extent of human and environmental antibiotic use in rural bangladesh roess aa 1, winch pj 1, afsana...
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EXTENT OF HUMAN AND EXTENT OF HUMAN AND ENVIRONMENTAL ANTIBIOTIC USE IN ENVIRONMENTAL ANTIBIOTIC USE IN
RURAL BANGLADESHRURAL BANGLADESH
Roess AARoess AA11, Winch PJ, Winch PJ11, , Afsana AAfsana A22, Afroz D, Afroz D22, Ali NA, Ali NA22, Shah , Shah RR22, Seraji H, Seraji H22, Baqui AH, Baqui AH11, Darmstadt GL, Darmstadt GL11, Arifeen SE, Arifeen SE22
Second International Conference on Improving Use of Second International Conference on Improving Use of Medicines, Chiang Mai, ThailandMedicines, Chiang Mai, Thailand
March 30-April 2, 2004March 30-April 2, 2004
Results of qualitative research
Funding provided by the Center for a Livable Future, JHSPH, USADoctoral fellowship for AA Roess provided by National Institute of Child Health and Development, NIH, USA
AbstractAbstractProblem Statement: Problem Statement: Studies from the United States and the European Union have demonstrated a Studies from the United States and the European Union have demonstrated a
direct link between livestock antibiotic usage and human infection caused by antibiotic-resistant direct link between livestock antibiotic usage and human infection caused by antibiotic-resistant pathogens. No information is available from resource-poor settings on the extent of pathogens. No information is available from resource-poor settings on the extent of environmental antibiotic usage or the prevalence of antibiotic-resistant bacteria in animals.environmental antibiotic usage or the prevalence of antibiotic-resistant bacteria in animals.
Objective:Objective: To assess the extent of environmental and human antibiotic usage in rural Bangladesh, To assess the extent of environmental and human antibiotic usage in rural Bangladesh, surrounding practices and beliefs, and the impact on antimicrobial-resistant bacteria in human surrounding practices and beliefs, and the impact on antimicrobial-resistant bacteria in human populations. populations.
Setting and Study Population:Setting and Study Population: Between July 2002 and May 2003, interviews were conducted with Between July 2002 and May 2003, interviews were conducted with 20 village doctors, local “pharmacists,” homeopaths, clinic workers, and local animal care 20 village doctors, local “pharmacists,” homeopaths, clinic workers, and local animal care providers to learn about their antibiotic prescription practices. Interviews were also conducted providers to learn about their antibiotic prescription practices. Interviews were also conducted with 40 randomly selected households in a remote region of Bangladesh to learn about human with 40 randomly selected households in a remote region of Bangladesh to learn about human and animal antibiotic usage practices and surrounding beliefs at the household level. A survey and animal antibiotic usage practices and surrounding beliefs at the household level. A survey instrument was developed to quantify these results in 700 households and is currently in use.instrument was developed to quantify these results in 700 households and is currently in use.
Outcome Measures: Outcome Measures: Average number of drugs/household, number of drugs/child case, number of Average number of drugs/household, number of drugs/child case, number of drugs/childhood disease type, percentage of drugs prescribed/provider type, average cost of drugs/childhood disease type, percentage of drugs prescribed/provider type, average cost of drugs/household, average cost of drugs/child, number of animal antibiotics/household, cost of drugs/household, average cost of drugs/child, number of animal antibiotics/household, cost of animal antibiotics/household.animal antibiotics/household.
Results:Results: Current human antibiotic use, defined as use within the last 1 month, was reported in every Current human antibiotic use, defined as use within the last 1 month, was reported in every household sampled. Children were the recipients of about 50% of antibiotics in use. Animal household sampled. Children were the recipients of about 50% of antibiotics in use. Animal antibiotic use was found in 60% of sampled households. Human and animal antibiotic use at the antibiotic use was found in 60% of sampled households. Human and animal antibiotic use at the household level was at suboptimal doses. Veterinarians are increasingly concerned about the household level was at suboptimal doses. Veterinarians are increasingly concerned about the unregulated use of animal antibiotics in rural areas, and several described treating “resistant” unregulated use of animal antibiotics in rural areas, and several described treating “resistant” cases with second-line antibiotics. An interesting parallel emerged between care-seeking cases with second-line antibiotics. An interesting parallel emerged between care-seeking behavior, antibiotic use, and prescriber practices for both humans and animals.behavior, antibiotic use, and prescriber practices for both humans and animals.
