Spatial and temporal variation in the community prevalence of antibiotic resistance in Bangladesh: an integrated surveillance study protocol

Introduction: Increasing antibiotic resistance (ABR) in low and middle-income countries such as Bangladesh presents a major health threat. However, assessing the scale of the health risk is problematic in the absence of reliable data on the community prevalence of antibiotic-resistant bacteria. We describe the protocol for a small-scale integrated surveillance programme that aims to quantify the prevalence of colonisation with antibiotic resistant bacteria and concentrations of antibiotic resistant genes from a ‘One Health’ perspective. The holistic assessment of antibiotic resistance in humans, animals and within the environment in urban and rural Bangladesh will generate comprehensive data to inform human health risk. Methods and analysis: The study design focuses on three exposure-relevant sites where there is enhanced potential for transmission of ABR between humans, animals and the environment: i) rural poultry-owning households, ii) commercial poultry farms and iii) urban live-bird markets. The comparison of ABR prevalence in human groups with high and low exposure to farming and poultry will enable us to test the hypothesis that ABR bacteria and genes from the environment and foodproducing animals are potential sources of transmission to humans. Escherichia coli is used as an ABR indicator organism due to its widespread environmental presence and colonisation in both the human and animal gastrointestinal tract. Ethics and dissemination: The study has been approved by the Institutional Review Board of the International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b) and Loughborough University Ethics Committee. Data for the project will be stored on the open access repository of the Centre for Ecology and Hydrology, Natural Environment Research Council. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. STRENGTHS AND LIMITATIONS OF THIS STUDY • We present a study protocol focused on integrated surveillance of ABR in urban and rural Bangladesh using a One Health approach • Assessment of the human, poultry and environmental prevalence of antibiotic resistant E. coli will identify potential hotspots for transmission in Bangladesh • Seasonal and spatial variation on the occurrence of antibiotic resistant bacteria in humans, poultry and the wider environment will be assessed • The two regions included in the study may not be typical of all regions within Banglades

Pathways of antibiotic use in Bangladesh: a qualitative protocol for the PAUSE study

Introduction: Global actions to reduce antimicrobial resistance include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers. The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation. Methods and analysis: In-depth interviews will be conducted with i) household members responsible for decision-making about illness and antibiotic use for family and livestock; ii) qualified and unqualified private and government healthcare providers in human and animal medicine and iii) stakeholders and policy makers as key informants on the development and implementation of policy around antimicrobial resistance (AMR). Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis. A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behaviour change and the development of effective interventions to reduce the health risks of antimicrobial resistance. Ethics and Dissemination Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) following review by the Research and Ethic committees (PR-16100) and from Loughborough University (R17-P081). Dissemination will take place through stakeholder workshops, international conferences and publication

Occurrence and genetic characteristics of mcr-1-positive colistin-resistant E. coli from poultry environments in Bangladesh

ObjectivesColistin is one of the last-resort antibiotics for treatment of multi-drug resistant (MDR) Gram negative bacterial infections. We determined occurrence and characteristics of mcr-1-producing E. coli obtained from live bird markets (LBM), rural poultry farms (RPF) and rural household backyard poultry (HBP) in Bangladesh.MethodsWe tested 104 extended-spectrum β-lactamase (ESBL)-producing E. coli isolated during 2017-2018 from poultry sources for colistin resistance. We analyzed the resistant isolates for mcr gene and characterized mcr positive isolates for antibiotic susceptibility, antibiotic resistance genes, transmissible plasmids and clonal diversity.ResultsOf 104 isolates, 98 (94%) had MICcolistin ≥4 μg/mL and 14 (13.5%) were positive for mcr-1 of which 10 were from LBM (n = 10), 3 from RFP and 1 from HBP. All 14 mcr-1 E. coli were resistant to third generation cephalosporin and tetracycline, while 12 were resistant to fluoroquinolone and sulphamethoxazole, 10 were to aminoglycosides and 3 were to nitrofurantoin. Four isolates carried conjugative mcr-1 plasmid of 23 to 55 MDa in size. The 55 MDa plasmid found in 2 isolates carried additional resistant genes including blaCTX-M-group-1 and blaTEM-1 (ESBL), qnrB (fluoroquinolone) and rmtB (aminoglycoside). These plasmids belong to IncF family with additional replicons: HI1 and N. ERIC-PCR revealed a heterogeneous banding pattern of mcr-1 positive isolates.ConclusionWe report a 13.5% prevalence of mcr-1 positive MDR E. coli in poultry fecal samples predominantly from LBMs in Bangladesh accentuating the need for safe disposal of poultry feces and hygiene practices among people exposed to poultry.</div

Water sanitation and hygiene status in the neighbourhood of Bangladeshi Islamic schools and mosques

Faith based interventions have been underutilized to improve water, sanitation and hygiene status and offers promise to promote behaviour in the community. Prior to delivering a faith based WASH intervention, we conducted a survey among the neighbouring households of eight Bangladeshi Islamic schools and associated mosques. We randomly selected 192 families from where any male attend mosque and interviewed adult women from that family. At baseline, almost all households used improved water sources and improved toilets. However, toilet cleanliness was poor. Faecal matter was disposed into the environment after emptying the pit/septic tank. Defecation and disposal among children <3years mostly occurred directly in the open which should be improved using behaviour change recommendations. Presence of hand washing agent in the hand washing place was low. Islamic faith based intervention should be designed and delivered in way that can promote hand washing, safe sanitation practices and safe disposal of child faeces

Human, animal and environmental contributors to antibiotic resistance in low resource settings: integrating behavioural, epidemiological and One Health approaches

Antibiotic resistance (ABR) is recognised as a One Health challenge because of the rapid emergence and dissemination of resistant bacteria and genes among humans, animals and the environment on a global scale. However, there is a paucity of research assessing ABR contemporaneously in humans, animals and the environment in low resource settings. This critical review seeks to identify the extent of One Health research on antibiotic resistance in low and middle income countries (LMICs). Existing research has highlighted hotspots for environmental contamination; food-animal production systems that are likely to harbour reservoirs or promote transmission of ABR as well as high and increasing human rates of colonisation with ABR commensal bacteria such as Escherichia coli. However, very few studies have integrated all three components of the One Health spectrum to understand the dynamics of transmission of AMR and the prevalence of community-acquired resistance in humans and animals. Microbiological, epidemiological and social science research is needed at community and population levels across the One Health spectrum in order to fill the large gaps in knowledge of ABR in low resource settings

Supplementary Table 1: Summary of studies directly assessing antibiotic resistant bacteria (ARB) and antibiotic resistant genes (ARG) in more than one domain of humans, food-producing animals and the environment from Human, animal and environmental contributors to antibiotic resistance in low-resource settings: integrating behavioural, epidemiological and One Health approaches

Antibiotic resistance (ABR) is recognized as a One Health challenge because of the rapid emergence and dissemination of resistant bacteria and genes among humans, animals and the environment on a global scale. However, there is a paucity of research assessing ABR contemporaneously in humans, animals and the environment in low-resource settings. This critical review seeks to identify the extent of One Health research on ABR in low- and middle-income countries (LMICs). Existing research has highlighted hotspots for environmental contamination; food-animal production systems that are likely to harbour reservoirs or promote transmission of ABR as well as high and increasing human rates of colonization with ABR commensal bacteria such as <i>Escherichia coli</i>. However, very few studies have integrated all three components of the One Health spectrum to understand the dynamics of transmission and the prevalence of community-acquired resistance in humans and animals. Microbiological, epidemiological and social science research is needed at community and population levels across the One Health spectrum in order to fill the large gaps in knowledge of ABR in low-resource settings

Supplementary Table 1: Summary of studies directly assessing antibiotic resistant bacteria (ARB) and antibiotic resistant genes (ARG) in more than one domain of humans, food-producing animals and the environment from Human, animal and environmental contributors to antibiotic resistance in low resource settings: integrating behavioural, epidemiological and One Health approaches

Antibiotic resistance (ABR) is recognized as a One Health challenge because of the rapid emergence and dissemination of resistant bacteria and genes among humans, animals and the environment on a global scale. However, there is a paucity of research assessing ABR contemporaneously in humans, animals and the environment in low-resource settings. This critical review seeks to identify the extent of One Health research on ABR in low- and middle-income countries (LMICs). Existing research has highlighted hotspots for environmental contamination; food-animal production systems that are likely to harbour reservoirs or promote transmission of ABR as well as high and increasing human rates of colonization with ABR commensal bacteria such as <i>Escherichia coli</i>. However, very few studies have integrated all three components of the One Health spectrum to understand the dynamics of transmission of AMR and the prevalence of community-acquired resistance in humans and animals. Microbiological, epidemiological and social science research is needed at community and population levels across the One Health spectrum in order to fill the large gaps in knowledge of ABR in low-resource settings

Multivariate analysis of observed handwashing behavior and subsequent diarrhea.

a<p>Odds ratio was calculated using a general estimated equations model that accounted for neighborhood clustering and repeated household sampling using a nested correlation structure.</p

Bivariate relationship between baseline characteristics and observed handwashing behaviors with subsequent diarrhea among children under age 5 y in the ensuing 24 mo.

a<p>When multiple handwash opportunities were observed in the same household, the household's handwashing behavior was classified on the basis of the most thorough handwashing behavior observed.</p>b<p>Adjusted for repeated measures of the same child and village clustering.</p>c<p>There were 24 fewer observations in the analysis with fathers' education, because there data were missing for one of the households.</p>d<p>Optimal hand drying (air drying or drying with a clean towel) was compared with hands not dried or dried on dirty towel or clothing; this analysis was restricted to episodes where handwashing was observed.</p>e<p>Washed one hand with water only was selected as the baseline category because too few people did not wash their hands at all to permit robust statistical evaluation.</p

Pathways of antibiotic use in humans and animals in Bangladesh: transcripts of interviews with household members and healthcare providers

The dataset presents transcripts of interviews conducted around antibiotic use in humans and animals in Bangladesh. Interviews examined antibiotic use and behaviours contributing to antibiotic resistance from the perspective of household members and healthcare providers in one urban and one rural site in Bangladesh. Household interviews were carried out with the household decision-maker or main care-giver (total 48 interviews). Healthcare provider interviews were carried out with a range of qualified and unqualified providers from human and veterinary medicine (total 46 interviews). The interviews gathered information on where people sought treatment for illnesses due to infection, what determined their choice of healthcare provider; factors contributing to antibiotic use in humans and animals; knowledge and understanding of antibiotic resistance. Similar questions about antibiotic prescribing and selling practices were asked of healthcare providers.Interviews were conducted in Bangla, audio-recorded and transcribed anonymously. All transcripts are available in Bangla as .pdf files. A proportion of transcripts have been translated to English and are available in word files. Further information on the study as well as details on methods and analysis are available under a CC-BY licence at https://doi.org/10.1136/bmjopen-2018-028215 or https://dspace.lboro.ac.uk/2134/36467The guides used to conduct the interviews are available at: https://doi.org/10.17028/rd.lboro.9333158.v1</p