Availability and Use of Antibiotics in the Dormaa Municipal District of the Bono Region in Ghana. Report for Fleming Fund Fellowship Programme

The rise observed in antimicrobial resistance over the past decades has been linked to the dramatic increase in use of antibiotics in humans and animals. Few studies have prospectively examined the availability and use of antibiotics in humans and animals at the residential level in Ghana. This study was conducted to gather data on the availability and use of antibiotics among residents in a suburban municipality in Ghana. Data from such studies may aid policy makers to devise strategies to help consumers to minimise inappropriate use of antibiotics at the community level. This study is a cross-sectional study during which the study team assessed the availability and use of antibiotics in humans at the community level in the Dormaa municipality of the Bono Region in Ghana. Structured questionnaires and the Drug Bag’ method were employed to quantify antibiotic types available at the community level, frequently used antibiotics in the community as well as the disease conditions these antibiotics are used to treat. A total of 100 households, 6 retail community pharmacy outlets and 11 out-patient health facilities were visited. Questionnaires were administered to participants in the pharmacies and out-patient facilities whilst the ‘Drug Bag’ method was combined with questionnaires to gather data in the households. The study results revealed that the top four antibiotics used by respondents in the households in the communities surveyed often without prescription were Amoxicillin Capsules, Metronidazole Tablets, Phenoxymethylpenicillin Tablets and Tetracycline Capsules. These antibiotics are normally obtained from Over-the-Counter Medicines Sellers facilities and peddlers although such outlets are not permitted by law to stock and dispense these antibiotics. The top three disease conditions given by respondents in the study communities for which antibiotics are used are gastrointestinal diseases, followed by fever with body pains and cough and cold conditions. Antibiotics known and used by respondents in the community was compared with the WHO AWaRe classification tool. The study revealed that 50% and 47% respectively of antibiotics known and used by respondents fell within the “Access” list while 11% and 8% respectively of antibiotics known and used by respondents fell within the “Watch” list. None of the antibiotics in the “Reserve” list was known to or had been used by respondents. The research found that 85% of households had used antibiotics three months prior to the study in the vicinity. The study has revealed common antibiotic use among residents in the Dormaa municipality, including for diseases which are preventable. This paper therefore suggests that preventive approaches including improving access to water and sanitation facilities may improve infection prevention and control, leading to decreased incidence of infections such as gastrointestinal disturbances and a decrease in the perceived need for frequent antibiotic use. Awareness creation is also key in sensitising communities about the dangers of excessive use of antibiotics, including the emergence of AMR

WASH and biosecurity interventions for reducing burdens of infection, antibiotic use and antimicrobial resistance in animal agricultural settings: a One Health mixed methods systematic review

Background: Infection prevention and control (IPC) is recognised as essential to addressing the emergence and spread of antimicrobial resistance (AMR) in human health, food production and the environment. How best to address this through a One Health perspective remains a challenge. This systematic review addresses this gap by identifying and synthesising evidence from interventions designed to improve water, hygiene, sanitation (WASH), and biosecurity in animal agriculture and in people that live and/or work with animals. This review aimed to capture evidence of effects of all types of intervention and across different settings. Methods: We conducted a systematic search for studies that reported on WASH and biosecurity interventions with the potential to reduce the burden of infections and reliance on antibiotics in animal production for populations living with animals and/or involved in agriculture/aquaculture with a primary focus on LMICs. We searched the following databases: Web of Science, PubMed, OVID, ProQuest, Epistemonikos, Trip, AgEcon, and Cochrane Library. For articles in Spanish, we searched Scielo, BIREME, E-Revistas, Redalyc, Lilacs, AfricaPortal, IMSEAR and WPRIM. A hand search of literature was also conducted in relevant sources, and Google Scholar and Open Grey were used for grey literature. The main outcomes of interest were: (i) reduction of infections/cases, (ii) reduction of bacterial load, and (iii) reduction of antimicrobial use and AMR. We extracted data from selected studies, performed a narrative synthesis, and developed a framework. PROSPERO Registration: The protocol for the systematic review was registered at PROSPERO, registration number CRD42020162345. Findings: A total of 104 studies were included in this systematic review. The majority of studies (64/104) (61.5%) were conducted in HICs, especially in Europe and the USA. Only 13 (12.5%) studies took place in LMICs. The majority of studies (77) were animal based, followed by 12 targeting both animals and the environment, nine focused exclusively on the environment, and only one study was exclusively about humans. Most studies were conducted in poultry (36) and pigs (27), and assessed impacts on multiple types of bacteria (commonly Salmonella spp. and Campylobacter spp.). Eighty-seven (87) studies assessed impact on IPC, 3 on AMU, and 14 on AMR. The interventions were classified as follows: 57 applied biological or chemical products to eliminate pathogens; 26 modified infrastructure and apparatus; 15 were educational/behavioural and one was a structural intervention. Around 52.8% (55/104) studies included WASH interventions focused on water quality (20), water quantity (2), hygiene (30), and sanitation (3). Likewise, 47.1% (49/104) included biosecurity interventions focused on bio-management (34), bio-containment (10), and bio-exclusion (5). Positive impacts were reported for 64 (61.5%) interventions, on infection burden (54/87), antibiotic use (3/3) or AMR (7/14). The majority were non-randomised studies (55), although a quarter were randomised controlled trials (26). A total of 27 studies were classified as having low risk of bias, 21 moderate and 56 high risk of bias. Interpretation: This review identifies a number of effective interventions to reduce the burden of infections, antimicrobial resistance and antibiotic use in animal agricultural settings. Interventions which undertook bio-management and bio-containment measures appeared to have positive effects most often. These measures attempted to create and maintain a conducive environment for animal raising in terms of physical infrastructure and protocols. The few studies reporting sanitation measures - which were similar to bio-containment interventions - all reported positive effects. By contrast, efforts to impact water quantity, water quality, and hygiene had more mixed effects on the outcomes assessed. Bio-exclusion interventions had mostly negative effects. Risk of bias was high or moderate in many studies, however, and publication bias should also be considered. The paucity of studies evaluating structural interventions needs to be addressed. There are opportunities to learn from biosecurity Interventions for WASH and we propose the 'A' In WASH represents both 'Animals' and 'Air' in recognition of pathways of infection that can be addressed to also impact AMR

