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Nayiga S, MacPherson EE, Mankhomwa J, Nasuwa F, Pongolani R, Kabuleta R, Kesby M, Dacombe R, Hilton S, Grace D, Feasey N, Chandler CI. "Arming half-baked people with weapons!" Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi. Glob Health Action 2024; 17:2322839. [PMID: 38441912 PMCID: PMC10916894 DOI: 10.1080/16549716.2024.2322839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The overuse of antimicrobial medicines is a global health concern, including as a major driver of antimicrobial resistance. In many low- and middle-income countries, a substantial proportion of antibiotics are purchased over-the-counter without a prescription. But while antibiotics are widely available, information on when and how to use them is not. OBJECTIVE We aimed to understand the acceptability among experts and professionals of sharing information on antibiotic use with end users - patients, carers and farmers - in Uganda, Tanzania and Malawi. METHODS Building on extended periods of fieldwork amongst end-users and antibiotic providers in the three countries, we conducted two workshops in each, with a total of 44 medical and veterinary professionals, policy makers and drug regulators, in December 2021. We carried out extensive documentary and literature reviews to characterise antibiotic information systems in each setting. RESULTS Participants reported that the general public had been provided information on medicine use in all three countries by national drug authorities, health care providers and in package inserts. Participants expressed concern over the danger of sharing detailed information on antibiotic use, particularly that end-users are not equipped to determine appropriate use of medicines. Sharing of general instructions to encourage professionally-prescribed practices was preferred. CONCLUSIONS Without good access to prescribers, the tension between enclaving and sharing of knowledge presents an equity issue. Transitioning to a client care-centred model that begins with the needs of the patient, carer or farmer will require sharing unbiased antibiotic information at the point of care.
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Affiliation(s)
- Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Eleanor E MacPherson
- Research and Innovation Services, University of Glasgow, Glasgow, UK
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | - John Mankhomwa
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | | | | | - Rita Kabuleta
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Mike Kesby
- School of Geography & Sustainable Development, University of St Andrews, St Andrews, UK
| | - Russell Dacombe
- Research and Innovation Services, University of Glasgow, Glasgow, UK
| | - Shona Hilton
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Delia Grace
- Natural Resources Institute, University of Greenwich, Chatham, UK
- International Livestock Research Institute, Nairobi, Kenya
| | - Nicholas Feasey
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
- The School of Medicine, University of St Andrews, St Andrews, UK
| | - Clare I.R. Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Cocker D, Chidziwisano K, Mphasa M, Mwapasa T, Lewis JM, Rowlingson B, Sammarro M, Bakali W, Salifu C, Zuza A, Charles M, Mandula T, Maiden V, Amos S, Jacob ST, Kajumbula H, Mugisha L, Musoke D, Byrne R, Edwards T, Lester R, Elviss N, Roberts AP, Singer AC, Jewell C, Morse T, Feasey NA. Investigating One Health risks for human colonisation with extended spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in Malawian households: a longitudinal cohort study. THE LANCET. MICROBE 2023; 4:e534-e543. [PMID: 37207684 PMCID: PMC10319635 DOI: 10.1016/s2666-5247(23)00062-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Low-income countries have high morbidity and mortality from drug-resistant infections, especially from enteric bacteria such as Escherichia coli. In these settings, sanitation infrastructure is of variable and often inadequate quality, creating risks of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales transmission. We aimed to describe the prevalence, distribution, and risks of ESBL-producing Enterobacterales colonisation in sub-Saharan Africa using a One Health approach. METHODS Between April 29, 2019, and Dec 3, 2020, we recruited 300 households in Malawi for this longitudinal cohort study: 100 each in urban, peri-urban, and rural settings. All households underwent a baseline visit and 195 were selected for longitudinal follow-up, comprising up to three additional visits over a 6 month period. Data on human health, antibiotic usage, health-seeking behaviours, structural and behavioural environmental health practices, and animal husbandry were captured alongside human, animal, and environmental samples. Microbiological processing determined the presence of ESBL-producing E coli and Klebsiella pneumoniae, and hierarchical logistic regression was performed to evaluate the risks of human ESBL-producing Enterobacterales colonisation. FINDINGS A paucity of environmental health infrastructure and materials for safe sanitation was identified across all sites. A total of 11 975 samples were cultured, and ESBL-producing Enterobacterales were isolated from 1190 (41·8%) of 2845 samples of human stool, 290 (29·8%) of 973 samples of animal stool, 339 (66·2%) of 512 samples of river water, and 138 (46·0%) of 300 samples of drain water. Multivariable models illustrated that human ESBL-producing E coli colonisation was associated with the wet season (adjusted odds ratio 1·66, 95% credible interval 1·38-2·00), living in urban areas (2·01, 1·26-3·24), advanced age (1·14, 1·05-1·25), and living in households where animals were observed interacting with food (1·62, 1·17-2·28) or kept inside (1·58, 1·00-2·43). Human ESBL-producing K pneumoniae colonisation was associated with the wet season (2·12, 1·63-2·76). INTERPRETATION There are extremely high levels of ESBL-producing Enterobacterales colonisation in humans and animals and extensive contamination of the wider environment in southern Malawi. Urbanisation and seasonality are key risks for ESBL-producing Enterobacterales colonisation, probably reflecting environmental drivers. Without adequate efforts to improve environmental health, ESBL-producing Enterobacterales transmission is likely to persist in this setting. FUNDING Medical Research Council, National Institute for Health and Care Research, and Wellcome Trust. TRANSLATION For the Chichewa translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Derek Cocker
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Kondwani Chidziwisano
- Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Blantyre, Malawi; Department of Civil and Environmental Engineering, University of Strathclyde, Glasgow, UK
| | - Madalitso Mphasa
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Taonga Mwapasa
- Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Joseph M Lewis
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Barry Rowlingson
- Centre for Health Informatics Computing and Statistics, Lancaster University, Lancaster, UK
| | - Melodie Sammarro
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Centre for Health Informatics Computing and Statistics, Lancaster University, Lancaster, UK
| | - Winnie Bakali
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Chifundo Salifu
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Allan Zuza
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Mary Charles
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tamandani Mandula
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Victor Maiden
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Stevie Amos
- Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Shevin T Jacob
- Global Health Security Department, Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Henry Kajumbula
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Lawrence Mugisha
- College of Health Sciences, and College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, Kampala, Uganda; Conservation and Ecosystem Health Alliance, Kampala, Uganda
| | - David Musoke
- Department of Disease Control and Environmental Health, Makerere University, Kampala, Uganda
| | - Rachel Byrne
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas Edwards
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rebecca Lester
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicola Elviss
- Science Group, United Kingdom Health Security Agency, London, UK
| | - Adam P Roberts
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Christopher Jewell
- Centre for Health Informatics Computing and Statistics, Lancaster University, Lancaster, UK
| | - Tracy Morse
- Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Blantyre, Malawi; Department of Civil and Environmental Engineering, University of Strathclyde, Glasgow, UK
| | - Nicholas A Feasey
- Malawi Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Cocker D, Sammarro M, Chidziwisano K, Elviss N, Jacob ST, Kajumbula H, Mugisha L, Musoke D, Musicha P, Roberts AP, Rowlingson B, Singer AC, Byrne RL, Edwards T, Lester R, Wilson CN, Hollihead B, Thomson NR, Jewell CP, Morse T, Feasey NA. Drivers of Resistance in Uganda and Malawi (DRUM): a protocol for the evaluation of One-Health drivers of Extended Spectrum Beta Lactamase (ESBL) resistance in Low-Middle Income Countries (LMICs). Wellcome Open Res 2023; 7:55. [PMID: 38817338 PMCID: PMC11137479 DOI: 10.12688/wellcomeopenres.17581.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 06/01/2024] Open
Abstract
In sub-Saharan Africa (sSA), there is high morbidity and mortality from severe bacterial infection and this is compounded by antimicrobial resistance, in particular, resistance to 3rd-generation cephalosporins. This resistance is typically mediated by extended-spectrum beta lactamases (ESBLs). To interrupt ESBL transmission it will be important to investigate how human behaviour, water, sanitation, and hygiene (WASH) practices, environmental contamination, and antibiotic usage in both urban and rural settings interact to contribute to transmission of ESBL E. coli and ESBL K. pneumoniae between humans, animals, and the environment. Here we present the protocol for the Drivers of Resistance in Uganda and Malawi (DRUM) Consortium, in which we will collect demographic, geospatial, clinical, animal husbandry and WASH data from a total of 400 households in Uganda and Malawi. Longitudinal human, animal and environmental sampling at each household will be used to isolate ESBL E. coli and ESBL K. pneumoniae. This will be complimented by a Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) survey and structured observations to understand the contextual and psychosocial drivers of regional WASH practices. Bacterial isolates and plate sweeps will be further characterised using a mixture of short-,long-read and metagenomic whole-genome sequencing. These datasets will be integrated into agent-based models to describe the transmission of EBSL resistance in Uganda and Malawi and allow us to inform the design of interventions for interrupting transmission of ESBL-bacteria.
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Affiliation(s)
- Derek Cocker
- Malawi-Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Melodie Sammarro
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Health Informatics Computing and Statistics, Lancaster University, Lancaster, UK
| | - Kondwani Chidziwisano
- Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Polytechnic, University of Malawi, Blantyre, Malawi
- Department of Civil and Environmental Engineering, University of Strathclyde, Glasgow, UK
| | - Nicola Elviss
- Science Group, United Kingdom Health Security Agency, London, UK
| | - Shevin T. Jacob
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Global Health Security Department, Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Henry Kajumbula
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lawrence Mugisha
- College of Veterinary Medicine, Animal Resources and Biosecurity (COVAB), Makerere University, Kampala, Uganda
- Conservation & Ecosystem Health Alliance, Kampala, Uganda
| | - David Musoke
- Department of Disease Control and Environmental Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Patrick Musicha
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
| | - Adam P. Roberts
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Barry Rowlingson
- Centre for Health Informatics Computing and Statistics, Lancaster University, Lancaster, UK
| | | | - Rachel L. Byrne
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas Edwards
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rebecca Lester
- Malawi-Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Catherine N. Wilson
- Malawi-Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Beth Hollihead
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicholas R. Thomson
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
- Department of Pathogen Molecular Biology, London School of Tropical Medicine and Hygiene, London, UK
| | - Christopher P. Jewell
- Centre for Health Informatics Computing and Statistics, Lancaster University, Lancaster, UK
| | - Tracy Morse
- Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Polytechnic, University of Malawi, Blantyre, Malawi
- Department of Civil and Environmental Engineering, University of Strathclyde, Glasgow, UK
| | - Nicholas A. Feasey
- Malawi-Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Kainga H, Phonera MC, Chikowe I, Chatanga E, Nyirongo H, Luwe M, Mponela J, Kachisi V, Kamanga N, Chulu J, Njunga G, Nabadda D, Fonchin A, Kallu SA, Mudenda S, Tembo R, Zulu M, Mwaba F, Mbewe N, Mpundu P, Samutela MT, Munyeme M, Muma JB, Simulundu E. Determinants of Knowledge, Attitude, and Practices of Veterinary Drug Dispensers toward Antimicrobial Use and Resistance in Main Cities of Malawi: A Concern on Antibiotic Stewardship. Antibiotics (Basel) 2023; 12:antibiotics12010149. [PMID: 36671349 PMCID: PMC9855151 DOI: 10.3390/antibiotics12010149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Antimicrobial resistance (AMR) is an emerging challenge to global public health. The use of antibiotics in the veterinary field is one of the contributing factors to AMR mostly due to poor knowledge, attitudes, and practices (KAP) of dispensers. Veterinary drug dispensers are expected to guide clients on indications, contraindications, and withdrawal periods of veterinary drugs. This study assessed veterinary drug dispensers' KAP toward AMR and associated potential contributing factors. A cross-sectional study, using a structured questionnaire, was conducted in three main cities of Malawi, namely Mzuzu, Lilongwe, and Blantyre. A total of 68 agrovet shops were selected using a simple random sampling technique. The KAP level was presented descriptively. Bivariate and multivariable analyses were run to investigate the relationships between the independent and outcome variable. Overall, the KAP score for knowledge, attitude, and practices was 46.7%, 49.2%, and 41.6%, respectively. The significant determinants of the knowledge were the practice of asking for a written prescription (OR: 16.291, 95% CI: 11.6-24.2) (p = 0.024), female (OR: 0.609, 95% CI: 0.3-0.9) (p = 0.001), and old age (≥35) (OR: 0.227, 95% CI: 0.1-0.5) (p = 0.04). Poor knowledge, negative attitude, and poor practices were observed among most of the participants. Sensitization and training on AMR and antimicrobial stewardship are recommended to address the KAP score gaps and the observed determinants among veterinary drug dispensers.
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Affiliation(s)
- Henson Kainga
- Department of Veterinary Epidemiology and Public Health, Faculty of Veterinary Medicine, Lilongwe University of Agriculture and Natural Resources, Lilongwe 207203, Malawi
- Correspondence: or ; Tel.: +265-996-618-212
| | - Marvin Collen Phonera
- Department of Animal Health and Livestock Development, Ministry of Agriculture, Lilongwe 207203, Malawi
| | - Ibrahim Chikowe
- Pharmacy Department, Kamuzu University of Health Sciences (KUHES), Blantyre P.O. Box 360, Malawi
| | - Elisha Chatanga
- Department of Veterinary Pathobiology, Faculty of Veterinary Medicine, Lilongwe University of Agriculture and Natural Resources, Lilongwe 207203, Malawi
| | - Hlupikire Nyirongo
- Department of Veterinary Epidemiology and Public Health, Faculty of Veterinary Medicine, Lilongwe University of Agriculture and Natural Resources, Lilongwe 207203, Malawi
| | - Mike Luwe
- Department of Animal Health and Livestock Development, Ministry of Agriculture, Lilongwe 207203, Malawi
| | - James Mponela
- Department of Animal Health and Livestock Development, Ministry of Agriculture, Lilongwe 207203, Malawi
| | | | - Nathani Kamanga
- Department of Animal Health and Livestock Development, Ministry of Agriculture, Lilongwe 207203, Malawi
| | - Julius Chulu
- Department of Animal Health and Livestock Development, Ministry of Agriculture, Lilongwe 207203, Malawi
| | - Gilson Njunga
- Department of Animal Health and Livestock Development, Ministry of Agriculture, Lilongwe 207203, Malawi
| | - Daisy Nabadda
- Department of Biosecurity, Ecosystems and Public Health, College of Veterinary Medicine, Makerere University, Kampala P.O. Box 7062, Uganda
| | - Alyce Fonchin
- Community Initiative for Sustainable Development, Manko-Bamenda P.O. Box 356, Cameroon
| | - Simegnew Adugna Kallu
- College of Veterinary Medicine, Haramaya University, Dire Dawa P.O. Box 138, Ethiopia
| | - Steward Mudenda
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Rabecca Tembo
- Department of Pathology and Microbiology, School of Medicine, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Mildred Zulu
- Department of Pathology and Microbiology, School of Medicine, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Florence Mwaba
- Department of Pathology and Microbiology, School of Medicine, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Natalia Mbewe
- Department of Basic and Clinical Nursing Sciences, School of Nursing Sciences, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Prudence Mpundu
- Department of Environmental and Occupational Health, Levy Mwanawasa Medical University, Lusaka P.O. Box 33991, Zambia
| | - Mulemba Tillika Samutela
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka P.O. Box 10101, Zambia
| | - Musso Munyeme
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 10101, Zambia
| | - John Bwalya Muma
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 10101, Zambia
| | - Edgar Simulundu
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 10101, Zambia
- Macha Research Trust, Choma P.O. Box 20100, Zambia
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