Knowledge, perceptions and practices on antimicrobial resistance in humans and animals in Wakiso district, Uganda: a cross sectional study

Despite increasing evidence on antimicrobial resistance (AMR), there is limited literature on antimicrobial access and use in humans and animals in community settings globally. This study assessed knowledge and perceptions of AMR, as well as practices relating to the use of antimicrobials in humans and animals in Wakiso district, Uganda. This was a cross-sectional study among 418 participants that employed quantitative data collection methods. A structured questionnaire that included questions on knowledge, perceptions, practices related to AMR, and perceptions on access to antimicrobials in humans and animals was used. Data was analysed in STATA version 10. The majority of participants 63.6% (266/418) had heard about AMR mainly from family and friends 57.5% (153/266), and most 70.8% (296/418) were aware that resistant microorganisms cause infections that are difficult to treat. Most participants 62.7% (262/418) thought that they should complete the full dose of antimicrobials when on treatment. However, on the last occasion of antimicrobial use, 13.0% (44/338) revealed that they did not complete the full course of treatment. Participants who were single (APR = 1.12, C.I = 1.03–1.12, p-value = 0.01) and earning between 91 and 290 USD on average per month (APR = 1.12, C.I = 1.02–1.23, p-value = 0.02) were more likely to have completed a given antimicrobial course as compared to those who were married/cohabiting and earned less than 15 USD respectively. The majority of participants 60% (251/418) owned animals, and 81.3% (204/251) reported using antimicrobials mainly for prevention 61.3% (125/204) or treatment of sick animals 70.6% (144/204). Among the participants, 57.4% (117/204) reported not having sold or consumed animal products within a week after exposure to antimicrobials. Interventions to prevent AMR should adopt a One Health approach to address the gap in knowledge and practices relating to the use of antimicrobials in humans and animals

Scaling-up interventions for strengthening antimicrobial stewardship using a one health approach in Wakiso District, Uganda

We implemented a multidisciplinary project between Uganda and the UK aimed at strengthening antimicrobial stewardship (AMS) in Wakiso district, with a focus on capacity building, stakeholder engagement, and knowledge exchange using a One Health approach. Project activities included: trainings and workshops on antimicrobial resistance (AMR), AMS, infection prevention and control (IPC); Global Point Prevalence Survey (GPPS) data collection and analysis; and the mentorship of lower level health facilities. Our project demonstrated that AMS interventions using a One Health approach can enhance understanding of the prudent use of antimicrobials and improve practices at health facilities and within communities

Access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda: a qualitative study

Background: Inappropriate use of antimicrobials in both humans and animals is a key driver of antimicrobial resistance (AMR). In addition, human behaviours such as poor disposal of antimicrobials in the environment can increase their exposure to microbes which can impact on humans and animals. However, evidence on access, use and disposal of antimicrobials for humans and animals at community level in Uganda is limited. This study therefore explored access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda. Methods: A qualitative study was conducted that involved focus group discussions (FGDs) and key informant interviews (KIIs). Participants of the FGDs were community health workers (CHWs) and farmers involved in animal husbandry, while key informants included: officials from the Ministry of Health; Ministry of Agriculture, Animal Industry and Fisheries; human and animal health professionals; district health officials; and members of the national AMR surveillance committee. Twelve FGDs were held (8 for CHWs and 4 for farmers) while 15 KIIs were conducted. Thematic analysis in NVivo (version 12) was performed. Results: Five main themes emerged from the study: access to antimicrobials in humans; access to antimicrobials in animals; use of antimicrobials in humans; use of antimicrobials in animals; and disposal of antimicrobials. Community members mainly accessed antimicrobials for humans from public health facilities such as government health centres, as well as private facilities, including drug shops and clinics. Antimicrobials for animals were obtained from veterinary practitioners and drug shops (both for humans and veterinary). Examples of inappropriate use of antimicrobials in both humans and animals was evident, such as sharing antibiotics among household members, and giving human-prescribed antimicrobials to food-producing animals as growth promoters. While some CHWs returned unused antimicrobials to public health facilities for proper disposal, community members mainly disposed of antimicrobials with general household waste including dumping in rubbish pits. Conclusions: There is a need to increase awareness among the population on proper access, use and disposal of antimicrobials for both humans and animals. Development of a drug disposal system at community level would facilitate improved waste management of antimicrobials. Together, these measures would help prevent the rate of progression of AMR in communities

Impact of the Introduction of a Package of Diagnostic Tools, Diagnostic Algorithm, and Training and Communication on Outpatient Acute Fever Case Management at 3 Diverse Sites in Uganda: Results of a Randomized Controlled Trial.

