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Bennett C, Russel W, Upton R, Frey F, Taye B. Social and ecological determinants of antimicrobial resistance in Africa: a systematic review of epidemiological evidence. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e119. [PMID: 39257424 PMCID: PMC11384158 DOI: 10.1017/ash.2024.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 09/12/2024]
Abstract
Background Antimicrobial resistance (AMR) is one of the greatest global health problems for humans, animals, and the environment. Although the association between various factors and AMR is being increasingly researched, the need to understand the contribution of social and ecological determinants, especially in developing nations, remains. This review fills these knowledge gaps by synthesizing existing evidence on the social and ecological determinants of AMR in Africa. Results Twenty-four studies were selected based on predefined criteria from PubMed. 58.33% (n = 14) and 29.17% (n = 7) of the studies reported on ecological and social determinants of AMR, respectively, and 3 (12.5%) studies documented both social and environmental determinants of AMR. Sociodemographic factors include increased household size, poor knowledge, attitudes toward AMR, low educational levels, and rural residences. Indicators of poor water sanitation and hygiene, framing practices, and consumption of farm products were among the common ecological determinants of AMR and AM misuse in Africa. Conclusion Our review demonstrates the importance of social and ecological determinants of AMR among African populations. The findings may be valuable to researchers, policymakers, clinicians, and those working in lower-income countries to implement AMR prevention programs utilizing a holistic approach.
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Affiliation(s)
- Catherine Bennett
- Department of Neuroscience, Colgate University, Hamilton, NY, USA
- Global Public Environmental Health, Colgate University, Hamilton, NY, USA
| | - Will Russel
- Global Public Environmental Health, Colgate University, Hamilton, NY, USA
- Department of Biology, Colgate University, Hamilton, NY, USA
| | - Rebecca Upton
- Global Public Environmental Health, Colgate University, Hamilton, NY, USA
| | - Frank Frey
- Global Public Environmental Health, Colgate University, Hamilton, NY, USA
- Department of Biology, Colgate University, Hamilton, NY, USA
| | - Bineyam Taye
- Global Public Environmental Health, Colgate University, Hamilton, NY, USA
- Department of Biology, Colgate University, Hamilton, NY, USA
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Zhang T, Nickerson R, Zhang W, Peng X, Shang Y, Zhou Y, Luo Q, Wen G, Cheng Z. The impacts of animal agriculture on One Health-Bacterial zoonosis, antimicrobial resistance, and beyond. One Health 2024; 18:100748. [PMID: 38774301 PMCID: PMC11107239 DOI: 10.1016/j.onehlt.2024.100748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 05/02/2024] [Indexed: 05/24/2024] Open
Abstract
The industrialization of animal agriculture has undoubtedly contributed to the improvement of human well-being by increasing the efficiency of food animal production. At the same time, it has also drastically impacted the natural environment and human society. The One Health initiative emphasizes the interdependency of the health of ecosystems, animals, and humans. In this paper, we discuss some of the most profound consequences of animal agriculture practices from a One Health perspective. More specifically, we focus on impacts to host-microbe interactions by elaborating on how modern animal agriculture affects zoonotic infections, specifically those of bacterial origin, and the concomitant emergence of antimicrobial resistance (AMR). A key question underlying these deeply interconnected issues is how to better prevent, monitor, and manage infections in animal agriculture. To address this, we outline approaches to mitigate the impacts of agricultural bacterial zoonoses and AMR, including the development of novel treatments as well as non-drug approaches comprising integrated surveillance programs and policy and education regarding agricultural practices and antimicrobial stewardship. Finally, we touch upon additional major environmental and health factors impacted by animal agriculture within the One Health context, including animal welfare, food security, food safety, and climate change. Charting how these issues are interwoven to comprise the complex web of animal agriculture's broad impacts on One Health will allow for the development of concerted, multidisciplinary interventions which are truly necessary to tackle these issues from a One Health perspective.
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Affiliation(s)
- Tengfei Zhang
- Key Laboratory of Prevention and Control Agents for Animal Bacteriosis (Ministry of Agriculture and Rural Affairs), Hubei Provincial Key Laboratory of Animal Pathogenic Microbiology, Institute of Animal Husbandry and Veterinary, Hubei Academy of Agricultural Sciences, Wuhan 430064, China
| | - Rhea Nickerson
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Wenting Zhang
- Key Laboratory of Prevention and Control Agents for Animal Bacteriosis (Ministry of Agriculture and Rural Affairs), Hubei Provincial Key Laboratory of Animal Pathogenic Microbiology, Institute of Animal Husbandry and Veterinary, Hubei Academy of Agricultural Sciences, Wuhan 430064, China
| | - Xitian Peng
- Institute of Quality Standard and Testing Technology for Agro-Products, Hubei Academy of Agricultural Sciences, Wuhan 430064, Hubei, China
- Hubei Key Laboratory of Nutritional Quality and Safety of Agro-products, Wuhan 430064, Hubei, China
- Ministry of Agriculture and Rural Affairs Laboratory of Quality and Safe Risk Assessment for Agro-products (Wuhan), Wuhan 430064, Hubei, China
| | - Yu Shang
- Key Laboratory of Prevention and Control Agents for Animal Bacteriosis (Ministry of Agriculture and Rural Affairs), Hubei Provincial Key Laboratory of Animal Pathogenic Microbiology, Institute of Animal Husbandry and Veterinary, Hubei Academy of Agricultural Sciences, Wuhan 430064, China
| | - Youxiang Zhou
- Institute of Quality Standard and Testing Technology for Agro-Products, Hubei Academy of Agricultural Sciences, Wuhan 430064, Hubei, China
- Hubei Key Laboratory of Nutritional Quality and Safety of Agro-products, Wuhan 430064, Hubei, China
- Ministry of Agriculture and Rural Affairs Laboratory of Quality and Safe Risk Assessment for Agro-products (Wuhan), Wuhan 430064, Hubei, China
| | - Qingping Luo
- Key Laboratory of Prevention and Control Agents for Animal Bacteriosis (Ministry of Agriculture and Rural Affairs), Hubei Provincial Key Laboratory of Animal Pathogenic Microbiology, Institute of Animal Husbandry and Veterinary, Hubei Academy of Agricultural Sciences, Wuhan 430064, China
- Hubei Hongshan Laboratory, Wuhan 430064, China
| | - Guoyuan Wen
- Key Laboratory of Prevention and Control Agents for Animal Bacteriosis (Ministry of Agriculture and Rural Affairs), Hubei Provincial Key Laboratory of Animal Pathogenic Microbiology, Institute of Animal Husbandry and Veterinary, Hubei Academy of Agricultural Sciences, Wuhan 430064, China
| | - Zhenyu Cheng
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
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Nguyen-Thanh L, Wernli D, Målqvist M, Graells T, Jørgensen PS. Characterising proximal and distal drivers of antimicrobial resistance: An umbrella review. J Glob Antimicrob Resist 2024; 36:50-58. [PMID: 38128730 DOI: 10.1016/j.jgar.2023.12.008] [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: 08/22/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a multifactorial challenge driven by a complex interplay of proximal drivers, such as the overuse and misuse of antimicrobials and the high burden of infectious diseases, and distal factors, encompassing broader societal conditions such as poverty, inadequate sanitation, and healthcare system deficiencies. However, distinguishing between proximal and distal drivers remains a conceptual challenge. OBJECTIVES We conducted an umbrella review, aiming to systematically map current evidence about proximal and distal drivers of AMR and to investigate their relationships. METHODS Forty-seven reviews were analysed, and unique causal links were retained to construct a causality network of AMR. To distinguish between proximal and distal drivers, we calculated a 'driver distalness index (Di)', defined as an average relative position of a driver in its causal pathways to AMR. RESULTS The primary emphasis of the literature remained on proximal drivers, with fragmented existing evidence about distal drivers. The network analysis showed that proximal drivers of AMR are associated with risks of resistance transmission (Di = 0.49, SD = 0.14) and antibiotic use (Di = 0.58, SD = 0.2), which are worsened by intermediate drivers linked with challenges of antibiotic discovery (Di = 0.62, SD = 0.07), infection prevention (Di = 0.67, SD = 0.14) and surveillance (Di = 0.69, SD = 0.16). Distal drivers, such as living conditions, access to sanitation infrastructure, population growth and urbanisation, and gaps in policy implementation were development and governance challenges, acting as deep leverage points in the system in addressing AMR. CONCLUSIONS Comprehensive AMR strategies aiming to address multiple chronic AMR challenges must take advantage of opportunities for upstream interventions that specifically address distal drivers.