Conclusions:Conclusions: The extent of antibiotic use in rural Bangladesh is much greater than previously The extent of antibiotic use in rural Bangladesh is much greater than previously thought. Most surprising was the widespread use of animal antibiotics and the anecdotal reports thought. Most surprising was the widespread use of animal antibiotics and the anecdotal reports of “resistant” animal infections. We are currently collecting specimens from people and animals to of “resistant” animal infections. We are currently collecting specimens from people and animals to determine the prevalence of antibiotic-resistant bacteria in the populations and the relationship determine the prevalence of antibiotic-resistant bacteria in the populations and the relationship between environmental antibiotic use and the emergence of antibiotic-resistant human between environmental antibiotic use and the emergence of antibiotic-resistant human pathogens. We are working with the Bangladesh Ministry of Fisheries and Livestock to assess pathogens. We are working with the Bangladesh Ministry of Fisheries and Livestock to assess the problem and make recommendations for future surveillance. the problem and make recommendations for future surveillance.
Increasing prevalence of antimicrobial Increasing prevalence of antimicrobial resistant (AMR) microbes in S Asiaresistant (AMR) microbes in S Asia
Community-acquired infectionsCommunity-acquired infections– MultidrugMultidrug resistant pneumococciresistant pneumococci– Drug-resistant Drug-resistant H. influenzaeH. influenzae– FQ- and ESC-resistant FQ- and ESC-resistant SalmonellaSalmonella– Multidrug resistant Multidrug resistant ShigellaShigella– FQ-resistant gonococciFQ-resistant gonococci– Multidrug-resistant Multidrug-resistant M. tuberculosisM. tuberculosis– Drug-resistant malariaDrug-resistant malaria
CHRP 2002
Risk factors for AMRRisk factors for AMR
Antibiotic useAntibiotic use
Recent hospital stay/visitRecent hospital stay/visit
CrowdingCrowding
TravelTravel
Animal antibiotic use (food animal & Animal antibiotic use (food animal & pet)pet)
Study Conceptual frameworkStudy Conceptual framework
Human disease AMR
Human Carriage AMR
Animal Carriage AMR
Human ab use
Animal ab use
SES HH CrowdingTown Clinic
Provider practices
Drug Use Policy
AMR conceptual framework with AMR conceptual framework with picpic 23Feb2004.doc 23Feb2004.doc
ObjectivesObjectives
To understand antibiotic use practices for To understand antibiotic use practices for people and animals at the household level people and animals at the household level in Sylhetin Sylhet
To design an instrument to quantify To design an instrument to quantify antibiotic useantibiotic use
MethodsMethods
Field ObservationsField Observations
In-depth interviewsIn-depth interviews– Ministers of Fisheries and LivestockMinisters of Fisheries and Livestock– Government veterinarians and scientistsGovernment veterinarians and scientists– Pharmaceutical representativesPharmaceutical representatives– Village doctors, drug-sellersVillage doctors, drug-sellers
Semi-structured interviewsSemi-structured interviews– 14 human use14 human use– 24 animal use24 animal use– 10 village doctors10 village doctors
Village doctor networkVillage doctor network
Crowding as a risk factorCrowding as a risk factor
Crowding – Especially in the capital and in the town centers throughout Bangladesh. Bangladesh is the 8th most populated countries with a population of about 140 million—for some perspective that’s equivalent to about half of the US’s population in Wisconsin.
Exposure to animals -- DhakaExposure to animals -- Dhaka
Town to village deliveryTown to village delivery
Pharmaceutical presence: Such carts from pharmaceuticals filled with human and animal antibiotics and medicines make deliveries to bazaars.
Smaller carts driven by rickshaws or pulled by delivery boys delivered to more remote areas.
