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

Formulating antibiotic policy: Analysis of India's ban on colistin use in food producing animals

Antibiotics remain key tools for maintaining human health, and in many settings, food production. However, emergence of antibiotic resistance has become a global challenge, one that has resulted in multi-national calls for policy to improve antibiotic use. One such call has been to restrict the use of antibiotics deemed critically important for human health, such as colistin, during the production of food producing animals. Between 2016 and 2019 numerous countries, including India, implemented policies to heavily restricted the use of colistin in livestock. While this represents a key shift in the antibiotic policy landscape, other classes of critically important antibiotics continue to be used during food production. This paper provides a policy analysis of India's 2019 colistin ban to provide insight into how this came to be and to identify factors which could shape the development of future legislation. The analysis revealed that while antibiotic reform in food production had been in the background of India's policy agenda for some time, it took key-focusing events to shift the policy climate into a period of action. These focusing events included reporting of mobile colistin resistance genes in bacteria isolated from pigs in China and colistin resistant bacteria isolated from food samples in India. Consistent narratives had been built around colistin's role as a last resort antibiotic which, together with relatively low proportion of colistin resistance in bacteria isolated from human patients, framed legislation as a worthwhile endeavour for policy makers. In addition, India acted as a global player in antibiotic stewardship and followed the precedent set by several other countries in restricting colistin use during food production. As most colistin for animal use was imported into India from China, and viable alternative animal treatments existed, there was limited industry opposition that could block legislation. We suggest evaluation of these five critical factors (focusing events, consistent narratives, worthwhile endeavour, precedent for change, and industry opposition) should be part of the policy formulation process for legislation regarding the use of other critically important antibiotics in food production.

Participatory identification of the causes of antimicrobial use and how they may vary according to differences in sector structure: The case of the Flemish pork and veal sectors

The increasing threat of antimicrobial resistance (AMR) to human health has prompted many countries to adopt national action plans to reduce antimicrobial use (AMU) in farm animals. To achieve this goal, it is necessary to gain a deeper understanding of the factors driving AMU in farm animals. While previous research has focused on gaining a better understanding of AMU from the perspective of farmers and veterinarians, less emphasis has been placed on examining the systemic and contextual factors that influence AMU from multiple viewpoints within the food supply chain. To this end, this paper describes a participatory approach involving multiple stakeholders from two distinct livestock sectors to identify the underlying drivers of AMU and explore their case-specificity. For each sector, we identified causes of AMU during four online focus groups, by co-creating a "problem tree", which resulted in the identification of over 50 technical, economic, regulatory, and sociocultural causes per sector and exploration of causal links. Following this, we analysed the focus group discussion through a content analysis and clustered causes of AMU that were related into 17 categories (i.e. main drivers of AMU), that we then classified as drivers of AMU at sector level or drivers of AMU at farm level. Finally, we compared the two sectors by assessing whether the generated categories (i.e. main drivers for AMU) had been discussed for both sectors and, if so, whether they involved the same causes and had the same implications. Through our analysis, we gained a better understanding of several main drivers of AMU at sector level, that result from systemic and/or contextual causes. As these cannot always be addressed by farmers and/or their veterinarian, we suggest that interventions should also target other actors related to these causes or consider them to help implement certain strategies. Furthermore, based on the results of our comparative analysis, we suggest that systemic structural differences, such as size and level of supply chain integration/fragmentation, may lead to differences in how animal health management is approached. This in turn may influence AMU's decision-making and the effectiveness of interventions, if they are generic and not tailored to the specificities of the sector.

Access to veterinary care: evaluating working definitions, barriers, and implications for animal welfare

Humans have a moral obligation to meet the physical and mental needs of the animals in their care. This requires access to resources such as veterinary care, which is integral to achieving animal welfare. However, "access" to veterinary care is not always homogenous across communities and currently lacks a consistent definition. The objectives of this scoping review were to (1) understand how "access" to veterinary care has been defined in the literature, (2) map a broad list of potential barriers that may influence access to veterinary care, and (3) identify how access to care impacts the welfare of companion and livestock animals. The literature search yielded a total of 1,044 publications, 77 of which were relevant to our inclusion criteria, and were published between 2002 and 2022. Studies were most frequently conducted in the United States (n = 17) and Canada (n = 11). Publications defining access to veterinary care (n = 10) or discussing its impacts on animal welfare (n = 13) were minimal. However, barriers to accessing veterinary care were thoroughly discussed in the literature (n = 69) and were categorized into ten themes according to common challenges and keywords, with financial limitations (n = 57), geographic location (n = 35), and limited personnel/equipment (n = 32) being the most frequently reported. The results of this scoping review informed our proposed definition of access to veterinary care. Additionally, our findings identified a need to further investigate several understudied barriers relating to access to care (i.e., veterinarian-client relationship, client identity) and to better understand how they potentially affect animal welfare outcomes.

Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study

BACKGROUND

Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda.

METHODS

This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis.

RESULTS

Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS.

CONCLUSION

There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda's fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.

Case Study: Using a Shared International Database to Document Veterinary Consumption of Antibiotics in Pakistan

In this paper, we present a case study of Pakistan documenting the use of antimicrobial drugs in poultry flocks in the VetCAb-ID database. Unlike other databases, this system allows international users to upload their data directly. Based on expert interviews and a review of the latest publications on the topic, we provide an alternative approach to harmonizing data collection among countries. This paper will provide impetus to formulate joint requirement documentation for an AMU database on a global level that international users can adapt for their own purposes and projects.

Crossover-Use of Human Antibiotics in Livestock in Agricultural Communities: A Qualitative Cross-Country Comparison between Uganda, Tanzania and India

Antibiotic use in animal agriculture contributes significantly to antibiotic use globally and is a key driver of the rising threat of antibiotic resistance. It is becoming increasingly important to better understand antibiotic use in livestock in low-and-middle income countries where antibiotic use is predicted to increase considerably as a consequence of the growing demand for animal-derived products. Antibiotic crossover-use refers to the practice of using antibiotic formulations licensed for humans in animals and vice versa. This practice has the potential to cause adverse drug reactions and contribute to the development and spread of antibiotic resistance between humans and animals. We performed secondary data analysis of in-depth interview and focus-group discussion transcripts from independent studies investigating antibiotic use in agricultural communities in Uganda, Tanzania and India to understand the practice of antibiotic crossover-use by medicine-providers and livestock-keepers in these settings. Thematic analysis was conducted to explore driving factors of reported antibiotic crossover-use in the three countries. Similarities were found between countries regarding both the accounts of antibiotic crossover-use and its drivers. In all three countries, chickens and goats were treated with human antibiotics, and among the total range of human antibiotics reported, amoxicillin, tetracycline and penicillin were stated as used in animals in all three countries. The key themes identified to be driving crossover-use were: (1) medicine-providers' and livestock-keepers' perceptions of the effectiveness and safety of antibiotics, (2) livestock-keepers' sources of information, (3) differences in availability of human and veterinary services and antibiotics, (4) economic incentives and pressures. Antibiotic crossover-use occurs in low-intensity production agricultural settings in geographically distinct low-and-middle income countries, influenced by a similar set of interconnected contextual drivers. Improving accessibility and affordability of veterinary medicines to both livestock-keepers and medicine-providers is required alongside interventions to address understanding of the differences between human and animal antibiotics, and potential dangers of antibiotic crossover-use in order to reduce the practice. A One Health approach to studying antibiotic use is necessary to understand the implications of antibiotic accessibility and use in one sector upon antibiotic use in other sectors.