Everybody needs to work together to address antibiotic resistance

This article was authored by Judy Bettridge. (Twitter @JudyBettridge)

Not that many years ago, I went to the doctor with a chesty cough that had been hanging around for several weeks.  Normally, I wouldn’t have bothered, but it made cycling to work difficult, so I went to get it checked out. The doctor gave me a course of antibiotics. After a week, I went back to report that they had made no difference to the cough at all. So he offered me a choice – did I want an inhaler or just some more antibiotics? I was rather surprised – surely the choice to take the antibiotics should not rest with me? He was the qualified professional, after all. Responsible antibiotic use was already widely promoted, so why was the medical professional suggesting simply dishing out more of these precious drugs to prolong a treatment that wasn’t working? Maybe he was simply having a bad day, but it seemed to me to show an irresponsible attitude towards the doctor’s role of antibiotic stewardship.

There are many reports of patients putting doctors under pressure to dispense antibiotics, and this is clearly problematic. In many cases, antibiotics are simply not an appropriate treatment and will make no difference to the speed of recovery, especially for viral illness. With widespread media coverage and advertising, many patients are now better informed about the problems of antimicrobial resistance, and that taking unnecessary antibiotics can put them and their families at risk of future infections from antibiotic-resistant bacteria. Doctors are the best-placed to know what is circulating in their local area, and can advise patients when their symptoms are most likely to arise from viral infections – and patients need to be ready to listen and take their advice. However, as my experience shows, doctors may also fall into the trap of anticipating patient expectations for antibiotics where no such pressure exists. Negotiation and understanding between doctor and patient is much more likely to result in satisfaction on both sides – and better compliance with any medication that is prescribed.

Doctors are the best-placed to know what is circulating in their local area, and can advise patients when their symptoms are most likely to arise from viral infections – and patients need to be ready to listen and take their advice.

The very same issues arise in the veterinary profession, with vets and owners or farmers needing to discuss these complex decisions surrounding whether or not antibiotic use is appropriate on a case-by-case basis. Great progress has been made in many areas, especially in eliminating the use of antibiotics as growth promoters in Europe, but there is still much room for improvement. With so much information now available on the internet, it is not uncommon for people to come with very fixed ideas about what is wrong with their animal, and exactly what treatment they want. It is important to remember that many conditions that look the same can have very different causes. The bacteria in our bodies and our environment evolve and change over time, so that even two infections with identical symptoms may be caused by completely different bugs – which need a completely different antibiotic to treat them. For this reason, keeping and reusing antibiotics at a later date is never advisable –especially injectable drugs that can go off within a few weeks of opening. All antibiotics have an expiry date, and using less potent drugs to treat infections is another factor that can encourage antimicrobial resistance to develop.

keeping and reusing antibiotics at a later date is never advisable –especially injectable drugs that can go off within a few weeks of opening

Always check the expiry date of drugs

Where we work in East Africa, as in many other parts of the world, an additional problem is that antibiotic sales and use are frequently unregulated. A lot of commercial animal feed still contains antibiotics – so always check the label and ask the vet or seller if you are in any doubt. Good hygiene in animal production is much better as a preventative, as this can also help reduce viral and parasite infections that will not be helped by in-feed antibiotics in any case. If animals are sick, then involving a vet at an early stage is important to get the right treatment, rather than just buying a drug from an untrained seller and hoping for the best. Especially in remote rural areas, antibiotics may be on sale in the local kiosk, alongside the soap, candles and sweets. These are often human drugs, and so using them in animals is problematic – not only because they are not formulated to give the right dose for that species, but also because there are certain drugs that should simply not be used in animals. This may be because of dangerous residues that pass into the meat, eggs or milk, and so veterinary workers should always advise on how long to leave after treatment before animal products are safe to eat again. If they don’t offer this advice, along with clear instructions on how to use the drugs – ask!  The other reason not to buy antibiotics from unqualified sellers is that there are some drugs that we want to preserve for use in only humans. These critically important antimicrobials are needed to treat difficult and often life-threatening infections in humans that don’t respond to other drugs. Some may be used by vets as a last resort, but their use should always be closely supervised.