This aerial shot was taken 3 months before the Monsoons. Statistics on flooding included that more than 50% of the country is underwater more than 50% of the year. Untreated human waste, animal waste, and pollutants
enter this water. People are exposed to this water either by contact or through using the water for household work of for drinking.
Flooding/InfrastructureFlooding/Infrastructure
Human medicines in stock at homeHuman medicines in stock at home
AntibioticAntibioticss
ParacetamolParacetamol Homeopath Homeopath (Vitamins)(Vitamins)
<1 year old<1 year old
1-10 years1-10 years
AdultsAdults
TotalTotal
Total Total packagespackages
14/14 9/14
7
9
8
5(8)/14
61
1
7
5
3
3
2
Care-providers/drug sellers rolesCare-providers/drug sellers roles
““Village Village doctors”doctors”
Treat Treat infantsinfants
Sell human Sell human medmed
Treat Treat animalsanimals
Sell animal Sell animal medmed
4343 3939 2727 88 1111
37 women were first asked who the 3 “most popular village doctors” were. Each woman was then asked to name an animal doctor if she hadn’t already. 43 different “doctors” were identified. 2 of the village doctors originally identified were thought to only treat animals.
Village doctor networkVillage doctor network
VD VD multiple roles multiple roles
Treatment patternsTreatment patterns
Examination/SymptomsExamination/Symptoms
DosageDosage
Animal ownershipAnimal ownership
AnimalAnimal AnyAny 1-51-5 >5>5
CowsCows
GoatsGoats
DucksDucks
ChickensChickens
Swans/pigeonsSwans/pigeons
ElephantElephant
8125
244
19
1
4
1
1317 4
54
5
24 households that owned at least 1 chicken were included to learn about animal medicine use and animal husbandry.
Expenditure for animal purchaseExpenditure for animal purchaseAnimalAnimal 00 30-200Tk30-200Tk
US$1-4US$1-4
201-500201-500
US$4-10US$4-10
501-9K501-9K
10-20010-200
10-25K10-25K
200-500200-500
CowsCows
GoatsGoats
DucksDucks
ChickensChickens
Swans/pigeonsSwans/pigeons
ElephantElephant
8
102
4
1
2
15
2
2
2
8
1 1 3
2
Animals are a large investment because they are sources of food (meat milk and eggs), and are a good source of income.
Animal useAnimal use
EggsEggs MeatMeat MilkMilk AgriculturAgriculturee
Raise Raise and selland sell
%%100 83 75 54 54
Animal medicine useAnimal medicine use
Heard of Heard of animal animal antibiotics/antibiotics/med?med?
Gave Gave animal animal med?med?
Animal Animal ever ill?ever ill?
Care Care seeking?seeking?
%%29 Yes 92 Yes 100 Yes 96 Yes
Animal diseasesAnimal diseases
Cow—diarrhea, back pain, blistersCow—diarrhea, back pain, blisters
Goat—diarrhea, stomach swelling Goat—diarrhea, stomach swelling
Duck/Chicken—white diarrhea, fever from Duck/Chicken—white diarrhea, fever from river, “doze”river, “doze”
Evil eye, bad spiritsEvil eye, bad spirits
Animal “medicine”Animal “medicine”
OxytetracyclineOxytetracycline
MetronidazoleMetronidazole
Growth promoter (2/24)Growth promoter (2/24)
ParacetomolParacetomol
HomeopathicHomeopathic
Injections (5/24)Injections (5/24)
Animal medicine costAnimal medicine cost20-60tk 20-60tk (US$1)(US$1)
61-12061-120
(US$2)(US$2)
121-181121-181
(US$3)(US$3)
181-220181-220
(US$4)(US$4)
220-2k220-2k
(US$12)(US$12)
TotalTotal 11 33 22 12 (50%)12 (50%)
10-60tk10-60tk
(US$1)(US$1)
61-12061-120
(US$2)(US$2)
121-181121-181
(US$3)(US$3)
181-220181-220
(US$4)(US$4)
>220>220
(US$5)(US$5)
TotalTotal 11 44 44 22 3 (22%)3 (22%)
•About 50% of households spent on average 12USD for animal medicine while more than 50% spent less than 3USD on human medicine. •Since animals are such a big investment this is understandable and expected by many of those in the animal medicine business in Bangladesh.
