Knowledge, Attitudes, and Practices of Poultry Farmers on Antimicrobial Use and Resistance in Kitwe, Zambia: Implications on Antimicrobial Stewardship

Introduction: The inappropriate antimicrobial usage (AMU) in chicken production has led to an increase in the prevalence of antimicrobial resistance (AMR). In Zambia, there is little information documented regarding the knowledge, attitude, and practices of poultry farmers on AMU and AMR. Therefore, this study assessed the knowledge, attitude and practices regarding AMU and AMR among poultry farmers in Kitwe, Zambia. Methods: This was a cross-sectional study conducted among 106 poultry farmers from November to December 2021 using a structured questionnaire. Data analysis was done using IBM Statistical Package for Social Sciences (SPSS) version 26. Results: Overall, of the 106 participants, 90.6% knew what antimicrobials were, but only 29.2% were aware of AMR. The study showed that 46.2% of the participants had low knowledge, 71.7% had negative attitudes, and 61.3% had poor practices regarding AMR. The prevalence of antibiotic use in poultry production was 83%. The most used antimicrobials were tetracycline (84%) and gentamicin (35.2%). The commonly reported reason for the use of antimicrobials was for the treatment (93.2%) and prevention (89.8%) of diseases. Further, 76.9% of the administered antimicrobials were usually done without veterinarian consultation or prescription. Conclusion: The study shows that there was high AMU in poultry farms in Kitwe. However, there was low knowledge, negative attitude, and poor practices towards AMU and AMR. Therefore, there is a need for educational and sensitisation programmes regarding AMU and AMR among poultry farmers in Kitwe, Zambia. Alongside this, antimicrobial stewardship and surveillance systems should be strengthened in the livestock production sector. This will ensure food safety and public health.

Prevalence and Antimicrobial Susceptibility Status of Gram-Negative and Gram-Positive Bacteria on Handheld Shopping Trolleys and Baskets in Supermarkets in Ndola, Zambia

Background: Supermarkets are a place visited by individuals with different health conditions daily where microbiological contaminants through touch onto fomites such as trolleys and baskets can be passed on to other people hence potentially spreading infectious diseases. This study aimed to investigate the presence of Gram-negative and Gram-positive bacteria on handheld shopping trolleys and baskets and their antimicrobial susceptibility status against commonly used antibiotics in Zambia. Methods: A cross-sectional study was conducted. Trolleys and basket handles were swabbed and standard microbiological methods were used to identify the bacteria and disc diffusion to determine their antimicrobial susceptibility status. Data was collected from December 2021 to April 2022. Data was analysed using IBM Statistical Package for Social Sciences (SPSS) Version 22. Results: Twenty-eight percent of the 200 total samples were found to be culture-positive and predominant isolates were Staphylococcus aureus (17.3%), Pseudomonas species (4.5%), Escherichia coli (2%), Corynebacterium species (2%), Staphylococcus species (1.5%) and Enterobacter aerogenes (0.5%). Staphylococcus aureus showed the most resistance to azithromycin (17%) followed by ciprofloxacin (2.8%), nitrofurantoin (2.8%) and chloramphenicol (2.8%). Escherichia coli showed 100% resistance to amoxicillin, cloxacillin and ampicillin, 75% resistance to ciprofloxacin and the least resistance to azithromycin (25%) while it was susceptible to nitrofurantoin. Staphylococcus species, Corynebacterium species, Enterobacter aerogenes and Pseudomonas species showed no resistance to any antibiotics. Conclusion: The study showed the presence of microorganisms with considerable antimicrobial resistance to antibiotics in Zambia on trolley and basket handles indicating the need for more initiatives to address proper hygiene in public environmental sites for better infection prevention and control.