Good hygiene in animal production is much better as a preventative, as this can also help reduce viral and parasite infections that will not be helped by in-feed antibiotics in any case.

An antibiotic being administered to a cow

This is why this year’s theme for World Antibiotic Awareness week is “Seek advice from a qualified healthcare professional before taking antibiotics”. Wherever you are in the world, this is sound advice. Advances in science mean that rapid diagnostic tests are coming ever closer, and within a few years, genetic identification not only of the organism causing the infection but also what drugs it is likely to respond to will be possible. This will allow a diagnosis within a few hours, rather than days to weeks it can take with current laboratory methods. Accurate diagnosis, antibiotic selection tailored to every individual case and open discussions between the healthcare professional and the patient or carer as to whether antibiotic use is appropriate in every circumstance are all part of tackling antimicrobial resistance. Whether the healthcare professional is a doctor, nurse, veterinary professional or pharmacist, by making the most of their knowledge to help guide the decision to use antibiotics, everyone can play their part in helping to guard these precious resources for future generations.

Accurate diagnosis, antibiotic selection tailored to every individual case and open discussions between the healthcare professional and the patient or carer as to whether antibiotic use is appropriate in every circumstance are all part of tackling antimicrobial resistance.

International One Health Day

International One Health Day, 2017

This blog entry was authored by Matthew Baylis, Principal Investigator-HORN Project

November 3rd is International One Health Day. One Health is the idea that the health of people, animals, plants and the environment are interlinked, and that health will be optimised by different disciplines (such as medicine, veterinary science, social science, economics, environmental science) working together rather than independently. It goes to the heart of multidisciplinarity in science, with large gains to be made by bringing together experts who may approach the similar problems with different skill sets and approaches.

Community members at the Mara being trained about holistic land management to optimize livestock productivity with minimal environmental impact by trainers from the Savory Institute; Photo credit: ZED Group

There are innumerable examples of advances in human medicine that have led to improvements in animal health – as just one example, some of the biggest equipment in the University of Liverpool’s animal clinics (such as MRI scanners) come from human hospitals.  But there are also many examples of veterinary medicine leading to improvements in human health or medicine.  In the UK, we are now safe to eat raw or undercooked eggs owing to a major programme to eliminate salmonellosis from the layer industry. The incidence of human rabies in much of East Africa has declined, owing to vaccination not of people, but of dogs.  My favourite example relates to transmissible spongiform encephalopathies. In the early 1960s members of the Foré tribe in Papua New Guinea were dying from a novel disease called Kuru (related to variant CJD). An American medic attempted transmission experiments with chimps that were not successful, leading to the conclusion that the disease was of genetic origin. The medic spoke on this in the UK and, in the audience, was a veterinarian.  The vet recognised that the characteristics of Kuru seemed identical to that of a sheep disease called scrapie, which had been shown to be transmissible. He alerted the medic, who repeated the experiments, this time successfully, and went on to get the Nobel Prize for Physiology (the medic, not the vet, of course).

A boy keenly reading a vaccination certification after his dog had been vaccinated against rabies; Photo credit: Rabies Free Kenya

Find out more about International One Health Day here: https://www.onehealthcommission.org/en/eventscalendar/one_health_day/

The University of Liverpool is a big player in the area of One Health. We have had a string of large projects in the area of zoonotic diseases and food systems which contribute significantly to non-communicable diseases. Most recently, we have been given a large RCUK-funded Global Challenges Research Fund (GCRF) Growing Research Capability (GROW) award called One Health Regional Network for the Horn of Africa (HORN), which aims to strengthen institutions and train researchers and support staff in areas relevant to One Health in 4 countries of the Horn of Africa: Kenya, Ethiopia, Eritrea and Somalia. It is early days, but you can follow progress here: https://www.facebook.com/groups/1473530819359799/

The One Health Regional Network Logo

Follow us on Twitter: @OneHealthHORN to get our One Health Day updates at the top of every hour today.

