through the food chain and the environment. Drivers of antibiotic resistance arecomplex and multi-sectoral particularly in Lower- and Middle-income countries. These includeinappropriate socio-ecological behaviors; poverty; overcrowding; lack of surveillance systems; foodsupply chain safety issues; highly contaminated waste effluents; and loose rules and regulations. Inorder to examine the drivers of antibiotic resistance from a "one health" perspective, a literaturereview was conducted on three databases including PubMed, Medline and Google Scholar. A totalof 485 studies of potential relevance were selected, out of which 182 were included in this review.Results have shown that the aforementioned market failures are the leading cause for the negativeexternality of antibiotic resistance that extends in scope from the individual to the global ecosystem.Incremental and sustainable global actions can make the change, however, the problem willcontinue to prevail if governments do not prioritize the "One health" approach and if individual'saccountability is still denied in a world struggling with profound socio-economic problems.

A process for developing a sustainable and scalable approach to community engagement: community dialogue approach for addressing the drivers of antibiotic resistance in Bangladesh

Background

Community engagement approaches that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources. They can be difficult to sustain and scale-up in low resource settings. Given the reach of health services into communities in low income countries, the health system provides a valuable and potentially sustainable entry point that would allow for scale-up of community engagement interventions. This study explores the process of developing an embedded approach to community engagement taking the global challenge of antibiotic resistance as an example.

Methods

The intervention was developed using a sequential mixed methods study design. This consisted of: exploring the evidence base through an umbrella review, and identifying key international standards on the appropriate use of antibiotics; undertaking detailed formative research through a) a qualitative study to explore the most appropriate mechanisms through which to embed the intervention within the existing health system and community infrastructure, and to understand patterns of knowledge, attitudes and practice regarding antibiotics and antibiotic resistance; and b) a household survey – which drew on the qualitative findings - to quantify knowledge, and reported attitudes and practice regarding antibiotics and antibiotic resistance within the target population; and c) drawing on appropriate theories regarding change mechanisms and experience of implementing community engagement interventions to co-produce the intervention processes and materials with key stakeholders at policy, health system and community level.

Results

A community engagement intervention was co-produced and was explicitly designed to link into existing health system and community structures and be appropriate for the cultural context, and therefore have the potential to be implemented at scale. We anticipate that taking this approach increases local ownership, as well as the likelihood that the intervention will be sustainable and scalable.

Conclusions

This study demonstrates the value of ensuring that a range of stakeholders co-produce the intervention, and ensuring that the intervention is designed to be appropriate for the health system, community and cultural context.

Quantification of Airborne Resistant Organisms With Temporal and Spatial Diversity in Bangladesh: Protocol for a Cross-Sectional Study

BACKGROUND

Antimicrobial resistance is a widespread, alarming issue in global health and a significant contributor to human death and illness, especially in low and middle-income countries like Bangladesh. Despite extensive work conducted in environmental settings, there is a scarcity of knowledge about the presence of resistant organisms in the air.

OBJECTIVE

The objective of this protocol is to quantify and characterize the airborne resistomes in Bangladesh, which will be a guide to identify high-risk environments for multidrug-resistant pathogens with their spatiotemporal diversity.

METHODS

This is a cross-sectional study with an environmental, systematic, and grid sampling strategy focused on collecting air samples from different outdoor environments during the dry and wet seasons. The four environmental compartments are the frequent human exposure sites in both urban and rural settings: urban residential areas (n=20), live bird markets (n=20), rural households (n=20), and poultry farms (n=20). We obtained air samples from 80 locations in two seasons by using an active microbial air sampler. From each location, five air samples were collected in different media to yield the total bacterial count of 3rd generation cephalosporin (3GC) resistant Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococci and methicillin-resistant Staphylococcus aureus.

RESULTS

The study started in January 2018, and the collection of air samples was completed in November 2018. We have received 800 air samples from 80 study locations in both dry and wet seasons. Currently, the laboratory analysis is ongoing, and we expect to receive the preliminary results by October 2019. We will publish the complete result as soon as we clean and analyze the data and draft the manuscript.