Human medicine costHuman medicine cost
Animal care expenditureAnimal care expenditure
Animals Animals food + income food + income
Buy animalsBuy animals– 5,000-18,000 Tk per cow5,000-18,000 Tk per cow– 0, 100-120 Tk per chicken0, 100-120 Tk per chicken
TreatmentTreatment– 200 Tk injection200 Tk injection– 16-60 Tk/tablet (oxytetracycline)16-60 Tk/tablet (oxytetracycline)
Human care expenditureHuman care expenditure
10Tk-320Tk, m=40Tk10Tk-320Tk, m=40Tk
VitaminVitamin
HomeopathicHomeopathic
ParacetomolParacetomol
AntibioticsAntibiotics
Animal ab useAnimal ab use
Drug sellersDrug sellersA drug seller gave us some insight into the human and animal medicine business. He described starting out as a human pharmacist and then making a gradual transition to human and animal medicine.
Eventually he switched to the exclusive sale of animal medicines because it is much more profitable and associated with less risk. His story was repeated several times in our other interviews.
Animal husbandryAnimal husbandry
AnimalAnimal ShedShed ““under bed”under bed” HouseHouse
CowsCows 1515 11
GoatsGoats 33 22
DucksDucks 44 66 22
ChickensChickens 88 1313 33
Swans/pigeonsSwans/pigeons 44
ElephantElephant 11
In rural areas proximity to livestock and household members is greater and so is the potential risk. For example we found that while the majority of cows had their own shed or special house chickens and goats not only lived in the house but lived in special baskets “under the bed”.
Animal care-takerAnimal care-taker
AnimalAnimal MaleMale FemaleFemale
CowsCows
GoatsGoats
ChickenChicken 240
3413
2
Female household members take care of both chickens and children, thus they introduce to their children another source of antibiotic resistant pathogens.
Animals, Fish, Food, WaterAnimals, Fish, Food, Water
Animals can transmit resistant bacteria and resistance agents through contamination of water. This type of setting is common throughout the world, fish are caught in this water that is contaminated with both human and animal waste, fish are consumed, water is used for many purposes, and resistance spreads.
Future data collectionFuture data collection
Currently we are using a survey instrument Currently we are using a survey instrument to quantify human and animal level antibiotic to quantify human and animal level antibiotic use, and related household and SES use, and related household and SES variables. Data will be obtained on the variables. Data will be obtained on the prevalence of human and animal carriage of prevalence of human and animal carriage of AMR bacteria and the relationship of the two. AMR bacteria and the relationship of the two. This information will be shared with the This information will be shared with the Government of Bangladesh and other Government of Bangladesh and other stakeholders with the goal of informing stakeholders with the goal of informing programs to reduce the spread of resistant programs to reduce the spread of resistant microbes.microbes.
Survey designSurvey design
AMR riskAMR risk– Animal exposure (crowding, waste, ab use)Animal exposure (crowding, waste, ab use)– Current antibiotic use (look at available Current antibiotic use (look at available
medicine)medicine)– Human waste removalHuman waste removal– Human crowdingHuman crowding
Antibiotic useAntibiotic use– HumanHuman
AcknowledgementsAcknowledgements
JHSPHJHSPH
Ellen K. SilbergeldEllen K. Silbergeld
Timothy BakerTimothy Baker
Diane Lynn FranciscoDiane Lynn Francisco
Mathuram SantoshamMathuram Santosham
Paul A. LawPaul A. Law
ICDDR,B, DSHICDDR,B, DSH
Tamanna SharminTamanna Sharmin
Ashraful Alam NeeloyAshraful Alam Neeloy
Samir K. SahaSamir K. Saha
Many thanks go to the Centre for a Livable Future at Johns Hopkins University School of Public Health and especially to Robert Lawrence and Polly Walker for their support and encouragement.