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Affiliation(s)
- Luong Nguyen-Thanh
- SWEDESD - Sustainability Learning and Research Center, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Uppsala Antibiotic Centre (UAC), Uppsala University, Uppsala, Sweden; Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden.
| | - Didier Wernli
- Global Studies Institute and Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Mats Målqvist
- SWEDESD - Sustainability Learning and Research Center, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Peter Søgaard Jørgensen
- SWEDESD - Sustainability Learning and Research Center, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden; Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden.
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Graells T, Lambraki IA, Cousins M, Léger A, Henriksson PJG, Troell M, Carson CA, Parmley EJ, Majowicz SE, Wernli D, Jørgensen PS. Exploring the factors that contribute to the successful implementation of antimicrobial resistance interventions: a comparison of high-income and low-middle-income countries. Front Public Health 2023; 11:1230848. [PMID: 37900049 PMCID: PMC10612146 DOI: 10.3389/fpubh.2023.1230848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/13/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a challenge to modern medicine. Interventions have been applied worldwide to tackle AMR, but these actions are often not reported to peers or published, leading to important knowledge gaps about what actions are being taken. Understanding factors that influence the implementation of AMR interventions and what factors are relevant in low-middle-income countries (LMICs) and high-income countries (HICs) were the key objectives of this exploratory study, with the aim to identifying which priorities these contexts need. Methods A questionnaire was used to explore context, characteristics, and success factors or obstacles to intervention success based on participant input. The context was analyzed using the AMR-Intervene framework, and success factors and obstacles to intervention success were identified using thematic analysis. Results Of the 77 interventions, 57 were implemented in HICs and 17 in LMICs. Interventions took place in the animal sector, followed by the human sector. Public organizations were mainly responsible for implementation and funding. Nine themes and 32 sub-themes emerged as important for intervention success. The themes most frequently reported were 'behavior', 'capacity and resources', 'planning', and 'information'. Five sub-themes were key in all contexts ('collaboration and coordination', 'implementation', 'assessment', 'governance', and 'awareness'), two were key in LMICs ('funding and finances' and 'surveillance, antimicrobial susceptibility testing and preventive screening'), and five were key in HICs ('mandatory', 'multiple profiles', 'personnel', 'management', and 'design'). Conclusion LMIC sub-themes showed that funding and surveillance were still key issues for interventions, while important HIC sub-themes were more specific and detailed, including mandatory enforcement, multiple profiles, and personnel needed for good management and good design. While behavior is often underrated when implementing AMR interventions, capacity and resources are usually considered, and LMICs can benefit from sub-themes captured in HICs if tailored to their contexts. The factors identified can improve the design, planning, implementation, and evaluation of interventions.
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Affiliation(s)
- Tiscar Graells
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
| | - Irene A. Lambraki
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Melanie Cousins
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Anaïs Léger
- Global Studies Institute, University of Geneva, Genève, Switzerland
| | - Patrik J. G. Henriksson
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
- Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
- WorldFish, Penang, Malaysia
| | - Max Troell
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
- Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Carolee A. Carson
- Centre for Foodborne, Environmental and Zoonotic Infectious Diseases; Public Health Agency of Canada, Guelph, ON, Canada
| | - Elizabeth Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shannon E. Majowicz
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Genève, Switzerland
| | - Peter Søgaard Jørgensen
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
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Raut J, Joshi A, Mudey A, Mehendale AM. The Past, Present, and Future of One Health in India: A Narrative Review. Cureus 2023; 15:e44992. [PMID: 37829943 PMCID: PMC10564975 DOI: 10.7759/cureus.44992] [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: 08/11/2023] [Accepted: 09/10/2023] [Indexed: 10/14/2023] Open
Abstract
Humans have experienced a long-lasting pandemic of COVID-19 going on since the year 2020. Such events have recently increased the demand for a competent disease outbreak response system, more precisely, a One Health platform. The interaction between humans, animals, and ecosystems is inevitable. It is a known fact that the interface between these three entities is important for survival. In rural areas, especially in developing countries, it is a common practice to keep the animal shed in close proximity to their homes. Further, this intricate relationship itself plays a role in the spread and transmission of the disease. The involvement of the human-animal interface in emerging and re-emerging diseases has caused havoc in recent times and might prove challenging to overcome. Over the years, many efforts have been made on international and national platforms to adopt and implement a transdisciplinary, collaborative, intersectoral approach in India. This review highlights the major initiatives taken for the implementation of one health and the challenges faced over the years in our country.
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Affiliation(s)
- Juhi Raut
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhishek Joshi
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhay Mudey
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ashok M Mehendale
- Preventive Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Wernli D, Søgaard Jørgensen P, Parmley EJ, Majowicz SE, Lambraki I, Carson CA, Cousins M, Graells T, Henriksson PJG, Léger A, Harbarth S, Troell M. Scope and applicability of social-ecological resilience to antimicrobial resistance. Lancet Planet Health 2023; 7:e630-e637. [PMID: 37438004 DOI: 10.1016/s2542-5196(23)00128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/15/2022] [Accepted: 05/31/2023] [Indexed: 07/14/2023]
Abstract
Social-ecological systems conceptualise how social human systems and ecological natural systems are intertwined. In this Personal View, we define the scope and applicability of social-ecological resilience to antimicrobial resistance. Resilience to antimicrobial resistance corresponds to the capacity to maintain the societal benefits of antimicrobial use and One Health systems' performance in the face of the evolutionary behaviour of microorganisms in response to antimicrobial use. Social-ecological resilience provides an appropriate framework to make sense of the disruptive impacts resulting from the emergence and spread of antimicrobial resistance; capture the diversity of strategies needed to tackle antimicrobial resistance and to live with it; understand the conditions that underpin the success or failure of interventions; and appreciate the need for adaptive and coevolutionary governance. Overall, resilience thinking is essential to improve understanding of how human societies dynamically can cope with, adapt, and transform to the growing global challenge of antimicrobial resistance.
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Affiliation(s)
- Didier Wernli
- Global Studies Institute, University of Geneva, Geneva, Switzerland.
| | - Peter Søgaard Jørgensen
- Global Economic Dynamics and the Biosphere, The Royal Swedish Academy of Sciences, Stockholm, Sweden; Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
| | - E Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shannon E Majowicz
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Irene Lambraki
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Carolee A Carson
- Centre for Food-borne, Environmental Zoonotic and Infectious Diseases, Public Health Agency of Canada, Guelph, ON, Canada
| | - Melanie Cousins
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, The Royal Swedish Academy of Sciences, Stockholm, Sweden; Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
| | - Patrik J G Henriksson
- Beijer Institute of Ecological Economics, The Royal Swedish Academy of Sciences, Stockholm, Sweden; Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden; WorldFish, Jalan Batu Maung, Penang, Malaysia
| | - Anaïs Léger
- Federal Food Safety and Veterinary Office, Bern, Switzerland
| | - Stephan Harbarth
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Max Troell
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
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Singleton D, Ibarz-Pavon A, Swarthout TD, Bonomali F, Cornick J, Kalizang'oma A, Ntiza N, Brown C, Chipatala R, Nyangulu W, Chirombo J, Kawalazira G, Chibowa H, Mwansambo C, Maleta KM, French N, Heyderman RS. Cross-sectional health centre and community-based evaluation of the impact of pneumococcal and malaria vaccination on antibiotic prescription and usage, febrile illness and antimicrobial resistance in young children in Malawi: the IVAR study protocol. BMJ Open 2023; 13:e069560. [PMID: 37173105 PMCID: PMC10186476 DOI: 10.1136/bmjopen-2022-069560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Vaccination is a potentially critical component of efforts to arrest development and dissemination of antimicrobial resistance (AMR), though little is known about vaccination impact within low-income and middle-income countries. This study will evaluate the impact of vaccination on reducing carriage prevalence of resistant Streptococcus pneumoniae and extended spectrum beta-lactamase-producing Escherichia coli and Klebsiella species. We will leverage two large ongoing cluster-randomised vaccine evaluations in Malawi assessing; first, adding a booster dose to the 13-valent pneumococcal conjugate vaccine (PCV13) schedule, and second, introduction of the RTS,S/AS01 malaria vaccine. METHODS AND ANALYSIS Six cross-sectional surveys will be implemented within primary healthcare centres (n=3000 users of outpatient facilities per survey) and their local communities (n=700 healthy children per survey): three surveys in Blantyre district (PCV13 component) and three surveys in Mangochi district (RTS,S/AS01 component). We will evaluate antibiotic prescription practices and AMR carriage in children ≤3 years. For the PCV13 component, surveys will be conducted 9, 18 and 33 months following a 3+0 to 2+1 schedule change. For the RTS,S/AS01 component, surveys will be conducted 32, 44 and 56 months post-RTS,S/AS01 introduction. Six health centres in each study component will be randomly selected for study inclusion. Between intervention arms, the primary outcome will be the difference in penicillin non-susceptibility prevalence among S. pneumoniae nasopharyngeal carriage isolates in healthy children. The study is powered to detect an absolute change of 13 percentage points (ie, 35% vs 22% penicillin non-susceptibility). ETHICS AND DISSEMINATION This study has been approved by the Kamuzu University of Health Sciences (Ref: P01-21-3249), University College London (Ref: 18331/002) and University of Liverpool (Ref: 9908) Research Ethics Committees. Parental/caregiver verbal or written informed consent will be obtained prior to inclusion or recruitment in the health centre-based and community-based activities, respectively. Results will be disseminated via the Malawi Ministry of Health, WHO, peer-reviewed publications and conference presentations.
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Affiliation(s)
- David Singleton
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Ana Ibarz-Pavon
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Todd D Swarthout
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Research Department of Infection, Division of Infection and Immunity, UCL, London, UK
| | - Farouck Bonomali
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jennifer Cornick
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Akuzike Kalizang'oma
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
- Research Department of Infection, Division of Infection and Immunity, UCL, London, UK
| | - Noah Ntiza
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Comfort Brown
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Raphael Chipatala
- Department of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Wongani Nyangulu
- Department of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - James Chirombo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | | | | | - Neil French
- Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Robert S Heyderman
- Research Department of Infection, Division of Infection and Immunity, UCL, London, UK
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Lambraki IA, Chadag MV, Cousins M, Graells T, Léger A, Henriksson PJG, Troell MF, Harbarth S, Wernli D, Jørgensen PS, Carson CA, Parmley EJ, Majowicz SE. Factors impacting antimicrobial resistance in the South East Asian food system and potential places to intervene: A participatory, one health study. Front Microbiol 2023; 13:992507. [PMID: 36687632 PMCID: PMC9849958 DOI: 10.3389/fmicb.2022.992507] [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: 07/14/2022] [Accepted: 12/07/2022] [Indexed: 01/07/2023] Open
Abstract
Background With AMU projected to increase, South East Asia (SEA) is at high risk of experiencing disproportionate health, social, and economic burdens due to antimicrobial resistance (AMR). Our objective was to identify factors influencing AMR in SEA's food system and places for intervention by integrating the perspectives of experts from the region to inform policy and management decisions. Materials and methods We conducted two 6.5 h workshops and two 90-min interviews involving 18 AMR and other disciplinary experts from human, animal, and environment sectors who brainstormed the factors influencing AMR and identified leverage points (places) for intervention. Transcripts and workshop materials were coded for factors and their connections and transcribed into a causal loop diagram (CLD). Thematic analysis described AMR dynamics in SEA's food system and leverage points for intervention. The CLD and themes were confirmed via participant feedback. Results Participants constructed a CLD of AMR in the SEA food system that contained 98 factors interlinked by 362 connections. CLD factors reflected eight sub-areas of the SEA food system (e.g., government). Seven themes [e.g., antimicrobial and pesticide use and AMR spread (n = 40 quotes)], six "overarching factors" that impact the entire AMR system [e.g., the drive to survive (n = 12 quotes)], and 10 places for intervention that target CLD factors (n = 5) and overarching factors (n = 2) emerged from workshop discussions. Conclusion The participant derived CLD of factors influencing AMR in the SEA food system demonstrates that AMR is a product of numerous interlinked actions taken across the One Health spectrum and that finding solutions is no simple task. Developing the model enabled the identification of potentially promising leverage points across human, animal, and environment sectors that, if comprehensively targeted using multi-pronged interventions, could evoke system wide changes that mitigate AMR. Even targeting some leverage points for intervention, such as increasing investments in research and capacity building, and setting and enforcing regulations to control antimicrobial supply, demand, and use could, in turn, shift mindsets that lead to changes in more difficult to alter leverage points, such as redefining the profit-driven intent that drives system behavior in ways that transform AMU and sustainably mitigate AMR.
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Affiliation(s)
- Irene Anna Lambraki
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada,*Correspondence: Irene Anna Lambraki, ✉
| | | | - Melanie Cousins
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden,Stockholm Resilience Center, Stockholm University, Stockholm, Sweden
| | - Anaïs Léger
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Patrik John Gustav Henriksson
- WorldFish, Penang, Malaysia,Stockholm Resilience Center, Stockholm University, Stockholm, Sweden,Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Max Fredrik Troell
- Stockholm Resilience Center, Stockholm University, Stockholm, Sweden,Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Stephan Harbarth
- Infection Control Program and WHO Collaborating Center on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Peter Søgaard Jørgensen
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden,Stockholm Resilience Center, Stockholm University, Stockholm, Sweden
| | - Carolee Anne Carson
- Foodborne Disease and Antimicrobial Resistance Surveillance Division, Public Health Agency of Canada, Guelph, ON, Canada
| | - Elizabeth Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shannon E. Majowicz
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
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Wernli D, Tediosi F, Blanchet K, Lee K, Morel C, Pittet D, Levrat N, Young O. A Complexity Lens on the COVID-19 Pandemic. Int J Health Policy Manag 2022; 11:2769-2772. [PMID: 34124870 PMCID: PMC9818100 DOI: 10.34172/ijhpm.2021.55] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 04/30/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Didier Wernli
- Geneva Transformative Governance Lab, Global Studies Institute, University of Geneva, Geneva, Switzerland
- School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, Faculty of Medicine, University of Geneva and Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Kelley Lee
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Chantal Morel
- Geneva Transformative Governance Lab, Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Levrat
- Geneva Transformative Governance Lab, Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Oran Young
- Bren School of Environmental Science and Management, University of California at Santa Barbara, Santa Barbara, CA, USA
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10
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Sneddon J, Guise T, Jenkins D, Mpundu M, Van Dongen M, Schouten J, Xiao J, Cordoba G, Nathwani D. Introducing the global antimicrobial stewardship partnership hub (GASPH): creating conditions for successful global partnership collaboration. JAC Antimicrob Resist 2022; 4:dlac115. [DOI: 10.1093/jacamr/dlac115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Abstract
In 2015, 196 countries formally committed to a Global Action Plan to address antimicrobial resistance (AMR). However, translating policy into practice is not happening at pace and the recent Global Research on AntiMicrobial resistance (GRAM) Project report confirms the burden of AMR is increasing. Despite progress in establishing surveillance data and investment in new antimicrobials, education and training including use of behavioural science approaches to change practice is lagging. To contribute to addressing this, we have invited organizations to join us as founding members of the Global Antimicrobial Stewardship Partnership Hub (GASPH) (https://global-asp-hub.com/). We will work together to share education resources and foster collaboration to meet the needs of learners and of partner organizations working on tackling AMR. Membership is open to all—professional societies, academic institutes, nongovernmental organizations/civil society, philanthropists and commercial partners interested in supporting a multi-stakeholder global antimicrobial stewardship (AMS) education platform and network.
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Affiliation(s)
| | - Tracey Guise
- British Society for Antimicrobial Chemotherapy , Birmingham , UK
| | - David Jenkins
- British Society for Antimicrobial Chemotherapy , Birmingham , UK
- Department of Microbiology, University Hospitals of Leicester NHS Trust , Leicester , UK
| | | | | | - Jeroen Schouten
- Department of Intensive Care and Radboudumc Center for Infectious Diseases, European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Antimicrobial Stewardship (ESGAP) , Nijmegen , The Netherlands
| | - Jonghong Xiao
- School of Medicine, Zhejiang University , Hangzhou , China
| | - Gloria Cordoba
- International Centre for Antimicrobial Resistance Solutions , Copenhagen , Denmark
| | - Dilip Nathwani
- British Society for Antimicrobial Chemotherapy , Birmingham , UK
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11
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Wozniak TM, Cuningham W, Ledingham K, McCulloch K. Contribution of socio-economic factors in the spread of antimicrobial resistant infections in Australian primary healthcare clinics. J Glob Antimicrob Resist 2022; 30:294-301. [PMID: 35700913 DOI: 10.1016/j.jgar.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 05/26/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To effectively contain antimicrobial resistant (AMR) infections, we must better understand the social determinates of health that contribute to transmission and spread of infections. METHODS We used clinical data from patients attending primary healthcare clinics across three jurisdictions of Australia (2007-2019). Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) isolates and their corresponding antibiotic susceptibilities were included. Using multivariable logistic regression analysis, we assessed associations between AMR prevalence and indices of social disadvantage as reported by the Australian Bureau of Statistics (i.e. remoteness, socio-economic disadvantage and average person per household). RESULTS This study reports 12 years of longitudinal data from 43,448 isolates from a high-burden low resource setting in Australia. Access to health and social services (as measured by remoteness index) was a risk factor for increased prevalence of third-generation cephalosporin-resistant (3GC) E. coli (odds ratio 5.05; 95% confidence interval 3.19, 8.04) and methicillin-resistant S. aureus (MRSA) (odds ratio 5.72; 95% confidence interval 5.02, 6.54). We did not find a positive correlation of AMR and socio-economic disadvantage or average person per household indices. CONCLUSIONS Remoteness is a risk factor for increased prevalence of 3GC-resistant E.coli and MRSA. We demonstrate that traditional disease surveillance systems can be repurposed to capture the broader social drivers of AMR. Access to pathogen-specific and social data early and within the local regional context will fill a significant gap in disease prevention and the global spread of AMR.
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Affiliation(s)
- Teresa M Wozniak
- Australian e-Health Research Centre CSIRO, Brisbane, Queensland, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory.