CONCLUSIONS

The existence of resistant bacteria in the air like those producing extended-spectrum beta-lactamases, carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococci, and methicillin-resistant Staphylococcus aureus will justify our hypothesis that the outdoor environment (air) in Bangladesh acts as a reservoir for bacteria that carry genes conferring resistance to antibiotics. To our knowledge, this is the first study to explore the presence of superbugs in the air in commonly exposed areas in Bangladesh.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14574.

Pathways to antibiotics in Bangladesh: A qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill

Background

To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals.

Methods

In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines.

Findings

People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important.

Conclusions

In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people.

Human, animal and environmental contributors to antibiotic resistance in low-resource settings: integrating behavioural, epidemiological and One Health approaches

Antibiotic resistance (ABR) is recognized as a One Health challenge because of the rapid emergence and dissemination of resistant bacteria and genes among humans, animals and the environment on a global scale. However, there is a paucity of research assessing ABR contemporaneously in humans, animals and the environment in low-resource settings. This critical review seeks to identify the extent of One Health research on ABR in low- and middle-income countries (LMICs). Existing research has highlighted hotspots for environmental contamination; food-animal production systems that are likely to harbour reservoirs or promote transmission of ABR as well as high and increasing human rates of colonization with ABR commensal bacteria such as Escherichia coli However, very few studies have integrated all three components of the One Health spectrum to understand the dynamics of transmission and the prevalence of community-acquired resistance in humans and animals. Microbiological, epidemiological and social science research is needed at community and population levels across the One Health spectrum in order to fill the large gaps in knowledge of ABR in low-resource settings.

Sensitive and Matrix-Tolerant Lateral Flow Immunoassay Based on Fluorescent Magnetic Nanobeads for the Detection of Clenbuterol in Swine Urine

The lack of sensitivity and poor matrix tolerance are the main bottlenecks of the lateral flow immunoassay (LFIA). Here, a sensitive and matrix-tolerant method that integrated immunomagnetic separation and fluorescent lateral flow immunoassay (IMS-FLFIA) based on fluorescent magnetic nanobeads was developed to detect the clenbuterol (CLE) residue in swine urine. The limit of detection (LOD) of IMS-FLFIA is 4 times lower than that of traditional colloidal gold LFIA. This method, which exhibits similar LOD and linearity range in both phosphate-buffered saline and urine swine, is highly correlated with liquid chromatography-tandem mass spectrometry for the detection of real swine urine samples. The result indicated that IMS-FLFIA has a universal resistance to the swine urine matrix. The merits of this assay, high sensitivity, matrix tolerance, accuracy, and specificity, ensure a promising future in detection of veterinary drug residues.

Spatial and temporal variation in the community prevalence of antibiotic resistance in Bangladesh: an integrated surveillance study protocol

INTRODUCTION

Increasing antibiotic resistance (ABR) in low-income and middle-income countries such as Bangladesh presents a major health threat. However, assessing the scale of the health risk is problematic in the absence of reliable data on the community prevalence of antibiotic-resistant bacteria. We describe the protocol for a small-scale integrated surveillance programme that aims to quantify the prevalence of colonisation with antibiotic-resistant bacteria and concentrations of antibiotic-resistant genes from a 'One Health' perspective. The holistic assessment of ABR in humans, animals and within the environment in urban and rural Bangladesh will generate comprehensive data to inform human health risk.

