Climate change and antimicrobial resistance in foodborne bacteria: a one health perspective for low- and middle-income countries

Antimicrobial resistance (AMR) is a critical global health threat that transcends human, animal, and environmental sectors, necessitating a One Health approach. AMR arises from the misuse and overuse of antimicrobial agents in clinical, veterinary, and environmental settings, resulting in treatment failures and heightened mortality rates. By 2050, AMR is projected to cause 10 million deaths annually and incur a global economic loss of 1 trillion USD. Low- and middle-income countries (LMICs) are expected to bear a significant burden, potentially accounting for 5 million of these deaths and facing substantial economic challenges due to limited access to healthcare resources and second-line antibiotics. In human health, excessive antibiotic prescriptions and hospital-acquired infections have been identified as major drivers of resistance, exacerbated by poor infection control and the lack of rapid diagnostic tools. Similarly, in veterinary medicine, the use of antimicrobials in livestock for disease prevention and growth promotion contributes significantly to AMR. Resistant bacteria from animals can transmit to humans through direct contact, the food chain, and environmental contamination. The environment further amplifies resistance through pharmaceutical waste, wastewater treatment inefficiencies, and the accumulation of resistant genes in ecosystems. Global efforts to address AMR include regulatory frameworks for prudent antimicrobial use in agriculture, human medicine, and waste management, alongside research into alternatives like phage therapy, immunotherapies, and improved diagnostics. Future solutions must focus on innovation, public engagement, and multi-sectoral collaboration to tackle the rising tide of resistance. The aim of this review is to explore the issue of Antimicrobial Resistance (AMR) from a One Health perspective, highlighting the challenges faced by low- and middle-income countries (LMICs).

Antimicrobial Use and Resistance in Pigs and Chickens: A Review of the Science, Policy and Control Practices from Farm to Slaughter – Executive Summary

Antimicrobial use in livestock production is linked to the emergence and spread of antimicrobial resistance (AMR), but large-scale studies on AMR changes in livestock isolates remain scarce. Here we applied whole-genome sequence analysis to 982 animal-derived Escherichia coli samples collected in China from the 1970s to 2019, finding that the number of AMR genes (ARGs) per isolate doubled-including those conferring resistance to critically important agents for both veterinary (florfenicol and norfloxacin) and human medicine (colistin, cephalosporins and meropenem). Plasmids of incompatibility groups IncC, IncHI2, IncK, IncI and IncX increased distinctly in the past 50 years, acting as highly effective vehicles for ARG spread. Using antimicrobials of the same class, or even unrelated classes, may co-select for mobile genetic elements carrying multiple co-existing ARGs. Prohibiting or strictly curtailing antimicrobial use in livestock is therefore urgently needed to reduce the growing threat from AMR.

Reducing antimicrobial use (AMU) in livestock may be one of the keys to limit the emergence of antimicrobial resistance (AMR) in bacterial populations, including zoonotic pathogens. This study assessed the temporal association between AMU in livestock and AMR among Campylobacter isolates from human infections in the Netherlands between 2004 - 2020. Moreover, the associations between AMU and AMR in livestock and between AMR in livestock and AMR in human isolates were assessed. AMU and AMR data per antimicrobial class (tetracyclines, macrolides and fluoroquinolones) for Campylobacter jejuni and Campylobacter coli from poultry, cattle, and human patients were retrieved from national surveillance programs. Associations were assessed using logistic regression and the Spearman correlation test. Overall, there was an increasing trend in AMR among human C. jejuni/coli isolates during the study period, which contrasted with a decreasing trend in livestock AMU. In addition, stable trends in AMR in broilers were observed. No significant associations were observed between AMU and AMR in domestically produced broilers. Moderate to strong positive correlations were found between the yearly prevalence of AMR in broiler and human isolates. Reducing AMU in Dutch livestock alone may therefore not be sufficient to tackle the growing problem of AMR in Campylobacter among human cases in the Netherlands. More insight is needed regarding the population genetics and the evolutionary processes involved in resistance and fitness among Campylobacter.

Data on the use of antimicrobials in humans and livestock may provide evidence to guide policy changes to mitigate the risk of antimicrobial resistance (AMR). However, there is limited information available about antimicrobial use in livestock in low- and middle-income countries, even though these nations are most vulnerable to the impact of AMR. This study aimed to assess the consumption of veterinary antimicrobials in Bhutan and identify areas for improvement to reduce the use of antimicrobials in livestock. National data on livestock numbers and annual procurement of veterinary antimicrobials over five years (2017-2021) were used to calculate rates of antimicrobial consumption and annual national expenditure on veterinary antimicrobials in Bhutan. The rate of antimicrobial consumption in Bhutan was 3.83 mg per population correction unit, which is lower than most countries in Europe, comparable with the rates of consumption in Iceland and Norway, and approximately 120-fold lower than published rates of antimicrobial consumption in South Asian countries, including Nepal and Pakistan. The low rates of antimicrobial consumption by the animal health sector in Bhutan could be attributable to stronger governance of antimicrobial use in Bhutan, higher levels of compliance with regulation, and better adherence to standard guidelines for antimicrobial treatment of livestock.

Dr Jyoti Joshi is an antimicrobial resistance (AMR) advisor at the International Centre for Antimicrobial Resistance Solutions (ICARS) in Copenhagen, Denmark. She was awarded her Doctor of Medicine and Specialization in Community Medicine degrees from Lady Hardinge Medical College in New Delhi, India, and a Master’s degree in infectious disease from the London School of Hygiene & Tropical Medicine, UK. Throughout her career, she has been instrumental in researching and implementing public health advances in areas of infectious disease, vaccine safety and AMR. Her work, both directly with communities and in high-level policymaking, is driving significant progress in maintaining and improving public health in several Asian countries and globally. In this interview, Jyoti talks about the need for breaking silos to achieve real progress in AMR control, the importance of family, and how an unexpected career decision can turn out to be the right one.After medical school, what motivated you to go into public health?Community medicine, which is how public health is typically referred to in India, was a subject at my medical college. That course really inspired me because, unlike treating patients in the clinic, community medicine is about preventing illness by working with people and communities before they become sick. I found this challenging because it is a holistic concept that does not regard health as merely the absence of disease, but it includes wellbeing in all dimensions. I loved clinical medicine, but I loved community medicine even more! After my MD, I worked on reproductive health and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) prevention in India and then moved to Dubai, where I worked in the Preventive Medicine Department in the government, focusing on vaccines and infection disease surveillance, including the World Health Organization (WHO)'s International Health Regulations. This motivated me to pursue further study, but, due to family commitments, rather than pursuing a full time PhD, I chose a second Master's degree in infectious disease. At that time, colleagues tried to convince me that infectious diseases were decreasing and it would be wiser to focus on non-communicable diseases, but I was intrigued by microbes and recognised that this challenge is ongoing, so I persisted. I'm very happy with my decision and the journey it has taken me on. I now view our efforts for tackling infectious diseases not as a battle, but as a path towards co-existing with microbes around us in a steady state of balance.“I now view our efforts for tackling infectious diseases not as a battle, but as a path towards co-existing with microbes around us in a steady state of balance.”What prompted you to move from infectious disease surveillance to AMR?After spending almost 15 years in infectious disease surveillance and vaccines, I realised what a big challenge AMR is to public health. AMR is not traditionally taught in the public health curriculum. Communities are not aware of the problem nor have they been typically involved in addressing AMR. This, in my opinion, is the key reason for the extent of AMR spread and the threats it poses. I'm glad I am working on this issue at the opportune time! The next few years are critical for AMR mitigation, especially in light of COVID-19 [the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection]. AMR is a pandemic that arrived long before COVID-19, and though it has been historically conceptualised as ‘invisible’, the reality is that it pervades our hospitals, communities, farms, rivers and the environment, with very visible impacts on human health. According to a report recently published in The Lancet, an estimated 1.27 million deaths were directly attributed to bacterial AMR in 2019 (Murray et al., 2022).Today, we are in a position to make the jump from talk to real action, especially within communities, and in addressing it in low- and middle-income countries. We can make visible contributions now, which is what makes work in community medicine so exhilarating. Its beneficial impact affects you both as professionals and as human beings.In public/community health, outreach and effective communication with the public are extremely important. Can you tell us about your approach?One of my teachers in medical college told me that community medicine is both an art and a science and this stuck with me. The science parts we know how to do, but implementing it among communities requires diplomacy, economic considerations, and sensitivity to behavioural and socio-cultural aspects – that's the art. This aspect requires context and skills. I tried early on to consciously learn this ‘art’ at three levels. First, education in low- and middle-income countries, where I mostly worked, is very siloed. Medicine has its own silo, so do law, engineering, economics, etc. Moreover, experts in different fields do not interact, but they are all needed when working with the community, in community medicine. So when I started my work, I consciously engaged with people that were not in the medical field. This enabled me to leverage greater resources to achieve the best for our communities. Second, I realised early on that how health messaging is packaged and communicated really matters. The more sensitive the topic, like HIV/AIDS used to be, the more important and urgent the communication is. This also involves talking to journalists and local thought leaders, which was not something that we as doctors were taught in medical school. We need to work with journalists, knowing the importance of their deadlines and terms, and communicate effectively through them. Third, understanding the local government structures and systems is essential. As community health specialists, we have vast amounts of technical knowledge. But how this is implemented within the community relies on the existing structures. Public health programmes can fail if they are not scientifically sound or are implemented poorly. Both aspects need to be addressed to ensure the right measures with correct messaging do reach the public in time. A good example of community involvement is the success of the HIV/AIDS prevention programme in involving the affected communities. Although AMR is an even bigger threat, community engagement is lacking. There is, in my view, too much stress on the ‘science’ and not enough on the ‘art’ aspects. We need to change that, and need effective community involvement to succeed.Since you mentioned the HIV/AIDS pandemic, what do you think is the key difference in public communication between AIDS, which reached pandemic levels in the 1980s, and COVID-19, which started in the social media era?I think tackling HIV/AIDS taught us what works and where the challenges are, and we need to heed those lessons as we attempt to address COVID-19. We also need to be mindful of the simple fact that HIV and SARS-CoV-2 are vastly different and cause completely different kinds of diseases. AIDS is and was a chronic disease, the science to address it progressed relatively slowly and there was (and still is) a strong stigma associated with it. Even though we can now successfully treat HIV-positive people and can efficiently stop the spread with relatively simple measures, we still don't have a vaccine. The situation is the complete opposite in COVID-19 – the acute nature of infection, the airborne transmission and the simple fact that we are still trying to understand the virus and the range of symptoms it causes, including chronic effects, means there still are many grey areas. This makes tackling COVID-19 even more challenging, particularly in the age of social media. With social media nothing gets forgotten, everything is scrutinised, and the anonymity allows people to be brutal. The science about SARS-CoV-2 is constantly evolving and the rapid pace can be complicated for the public to appreciate, unless it is communicated promptly and clearly. This affects the community's ability to embrace the new learnings, adapt through behaviour change and move forward. Timely communication can affect global pandemic mitigation efforts, as was experienced during the 2009 H1N1 influenza and ongoing COVID pandemics, and is unlike the communication required for a slow-evolving chronic disease like AIDS.Antibiotics seem to be most commonly discussed, at least in the West, but are there other crucial antimicrobials that are at a high risk of losing their effectiveness?AMR indeed encompasses a broad range of agents – antibacterials, antifungals, antiparasitics and antivirals. In low- and middle-income countries in particular, infectious diseases caused by parasites remain a big problem and the need for effective drugs to treat them is high. During severe COVID-19 outbreak in India, mucormycoses, infection caused by a drug-resistant opportunistic fungus, became a significant problem. Similarly, in malaria-endemic regions, artemisinin-resistant malarial parasite species are spreading and we don't have alternative drugs. Extensively drug-resistant (X-DR) tuberculosis and typhoid are fast-emerging problems in Southeast Asia, meaning that currently used antibiotics may soon lose their effectiveness.How are the causes and consequences of AMR in these regions different to those in high-income countries?I think part of the problem is that antibiotic use in low- and middle-income countries is very different from that in high-income countries. Access to healthcare, including medicines, is a huge challenge, and infectious diseases still have high mortality and morbidity. So, to improve access to care, antibiotics are freely available and are taken even without prescription, in inappropriate doses for incorrect periods, which, together with poor regulatory control, contributes to antibiotic misuse and the burden of AMR. This disproportionately high burden of AMR does not just affect human health, but also other aspects of life, as antibiotics are used in animal farms and then washed out into the environment. Since human health, veterinary medicine, and environment management systems are siloed, fragmented and in different states of maturity in most countries, tackling a ‘One Health’ problem like AMR becomes even more challenging. Antibiotic misuse is the most critical concern, and estimates from the aforementioned study (Murray et al., 2022) have established that AMR is now an even bigger problem than AIDS and malaria combined. Furthermore, the AMR burden is highest in low- and middle-income countries, which unfortunately have the fewest resources to tackle it.“This disproportionately high burden of AMR does not just affect human health, but also other aspects of life, as antibiotics are used in animal farms and then washed out into the environment. Since human health, veterinary medicine, and environment management systems are siloed, fragmented and in different states of maturity in most countries, tackling a ‘One Health’ problem like AMR becomes even more challenging.”Clearly, this is an issue that requires global collaboration. The WHO recently named AMR as one of the top ten global health challenges. What do you think will be the effects of this announcement?I feel fortunate to have worked in the field in developing countries and am now based at the newly established International Centre for Antimicrobial Resistance Solutions (ICARS) in Copenhagen, Denmark. ICARS supports low- and middle-income countries to co-create and implement context-specific and cost-effective solutions to tackle AMR. The scale and spread of AMR requires all stakeholders (countries, companies and foundations) to work together to address this challenge. WHO's announcement highlights this imminent threat, but this alone is not enough. Efforts are needed to harmonise standards for the surveillance and reporting of antimicrobial use. The role of the environment in the development and spread of AMR is very poorly understood and understudied, especially in the Global South. It is thus welcome that the WHO, which was already working with the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE) as part of a tripartite partnership, has now included the United Nations Environmental Programme (UNEP) in a Tripartite Plus platform to tackle AMR. Implementation of all these partnerships at regional, national and sub-national levels in these sectors is, of course, critical.You have had a long and successful career. Can you tell us who inspired you along the way?There are a several people who have been instrumental in making me continue in my chosen career path. First, my mother, who is no longer alive. She motivated me to study medicine, although I found it really difficult to explain to her that I didn't want to be a physician and would rather work in the community. She respected my decision to specialise in community medicine and was happy as I progressed in my career. I also have a supportive husband, son and mother-in-law, who shared responsibility on the home front as I travelled extensively as part of my job. I have also been inspired by many colleagues (both female and male) who encouraged and helped me deal with balancing career and home life.In science, including public health, mentorship is an essential part of training. Can you tell us a bit about your approach to training/mentoring younger colleagues? What, in your personal opinion, are the biggest challenges and rewards?I am a team player and value the concept of mentorship. I have always tried to establish a personal connection with each and every team member. I enjoy engaging with people and hearing their thoughts and ideas. I always learn new things from my engagement with colleagues from diverse backgrounds, of any age or gender. I have met some amazing women in my journey so far. I think woman-to-woman mentorship is very important as more and more women in low- and middle-income countries enter the workforce and take on more professional responsibility. As a mentor, I grow with my network, and it fills me with pride to see my own mentees grow and succeed both in their professional and personal lives.And finally, what do you enjoy doing outside of work?I love spending time with family, especially my teenage daughter who has special needs. She is extremely loving, very demonstrative in her expressions and chatty. She helps me stay grounded and true to my own emotions, enabling me to be mentally strong. I love cooking and trying different cuisines, reading, and spending time with communities in the field.DMM thanks Dr Jyoti Joshi for her willingness to be interviewed and for sharing her unique experiences and perspectives with us. Jyoti was interviewed by Julija Hmeljak, Scientific Editor for DMM, and this interview has been edited and condensed with the interviewee's approval.

Impacts of small-scale chicken farming activity on antimicrobial-resistant Escherichia coli carriage in backyard chickens and children in rural Ecuador

Interventions to change antimicrobial use in livestock: A scoping review and an impact pathway analysis of what works, how, for whom and why.