| | - Will Cuningham
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory
| | - Katie Ledingham
- Department of Science, Innovation, Technology and Entrepreneurship, University of Exeter Business School
| | - Karen McCulloch
- Department of Infectious Diseases, Melbourne Medical School, University of Melbourne at the Peter Doherty Institute for Infection and Immunity; WHO Collaborating Centre for Viral Hepatitis, Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity
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Hamers RL, Cassini A, Asadinia KS, Bertagnolio S. Developing a priority global research agenda for antimicrobial resistance in the human health sector: protocol for a scoping review. BMJ Open 2022; 12:e060553. [PMID: 35654465 PMCID: PMC9163534 DOI: 10.1136/bmjopen-2021-060553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION To accelerate the response to the public health threat by antimicrobial resistance (AMR), the WHO is developing a Global Research Agenda for AMR in the human health sector that aims to provide a global and transparent assessment of priority knowledge gaps related to critical bacteria-including Mycobacterium tuberculosis-and fungi that inform control and response strategies to tackle AMR by 2030. A literature scoping review represents the first phase in a stepwise process, and we hereby outline the protocol to review current knowledge gaps and research questions on AMR in the human health sector. METHODS AND ANALYSIS This literature scoping review will follow the Arksey and O'Malley (2005) methodology and will include: (1) a hand search to identify relevant WHO guidelines and documents suggested by the WHO Steering Group for the AMR Global Research Agenda; (2) a grey literature search through a stakeholder mapping process and google searches of organisational websites; (3) a systematic search of relevant systematic reviews through bibliographic databases (PubMed, Embase and Web of Science); (4) screening of the reference lists of included studies. We will include relevant publications from the last 10 years (January 2012 to December 2021). Two researchers separately will review the yielded citations to determine eligibility based on predefined criteria. Relevant research questions with attributes will be extracted using a tool developed through an iterative process by the research team. Each identified research question will be classified and aggregated according to a conceptual framework (ie, 'knowledge matrix'), composed of three themes (ie, Prevention, Diagnosis and Care & Treatment) and four cross-cutting domains (ie, Descriptive, Discovery, Development, Delivery). We will present numerical and thematic summaries of the knowledge matrix. A qualitative content analysis is out of the scope of this protocol. ETHICS AND DISSEMINATION The scoping review process will only involve identification, selection and analysis of documents available for use in the public domain, and will not include any personal information on individuals, therefore ethical approval is not required. The findings will be disseminated through a peer-reviewed publication and stakeholder meetings.
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Affiliation(s)
- Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Alessandro Cassini
- Department of Surveillance, Prevention and Control, Division of Antimicrobial Resistance, World Health Organization, Geneva, Switzerland
| | | | - Silvia Bertagnolio
- Department of Surveillance, Prevention and Control, Division of Antimicrobial Resistance, World Health Organization, Geneva, Switzerland
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Studying Factors Affecting Success of Antimicrobial Resistance Interventions through the Lens of Experience: A Thematic Analysis. Antibiotics (Basel) 2022; 11:antibiotics11050639. [PMID: 35625282 PMCID: PMC9137464 DOI: 10.3390/antibiotics11050639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance (AMR) affects the environment, and animal and human health. Institutions worldwide have applied various measures, some of which have reduced antimicrobial use and AMR. However, little is known about factors influencing the success of AMR interventions. To address this gap, we engaged health professionals, designers, and implementers of AMR interventions in an exploratory study to learn about their experience and factors that challenged or facilitated interventions and the context in which interventions were implemented. Based on participant input, our thematic analysis identified behaviour; institutional governance and management; and sharing and enhancing information as key factors influencing success. Important sub-themes included: correct behaviour reinforcement, financial resources, training, assessment, and awareness of AMR. Overall, interventions were located in high-income countries, the human sector, and were publicly funded and implemented. In these contexts, behaviour patterns strongly influenced success, yet are often underrated or overlooked when designing AMR interventions. Improving our understanding of what contributes to successful interventions would allow for better designs of policies that are tailored to specific contexts. Exploratory approaches can provide encouraging results in complex challenges, as made evident in our study. Remaining challenges include more engagement in this type of study by professionals and characterisation of themes that influence intervention outcomes by context.
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14
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Factors influencing antimicrobial resistance in the European food system and potential leverage points for intervention: A participatory, One Health study. PLoS One 2022; 17:e0263914. [PMID: 35192666 PMCID: PMC8863257 DOI: 10.1371/journal.pone.0263914] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/29/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a global crisis that evolves from a complex system of factors. Understanding what factors interact is key to finding solutions. Our objective was to identify the factors influencing AMR in the European food system and places to intervene. Materials and methods We conducted two workshops involving participants with diverse perspectives to identify the factors influencing AMR and leverage points (places) to target interventions. Transcripts were open coded for factors and connections, then transcribed into Vensim 8.0.4 to develop a causal loop diagram (CLD) and compute the number of feedback loops. Thematic analysis followed to describe AMR dynamics in Europe’s food system and places for intervention. The CLD and themes were confirmed via participant feedback. Results Seventeen participants representing human, animal and agricultural sectors identified 91 CLD factors and 331 connections. Seven themes (e.g., social and economic conditions) describing AMR dynamics in Europe’s food system, five ‘overarching factors’ that impact the entire CLD system (e.g., leadership) and fourteen places for intervention (e.g., consumer demand) emerged from workshop discussions. Most leverage points fell on highly networked feedback loops suggesting that intervening at these places may create unpredictable consequences. Conclusions Our study produced a CLD of factors influencing AMR in Europe’s food system that implicates sectors across the One Health spectrum. The high connectivity between the CLD factors described by participants and our finding that factors are connected with many feedback mechanisms underscores the complexity of the AMR problem and the challenge with finding long-term solutions. Identifying factors and feedbacks helped identify relevant leverage points in the system. Some actions, such as government’s setting AMU standards may be easier to implement. These actions in turn can support multi-pronged actions that can help redefine the vision, values and goals of the system to sustainably tackle AMR.
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15
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Nathwani D. BSAC Vanguard Series: The future of healthcare workers and antimicrobial stewardship-educate, innovate, or pay the price. J Antimicrob Chemother 2022; 77:1213-1215. [PMID: 35022733 PMCID: PMC9383162 DOI: 10.1093/jac/dkab484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 12/04/2022] Open
Abstract
In delivering global healthcare, and in the context of antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) where information and knowledge is rapidly evolving, it is universally accepted that education and training of the healthcare workforce underpins the implementation of AMS and the effective use of existing and new health care technologies, therapies and informatics. Despite this, resourcing healthcare workforce education and training is often seen as a low priority, particularly in the resource-limited settings where the burden of AMR is greatest and healthcare resources are the most stretched. Therefore, it is disappointing to observe that, when funding the multi-dimensional AMR and AMS response, specific funding earmarked to support the development and implementation of both traditional and, increasingly, innovative education (particularly in the form of digital learning) is insufficient or lacking. In this article, I propose several novel strategies for addressing this deficit and to steer us to learn from the significant developments and support for education during the COVID-19 pandemic. If we do not invest in both traditional and innovative forms of education, our ability to create a well-trained healthcare workforce to deliver high-quality care and treatment, with better patient outcomes against AMR, will evaporate—and we will likely pay a far higher price as a consequence.