METHODS AND ANALYSIS

The study design focuses on three exposure-relevant sites where there is enhanced potential for transmission of ABR between humans, animals and the environment: (1) rural poultry-owning households, (2) commercial poultry farms and (3) urban live-bird markets. The comparison of ABR prevalence in human groups with high and low exposure to farming and poultry will enable us to test the hypothesis that ABR bacteria and genes from the environment and food-producing animals are potential sources of transmission to humans. Escherichia coli is used as an ABR indicator organism due to its widespread environmental presence and colonisation in both the human and animal gastrointestinal tract.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board of the International Centre for Diarrhoeal Disease Research, Bangladesh, and Loughborough University Ethics Committee. Data for the project will be stored on the open access repository of the Centre for Ecology and Hydrology, Natural Environment Research Council. The results of this study will be published in peer-reviewed journals and presented at national and international conferences.

Domesticated animals as hosts of henipaviruses and filoviruses: A systematic review

Bat-borne viruses carry undeniable risks to the health of human beings and animals, and there is growing recognition of the need for a 'One Health' approach to understand their frequently complex spill-over routes. While domesticated animals can play central roles in major spill-over events of zoonotic bat-borne viruses, for example during the pig-amplified Malaysian Nipah virus outbreak of 1998-1999, the extent of their potential to act as bridging or amplifying species for these viruses has not been characterised systematically. This review aims to compile current knowledge on the role of domesticated animals as hosts of two types of bat-borne viruses, henipaviruses and filoviruses. A systematic literature search of these virus-host interactions in domesticated animals identified 72 relevant studies, which were categorised by year, location, design and type of evidence generated. The review then focusses on Africa as a case study, comparing research efforts in domesticated animals and bats with the distributions of documented human cases. Major gaps remain in our knowledge of the potential ability of domesticated animals to contract or spread these zoonoses. Closing these gaps will be necessary to fully evaluate and mitigate spill-over risks of these viruses, especially with global agricultural intensification.

The threat of antimicrobial resistance in developing countries: causes and control strategies

The causes of antimicrobial resistance (AMR) in developing countries are complex and may be rooted in practices of health care professionals and patients' behavior towards the use of antimicrobials as well as supply chains of antimicrobials in the population. Some of these factors may include inappropriate prescription practices, inadequate patient education, limited diagnostic facilities, unauthorized sale of antimicrobials, lack of appropriate functioning drug regulatory mechanisms, and non-human use of antimicrobials such as in animal production. Considering that these factors in developing countries may vary from those in developed countries, intervention efforts in developing countries need to address the context and focus on the root causes specific to this part of the world. Here, we describe these health-seeking behaviors that lead to the threat of AMR and healthcare practices that drive the development of AMR in developing countries and we discuss alternatives for disease prevention as well as other treatment options worth exploring.

The threat of antimicrobial resistance in developing countries: causes and control strategies

The causes of antimicrobial resistance (AMR) in developing countries are complex and may be rooted in practices of health care professionals and patients’ behavior towards the use of antimicrobials as well as supply chains of antimicrobials in the population. Some of these factors may include inappropriate prescription practices, inadequate patient education, limited diagnostic facilities, unauthorized sale of antimicrobials, lack of appropriate functioning drug regulatory mechanisms, and non-human use of antimicrobials such as in animal production. Considering that these factors in developing countries may vary from those in developed countries, intervention efforts in developing countries need to address the context and focus on the root causes specific to this part of the world. Here, we describe these health-seeking behaviors that lead to the threat of AMR and healthcare practices that drive the development of AMR in developing countries and we discuss alternatives for disease prevention as well as other treatment options worth exploring.

Screening food-borne and zoonotic pathogens associated with livestock practices in the Sumapaz region, Cundinamarca, Colombia