Increased use of malaria rapid diagnostic tests improves targeting of anti-malarial treatment in rural Tanzania: implications for nationwide rollout of malaria rapid diagnostic tests.

ABSTRACT: BACKGROUND: The World Health Organization recommends parasitological confirmation of all malaria cases. Tanzania is implementing a phased rollout of malaria rapid diagnostic tests (RDTs) for routine use in all levels of care as one strategy to increase parasitological confirmation of malaria diagnosis. This study was carried out to evaluated artemisinin combination therapy (ACT) prescribing patterns in febrile patients with and without uncomplicated malaria in one pre-RDT implementation and one post-RDT implementation area. METHODS: A cross-sectional health facility surveys was conducted during high and low malaria transmission seasons in 2010 in both areas. Clinical information and a reference blood film on all patients presenting for an initial illness consultation were collected. Malaria was defined as a history of fever in the past 48 hours and microscopically confirmed parasitaemia. Routine diagnostic testing was defined as RDT or microscopy ordered by the health worker and performed at the health facility as part of the health worker-patient consultation. Correct diagnostic testing was defined as febrile patient tested with RDT or microscopy. Over-testing was defined as a febrile patient tested with RDT or microscopy. Correct treatment was defined as patient with malaria prescribed ACT. Over-treatment was defined as patient without malaria prescribed ACT. RESULTS: A total of 1,247 febrile patients (627 from pre-implementation area and 620 from post-implementation area) were included in the analysis. In the post-RDT implementation area, 80.9% (95% CI, 68.2-89.3) of patients with malaria received recommended treatment with ACT compared to 70.3% (95% CI, 54.7-82.2) of patients in the pre-RDT implementation area. Correct treatment was significantly higher in the post-implementation area during high transmission season (85.9% (95%CI, 72.0-93.6) compared to 58.3% (95%CI, 39.4-75.1) in pre-implementation area (p=0.01). Over-treatment with ACT of patients without malaria was less common in the post-RDT implementation area (20.9%; 95% CI, 14.7-28.8) compared to the pre-RDT implementation area (45.8%; 95% CI, 37.2-54.6) (p<0.01) in high transmission. The odds of overtreatment was significantly lower in post- RDT area (adjusted Odds Ratio (OR: 95%CI) 0.57(0.36-0.89); and much higher with clinical diagnosis adjusted OR (95%CI) 2.24(1.37-3.67) CONCLUSION: Implementation of RDTs increased use of RDTs for parasitological confirmation and reduced over-treatment with ACT during high malaria transmission season in one area in Tanzania. Continued monitoring of the national RDT rollout will be needed to assess whether these changes in case management practices will be replicated in other areas and sustained over time. Additional measures (such as refresher trainings, closer supervisions, etc) may be needed to improve ACT targeting during low transmission seasons

"Even if the test result is negative, they should be able to tell us what is wrong with us": a qualitative study of patient expectations of rapid diagnostic tests for malaria.