BACKGROUND: Increasing trends of antimicrobial resistance are observed around the world, driven in part by excessive use of antimicrobials. Limited access to diagnostics, particularly in low- and middle-income countries, contributes to diagnostic uncertainty, which may promote unnecessary antibiotic use. We investigated whether introducing a package of diagnostic tools, clinical algorithm, and training-and-communication messages could safely reduce antibiotic prescribing compared with current standard-of-care for febrile patients presenting to outpatient clinics in Uganda. METHODS: This was an open-label, multicenter, 2-arm randomized controlled trial conducted at 3 public health facilities (Aduku, Nagongera, and Kihihi health center IVs) comparing the proportions of antibiotic prescriptions and clinical outcomes for febrile outpatients aged ≥1 year. The intervention arm included a package of point-of-care tests, a diagnostic and treatment algorithm, and training-and-communication messages. Standard-of-care was provided to patients in the control arm. RESULTS: A total of 2400 patients were enrolled, with 49.5% in the intervention arm. Overall, there was no significant difference in antibiotic prescriptions between the study arms (relative risk [RR]: 1.03; 95% CI: .96-1.11). In the intervention arm, patients with positive malaria test results (313/500 [62.6%] vs 170/473 [35.9%]) had a higher RR of being prescribed antibiotics (1.74; 1.52-2.00), while those with negative malaria results (348/688 [50.6%] vs 376/508 [74.0%]) had a lower RR (.68; .63-.75). There was no significant difference in clinical outcomes. CONCLUSIONS: This study found that a diagnostic intervention for management of febrile outpatients did not achieve the desired impact on antibiotic prescribing at 3 diverse and representative health facility sites in Uganda

Advancing Access to Diagnostic Tools Essential for Universal Health Coverage and Antimicrobial Resistance Prevention: An Overview of Trials in Sub-Saharan Africa.

We introduce the Antimicrobial Resistance Diagnostic Use Accelerator program, and the articles in this Supplement, which cover the program in 3 sub-Saharan Africa countries

Antibiotic Prescribing Patterns in Ghana, Uganda, Zambia and Tanzania Hospitals: Results from the Global Point Prevalence Survey (G-PPS) on Antimicrobial Use and Stewardship Interventions Implemented

Antimicrobial resistance (AMR) remains an important global public health issue with antimicrobial misuse and overuse being one of the main drivers. The Global Point Prevalence Survey (G-PPS) of Antimicrobial Consumption and Resistance assesses the prevalence and the quality of antimicrobial prescriptions across hospitals globally. G-PPS was carried out at 17 hospitals across Ghana, Uganda, Zambia and Tanzania. The overall prevalence of antimicrobial use was 50% (30–57%), with most antibiotics prescribed belonging to the WHO ‘Access’ and ‘Watch’ categories. No ‘Reserve’ category of antibiotics was prescribed across the study sites while antimicrobials belonging to the ‘Not Recommended’ group were prescribed infrequently. Antimicrobials were most often prescribed for prophylaxis for obstetric or gynaecological surgery, making up between 12 and 18% of total prescriptions across all countries. The most prescribed therapeutic subgroup of antimicrobials was ‘Antibacterials for systemic use’. As a result of the programme, PPS data are now readily available for the first time in the hospitals, strengthening the global commitment to improved antimicrobial surveillance. Antimicrobial stewardship interventions developed included the formation of AMS committees, the provision of training and the preparation of new AMS guidelines. Other common interventions included the presentation of findings to clinicians for increased awareness, and the promotion of a multi-disciplinary approach to successful AMS programmes. Repeat PPS would be necessary to continually monitor the impact of interventions implemented. Broader participation is also encouraged to strengthen the evidence base

Non-adherence to anti-TB drugs among TB/HIV co-infected patients in Mbarara Hospital Uganda: Prevalence and associated factors

Background: Non-adherence to treatment remains a major obstacle to efficient tuberculosis control in developing countries. The dual infection of Tuberculosis and HIV presents further adherence problems because of high pill burden and adverse effects. This poses a risk of increased multi-drug resistant TB. However, the prevalence of non-adherence and its associated factors have not been studied in these patients in Uganda.Objectives: To determine the prevalence and factors associated with non-adherence to anti-TB drugs among TB/HIV co-infected patients in Mbarara hospital.Methods: A cross-sectional study with qualitative and quantitative data collection methods was conducted among TB/HIV coinfected adults in Mbarara hospital from January to March 2008. Consecutive sampling was used to select 140 participants. Adherence was assessed over a 5-day period prior to the interview using patients self-reports. Data was collected using an interviewer administered questionnaire. Qualitative data was collected through key informant interviews using a topic guide and was analyzed manually. Quantitative data was analyzed using STATA version 8. Logistic regression was used to determine factors associated with nonadherence.Results: The prevalence of non-adherence was 25% (95% CI=17.8-32%). Being on continuous phase of the TB regimen was significantly associated with non-adherence (OR=6.24,

Patients’ Experiences and Preferences for Medicine Information: An International Comparison Between Malaysia, Thailand, Uganda, and England

Pitchaya Nualdaisri,1,2 Sarah A Corlett,2,3 Immaculate Akaso,4 Barbra Katusiime,5 Freddy Eric Kitutu,4 Siew Siang Chua,6 Janet Krska2 1Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Thailand; 2Medway School of Pharmacy, Universities of Kent and Greenwich, Chatham Maritime, Kent, UK; 3Pharmacy Department, Medway Foundation NHS Trust, Kent, UK; 4Department of Pharmacy, School of Health Sciences, Makerere University, Kampala, Uganda; 5School of Life Sciences, Pharmacy and Chemistry, Department of Pharmacy, Kingston University, London, UK; 6School of Pharmacy, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya, Selangor, MalaysiaCorrespondence: Pitchaya Nualdaisri, Email [email protected]: Verbal and written medicine information are available to the public but the quality, ease of access, ease of understanding and use of these resources varies greatly between countries. Timely access to quality medicine information is essential to support patient safety.Objective: This international cross-sectional survey, conducted in low-to high-income countries, aimed to compare experiences of and preferences for medicine information sources among respondents with recent medicine use.Methods: The survey was originally developed in England (Kent), then adapted and translated for use in southern Thailand (Songkhla), Malaysia (Klang Valley), and central Uganda (Kampala). Data were analysed using simple descriptive statistics and Chi-squared tests.Results: A total 1588 respondents were involved in the study. Community pharmacies were the primary source of medicines in all four countries (40.7 to 65.3%). Most respondents (1460; 92%) had received at least one form of information with their medicine, but provision of written medicine information (WMI) varied between countries. A manufacturer’s leaflet was the most frequent information source for patients in England, while verbal information was common in Thailand, Malaysia and Uganda. There was commonality across countries in the desire for verbal information with or without WMI (1330; 84.8%); aspects of medicine information wanted most frequently were instructions on medicine use (98.3%), indication (98.2%), name (94.4%) and possible side effects (94.3%); and the importance of providing leaflets with all medicines (87.5%). Fewer than 10% in Uganda would use internet based WMI, compared to between 20% and 55% elsewhere.Conclusion: Preferences for medicine information are similar across countries: verbal information is seen as most desirable, and the most wanted aspects of information are common internationally. Accessibility and understandability are key influences on preferred information sources. In-country regulations and practices should ensure that all medicine users can access the information necessary to maximise safe medicine use.Keywords: medicine information sources, patient information leaflets, patient preference, cross-country comparison, international surve

Ethical challenges in designing and conducting medicine quality surveys

Poor quality medicines and medical products jeopardize national, regional and global attempts to improve access to effective treatment and health care. Both poor quality manufacture and deliberate falsification of medicines are widespread and many examples have been highlighted globally. Ethically designed surveys are essential for an in-depth understanding of this phenomenon to ensure corrective actions. Objectives: In this paper we identify and discuss the main ethical challenges related to the conduct of surveys and make suggestions on how to address them. Methods: Most evidence-based information regarding medicine quality derives from surveys. However, existing research ethical guidelines do not provide specific guidance for medicine quality surveys. Hence, those conducting surveys are often left wondering how to judge what counts as best practice. A list of the main ethical challenges in the design and conduct of surveys is presented. Results and conclusions: It is vital that the design and conduct of medicine quality surveys upholds moral and ethical obligations and analyses the ethical implications and consequences of such work, i.e. impact on the local availability of and access to medicines; the confidentiality and privacy of the surveyors and the surveyed; questions as to whether outlet staff personnel should be told they are part of a survey; the need of ethical and regulatory approvals; and how the findings should be disseminated. Medicine quality surveys should ideally be conducted in partnership with the concerned national Medicine Regulatory Authorities (MRA). An international, but contextually sensitive, model of good ethical practice for such surveys is needed