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Bertolino G, Marras L, Mureddu V, Camboni M, Cadeddu A. Trends of Antimicrobial Consumption in Hospital: Tackling the Hidden Part of the Iceberg with an Electronic Personalised Prescription Software for Antimicrobial Stewardship. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022. [DOI: 10.1007/5584_2022_752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Garza M, Mohan CV, Brunton L, Wieland B, Häsler B. Typology of interventions for antimicrobial use and antimicrobial resistance in aquaculture systems in low- and middle-income countries. Int J Antimicrob Agents 2022; 59:106495. [PMID: 34896577 DOI: 10.1016/j.ijantimicag.2021.106495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/17/2022]
Abstract
Indiscriminate antimicrobial use (AMU) in aquaculture to treat and prevent diseases is common and can lead to the emergence of antimicrobial-resistant micro-organisms, potentially impacting public health and connected ecosystems. This study aimed to develop a typology to classify and characterise interventions to reduce AMU in aquaculture and identify points of action. Seventeen aquaculture and animal health professionals in Asian and African countries were interviewed to gather information on characteristics of interventions in different contexts to develop a typology. Seven types of interventions were defined: (i) legislation and regulations; (ii) industry rules and standards; (iii) voluntary instruments; (iv) commercial technology and alternatives to antimicrobials; (v) on-farm management; (vi) learning and awareness-raising; and (vii) activities with co-benefits. Types were based on intervention function, scope of implementation, implementer, compulsion, strength of the intervention, AMU/antimicrobial resistance (AMR) objective and stakeholder to influence. For each type, examples were described and discussed. The most common interventions to address AMU and AMR were legislative and regulatory frameworks and voluntary instruments, including National Action Plans. Interventions addressing AMU/AMR specifically were scarce. Other interventions focused on indirect effect pathways to AMU and AMR reduction aiming to improve good aquaculture practices, disease prevention and improved management. Monitoring and evaluation of these interventions were found to be rare, only present for interventions driven by development projects and international agencies. The presented typology of existing strategies and interventions addressing AMU/AMR in aquaculture systems can guide evaluation of AMR-sensitive interventions that promote responsible AMU, and informs the design and implementation of future interventions.
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Affiliation(s)
- Maria Garza
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hatfield, United Kingdom
| | - Chadag V Mohan
- WorldFish, Jalan Batu Maung, Batu Maung, 11960 Bayan Lepas, Penang, Malaysia
| | - Lucy Brunton
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hatfield, United Kingdom
| | - Barbara Wieland
- International Livestock Research Institute (ILRI), Addis Ababa, Ethiopia; Institute of Virology and Immunology (IVI), Mittelhäusern, Switzerland; Department of Infectious Diseases and Pathobiology (DIP), Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Barbara Häsler
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hatfield, United Kingdom
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18
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Léger A, Lambraki I, Graells T, Cousins M, Henriksson PJG, Harbarth S, Carson CA, Majowicz SE, Troell M, Parmley EJ, Jørgensen PS, Wernli D. Characterizing social-ecological context and success factors of antimicrobial resistance interventions across the One Health spectrum: analysis of 42 interventions targeting E. coli. BMC Infect Dis 2021; 21:873. [PMID: 34445962 PMCID: PMC8390193 DOI: 10.1186/s12879-021-06483-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is among the most pressing One Health issues. While interventions and policies with various targets and goals have been implemented, evidence about factors underpinning success and failure of interventions in different sectors is lacking. The objective of this study is to identify characteristics of AMR interventions that increase their capacity to impact AMR. This study focuses on AMR interventions targeting E. coli. Methods We used the AMR-Intervene framework to extract descriptions of the social and ecological systems of interventions to determine factors contributing to their success. Results We identified 52 scientific publications referring to 42 unique E. coli AMR interventions. We mainly identified interventions implemented in high-income countries (36/42), at the national level (16/42), targeting primarily one sector of society (37/42) that was mainly the human sector (25/42). Interventions were primarily funded by governments (38/42). Most intervention targeted a low leverage point in the AMR system, (36/42), and aimed to change the epidemiology of AMR (14/42). Among all included publications, 55% (29/52) described at least one success factor or obstacle (29/52) and 19% (10/52) identified at least one success factor and one obstacle. Most reported success factors related to communication between the actors and stakeholders and the role of media, and stressed the importance of collaboration between disciplines and external partners. Described obstacles covered data quality, access to data and statistical analyses, and the validity of the results. Conclusions Overall, we identified a lack of diversity regarding interventions. In addition, most published E. coli interventions were poorly described with limited evidence of the factors that contributed to the intervention success or failure. Design and reporting guidelines would help to improve reporting quality and provide a valuable tool for improving the science of AMR interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06483-z.
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Affiliation(s)
- Anaïs Léger
- Global Studies Institute, University of Geneva, Sciences II, Quai Ernest-Ansermet 30, Case postale, 1211, Geneva, Switzerland.
| | - Irene Lambraki
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, The Royal Swedish Academy of Sciences, Box 50005, 104 05, Stockholm, Sweden.,Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691, Stockholm, Sweden
| | - Melanie Cousins
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Patrik J G Henriksson
- Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691, Stockholm, Sweden.,Beijer Institute of Ecological Economics, The Royal Swedish Academy of Sciences, P.O. Box 50005, 104 05, Stockholm, Sweden.,WorldFish, Jalan Batu Maung, 11960, Bayan Lepas, Penang, Malaysia
| | - Stephan Harbarth
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Carolee A Carson
- Centre for Food-Borne, Environmental and Zoonotic Infectious Diseases, Public Health Agency of Canada, Guelph, Canada
| | - Shannon E Majowicz
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Max Troell
- Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691, Stockholm, Sweden.,Beijer Institute of Ecological Economics, The Royal Swedish Academy of Sciences, P.O. Box 50005, 104 05, Stockholm, Sweden
| | - E Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, ON, N1G 2W1, Canada
| | - Peter S Jørgensen
- Global Economic Dynamics and the Biosphere, The Royal Swedish Academy of Sciences, Box 50005, 104 05, Stockholm, Sweden.,Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691, Stockholm, Sweden
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Sciences II, Quai Ernest-Ansermet 30, Case postale, 1211, Geneva, Switzerland
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Desbois AP, Garza M, Eltholth M, Hegazy YM, Mateus A, Adams A, Little DC, Høg E, Mohan CV, Ali SE, Brunton LA. Systems-thinking approach to identify and assess feasibility of potential interventions to reduce antibiotic use in tilapia farming in Egypt. AQUACULTURE (AMSTERDAM, NETHERLANDS) 2021; 540:736735. [PMID: 34276104 PMCID: PMC8164158 DOI: 10.1016/j.aquaculture.2021.736735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/31/2021] [Accepted: 04/03/2021] [Indexed: 06/01/2023]
Abstract
Antibiotics are used in aquaculture to maintain the health and welfare of stocks; however, the emergence and selection of antibiotic resistance in bacteria poses threats to humans, animals and the environment. Mitigation of antibiotic resistance relies on understanding the flow of antibiotics, residues, resistant bacteria and resistance genes through interconnecting systems, so that potential solutions can be identified and issues around their implementation evaluated. Participatory systems-thinking can capture the deep complexity of a system while integrating stakeholder perspectives. In this present study, such an approach was applied to Nile tilapia (Oreochromis niloticus) production in the Nile Delta of Egypt, where disease events caused by antibiotic-resistant pathogens have been reported. A system map was co-produced with aquaculture stakeholders at a workshop in May 2018 and used to identify hotspots of antibiotic use, exposure and fate and to describe approaches that would promote fish health and thus reduce antibiotic use. Antibiotics are introduced into the aquaculture system via direct application for example in medicated feed, but residues may also be introduced into the system through agricultural drainage water, which is the primary source of water for most fish farms in Egypt. A follow-up survey of stakeholders assessed the perceived feasibility, advantages and disadvantages of potential interventions. Interventions that respondents felt could be implemented in the short-term to reduce antibiotic usage effectively included: more frequent water exchanges, regular monitoring of culture water quality parameters, improved storage conditions for feed, use of probiotics and greater access to farmer and service providers training programmes. Other potential interventions included greater access to suitable and rapid diagnostics, high quality feeds, improved biosecurity measures and genetically-improved fish, but these solutions were expected to be achieved as long-term goals, with cost being of one of the noted barriers to implementation. Identifying feasible and sustainable interventions that can be taken to reduce antibiotic use, and understanding implementation barriers, are important for addressing antibiotic resistance and ensuring the continued efficacy of antibiotics. This is vital to ensuring the productivity of the tilapia sector in Egypt. The approach taken in the present study provides a means to identify points in the system where the effectiveness of interventions can be evaluated and thus it may be applied to other food production systems to combat the problem of antibiotic resistance.