Familiarity, Knowledge and Practices of Healthcare Professionals Regarding the Pharmacovigilance of Biological Medicines in Lusaka, Zambia: A Multi-Facility Cross-Sectional Study

Background: Pharmacovigilance of biological medicines is crucial because it ensures that medicines meet the World Health Organization (WHO) standards. In Zambia, there is little information on healthcare professionals’ familiarity, knowledge and practices on the pharmacovigilance of biological and biosimilar medicines. Therefore, this study investigated the familiarity, knowledge, and practices related to the pharmacovigilance (PV) of biological and biosimilar medicines at selected hospitals in Lusaka, Zambia. Methods: The study was an analytical questionnaire-based cross-sectional study conducted among healthcare professionals (HCPs) at the Adult hospital, Cancer Diseases hospital, Paediatrics hospital and Women and New Born Hospital in Lusaka. Data were collected over four weeks in May and June 2021 and subsequently analysed using IBM SPSS version 21. The statistical significance was set at a 95% confidence interval. Results: Of 245 participants, only 115 (48.9%) of the HCPs were familiar with biological medicines to a basic understanding. Regarding the term biosimilars, most of the HCPs (40.9%) never heard of this word. The mean score for knowledge regarding the PV considerations of biological medicines was 4.1 out of 8 questions. Most HCPs used non-proprietary names (44.2%) when prescribing, dispensing, or administering biological medicines. Additionally, more than half (57.3%) of HCPs did not record batch numbers when dispensing or administering biological medicines. Conclusion: Healthcare professionals were more familiar with the term biological medicines than biosimilars. Healthcare professionals generally scored poorly when their knowledge regarding the PV considerations of biological medicines was assessed. Thus, there is a need to provide adequate training and continuous professional development among healthcare professionals on the pharmacovigilance of biological and biosimilar medicines.

Psychological Impact of COVID-19 on Healthcare Workers in Africa, Associated Factors and Coping Mechanisms: A Systematic Review

Background: The coronavirus disease 2019 (COVID-19) is a public health problem that has caused harm to the mental health of healthcare workers. In Africa, the COVID-19 pandemic has led healthcare workers to experience mental health disorders such as anxiety, depression, stress, insomnia and burnout. This study aimed to review published studies on the effect of COVID-19 on the mental health of healthcare workers, associated factors and coping strategies that have been employed in Africa. Methods: This was a systematic review that was conducted through searching databases including;PubMed/Medline and Google Scholar. The study included published literature from January 2020 to May 2022 that met the inclusion criteria. The selection of articles was conducted following the 2020 PRISMA guidelines. Results: A total of 39 articles were retrieved, of which only 18 met the inclusion criteria and were used in this study. Our review revealed that healthcare workers experienced mental health disorders such as anxiety, depression, insomnia, stress and burnout that were associated with the COVID-19 pandemic. Coping strategies such as religious practices, support from family members and colleagues and avoiding listening to social media about COVID-19 were used to minimize mental health problems. Conclusion: The COVID-19 pandemic has caused increased mental health disorders among healthcare workers in Africa. Identification of factors associated with mental health problems is cardinal in developing coping mechanisms against the psychological impact of COVID-19. Therefore, there is a need for governments to develop and implement strategies for protecting the mental health of healthcare workers during crises such as the COVID-19 pandemic.

Comment on “Effect of biofilm formation by clinical isolates of Helicobacter pylori on the efflux-mediated resistance to commonly used antibiotics”

Attaran et al[1] have recently shown that decreased susceptibility of established Helicobacter pylori(H. pylori) biofilms to specific antibiotics,was associated with the overtly enhanced transcription of two efflux pump genes,hp1165 and hef A,involved in specific resistance to tetracycline and multiple antibiotics,respectively. Apart from antibiotic exposure,secretion of multiple antimicrobial peptides,such as human β-defensins(hβDs),by the gastric epithelium upon Hp challenge,may act as early triggering events that positively impact biofilm formation and thus,antibiotic resistance. In this regard,we undertook genomic transcriptional studies using Hp 26695 strain following exposure to sublethal,similar to those present in the gastric niche,concentrations of hβDs in an attempt to provide preliminary data regarding possible mechanisms of immune evasion and selective sensitivity of Hp. Our preliminary results indicate that hβD exposure ignites a rapid response that is largely due to the activation of several,possibly interconnected transcriptional regulatory networks – origons-that ultimately coordinate cellular processes needed to maintain homeostasis and successful adaptation of the bacterium in the gastric environment. In addition,we have shown that both antibiotic and hβD resistance are mediated by dedicated periplasmic transporters,including the aforementioned efflux pump genes hp1165 and hef A,involved in active export of antibiotics from the cell membrane and/or,as recently suggested,substrate sensing and signalling. Furthermore,itappears that sublethal doses of hβDs may enhance biofilm formation by the sustained expression of,mainly,quorum sensing-related genes. In conclusion,we provide additional data regarding the role of specific innate immune molecules in antibiotic cross-resistance mechanisms that may deepen our understanding in the context of the development of novel eradication regimens.

A One-Health Sampling Strategy to Explore the Dissemination and Relationship Between Colistin Resistance in Human,Animal,and Environmental Sectors in Laos

This study was designed to investigate the molecular epidemiology of mobile colistin resistance(mcr)using a"One-Health"approach in Laos and to predict whether any dominant plasmid backbone and/or strain type influences the dissemination of mcr.We collected 673 samples from humans(rectal normal flora),poultry,and the environment(water,flies,birds,etc.)in Vientiane,Lao People’s Democratic Republic(Laos),from May to September 2018.A total of 238 Escherichia coli(E.coli)isolated from nonduplicative samples,consisting of 98 MCR-positive E.coli(MCRPEC)("mcr"denotes the gene encoding mobile colistin resistance,and"MCR"denotes the subsequent protein encoded by mcr)and 140 MCRnegative E.coli(MCRNEC),were characterized by phenotype and Illumina sequencing.A subset of MCRPEC was selected for Min ION sequencing,conjugation assay,plasmid stability,and growth kinetics in vitro.The prevalence of MCRPEC was found to be 14.6%(98/673),with the highest prevalence in human rectal swabs(45.9%(45/98),p<0.0001,odds ratio(OR):0.125,95% confidence interval(CI):0.077-0.202).The percentages of MCRPEC from other samples were 14.3%(2/14)in dog feces,12.0%(24/200)in flies,11.0%(11/100)in chicken meat,8.9%(8/90)in chicken cloacal,8.0%(4/50)in chicken caeca,and 7.5%(4/53)in wastewater.MCRPEC was significantly more resistant to co-amoxiclav,sulfamethoxazoletrimethoprim,levofloxacin,ciprofloxacin,and gentamicin than MCRNEC(p<0.05).Genomic analysis revealed the distribution of MCRPEC among diverse clonal types.The putative plasmid Inc types associated with mcr-1 were Inc X4,Inc HI2,Inc P1,Inc I2,and Inc FIA,and those associated with mcr-3 were Inc FII,Inc FIA,Inc FIB,Inc P1,and Inc R.Recovery of highly similar plasmids from both flies and other sampling sectors implied the role of flies in the dissemination of mcr-1.mcr-positive plasmids were shown to be conjugative,and a significantly high transfer rate into a hypervirulent clone ST1193 was observed.Plasmids containing mcr irrespective of Inc type were highly stable and invariably did not exert a fitness effect upon introduction into a new host.These findings signify the urgent need for a standard infection control program to radically decontaminate the source of resistance.