Hazardous practices regarding antibiotics misuse, unsanitary milking procedures, and the commercial sales of raw milk and unpasteurized dairy products are currently being practiced by livestock farmers in the Sumapaz region (Colombia). The purpose of this study was to screen for food-borne and zoonotic pathogens associated with local livestock practices. We evaluated 1098 cows from 46 livestock farms in the Sumapaz region that were selected by random. Of the total population of cattle, 962 animals (88%) were tested for bovine TB using a caudal-fold tuberculin test and 546 (50%) for brucellosis by a competitive ELISA. In the population tested, 23 cows were positive for Brucella sp. representing a 4.2% seroprevalence and no cases of bovine tuberculosis were found. In addition, food-borne contamination with Escherichia coli and Staphylococcus aureus was assessed together with antibiotic susceptibility for ten different antibiotics in milk samples from 16 livestock farms. We found that 12 of the farms (75%) were contaminated with these food-borne pathogens. Noteworthy, all of the isolated pathogenic strains were resistant to multiple antibiotics, primarily to oxytetracycline and erythromycin. Our findings suggest that livestock products could be a source of exposure to Brucella and multidrug-resistant E. coli and S. aureus strains as a result of unhygienic livestock practices in the Sumapaz region. Training in good farming practices is the key to improving safety in food production.

One Health research and training and government support for One Health in South Asia

Introduction

Considerable advocacy, funding, training, and technical support have been provided to South Asian countries to strengthen One Health (OH) collaborative approaches for controlling diseases with global human pandemic potential since the early 2000s. It is essential that the OH approach continues to be strengthened given South Asia is a hot spot for emerging and endemic zoonotic diseases. The objectives of this article are to describe OH research and training and capacity building activities and the important developments in government support for OH in these countries to identify current achievements and gaps.

Materials and methods

A landscape analysis of OH research, training, and government support in South Asia was generated by searching peer-reviewed and grey literature for OH research publications and reports, a questionnaire survey of people potentially engaged in OH research in South Asia and the authors’ professional networks.

Results

Only a small proportion of zoonotic disease research conducted in South Asia can be described as truly OH, with a significant lack of OH policy-relevant research. A small number of multisectoral OH research and OH capacity building programmes were conducted in the region. The governments of Bangladesh and Bhutan have established operational OH strategies, with variable progress institutionalising OH in other countries. Identified gaps were a lack of useful scientific information and of a collaborative culture for formulating and implementing integrated zoonotic disease control policies and the need for ongoing support for transdisciplinary OH research and policy-relevant capacity building programmes.

Discussion

Overall we found a very small number of truly OH research and capacity building programmes in South Asia. Even though significant progress has been made in institutionalising OH in some South Asian countries, further behavioural, attitudinal, and institutional changes are required to strengthen OH research and training and implementation of sustainably effective integrated zoonotic disease control policies.

Efficiency of the Clinical Veterinary Diagnostic Practices and Drug Choices for Infectious Diseases in Livestock in Bangladesh

As in most low-income countries, adequate laboratory facilities are not available in Bangladesh to assist veterinarians in diagnosing animal diseases. We aimed to determine the efficiency of veterinary diagnoses for two common ruminant diseases in Bangladesh: Peste des petits ruminants (PPR) and foot-and-mouth disease (FMD). We conducted the study from May 2009 to August 2010 in three government veterinary hospitals where veterinarians collected samples from sick livestock and recorded the presumptive diagnosis on the basis of clinical presentations. Samples were tested for PPR and FMD using real-time RT-PCR. We estimated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the presumptive diagnoses when compared to laboratory tests. We tested 539 goats for PPR and 340 cattle and goats for FMD. Our results indicate that the veterinarians' presumptive diagnoses were different from laboratory findings for both PPR (P < 0.05) and FMD (P < 0.05). The overall sensitivity of the presumptive clinical diagnoses was 54% (95% CI: 47-61%) while specificity was 81% (95% CI: 78-84%) compared to real-time RT-PCR tests. The kappa value obtained in our validation process for PPR (kappa: 0.25) and FMD (kappa 0.36) indicated a poor performance of the presumptive diagnoses. Most of the animals (93%) were treated with antibiotics. Our findings indicate that veterinarians can detect animals not infected with FMD or PPR but miss the true cases. The clinical competency of these veterinarians needs to be improved and access to laboratory diagnostic facilities could help veterinarians to improve the diagnostics and outcomes. The rational use of antibiotics by veterinarians in animals must be ensured.