BACKGROUND: The debate on rapid diagnostic tests (RDTs) for malaria has begun to shift from whether RDTs should be used, to how and under what circumstances their use can be optimized. This has increased the need for a better understanding of the complexities surrounding the role of RDTs in appropriate treatment of fever. Studies have focused on clinician practices, but few have sought to understand patient perspectives, beyond notions of acceptability. METHODS: This qualitative study aimed to explore patient and caregiver perceptions and experiences of RDTs following a trial to assess the introduction of the tests into routine clinical care at four health facilities in one district in Ghana. Six focus group discussions and one in-depth interview were carried out with those who had received an RDT with a negative test result. RESULTS: Patients had high expectations of RDTs. They welcomed the tests as aiding clinical diagnoses and as tools that could communicate their problem better than they could, verbally. However, respondents also believed the tests could identify any cause of illness, beyond malaria. Experiences of patients suggested that RDTs were adopted into an existing system where patients are both physically and intellectually removed from diagnostic processes and where clinicians retain authority that supersedes tests and their results. In this situation, patients did not feel able to articulate a demand for test-driven diagnosis. CONCLUSIONS: Improvements in communication between the health worker and patient, particularly to explain the capabilities of the test and management of RDT negative cases, may both manage patient expectations and promote patient demand for test-driven diagnoses

A cost-effectiveness analysis of provider and community interventions to improve the treatment of uncomplicated malaria in Nigeria: study protocol for a randomized controlled trial.

BACKGROUND: There is mounting evidence of poor adherence by health service personnel to clinical guidelines for malaria following a symptomatic diagnosis. In response to this, the World Health Organization (WHO) recommends that in all settings clinical suspicion of malaria should be confirmed by parasitological diagnosis using microscopy or Rapid Diagnostic Test (RDT). The Government of Nigeria plans to introduce RDTs in public health facilities over the coming year. In this context, we will evaluate the effectiveness and cost-effectiveness of two interventions designed to support the roll-out of RDTs and improve the rational use of ACTs. It is feared that without supporting interventions, non-adherence will remain a serious impediment to implementing malaria treatment guidelines. METHODS/DESIGN: A three-arm stratified cluster randomized trial is used to compare the effectiveness and cost-effectiveness of: (1) provider malaria training intervention versus expected standard practice in malaria diagnosis and treatment; (2) provider malaria training intervention plus school-based intervention versus expected standard practice; and (3) the combined provider plus school-based intervention versus provider intervention alone. RDTs will be introduced in all arms of the trial. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit primary health centers, pharmacies, and patent medicine dealers. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider and community knowledge. Costs will be estimated from both a societal and provider perspective using standard economic evaluation methodologies. TRIAL REGISTRATION: Clinicaltrials.gov NCT01350752

Motivation and incentives of rural maternal and neonatal health care providers: a comparison of qualitative findings from Burkina Faso, Ghana and Tanzania.

In Burkina Faso, Ghana and Tanzania strong efforts are being made to improve the quality of maternal and neonatal health (MNH) care. However, progress is impeded by challenges, especially in the area of human resources. All three countries are striving not only to scale up the number of available health staff, but also to improve performance by raising skill levels and enhancing provider motivation. In-depth interviews were used to explore MNH provider views about motivation and incentives at primary care level in rural Burkina Faso, Ghana and Tanzania. Interviews were held with 25 MNH providers, 8 facility and district managers, and 2 policy-makers in each country. Across the three countries some differences were found in the reasons why people became health workers. Commitment to remaining a health worker was generally high. The readiness to remain at a rural facility was far less, although in all settings there were some providers that were willing to stay. In Burkina Faso it appeared to be particularly difficult to recruit female MNH providers to rural areas. There were indications that MNH providers in all the settings sometimes failed to treat their patients well. This was shown to be interlinked with differences in how the term 'motivation' was understood, and in the views held about remuneration and the status of rural health work. Job satisfaction was shown to be quite high, and was particularly linked to community appreciation. With some important exceptions, there was a strong level of agreement regarding the financial and non-financial incentives that were suggested by these providers, but there were clear country preferences as to whether incentives should be for individuals or teams. Understandings of the terms and concepts pertaining to motivation differed between the three countries. The findings from Burkina Faso underline the importance of gender-sensitive health workforce planning. The training that all levels of MNH providers receive in professional ethics, and the way this is reinforced in practice require closer attention. The differences in the findings across the three settings underscore the importance of in-depth country-level research to tailor the development of incentives schemes

A cost-effectiveness analysis of provider interventions to improve health worker practice in providing treatment for uncomplicated malaria in Cameroon: a study protocol for a randomized controlled trial

BACKGROUND: Governments and donors all over Africa are searching for sustainable, affordable and cost-effective ways to improve the quality of malaria case management. Widespread deficiencies have been reported in the prescribing and counselling practices of health care providers treating febrile patients in both public and private health facilities. Cameroon is no exception with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials and the use of incorrect dosages. This study evaluates the effectiveness and cost-effectiveness of introducing two different provider training packages, alongside rapid diagnostic tests (RDTs), designed to equip providers with the knowledge and practical skills needed to effectively diagnose and treat febrile patients. The overall aim is to target antimalarial treatment better and to facilitate optimal use of malaria treatment guidelines. METHODS/DESIGN: A 3-arm stratified, cluster randomized trial will be conducted to assess whether introducing RDTs with provider training (basic or enhanced) is more cost-effective than current practice without RDTs, and whether there is a difference in the cost effectiveness of the provider training interventions. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit public and mission health facilities. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider knowledge. Costs will be estimated from a societal and provider perspective using standard economic evaluation methodologies. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00981877

Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia.

Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme. The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance