Here’s taking a look at some of the interesting research papers that popped up in my inbox this week. I try to keep my reading wider than the work I am currently involved in; that might be criticized as loss of focus, but I like to think of it as keeping my eyes open to the wider array of medical and public health areas that interest me. Every week, I shall try to bring a selection of articles that piqued my interest (in no particular order – I do not have that much time!) and a “cover art” of interest. This week’s list is slightly truncated since I have not included some of the stuff I read earlier on in the week. The cover comes from the current issue of the CDC’s Emerging Infectious Diseases journal. The reason for selecting this piece is clearly elucidated in the accompanying editorial note:
Wildlife have historically been a significant source of infectious disease pathogens, and a plethora of known pathogenic agents can be transmitted directly or indirectly from animals to humans via a variety of routes. Assuming Rubens’ hunters bested their quarry, then other exposures to pathogenic agents, including bacteria, viruses, parasites, and fungi that cause zoonotic diseases, could occur when the animals are field-dressed for their meat, bones, ivory, and hides; consumed during a celebratory banquet; or shared with others. Besides Rubens’ hippopotamus and crocodile, other sources of pathogen exposure include rodents; mosquitoes and other insects; and birds that dwell on the riverbank, in the water, or among the vegetation.
As our understanding of the process of cross-species transmission of pathogens continues to unfold, the enhanced interface between humans and animals through hunting, commerce, animal husbandry, and domestication of exotic pets increases the likelihood of zoonotic infections. Because so many infectious diseases in humans are acquired from animals, initiatives such as One Health that encourage collaboration among multiple disciplines are useful for achieving the best health for people, animals, and the environment.
Food-producing animals throughout the world are likely to be exposed to antimicrobial (AM) treatment. The crossover in AM use between human and veterinary medicine raises concerns that antimicrobial resistance (AMR) may spread from food-producing animals to humans, driving the need for further understanding of how AMs are used in livestock practice as well as stakeholder beliefs relating to their use. A rapid evidence assessment (REA) was used to collate research on AM use published in peer-reviewed journals between 2000 and 2016. Forty-eight papers were identified and reviewed. The summary of findings highlights a number of issues regarding current knowledge of the use of AMs in food-producing animals and explores the attitudes of interested parties regarding the reduction of AM use in livestock. Variation between and within countries, production types and individual farms demonstrates the complexity of the challenge involved in monitoring and regulating AM use in animal agriculture. Many factors that could influence the prevalence of AMR in livestock are of concern across all sections of the livestock industry. This REA highlights the potential role of farmers and veterinarians and of other advisors, public pressure and legislation to influence change in the use of AMs in livestock.
Due to the extensive use of antimicrobial agents in human and agricultural practices, antimicrobial-resistant (AMR) bacteria have become a critical worldwide health issue. This study evaluated the prevalence of antimicrobial resistance in E. coli, Salmonella and Campylobacter isolates obtained from animal and food samples between 2007 and 2013. A total of 265 bacterial isolates consisting of 66 E. coli, 121 Salmonella and 78 Campylobacter were tested with the Kirby-Bauer disc diffusion method for their susceptibility to 12 antimicrobials representing nine different categories. Tetracycline (TCY) was the antimicrobial agent that showed the highest frequency of resistance among E. coli and Salmonella isolates (62.1% and 13.2%, respectively), while the most frequent trimethoprim-sulfamethoxazole (SXT) resistance was detected among Campylobacter isolates (58.3%). Approximately 19.7% of E. coli, 5.0% of Salmonella and 23.1% of Campylobacter isolates exhibited resistance to three or more categories of antimicrobials, meeting criteria for multi-drug resistance (MDR). Eighty-three percent of E. coli, 31% of Salmonella and 94% of Campylobacter isolates were found to be resistant to at least one of the antimicrobials tested in this study. While one strain of Salmonella demonstrated resistance to eight antimicrobials, it was still susceptible to meropenem (MEM), amikacin (AMK), ciprofloxacin (CIP), and nalidixic acid (NAL). In addition, two Campylobacter isolates demonstrated intermediate resistance to 10 antimicrobials. Findings in this study clearly demonstrate different patterns of resistance among bacterial species that present in our environment and further emphasize the need for judicious and careful use of antimicrobials in human and agricultural practices to help reduce future manifestations of MDR bacteria in food-borne illnesses.
Objective This study assessed adherence with first-line gonorrhoea treatment recommendations in Ontario, Canada, following recent guideline changes due to antibiotic resistance.
Methods We used interrupted times-series analyses to analyse treatment data for cases of uncomplicated gonorrhoea reported in Ontario, Canada, between January 2006 and May 2014. We assessed adherence with first-line treatment according to the guidelines in place at the time and the use of specific antibiotics over time. We used the introduction of new recommendations in the Canadian Guidelines for Sexually Transmitted Infections in 2008 and 2011 and the release of the province of Ontario’s Guidelines for the Treatment and Management of Gonococcal Infections in Ontario in 2013 as interruptions in the time-series analysis.
Results Overall, 34 287 gonorrhoea cases were reported between 1 January 2006 and 31 May 2014. Treatment data were available for 32 312 (94.2%). Our analysis included 32 272 (94.1%) cases without either a conjunctival or disseminated infection. Following the release of the 2011 recommendations, adherence with first-line recommendations immediately decreased to below 30%. Adherence slowly increased but did not reach baseline levels before the 2013 guidelines were released. Following release of the 2013 guidelines, adherence again decreased; adherence is slowly recovering but by May 2014, was only approximately 60%.
Conclusions Due to concerns about antibiotic resistance, gonorrhoea treatment guidelines need to be updated regularly and rapidly adopted in practice. Our study showed poor adherence following dissemination of updated guidelines. Over a year after the latest Ontario guidelines were released, 40% of patients did not receive first-line treatment, putting them at risk of treatment failure and potentially promoting further drug resistance. Greater attention should be devoted to dissemination and implementation of new guidelines.
Salmonella enterica has been documented as one of the leading causes of salmonellosis throughout the world and is most commonly associated with the consumption of contaminated food products. Thus, this research was aimed at studying the antimicrobial susceptibility pattern and detection of quinolone resistance in Salmonella spp isolated from food of animal origin. Thirty-six Salmonella isolates comprising 8 from poultry and 28 from seafood (clams) were identified, serotyped and characterized for their antimicrobial susceptibility against 10 different antibiotics. Plasmid DNA was isolated from all the isolates by alkaline lysis, quinolone resistant non-typhoidal S. Weltevreden were examined for mutation in the DNA gyrase coding gene. Among the 36 Salmonella isolates, 20 were S. weltevreden (8 from poultry and 12 from seafood) and 16 were S. Typhimurium (from seafood). All the isolates showed multiple resistance to nalidixic acid, tetracycline, co-trimoxazole and nitrofurantoin, but, interestingly, the isolates were 100% susceptible to ampicillin, chloramphenicol and gentamicin. Resistant isolates from the study carried the genes responsible for resistance to respective antibiotics. The strain S130 isolated in the study showed single point mutation, Asp87Gly, at position 87 in quinolone resistance determining region. It revealed mutation in quinolone resistance determining region as a cause for quinolone resistance in non-typhoidal Salmonellae. The occurrence of genes accountable for plasmid mediated resistance to quinolones (viz., qnrA, qnrB and qnrS) in plasmid of non-typhoidal Salmonellae isolates provides evidence for plasmid mediated quinolone resistance.
Rapid emergence of antibiotic resistance (AR) in developing countries is posing a greater health risk and increasing the global disease burden. Lack of access to safe drinking water, poor sanitation and inadequate sewage treatment facilities in these countries are fueling the problem associated with emergence of AR. Rapid proliferation of AR mediated by treated and untreated discharges from sewage treatment plants (STPs) is a prime public health concern. This study aims to understand the occurrence, fate, and routes of proliferation of carbapenem (KPC) and extended spectrum β-lactam (ESBL) resistant bacteria, and selected resistant genes in the samples collected from different unit operations in 12 STPs in New Delhi over two seasons. Strong correlation observed between faecal coliform levels and KPC (R = 0.95,p = 0.005,n = 60) and ESBL (R = 0.94,p = 0.004,n = 60) resistant bacteria levels indicates possible association of resistant bacteria with faecal matter. Different unit operations in STPs proved inefficient in treating resistant bacteria and genes present in the wastewater. However, inclusion of tertiary treatment (chlorination) unit and anaerobic digester in the present STPs resulted in better removal of AR. Significant correlations between antibiotic resistant genes (ARGs) and integron levels indicates a potential for higher rate of AR proliferation in the environment. Microbial culturing indicated the presence of clinically significant drug-resistant pathogens such as Escherichia coli, Pseudomonas putida, Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella pneumoniae, Klebsiella oxytoca, Acinetobacter baumannii, Shigella dysentery and Aeromonas caviae in the STP effluents. The emergence and spread of resistant bacteria through STP effluents poses exposure risk for the residents of the city.
- Presence of high levels of antibiotic resistance (ARB and ARGs) in STP effluents in New Delhi.
- Significant correlations between ARB and FC as well as ARGs and integron genes were observed.
- High abundance of carbapenem resistant Escherichia coli and Pseudomonas aeruginosa in the STP effluents.
- STP having chlorination unit and anaerobic digester performed better in treating ARB and ARGs.
To the Editor: The inappropriate and excessive use of antimicrobial agents has cultivated the development and progression of antimicrobial resistance worldwide, which has been recognised as a threat to global health and safety. In response to this alarming growth in antimicrobial resistance, antimicrobial stewardship initiatives, which aim to improve the judicious use of antimicrobial agents, have gained global support. The Antimicrobial Resistance Strategy Framework in South Africa (SA) recognises the education of healthcare professionals as a strategy for containment of antimicrobial resistance in SA.
Infections with Corynebacterium striatum have been described in the literature over the last two decades, with the majority being bacteremia, central line infections, and occasionally endocarditis. In recent years, the frequency of C. striatum infections appears to be increasing; a likely factor contributing to this is the increased ease and accuracy of the identification of Corynebacterium spp., including C. striatum, from clinical cultures. The objective of this study was to retrospectively characterize C. striatum isolates recovered from specimens submitted as part of routine patient care at a 1250 bed, tertiary care academic medical center. Multiple strain types were recovered, as demonstrated by repetitive-sequence-based PCR. Most of the strains of C. striatum characterized were resistant to antimicrobials commonly used to treat Gram positive organisms, such as penicillin, ceftriaxone, meropenem, clindamycin, and tetracycline. The MIC50 for ceftaroline was >32 μg/mL. Although there are no interpretive criteria for susceptibility, telavancin appeared to have potent in vitro efficacy against this species, with an MIC50 and MIC90 of 0.064 and 0.125 μg/mL, respectively. Finally, as previously reported in case studies, we demonstrated rapid in vitrodevelopment of daptomycin resistance in 100% of isolates tested (n=50), indicating caution should be exhibited when using daptomycin for treatment of C. striatum infections. C. striatum is an emerging, multidrug pathogen that can be associated with a variety of infection types.
Health Policy and Systems Research
The 2004 Mexico Declaration, and subsequent World Health Assembly resolutions, proposed a concerted support for the global development of health policy and systems research (HPSR). This included coordination across partners and advocates for the field of HPSR to monitor the development of the field, while promoting decision-making power and implementing responsibilities in low- and middle-income countries (LMICs).
We used a network science approach to examine the structural properties of the HPSR co-authorship network across country economic groups in the PubMed citation database from 1990 to 2015. This analysis summarises the evolution of the publication, co-authorship and citation networks within HPSR.
This method allows identification of several features otherwise not apparent. The co-authorship network has evolved steadily from 1990 to 2015 in terms of number of publications, but more importantly, in terms of co-authorship network connectedness. Our analysis suggests that, despite growth in the contribution from low-income countries to HPSR literature, co-authorship remains highly localised. Lower middle-income countries have made progress toward global connectivity through diversified collaboration with various institutions and regions. Global connectivity of the upper middle-income countries (UpperMICs) are almost on par with high-income countries (HICs), indicating the transition of this group of countries toward becoming major contributors to the field.
Network analysis allows examination of the connectedness among the HSPR community. Initially (early 1990s), research groups operated almost exclusively independently and, despite the topic being specifically on health policy in LMICs, HICs provided lead authorship. Since the early 1990s, the network has evolved significantly. In the full set analysis (1990–2015), for the first time in HPSR history, more than half of the authors are connected and lead authorship from UpperMICs is on par with that of HICs. This demonstrates the shift in participation and influence toward regions which HPSR primarily serves. Understanding these interactions can highlight the current strengths and future opportunities for identifying new strategies to enhance collaboration and support capacity-building efforts for HPSR.