Irrational use of antimicrobials in humans, livestock, and poultry is often cited as the key driver of the accelerated emergence of antimicrobial resistance (AMR) in humans and animals. In Pakistan, the use of antimicrobials in livestock and poultry is not well-regulated, owing to limited and/or ineffective implementation of existing legislations and lack of coordination amongst the key stakeholders. To gather data and information pertinent to the supply chain mapping and the usage of antibiotics in the livestock and poultry sectors of Pakistan, a national workshop for selected influential stakeholders was held in Islamabad, Pakistan during March 2020 to map the supply chain and the usage of antibiotics in the country. Participants from all relevant organizations identified the supply chain and discussed the status, challenges, and the way forward to enhance data collection and monitoring of antimicrobial usage (AMU) in livestock and poultry sectors to contain the emergence of AMR. The pre-workshop questionnaire was designed to gather relevant information on AMU and its distribution among diverse markets and users from the workshop participants, utilizing open-ended questions. A chart depicting the relative magnitude of an antimicrobial use (AMU) supply chain was constructed to illustrate the flow of antimicrobials from import and production to end-use at the farm level. This chart was shared with participants to gather their professional opinions and potential corrections. It also presented a list of agencies and their roles in regulating AMU, along with the types of AMU data available at each level. Specific recommendations were made at the end of the workshop to review and update legislation to cover the entire AMU supply chain, enhance regulations to restrict the use of antimicrobial growth promoters, build an integrated national AMU database system, and raise awareness about the responsible use of antimicrobials in the livestock and poultry sectors. It was concluded that the AMU supply chain in the veterinary sector of Pakistan is fragmented and is co-regulated by various federal and provincial stakeholders. There are some drugs, such as antibiotic growth promoters, which are not regulated at all. The approach and findings from this study can serve as a model to validate the use and management of antibiotics in other, similar countries currently grappling with serious antimicrobial resistance (AMR) crises.

Countries from across the world gathered in Astana, Kazakhstan, in October 2018, to reaffirm and expand their commitment to prioritise, promote, and protect the health and wellbeing of their populations. This was the opportunity for a new generation of health policy makers and leaders to honour the ideals of the 1978 Alma-Ata Declaration1WHOGlobal Conference on Primary Health Care, 25–26 October 2018.https://www.who.int/primary-health/conference-phcDate: 2018Date accessed: March 20, 2019Google Scholar and to reinterpret these in the current era. Over the past 40 years, many countries have designed health systems that improve access to quality essential services, social stability, and health security, as well as having economic benefits.2WHOTogether on the road to universal health coverage. A call to action.https://apps.who.int/iris/bitstream/handle/10665/258962/WHO-HIS-HGF-17.1-eng.pdf;jsessionid=F247E4CB8C9AEA227138F1844D636EF1?sequence=1Date: 2017Date accessed: March 18, 2019Google Scholar The health-related aspects of the UN Sustainable Development Goals have a strong focus on universal health coverage (UHC), with quality of health services increasingly emphasised as essential for success.3WHODelivering quality health services: a global imperative for universal health coverage.https://www.who.int/servicedeliverysafety/quality-report/en/Date: 2018Date accessed: March 18, 2019Google Scholar When Florence Nightingale, considered the mother of infection prevention and control (IPC), echoed the Hippocratic ideal to "first, do no harm" in the 1860s, she recognised that the first steps to providing organised beneficial health care were inherently risky in nature. Although Florence Nightingale was a late adopter of the germ theory of disease, she was among the first to recognise that a caregiver could be at the origin of patient harm, particularly infection. She was an early pioneer of the practical application of quality improvement at the bedside. Health-care-associated infection remains an ever-present companion, irrespective of where and when it is delivered. Health-care-associated infections are a consequence of poor-quality care and a deadly cause of harm affecting hundreds of millions of patients worldwide every year.4WHOReport on the burden of endemic health-care associated infection worldwide: a systematic review of the literature.https://apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf;jsessionid=B24D98407633F9FEE01C9329D89EDA7B?sequence=1Date: 2011Date accessed: March 18, 2019Google Scholar They generate twice the total burden of disability-adjusted life-years than all other 32 communicable diseases reported in Europe.5Cassini A Plachouras D Eckmanns T et al.Burden of six healthcare-associated infections on European population health. Estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study.PLoS Med. 2016; 13: e1002150Crossref PubMed Scopus (295) Google Scholar Antibiotic-resistant microorganisms are responsible for most infections and 75% of disability-adjusted life-years attributable to antimicrobial resistance (AMR) in Europe are due to health-care-associated infections.6European Centre for Disease Control and Prevention and OECDAntimicrobial resistance. Tackling the burden in the European Union. Briefing note for EU/EAA countries.https://www.oecd.org/health/health-systems/AMR-Tackling-the-Burden-in-the-EU-OECD-ECDC-Briefing-Note-2019.pdfDate: 2019Date accessed: March 18, 2019Google Scholar This places a clear duty on policymakers, health leaders, facility managers, and practitioners who design, build, and operate health systems to ensure that they prevent the spread of infections. Without this essential foundation for quality health services, UHC risks being an empty promise.7Ghebreyesus T How could health care be anything other than high quality?.Lancet Glob Health. 