Our website, www.onehealthHORN.net (coming soon!)

 

Uppsala Health Summit: Behaviour change and biosciences necessary to tackle infectious diseases threats

This blog entry has been reblogged from the CGIAR research programme on livestock website featuring the Uppsala Health Summit, themed “Tackling Infectious Disease Threats” that was held as from 10th to 11th October, 2017 of which the team lead of our ZED Group, Prof Eric Fèvre, presented work from our Urban Zoo project on how pathogens from livestock are introduced and spread in urban environments .

Photo credit: Fernanda Dórea

Research shows that six out of 10 emerging human infectious diseases are zoonoses. Thirteen zoonotic diseases sicken over 2 billion people and they kill 2.2 million each year, mostly in developing countries. Poor people are more exposed to zoonoses because of their greater contact with animals, less hygienic environments, lack of knowledge on hazards, and lack of access to healthcare. 80% of the burden of these zoonotic diseases thus falls on people in low and middle income countries.

A workshop at last week’s Uppsala Health Summit zoomed in on zoonotic diseases in livestock and ways to mitigate risk behaviour associated with their emergence and spread. Critical roles and behaviours of people and institutions in preventing, detecting and responding to zoonotic livestock diseases were identified – as well as necessary changes and incentives so we are well-prepared for infections long before they reach people.

These zoonotic infections often originate from livestock which can serve as a bridge for disease transmission between animals and humans. Thus, controlling zoonotic diseases in livestock is an important means to reduce infectious disease threats to humans. Zoonotic diseases are a threat not only to public health, but also to food production, food safety, animal welfare, and rural livelihood.

Within their own sectors, researchers and practitioners from different fields have a considerable understanding of outbreaks of disease and how to handle them. They also know they must bear in mind how local factors, traditions and politics can determine the outcome. But a disease outbreak causing deaths and disruption is always a complex picture. It requires all actors to gather knowledge from beyond their own field of expertise to be fully able to address disease outbreaks efficiently.

The 50 or so workshop participants, comprising vets and medics in a one health context, tackled two objectives. First, they identified who is involved in preventing, detecting and responding to zoonotic livestock diseases and the associated behaviours that need to change. Second, they set out some initial recommendations and incentives to mitigate risky behaviours.

Biosciences and behaviour

Co-organizer Ulf Magnusson from the Swedish University of Agricultural Sciences explained in his opening remarks that the challenge for the group lies at the intersection between biosciences and behaviour. We know a lot about the biosciences; but for the biosciences to be effective, we need to change and strengthen the behaviours of different actors involved in infectious diseases.  He particularly emphasized the ‘one health’ element, that we need to look beyond animals to develop productive collaboration across the veterinary and medical professions.

Three people were charged to set the scene: Barbara Wieland from the International Livestock Research Institute (ILRI) introduced mainly Ethiopian experiences from rural settings; Eric Fèvre from the University of Liverpool and ILRI gave some urban perspectives from Kenya; and Elisabeth Lindahl-Rajala from the Swedish University of Agricultural Sciences shared a case on controlling Brucella in Tajikistan.

Wieland argued that effective prevention, detection and response requires good understanding of the specific ‘local’ situations in which livestock are kept and especially the roles of different people in this. Her research pointed to major gender differences with women closer to the animals, their care and feeding, and the farmstead and men more involved in marketing, slaughter and dealing with externals like vets. She also pointed to local cultural practices and their effect on handling and consumption of some animal-source products like milk or cheese. Taking account of these role differences and cultural aspects is very critical when designing interventions to tackle zoonotic infectious diseases. Focusing on the farmer actor, she identified especially the need for smaller more manageable changes, the transformative opportunities offered by information and communication technologies and the potential of one health to help overcome capacity and infrastructure problems in remote rural areas.

