Strategic Approach for Prioritising Local and Regional Sanitation Interventions for Reducing Global Antibiotic Resistance

Globally increasing antibiotic resistance (AR) will only be reversed through a suite of multidisciplinary actions (One Health), including more prudent antibiotic use and improved sanitation on international scales. Relative to sanitation, advanced technologies exist that reduce AR in waste releases, but such technologies are expensive, and a strategic approach is needed to prioritize more affordable mitigation options, especially for Low- and Middle-Income Countries (LMICs). Such an approach is proposed here, which overlays the incremental cost of different sanitation options and their relative benefit in reducing AR, ultimately suggesting the “next-most-economic” options for different locations. When considering AR gene fate versus intervention costs, reducing open defecation (OD) and increasing decentralized secondary wastewater treatment, with condominial sewers, will probably have the greatest impact on reducing AR, for the least expense. However, the best option for a given country depends on the existing sewerage infrastructure. Using Southeast Asia as a case study and World Bank/WHO/UNICEF data, the approach suggests that Cambodia and East Timor should target reducing OD as a national priority. In contrast, increasing decentralized secondary treatment is well suited to Thailand, Vietnam and rural Malaysia. Our approach provides a science-informed starting point for decision-makers, for prioritising AR mitigation interventions; an approach that will evolve and refine as more data become available.

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Characteristics of a Nationwide Voluntary Antibiotic Resistance Awareness Campaign in India; Future Paths and Pointers for Resource Limited Settings/Low and Middle Income Countries

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16245141 ◽

2019 ◽

Vol 16 (24) ◽

pp. 5141

Author(s):

Ashok J. Tamhankar ◽

Ramesh Nachimuthu ◽

Ravikant Singh ◽

Jyoti Harindran ◽

Gautam Kumar Meghwanshi ◽

...

Keyword(s):

Antibiotic Resistance ◽

Antibiotic Use ◽

World Health ◽

Awareness Campaign ◽

Resource Limited Settings ◽

Middle Income ◽

Middle Income Countries ◽

Awareness Campaigns ◽

Resource Limited ◽

Low And Middle Income

Antibiotic resistance has reached alarming proportions globally, prompting the World Health Organization to advise nations to take up antibiotic awareness campaigns. Several campaigns have been taken up worldwide, mostly by governments. The government of India asked manufacturers to append a ‘redline’ to packages of antibiotics as identification marks and conducted a campaign to inform the general public about it and appropriate antibiotic use. We investigated whether an antibiotic resistance awareness campaign could be organized voluntarily in India and determined the characteristics of the voluntarily organized campaign by administering a questionnaire to the coordinators, who participated in organizing the voluntary campaign India. The campaign characteristics were: multiple electro–physical pedagogical and participatory techniques were used, 49 physical events were organized in various parts of India that included lectures, posters, booklet/pamphlet distribution, audio and video messages, competitions, and mass contact rallies along with broadcast of messages in 11 local languages using community radio stations (CRS) spread all over India. The median values for campaign events were: expenditure—3000 Indian Rupees/day (US$~47), time for planning—1 day, program spread—4 days, program time—4 h, direct and indirect reach of the message—respectively 250 and 500 persons/event. A 2 min play entitled ‘Take antibiotics as prescribed by the doctor’ was broadcast 10 times/day for 5 days on CRS with listener reach of ~5 million persons. More than 85%ofcoordinators thought that the campaign created adequate awareness about appropriate antibiotic use and antibiotic resistance. The voluntary campaign has implications for resource limited settings/low and middle income countries.