Frequency and distribution of neglected tropical diseases in Mozambique:a systematic review

Background:Neglected tropical diseases(NTDs)affect more than one billion people living in vulnerable conditions.In spite of initiatives recently contributing to fill NTDs gaps on national and local prevalence and distribution,more epidemiological data are still needed for effective control and elimination interventions.Main text:Mozambique is considered one of the countries with highest NTDs burden although available data is scarce.This study aims to conduct a systematic review on published available data about the burden and distribution of the different NTDs across Mozambique since January 1950 until December 2018.We identified manuscripts from electronic databases(Pubmed,EmBase and Global Health)and paper publications and grey literature from Mozambique Ministry of Health.Manuscripts fulfilling inclusion criteria were:crosssectional studies,ecological studies,cohorts,reports,systematic reviews,and narrative reviews capturing epidemiological information of endemic NTDs in Mozambique.Case-control studies,letters to editor,case reports and case series of imported cases were excluded.A total of 466 manuscripts were initially identified and 98 were finally included after the revision following PRISMA guidelines.Eleven NTDs were reported in Mozambique during the study span.Northern provinces(Nampula,Cabo Delgado,Niassa,Tete and Zambezia)and Maputo province had the higher number of NTDs detected.Every disease had their own report profile:while schistosomiasis have been continuously reported since 1952 until nowadays,onchocerciasis and cysticercosis last available data is from 2007 and Echinococcosis have never been evaluated in the country.Thus,both space and time gaps on NTDs epidemiology have been identified.Conclusions:This review assembles NTDs burden and distribution in Mozambique.Thus,contributes to the understanding of NTDs epidemiology in Mozambique and highlights knowledge gaps.Hence,the study provides key elements to progress towards the control and interruption of transmission of these diseases in the country.

Global Strategies to Combat Antimicrobial Resistance: A One Health Perspective

Background: Antimicrobial resistance (AMR) is a global health challenge that has escalated due to the inappropriate use of antimicrobials in humans, animals, and the environment. Developing and implementing strategies to reduce and combat AMR is critical. Purpose: This study aimed to highlight some global strategies that can be implemented to address AMR using a One Health approach. Methods: This study employed a narrative review design that included studies published from January 2002 to July 2023. The study searched for literature on AMR and antimicrobial stewardship (AMS) in PubMed and Google Scholar using the 2020 PRISMA guidelines. Results: This study reveals that AMR remains a significant global public health problem. Its severity has been markedly exacerbated by inappropriate use of antimicrobials in humans, animals, and the broader ecological environment. Several strategies have been developed to address AMR, including the Global Action Plan (GAP), National Action Plans (NAPs), AMS programs, and implementation of the AWaRe classification of antimicrobials. These strategies also involve strengthening surveillance of antimicrobial consumption and resistance, encouraging the development of new antimicrobials, and enhancing regulations around antimicrobial prescribing, dispensing, and usage. Additional measures include promoting global partnerships, combating substandard and falsified antimicrobials, advocating for vaccinations, sanitation, hygiene and biosecurity, as well as exploring alternatives to antimicrobials. However, the implementation of these strategies faces various challenges. These challenges include low awareness and knowledge of AMR, a shortage of human resources and capacity building for AMR and AMS, in adequate funding for AMR and AMS initiatives, limited laboratory capacities for surveillance, behavioural change issues, and ineffective leadership and multidisciplinary teams. Conclusion: In conclusion, this study established that AMR is prevalent among humans, animals, and the environment. Successfully addressing AMR calls for a collaborative, multifaceted One Health approach. Despite this, some gaps remain effectively implementing strategies currently recommended to combat AMR. As a result, it is essential to reinforce the strategies that are deployed to counter AMR across the human, animal, and environmental sectors.

Effects of improved sanitation on diarrheal reduction for children under five in Idiofa,DR Congo:a cluster randomized trial

Background:The lack of safe water and sanitation contributes to the rampancy of diarrhea in many developing countries.Methods:This study describes the design of a cluster-randomized trial in Idiofa,the Democratic Republic of the Congo,seeking evidence of the impact of improved sanitation on diarrhea for children under four.Of the 276 quartiers,18 quartiers were randomly allocated to the intervention or control arm.Seven hundred and-twenty households were sampled and the youngest under-four child in each household was registered for this study.The primary endpoint of the study is diarrheal incidence,prevalence and duration in children under five.Discussion:Material subsidies will be provided only to the households who complete pit digging plus superstructure and roof construction,regardless of their income level.This study employs a Sanitation Calendar so that the mother of each household can record the diarrheal episodes of her under-four child on a daily basis.The diary enables examination of the effect of the sanitation intervention on diarrhea duration and also resolves the limitation of the small number of clusters in the trial.In addition,the project will be monitored through the‘Sanitation Map’,on which all households in the study area,including both the control and intervention arms,are registered.To avoid information bias or courtesy bias,photos will be taken of the latrine during the household visit,and a supervisor will determine well-equipped latrine uptake based on the photos.This reduces the possibility of recall bias and under-or over-estimation of diarrhea,which was the main limitation of previous studies.Trial registration:The study was approved by the Institutional Review Board of the School of Public Health,Kinshasa University(ESP/CE/040/15;April 13,2015)and registered as an International Standard Randomized Controlled Trial(ISRCTN:10,419,317)on March 13,2015.

Antibiotic Prescribing Patterns in Adult Patients According to the WHO AWaRe Classification: A Multi-Facility Cross-Sectional Study in Primary Healthcare Hospitals in Lusaka, Zambia

Introduction: Indiscriminate prescribing and using of antibiotics have led to the development of antimicrobial resistance (AMR). To reduce this problem, the World Health Organization (WHO) developed the “Access”, “Watch”, and “Reserve” (AWaRe) classification of antibiotics that promotes antimicrobial stewardship (AMS). In Zambia, there are gaps in practice regarding prescribing of antibiotics based on the AWaRe protocol. This study assessed antibiotic prescribing patterns in adult in-patients in selected primary healthcare hospitals in Lusaka, Zambia. Materials and Methods: This retrospective cross-sectional study was conducted using 388 patient medical files from September 2021 to November 2021, five primary healthcare hospitals namely;Chawama, Matero, Chilenje, Kanyama, and Chipata. Data analysis was performed using the Statistical Package for Social Sciences version 23. Results: Of the selected medical files, 52.3% (n = 203) were for male patients. Overall, the prevalence of antibiotic use was 82.5% (n = 320) which was higher than the WHO recommendation of a less than 30% threshold. The most prescribed antibiotic was ceftriaxone (20.3%), a Watch group antibiotic, followed by metronidazole (17.8%) and sulfamethoxazole/trimethoprim (16.3%), both belonging to the Access group. Furthermore, of the total antibiotics prescribed, 41.9% were prescribed without adhering to the standard treatment guidelines. Conclusion: This study found a high prescription of antibiotics (82.5%) that can be linked to non-adherence to the standard treatment guidelines in primary healthcare hospitals. The most prescribed antibiotic was ceftriaxone which belongs to the Watch group, raising a lot of concerns. There is a need for rational prescribing of antibiotics and implementation of AMS programs in healthcare facilities in Zambia, and this may promote surveillance of irrational prescribing and help reduce AMR in the future.

Pay-it-forward gonorrhea and chlamydia testing among men who have sex with men in China:a study protocol for a three-arm cluster randomized controlled trial