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Affiliation(s)
- Andrew P. Desbois
- Institute of Aquaculture, University of Stirling, FK9 4LA, United Kingdom
| | - Maria Garza
- Royal Veterinary College, University of London, AL9 7TA, United Kingdom
| | - Mahmoud Eltholth
- Institute of Aquaculture, University of Stirling, FK9 4LA, United Kingdom
- Department of Hygiene and Preventive Medicine, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
- Global Academy of Agriculture and Food Security, The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, EH25 9RG, UK
| | - Yamen M. Hegazy
- Department of Animal Medicine, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Ana Mateus
- Royal Veterinary College, University of London, AL9 7TA, United Kingdom
| | - Alexandra Adams
- Institute of Aquaculture, University of Stirling, FK9 4LA, United Kingdom
| | - David C. Little
- Institute of Aquaculture, University of Stirling, FK9 4LA, United Kingdom
| | - Erling Høg
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | | | - Shimaa E. Ali
- WorldFish, Penang, Malaysia
- Department of Hydrobiology, National Research Centre, Egypt
| | - Lucy A. Brunton
- Royal Veterinary College, University of London, AL9 7TA, United Kingdom
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20
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Léger A, Lambraki I, Graells T, Cousins M, Henriksson PJG, Harbarth S, Carson C, Majowicz S, Troell M, Parmley EJ, Jørgensen PS, Wernli D. AMR-Intervene: a social-ecological framework to capture the diversity of actions to tackle antimicrobial resistance from a One Health perspective. J Antimicrob Chemother 2021; 76:1-21. [PMID: 33057678 DOI: 10.1093/jac/dkaa394] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The global threat of antimicrobial resistance (AMR) requires coordinated actions by and across different sectors. Increasing attention at the global and national levels has led to different strategies to tackle the challenge. The diversity of possible actions to address AMR is currently not well understood from a One Health perspective. AMR-Intervene, an interdisciplinary social-ecological framework, describes interventions to tackle AMR in terms of six components: (i) core information about the publication; (ii) social system; (iii) bio-ecological system; (iv) triggers and goals; (v) implementation and governance; and (vi) assessment. AMR-Intervene provides a broadly applicable framework, which can inform the design, implementation, assessment and reporting of interventions to tackle AMR and, in turn, enable faster uptake of successful interventions to build societal resilience to AMR.
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Affiliation(s)
- Anaïs Léger
- Global Studies Institute, University of Geneva, Sciences II, Quai Ernest-Ansermet 30, CH -1211 Genève 4, Switzerland
| | - Irene Lambraki
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, The Royal Swedish Academy of Sciences, Box 50005, 104 05 Stockholm, Sweden.,Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691 Stockholm, Sweden
| | - Melanie Cousins
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Patrik J G Henriksson
- Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691 Stockholm, Sweden.,Beijer Institute of Ecological Economics, The Royal Swedish Academy of Sciences, PO Box 50005, SE-104 05 Stockholm, Sweden.,WorldFish, Jalan Batu Maung, 11960 Bayan Lepas, Penang, Malaysia
| | - Stephan Harbarth
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Carolee Carson
- Canadian Integrated Program for Antimicrobial Resistance Surveillance; Public Health Agency of Canada, Guelph, Canada
| | - Shannon Majowicz
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Max Troell
- Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691 Stockholm, Sweden.,Beijer Institute of Ecological Economics, The Royal Swedish Academy of Sciences, PO Box 50005, SE-104 05 Stockholm, Sweden
| | - E Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, ON N1G 2W1, Canada
| | - Peter S Jørgensen
- Global Economic Dynamics and the Biosphere, The Royal Swedish Academy of Sciences, Box 50005, 104 05 Stockholm, Sweden.,Stockholm Resilience Centre, Stockholm University, Kräftriket 2B, 10691 Stockholm, Sweden
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Sciences II, Quai Ernest-Ansermet 30, CH -1211 Genève 4, Switzerland
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Lambraki IA, Majowicz SE, Parmley EJ, Wernli D, Léger A, Graells T, Cousins M, Harbarth S, Carson C, Henriksson P, Troell M, Jørgensen PS. Building Social-Ecological System Resilience to Tackle Antimicrobial Resistance Across the One Health Spectrum: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e24378. [PMID: 34110296 PMCID: PMC8262547 DOI: 10.2196/24378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/26/2021] [Accepted: 03/17/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is an escalating global crisis with serious health, social, and economic consequences. Building social-ecological system resilience to reduce AMR and mitigate its impacts is critical. OBJECTIVE The aim of this study is to compare and assess interventions that address AMR across the One Health spectrum and determine what actions will help to build social and ecological capacity and readiness to sustainably tackle AMR. METHODS We will apply social-ecological resilience theory to AMR in an explicit One Health context using mixed methods and identify interventions that address AMR and its key pressure antimicrobial use (AMU) identified in the scientific literature and in the gray literature using a web-based survey. Intervention impacts and the factors that challenge or contribute to the success of interventions will be determined, triangulated against expert opinions in participatory workshops and complemented using quantitative time series analyses. We will then identify indicators using regression modeling, which can predict national and regional AMU or AMR dynamics across animal and human health. Together, these analyses will help to quantify the causal loop diagrams (CLDs) of AMR in the European and Southeast Asian food system contexts that are developed by diverse stakeholders in participatory workshops. Then, using these CLDs, the long-term impacts of selected interventions on AMR will be explored under alternate future scenarios via simulation modeling and participatory workshops. A publicly available learning platform housing information about interventions on AMR from a One Health perspective will be developed to help decision makers identify promising interventions for application in their jurisdictions. RESULTS To date, 669 interventions have been identified in the scientific literature, 891 participants received a survey invitation, and 4 expert feedback and 4 model-building workshops have been conducted. Time series analysis, regression modeling of national and regional indicators of AMR dynamics, and scenario modeling activities are anticipated to be completed by spring 2022. Ethical approval has been obtained from the University of Waterloo's Office of Research Ethics (ethics numbers 40519 and 41781). CONCLUSIONS This paper provides an example of how to study complex problems such as AMR, which require the integration of knowledge across sectors and disciplines to find sustainable solutions. We anticipate that our study will contribute to a better understanding of what actions to take and in what contexts to ensure long-term success in mitigating AMR and its impact and provide useful tools (eg, CLDs, simulation models, and public databases of compiled interventions) to guide management and policy decisions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/24378.