Recognising radical shifts in the global health research (GHR) environment, participants in a 2013 deliberative dialogue called for careful consideration of equity-centred principles that should inform Canadian funding polices. This study examined the existing funding structures and policies of Canadian and international funders to inform the future design of a responsive GHR funding landscape.
We used a three-pronged analytical framework to review the ideas, interests and institutions implicated in publically accessible documents relevant to GHR funding. These data included published literature and organisational documents (e.g. strategic plans, progress reports, granting policies) from Canadian and other comparator funders. We then used a deliberative approach to develop recommendations with the research team, advisors, industry informants and low- and middle-income country (LMIC) partners.
In Canada, major GHR funders invest an estimated CA$90 M per annum; however, the post-2008 re-organization of funding structures and policies resulted in an uncoordinated and inefficient Canadian strategy. Australia, Denmark, the European Union, Norway, Sweden, the United Kingdom and the United States of America invest proportionately more in GHR than Canada. Each of these countries has a national strategic plan for global health, some of which have dedicated benchmarks for GHR funding and policy to allow funds to be held by partners outside of Canada. Key constraints to equitable GHR funding included (1) funding policies that restrict financial and cost burden aspects of partnering for GHR in LMICs; and (2) challenges associated with the development of effective governance mechanisms. There were, however, some Canadian innovations in funding research that demonstrated both unconventional and equitable approaches to supporting GHR in Canada and abroad. Among the most promising were found in the International Development Research Centre and the (no longer active) Global Health Research Initiative.
Promoting equitable GHR funding policies and practices in Canada requires cooperation and actions by multiple stakeholders, including government, funding agencies, academic institutions and researchers. Greater cooperation and collaboration among these stakeholders in the context of recent political shifts present important opportunities for advancing funding policies that enable and encourage more equitable investments in GHR.
Nepal is highly vulnerable to global climate change, despite its negligible emission of global greenhouse gases. The vulnerable climate-sensitive sectors identified in Nepal’s National Adaptation Programme of Action (NAPA) to Climate Change 2010 include agriculture, forestry, water, energy, public health, urbanization and infrastructure, and climate-induced disasters. In addition, analyses carried out as part of the NAPA process have indicated that the impacts of climate change in Nepal are not gender neutral. Vector-borne diseases, diarrhoeal diseases including cholera, malnutrition, cardiorespiratory diseases, psychological stress, and health effects and injuries related to extreme weather are major climate-sensitive health risks in the country. In recent years, research has been done in Nepal in order to understand the changing epidemiology of diseases and generate evidence for decision-making. Based on this evidence, the experience of programme managers, and regular surveillance data, the Government of Nepal has mainstreamed issues related to climate change in development plans, policies and programmes. In particular, the Government of Nepal has addressed climate-sensitive health risks. In addition to the NAPA report, several policy documents have been launched, including the Climate Change Policy 2011; the Nepal Health Sector Programme – Implementation Plan II (NHSP-IP 2) 2010–2015; the National Health Policy 2014; the National Health Sector Strategy 2015–2020 and its implementation plan (2016–2021); and the Health National Adaptation Plan (H-NAP): climate change and health strategy and action plan (2016–2020). However, the translation of these policies and plans of action into tangible action on the ground is still in its infancy in Nepal. Despite this, the health sector’s response to addressing the impact of climate change in Nepal may be taken as a good example for other low- and middle-income countries.
Since the market for e-health applications is constantly growing, it is getting an ever more complex endeavor to select and prioritize the right service offering given a particular situation. In examining the extant literature, it was revealed that little emphasis is actually placed on how to analyze contextual or environmental factors prior to the selection and prioritization of e-health services. With this paper, we therefore propose a formative framework consisting of six fundamental yet very pragmatic steps that may support decision makers in identifying the most important contextual pre-requisites that e-health services need to fulfill in order to be considered as effective for their environment to be implemented.
Beyond the evidence provided by randomized controlled trials, there is a need for supplementing and contextualizing efficacy findings through early evidence. This may include evidence of program costs, quality implementation processes, and impact of programs on different groups. This article considers the Quality and Impact of Component Evidence Assessment and other exemplary efforts for translating early evidence for policy making within a common framework. This framework includes processes for strategic review, development of guiding standards on the quality of evidence, and active communication with policy makers.