Background:Gonorrhea and chlamydia testing rates are poor among Chinese men who have sex with men(MSM).A quasi-experimental study suggested that a pay-it-forward strategy increased dual gonorrhea/chlamydia testing among MSM.Pay-it-forward offers an individual a gift(e.g.,a free test)and then asks the same person if they would like to give a gift to another person.This article reports the protocol of a randomized controlled trial to evaluate dual gonorrhea/chlamydia test uptake and other outcomes among MSM in three arms-a pay-it-forward arm,a pay-what-you-want arm,and a standard of care arm.Methods:Three hundred MSM will be recruited at three HIV testing sites in Guangzhou and Beijing.Testing sites include two hospital-based MSM sexually transmitted diseases clinics and one MSM community-based organization.Eligible participants will be born biologically male,aged 16 years or older,reporting previous anal sex with another man,having never participated in the pay-it-forward program,without previous gonorrhea and chlamydia testing in the past 12 months,and residing in China.Following a cluster randomized design,every cluster of ten participants will be randomly allocated into one of three arms:(1)a pay-it-forward arm in which men are offered free gonorrhea and chlamydia testing and then asked whether they would like to donate("pay it forward")toward testing for future testers;(2)a pay-what-you-want arm in which men are offered free testing and told to decide how much to pay after receiving the test;(3)a standard of care arm in which men can pay the full price for dual gonorrhoea and chlamydia testing.The primary outcome is dual gonorrhoea/chlamydia testing as verified by administrative records.Secondary outcomes include incremental cost per test,incremental cost per diagnosis,community connectedness,and social cohesion.Primary outcome will be calculated for each arm using intention-to-treat and compared using one-sided 95%confidence intervals with a margin of 20%increase defined as superiority.Discussion:This study will examine the pay-it-forward strategy in comparison to the standard of care in improving test uptake for gonorrhea and chlamydia.We will leverage the cluster randomized controlled trial to provide scientific evidence on the potential effect of pay-it-forward.Findings from this study will shed light on novel intervention methods for increasing preventive health service utilization and innovate ways to finance it among communities.Trial registration:ClinicalTrials.gov,NCT03741725.Registered on 12 November 2018.

Elevated plasma interleukin-8 as a risk factor for mortality in children presenting with cerebral malaria

Background Cerebral malaria(CM)is a neuropathology which remains one of the deadliest forms of malaria among African children.The kinetics of the pathophysiological mechanisms leading to neuroinflammation and the death or survival of patients during CM are still poorly understood.The increasing production of cytokines,chemokines and other actors of the inflammatory and oxidative response by various local actors in response to neuroinflammation plays a major role during CM,participating in both the amplification of the neuroinflammation phenomenon and its resolution.In this study,we aimed to identify risk factors for CM death among specific variables of inflammatory and oxidative responses to improve our understanding of CM pathogenesis.Methods Children presenting with CM(n=70)due to P.falciparum infection were included in southern Benin and divided according to the clinical outcome into 50 children who survived and 20 who died.Clinical examination was complemented by fundoscopic examination and extensive blood biochemical analysis associated with molecular diagnosis by multiplex PCR targeting 14 pathogens in the patients'cerebrospinal fluid to rule out coinfections.Luminex technology and enzyme immunoassay kits were used to measure 17 plasma and 7 urinary biomarker levels,respectively.Data were analysed by univariate analysis using the nonparametric Mann-Whitney U test and Pearson’s Chi2 test.Adjusted and multivariate analyses were conducted separately for plasma and urinary biomarkers to identify CM mortality risk factors.Results Univariate analysis revealed higher plasma levels of tumour necrosis factor(TNF),interleukin-1beta(IL-1β),IL-10,IL-8,C-X-C motif chemokine ligand 9(CXCL9),granzyme B,and angiopoietin-2 and lower urinary levels of prostanglandine E2 metabolite(PGEM)in children who died compared to those who survived CM(Mann-Whitney U-test,P-values between 0.03 and<0.0001).The multivariate logistic analysis highlighted elevated plasma levels of IL-8 as the main risk factor for death during CM(adjusted odd ratio=14.2,P-value=0.002).Values obtained during follow-up at D3 and D30 revealed immune factors associated with disease resolution,including plasma CXCL5,C-C motif chemokine ligand 17(CCL17),CCL22,and urinary 15-F2t-isoprostane.Conclusions The main risk factor of death during CM was thus elevated plasma levels of IL-8 at inclusion.Follow-up of patients until D30 revealed marker profiles of disease aggravation and resolution for markers implicated in neutrophil activation,endothelium activation and damage,inflammatory and oxidative response.These results provide important insight into our understanding of CM pathogenesis and clinical outcome and may have important therapeutic implications.