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Affiliation(s)
- Irene Anna Lambraki
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | | | - Elizabeth Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Anaïs Léger
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
| | - Melanie Cousins
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Stephan Harbarth
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Carolee Carson
- Canadian Integrated Program for Antimicrobial Resistance Surveillance, Public Health Agency of Canada, Guelph, ON, Canada
| | - Patrik Henriksson
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
- Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
- WorldFish, Penang, Malaysia
| | - Max Troell
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
- Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Peter Søgaard Jørgensen
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
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22
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Call for action to healthcare professional societies and other groups: Creating a global open access E-learning knowledge platform for Antimicrobial Stewardship [AMS] with a focus on LMIC's. Indian J Med Microbiol 2021; 39:145-146. [PMID: 33875310 DOI: 10.1016/j.ijmmb.2021.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/18/2021] [Indexed: 11/21/2022]
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Belay S, Giday M, Manyazewal T. Harnessing Clinical Trial Capacity to Mitigate Zoonotic Diseases: The Role of Expert Scientists in Ethiopia. Front Public Health 2021; 9:621433. [PMID: 33869126 PMCID: PMC8047130 DOI: 10.3389/fpubh.2021.621433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background: The emergence and resurgence of zoonotic diseases have continued to be a major threat to global health and the economy. Developing countries are particularly vulnerable due to agricultural expansions and domestication of animals with humans. Scientifically sound clinical trials are important to find better ways to prevent, diagnose, and treat zoonotic diseases, while there is a lack of evidence to inform the clinical trials' capacity and practice in countries highly affected with the diseases. This study aimed to investigate expert scientists' perceptions and experiences in conducting clinical trials toward zoonotic diseases in Ethiopia. Methods: This study employed a descriptive, qualitative study design. It included major academic and research institutions in Ethiopia that had active engagements in veterinary and public health researches. It included the National Veterinary Institute, the National Animal Health Diagnostic and Investigation Center, the College of Veterinary Medicine at Addis Ababa University, the Ethiopian Public Health Institute, the Armauer Hansen Research Institute, and the College of Health Sciences at Addis Ababa University. In-depth interviews were conducted with expert scientists. Data were collected from October 2019 to April 2020. Data analysis was undertaken using open code 4.03 for qualitative data analysis. Results: Five major themes, with 18 sub-themes, emerged from the in-depth interviews. These were: challenges in the prevention, control, and treatment of zoonotic diseases; One Health approach to mitigate zoonotic diseases; personal and institutional experiences in conducting clinical trials on zoonotic diseases; barriers in conducting clinical trials toward zoonotic diseases; and strategies that promote conducting clinical trials on zoonotic diseases. Conducting clinical trials on zoonotic diseases in Ethiopia is hampered by a lack of clearly articulated ethics and regulatory frameworks, trial experts, financial resources, and good governance. Conclusion: In Ethiopia, conducting clinical trials on zoonotic diseases deserves due attention. Strengthening institutional and human resources capacity is a pre-condition to harness effective implementation of clinical trials on zoonotic diseases in the country. In Ethiopia where skilled human resource is scarce, One Health approach has the potential to form multidisciplinary teams to systematically improve clinical trials capacity and outcomes in the country.
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Affiliation(s)
- Senait Belay
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Faculty of Veterinary Medicine, Hawassa University, Hawassa, Ethiopia
| | - Mirutse Giday
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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24
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Ellwanger JH, Veiga ABGD, Kaminski VDL, Valverde-Villegas JM, Freitas AWQD, Chies JAB. Control and prevention of infectious diseases from a One Health perspective. Genet Mol Biol 2021; 44:e20200256. [PMID: 33533395 PMCID: PMC7856630 DOI: 10.1590/1678-4685-gmb-2020-0256] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/18/2020] [Indexed: 12/18/2022] Open
Abstract
The ongoing COVID-19 pandemic has caught the attention of the global community and rekindled the debate about our ability to prevent and manage outbreaks, epidemics, and pandemics. Many alternatives are suggested to address these urgent issues. Some of them are quite interesting, but with little practical application in the short or medium term. To realistically control infectious diseases, human, animal, and environmental factors need to be considered together, based on the One Health perspective. In this article, we highlight the most effective initiatives for the control and prevention of infectious diseases: vaccination; environmental sanitation; vector control; social programs that encourage a reduction in the population growth; control of urbanization; safe sex stimulation; testing; treatment of sexually and vertically transmitted infections; promotion of personal hygiene practices; food safety and proper nutrition; reduction of the human contact with wildlife and livestock; reduction of social inequalities; infectious disease surveillance; and biodiversity preservation. Subsequently, this article highlights the impacts of human genetics on susceptibility to infections and disease progression, using the SARS-CoV-2 infection as a study model. Finally, actions focused on mitigation of outbreaks and epidemics and the importance of conservation of ecosystems and translational ecology as public health strategies are also discussed.
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Affiliation(s)
- Joel Henrique Ellwanger
- Universidade Federal do Rio Grande do Sul - UFRGS, Departamento de Genética, Laboratório de Imunobiologia e Imunogenética, Porto Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul - UFRGS, Departamento de Genética, Programa de Pós-Graduação em Genética e Biologia Molecular - PPGBM, Porto Alegre, RS, Brazil
| | | | - Valéria de Lima Kaminski
- Universidade Federal de São Paulo - UNIFESP, Instituto de Ciência e Tecnologia - ICT, Laboratório de Imunologia Aplicada, Programa de Pós-Graduação em Biotecnologia, São José dos Campos, SP, Brazil
| | - Jacqueline María Valverde-Villegas
- Universidade Federal do Rio Grande do Sul - UFRGS, Departamento de Genética, Laboratório de Imunobiologia e Imunogenética, Porto Alegre, RS, Brazil
- Institut de Génétique Moléculaire de Montpellier (IGMM), Centre National de la Recherche Scientifique (CNRS), Laboratoire coopératif IGMM/ABIVAX, UMR 5535, Montpellier, France
| | - Abner Willian Quintino de Freitas
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA, Programa de Pós-Graduação em Tecnologias da Informação e Gestão em Saúde, Porto Alegre, RS, Brazil
| | - José Artur Bogo Chies
- Universidade Federal do Rio Grande do Sul - UFRGS, Departamento de Genética, Laboratório de Imunobiologia e Imunogenética, Porto Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul - UFRGS, Departamento de Genética, Programa de Pós-Graduação em Genética e Biologia Molecular - PPGBM, Porto Alegre, RS, Brazil
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