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.