Fèvre reported on research in Nairobi to understand how pathogens from livestock are introduced and spread in urban environments. He introduced the notion of ‘interfaces’ – physical and social – as useful to help understand disease transmission between livestock and food systems, arguing that the behaviours of people, institutions and policies in and across these interfaces are critical in zoonotic disease spread. Looking at the food systems in a city like Nairobi, value chains connect the many different actors, moving animals and products, moving payments, moving animal health information, and ultimately also accelerating or hindering the spread of diseases. While Wieland focused on rural farmers as a primary actor, the urban systems and chains that Fèvre isolated comprise many different public and private actors, each with specialized roles and sets of desirable behaviours. Mapping and measuring these from a zoonotic perspective will allow current and future disease risks to be understood, leading to improved prevention, detection, and response.

Photo credit: Tanja Strand

Lindahl-Rajala reported on research on the prevalence of Brucella, the cause of brucellosis, in the city of Dushanbe in Tajikistan. Globally, some 500,000 cases of brucellosis occur each year, making it one of the most common bacterial infection spread from animals to humans worldwide. In Tajikistan, increasing urbanization of people is leading to increasing urbanization of animals and increased threats from brucellosis though consumption of raw dairy products or direct contact with infected animals. Research showed Brucella to be widespread in the city’s animals. It also showed low levels of awareness of the diseases among producer and consumers as well as several risky behaviours.  Lindahl-Rajala identified three priority actor groups who need to be targeted to tackle the spread of this disease:  farmers who need to adopt safer behaviours, consumers who need to avoid raw milk from street vendors and policy makers who need to give greater attention and devise a long-lasting control program.

Mapping actors and behaviours

Starting from the three presentations and using their own expertise, the initial task of participants was to take each of the three priorities – prevent, detect and respond – and map the main actors and the desirable behaviours/roles necessary to tackle the spread of zoonotic infectious diseases.

Actors identified across the different priorities included livestock owners and keepers, household members, vets, researchers and academics, diagnostic labs, local government, ministries, traders, transporters, medics and physicians, the media, private companies and consumers. One group, tackling ‘responding’ identified the animals themselves as key actors, in this case to ‘stay put’ and avoid people.

After this broad mapping of the actors, participants were asked to dive deeper, to prioritize the most important actors and behaviour changes for different rural and urban scenarios and likely incentives to achieve these changes. This led to more focus on specific actors and behaviours and to a wide range of useful materials and lessons to build out recommendations in this area (see photos below).

Emerging messages

Sofia Boqvist from the Swedish University of Agricultural Sciences reported some key insights to the summit plenary (see picture top of this post).

Under ‘prevention’, the three key messages identified were: effective biosecurity measures, good communication all round, and long term investment. She emphasized a point from within the group that detecting, and treating, a zoonotic infection in a sick person is an indicator of failure. Investing in up-front prevention of disease in animals will keep people healthy.

Under ‘detection’, the three key messages identified were: good infrastructure in rural areas – to overcome geography, distance and poor connectivity, joint medical/veterinary surveillance so all the key actors look out for all the risks, and proper compensation to protect livelihoods when animals need to be culled to protect lives.

Under ‘response’, the three key messages identified were: the importance of strong and effective institutions that do their assigned tasks and roles well, effective communications and especially media engagement to provide proper information and avoid scares, and sufficient resources and expertise to actually tackle the situations. In an informal unscientific poll of participant perceptions in the workshop, this was the area highlighted as the weakest link among the prevent, detect and respond priorities.

Participants discuss zoonotic disease mitigation priorities. Photo credit: Erik Bongcam-Rudloff

More information

The workshop was organized by Sofia Boqvist and Ulf Magnusson from the Swedish University of Agricultural Sciences. Magnusson leads the Livestock Health Flagship of the CGIAR Research Program on Livestock.