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Optical maps of plasmids as a proxy for clonal spread of MDR bacteria: a case study of an outbreak in a rural Ethiopian hospital

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dkaa258 ◽

2020 ◽

Vol 75 (10) ◽

pp. 2804-2811

Author(s):

Yii-Lih Lin ◽

Tsegaye Sewunet ◽

Sriram KK ◽

Christian G Giske ◽

Fredrik Westerlund

Keyword(s):

Antibiotic Resistance ◽

Resistance Genes ◽

Large Fraction ◽

Antibiotic Resistance Genes ◽

Future Application ◽

Resistant Bacteria ◽

Middle Income ◽

Middle Income Countries ◽

Clonal Spread

Abstract Objectives MDR bacteria have become a prevailing health threat worldwide. We here aimed to use optical DNA mapping (ODM) as a rapid method to trace nosocomial spread of bacterial clones and gene elements. We believe that this method has the potential to be a tool of pivotal importance for MDR control. Methods Twenty-four Escherichia coli samples of ST410 from three different wards were collected at an Ethiopian hospital and their plasmids were analysed by ODM. Plasmids were specifically digested with Cas9 targeting the antibiotic resistance genes, stained by competitive binding and confined in nanochannels for imaging. The resulting intensity profiles (barcodes) for each plasmid were compared to identify potential clonal spread of resistant bacteria. Results ODM demonstrated that a large fraction of the patients carried bacteria with a plasmid of the same origin, carrying the ESBL gene blaCTX-M-15, suggesting clonal spread. The results correlate perfectly with core genome (cg)MLST data, where bacteria with the same plasmid also had very similar cgMLST profiles. Conclusions ODM is a rapid discriminatory method for identifying plasmids and antibiotic resistance genes. Long-range deletions/insertions, which are challenging for short-read next-generation sequencing, can be easily identified and used to trace bacterial clonal spread. We propose that plasmid typing can be a useful tool to identify clonal spread of MDR bacteria. Furthermore, the simplicity of the method enables possible future application in low- and middle-income countries.

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Development of Antimicrobial Stewardship Programmes in Low and Middle-Income Countries: A Mixed-Methods Study in Nigerian Hospitals

Antibiotics ◽

10.3390/antibiotics9040204 ◽

2020 ◽

Vol 9 (4) ◽

pp. 204 ◽

Cited By ~ 3

Author(s):

Eneyi E. Kpokiri ◽

David G. Taylor ◽

Felicity J. Smith

Keyword(s):

Antibiotic Resistance ◽

Antimicrobial Resistance ◽

Antimicrobial Stewardship ◽

Antibiotic Use ◽

World Health ◽

Local Context ◽

Prescribing Practices ◽

Middle Income ◽

Middle Income Countries ◽

Low And Middle Income

Antimicrobial resistance (AMR) is a major concern facing global health today, with the greatest impact in developing countries where the burden of infectious diseases is much higher. The inappropriate prescribing and use of antibiotics are contributory factors to increasing antibiotic resistance. Antimicrobial stewardship programmes (AMS) are implemented to optimise use and promote behavioural change in the use of antimicrobials. AMS programmes have been widely employed and proven to improve antibiotic use in many high-income settings. However, strategies to contain antimicrobial resistance have yet to be successfully implemented in low-resource settings. A recent toolkit for AMS in low- and middle-income countries by the World Health Organisation (WHO) recognizes the importance of local context in the development of AMS programmes. This study employed a bottom-up approach to identify important local determinants of antimicrobial prescribing practices in a low-middle income setting, to inform the development of a local AMS programme. Analysis of prescribing practices and interviews with prescribers highlighted priorities for AMS, which include increasing awareness of antibiotic resistance, development and maintenance of guidelines for antibiotic use, monitoring and surveillance of antibiotic use, ensuring the quality of low-cost generic medicines, and improved laboratory services. The application of an established theoretical model for behaviour change guided the development of specific proposals for AMS. Finally, in a consultation with stakeholders, the feasibility of the plan was explored along with strategies for its implementation. This project provides an example of the design, and proposal for implementation of an AMS plan to improve antibiotic use in hospitals in low-middle income settings.

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Awareness of Antibiotic Use and Resistance in Jordanian Community

Journal of Primary Care & Community Health ◽

10.1177/2150132720961255 ◽

2020 ◽

Vol 11 ◽

pp. 215013272096125 ◽

Cited By ~ 1

Author(s):

Derar H. Abdel-Qader ◽

Abdullah Albassam ◽

Najlaa Saadi Ismael ◽

Asma’ A. El-Shara’ ◽

Aisha Shehri ◽

...