Traditional Ecological Knowledge (TEK) is a term, relatively new to Western science, that encompasses a subset of traditional knowledge maintained by Indigenous nations about the relationships between people and the natural environment. The term was first shared by tribal elders in the 1980s to help raise awareness of the importance of TEK. TEK has become a construct that Western scientists have increasingly considered for conducting culturally relevant research with Tribal nations.
The authors aim to position TEK in relation to other emerging schools of thought, that is, concepts such as the exposome, social determinants of health (SDoH), and citizen science, and to explore TEK’s relevance to environmental health research. This article provides examples of successful application of TEK principles in federally funded research when implemented with respect for the underlying cultural context and in partnership with Indigenous communities.
Rather than treating TEK as an adjunct or element to be quantified or incorporated into Western scientific studies, TEK can instead ground our understanding of the environmental, social, and biomedical determinants of health and improve our understanding of health and disease. This article provides historical and recent examples of how TEK has informed Western scientific research.
This article provides recommendations for researchers and federal funders to ensure respect for the contributions of TEK to research and to ensure equity and self-determination for Tribal nations who participate in research.
Health worker retention in rural and underserved areas remains a persisting problem in many low and middle income countries, and this directly affects the quality of health services offered.
This paper explores the drivers of long-term retention and describes health worker coping mechanisms in rural Uganda.
A descriptive qualitative study explored the factors that motivated health workers to stay, in three rural districts of Uganda: Kamuli, Pallisa, and Kibuku. In-depth interviews conducted among health workers who have been retained for at least 10 years explored factors motivating the health workers to stay within the district, opportunities, and the benefits of staying.
Twenty-one health workers participated. Ten of them male and 11 female with the age range of 33-51 years. The mean duration of stay among the participants was 13, 15, and 26 years for Kamuli, Kibuku, and Pallisa respectively. Long-term retention was related to personal factors, such as having family ties, community ties, and opportunities to invest. The decentralization policy and pension benefits also kept workers in place. Opportunities for promotion or leadership motivated long stay only if they came with financial benefits. Workload reportedly increased over the years, but staffing and emoluments had not increased. Multiple job, family support, and community support helped health workers cope with the costs of living, and holding a secure pensionable government job was valued more highly than seeking uncertain job opportunities elsewhere.
The interplay between the costs of leaving and the benefit of staying is demonstrated. Family proximity, community ties, job security, and pension enhance staying, while higher costs of living and an unpredictable employment market make leaving risky. Health workers should be able to access investment opportunities in order to cope with inadequate remuneration. Promotions and leadership opportunities only motivate if accompanied by financial benefits.
Background: Dissemination of health communication materials is one of the most important strategies to increase awareness on the prevention and control of leptospirosis. One of the projects under the Program on the Prevention and Control of Leptospirosis in the Philippines (LepCon) is the dissemination of health communication materials.
Objectives: This study assessed the dissemination of health communication materials to 14 city and municipal health offices in the National Capital Region (NCR), Philippines. Specifically, this study determined: (1) how the health communication materials were disseminated by the city and municipal health offices; (2) the placement of the materials in the health facilities; and (3) the challenges encountered during the dissemination process.
Results: The city/municipal health offices used different approaches in disseminating the health
communication materials and these are classified into distribution for public consumption, utilization as health education materials, and maintenance of supply by reproducing the materials in other forms. Eleven (11) out of the 14 city/municipal health offices (78.6%) still had leptospirosis posters. Seven (50%) of them posted the poster in the health facility. However, only four (28.6%) facilities placed the posters in locations where health facility clients can easily see and read them. Two of the 14 city/municipal health offices (14.3%) had an information, education and communication (IEC) display area where the LepCon fan is one of the health communication materials on display. The number of materials provided to the health offices was noted to be inadequate to reach the health facilities’ target audiences. Finally, the monitoring and evaluation of health communication materials disseminated to facilities under health offices’ jurisdiction was also a big challenge.
Conclusions: Different approaches were used in disseminating the posters and fans to the health facilities under the jurisdiction of the city/municipal health offices. It was also noted that the number of materials provided to the health offices was not adequate to reach the health facilities’ target audiences. Although three-fourths of the health offices covered still have health communication materials in their facility, only less than 25% of these facilities have posters placed in strategic locations in the facility. A formal scheme of monitoring the dissemination of the materials was expressed by the informants.