A summary report from the workshop will be produced as part of the overall summit report.

See the presentation by Barbara Wieland; more on this work

See the presentation by Eric Fèvre; more on this work

See more on Elisabeth Lindahl-Rajala’s work in Tajikistan

A Pilot Study to Investigate the potential for developing syndromic surveillance system based on meat inspection records in Western Kenya

Training of meat inspectors on how to use hand held device for syndromic surveillance

Article by Joseph Ogola, ZooLinK Consultant

During our field visits in preparation for the ZooLink research project, we selected Kimilili and Webuye slaughterhouses in Bungoma County to participate in the syndromic surveillance pilot study. The two facilities within the study area were identified based on infrastructure and the willingness of the two meat inspectors to participate in the project. The rationale of this pilot project is to assess the feasibility of using slaughterhouse data to enhance the coverage and efficiency of the surveillance system in the study area alongside the routine laboratory based surveillance system. We developed a data collection form from the monthly reports from meat inspection records which

The rationale of this pilot project is to assess the feasibility of using slaughterhouse data to enhance the coverage and efficiency of the surveillance system in the study area alongside the routine laboratory based surveillance system. We developed a data collection form from the monthly reports from meat inspection records which

We developed a data collection form from the monthly reports from meat inspection records which were loaded onto a handheld device. The form captures information related to the carcass inspection together with animal location and movement data. The two meat inspectors after a short training session were then provided with two mobile phones to use daily to record data
(including any relevant photos) of animals slaughtered over a 6 month period. The data collected are sent directly to our data management platform.

We look forward to share the outcomes of this study in subsequent editions of the newsletter!

 

Zoonoses in Livestock in Kenya – The Beginnings of Surveillance

By Steven Kemp, PhD student, University of Liverpool

After a period of intense lab work at both KEMRI and the UK, investigating the patterns of antimicrobial resistance in faecal bacteria isolated from slaughterhouse workers in Busia County and the surrounding areas, I have returned to Kenya to begin the next phase of my PhD project.

ZooLinK is a cyclical programme which aims to set up surveillance systems of both human and animal health sectors over a long period of time. Surveillance of disease is particularly important, as the more information we have, the better we can treat diseases in both human and animal sectors. Recent research by colleagues indicates that the incidence of several zoonotic diseases, including E. coli, Salmonella sp. and others are vastly underestimated.

In recent times, we often hear about how we should now look to conform to the ‘One Health’ approach; this is where, in order to combat issues surrounding antimicrobial resistance and associated issues effectively, intersectoral approaches which share the cost and responsibility evenly between environmental, human & veterinary health professionals is required. In theory, this would be a perfect way to help educate and better promote antimicrobial stewardship.

Currently, I have large amounts of data on access to, use of, and perceptions of antimicrobials from a variety of parties, including animal healthcare workers, district veterinary offices, farmers and agrovet shops. Over the last three months, I have added to this repository by investigating the amounts of antibiotic resistance found in E. coli, which have been isolated from the faeces of workers in 142 slaughterhouses which were selected in western Kenya. These included slaughterhouses in Busia County and the surrounding Kakamega and Bungoma counties.

For the next portion of this study, I am attempting to collect four different sets of samples – to complete the ‘picture’. I will attempt to collect both human and animal faecal samples, from farmers and farm animals, water samples (to determine if there are patterns of resistance in animals which share common grazing grounds) and environmental samples (from the inside of homesteads, where animals are allowed to roam). By covering all of these bases, we will be able to eventually determine not only if there is transfer of antimicrobial resistance between animals and humans and the environment, but also which direction it is going in.

Typical small-holder farm in Funyula, Busia. Most farmers manage between 5-25 cattle.

Example of environment which may also be a good idea to sample in the future. If antimicrobial resistance can be found in the envi-ronment, then why not in wild animals such as these Zebra?

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