Keyword(s):

Antibiotic Resistance ◽

Public Awareness ◽

Antibiotic Use ◽

Cross Sectional ◽

Middle Income ◽

The Public ◽

Inappropriate Use ◽

Middle Income Countries ◽

Antibiotics Use ◽

Deprived Areas

Background The public awareness toward the causes and consequences of antibiotic resistance (AR) is crucial to mitigate the inappropriate use of antibiotics (ABs), particularly in the low- and middle-income countries. There was no previous study that assessed the awareness, attitude, and knowledge about antibiotic use and AR among the Jordanian public in affluent and deprived areas. Objective This study aimed to assess the awareness, attitude, and knowledge about antibiotic use and AR in affluent and deprived areas in Jordan. Setting The survey was conducted in November 2019 in Amman, the capital of Jordan. Method A cross-sectional questionnaire was used to survey households in their areas in each of West Amman (affluent region) and East Amman (deprived region), Households were selected using proportionate random sampling method. Results A total of 620 householders (310 per area) completed the questionnaire. Pharmacists were perceived as strong influencers on householders’ decision, as 80.32% (n = 465/580) of those who used antibiotics in the last year follow pharmacists’ advice. Our results showed poor understanding of antibiotic usage among the Jordanian public, as only 14.2% (n = 44/310) of the sample in West Amman and 2.9% (n = 9/310) in East Amman disagreed with the statement “ Antibiotics work on most coughs and colds.” Householders in West Amman showed much better understanding of AR compared to those in East Amman; 82.3% (n = 255/310) of West Amman respondents agreed with the statement “ Antibiotic resistance occurs when bacteria change in some way that reduces or eliminates the effectiveness of the antibiotic.” compared to 31.9% (n = 99/310) of East Amman respondents on the same statement ( P < .05). Conclusion The Jordanian community generally had poor knowledge and awareness toward antibiotics use and AR. Socio-economic factors could influence the public’s attitude toward antibiotics use and AR.

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Determinants of trends in reported antibiotic use among sick children under five years of age across low-income and middle-income countries in 2005-17: a systematic analysis of user characteristics based on 132 national surveys from 73 countries

International Journal of Infectious Diseases ◽

10.1016/j.ijid.2021.05.058 ◽

2021 ◽

Author(s):

Gbemisola Allwell-Brown ◽

Laith Hussain-Alkhateeb ◽

Maquins Odhiambo Sewe ◽

Freddy Eric Kitutu ◽

Susanne Strömdahl ◽

...

Keyword(s):

Low Income ◽

Antibiotic Use ◽

User Characteristics ◽

Systematic Analysis ◽

Middle Income ◽

Children Under Five ◽

Under Five ◽

National Surveys ◽

Middle Income Countries ◽

Sick Children

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The challenge of cancer in middle-income countries with an ageing population: Mexico as a case study

ecancermedicalscience ◽

10.3332/ecancer.2015.536 ◽

2015 ◽

Vol 9 ◽

Cited By ~ 14

Author(s):

Ajay Aggarwal

Keyword(s):

Ageing Population ◽

Middle Income ◽

Middle Income Countries

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Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda

Gates Open Research ◽

10.12688/gatesopenres.13214.1 ◽

2021 ◽

Vol 5 ◽

pp. 72

Author(s):

Lisa R. Hirschhorn ◽

Miriam Frisch ◽

Jovial Thomas Ntawukuriryayo ◽

Amelia VanderZanden ◽

Kateri Donahoe ◽

...

Keyword(s):

Health System ◽

Implementation Research ◽

Contextual Factors ◽

Common Pathway ◽

Middle Income ◽

Middle Income Countries ◽

Mixed Methods Case Study ◽

Hybrid Framework ◽

Successes And Challenges

Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) – deaths preventable through health system-delivered evidence-based interventions (EBIs) – in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification and testing of strategies, work to achieve sustainability at scale and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda’s actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country’s success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.

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