2018; 6: e1140-e1141Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar IPC is an evidence-based approach to halt the spread of infection and AMR.8Storr J Twyman A Zingg W et al.Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations.Antimicrob Resist Infect Control. 2017; 6: 6Crossref PubMed Scopus (194) Google Scholar It embodies all three core domains of quality care (ie, care that is safe, effective, and people-centred), and strongly supports the attainment of other key global health priorities that will eventually contribute to high-quality UHC (figure). Strong IPC capacity and programmes ensure adequate preparedness and response to protect people from outbreaks. Their reinforcement is an essential pillar for recovery and health system strengthening after the shock of an epidemic. IPC is also complementary to and enhances water, sanitation, and hygiene (WASH) interventions. WASH monitors infrastructure indicators, whereas IPC provides evidence of an effect on health workers' behaviour and patient outcomes through improved infrastructures. Synergies and interconnections are particularly effective when IPC supports strategies aimed at reducing AMR. Notably, the increasing availability of IPC equipment and infrastructure (eg, alcohol-based handrubs) at the point of care and isolation beds are associated with a proportionate reduction of the most common AMR patterns that are associated with health care.8Storr J Twyman A Zingg W et al.Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations.Antimicrob Resist Infect Control. 2017; 6: 6Crossref PubMed Scopus (194) Google Scholar Combining IPC interventions with antimicrobial stewardship programmes is the most effective approach.8Storr J Twyman A Zingg W et al.Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations.Antimicrob Resist Infect Control. 2017; 6: 6Crossref PubMed Scopus (194) Google Scholar, 9Baur D Gladstone BP Burkert F et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Summary Full Text Full Text PDF PubMed Scopus (389) Google Scholar Among these, hand hygiene is the most crucial, whether implemented as a stand-alone intervention or integrated into multifaceted interventions.9Baur D Gladstone BP Burkert F et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Summary Full Text Full Text PDF PubMed Scopus (389) Google Scholar, 10Luangasanatip N Hongsuwan M Limmathurotsakul D et al.Comparative efficacy of interventions to promote hand hygiene in hospitals: systematic review and network meta-analysis.BMJ Glob Health. 2015; 351: h3278Google Scholar IPC interventions often provide a starting point for developing a culture of quality improvement in health facilities. Despite this compelling evidence, only 58% of countries report having a national IPC programme or plan and related guidelines. Even more alarmingly, only 15% have a system to assess their compliance and effectiveness.11WHOFood and Agriculture Organization of the United Nations (FAO)World Organisation for Animal Health (OIE)https://apps.who.int/iris/bitstream/handle/10665/273128/9789241514422-eng.pdf?ua=1Date accessed: March 19, 2019Google Scholar These gaps are more striking in low-income countries where surveillance indicators for infections associated with health care are present in only 5% of countries and the monitoring of IPC in only 30% (WHO, unpublished data). In a global call to action in 2017, leaders of the Global IPC Network identified global and country-specific IPC priorities to be achieved by 2022.12Allegranzi B Kilpatrick C Storr J Kelley E Park BJ Donaldson L Global Infection Prevention and Control Network. Global infection prevention and control priorities 2018–22: a call for action.Lancet Glob Health. 2017; 5: e1178-e1180Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar These priorities require serious reflection and forceful actions. World Health Assembly resolutions can provide a strong basis for policy and regulation development and enforcement. Powerful resolutions on AMR and sepsis prevention already exist and new ones on patient safety and WASH are in the pipeline for full endorsement by the World Health Assembly in 2019. IPC is a key element. None of these resolutions can be implemented without strengthening the size and competencies of health work forces, which are also essential to achieve UHC, because inadequate staffing substantially increases the risk of infection and spread of AMR.7Ghebreyesus T How could health care be anything other than high quality?.Lancet Glob Health. 2018; 6: e1140-e1141Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar As an immediate tangible action, WHO calls upon everyone this year to be inspired by the global movement to achieve quality UHC and has crafted its global hand hygiene campaign message to achieve this wider goal: "clean care for all—it's in your hands!" The call to action has also been expanded and adapted to facilitate ownership and adoption by specific audiences, including highlighting clean care as a human right for all patients. Additionally, WHO strongly encourages ministries of health and health-care facilities to bridge the gap in the scarcity of IPC data by participating in a global survey on the level of progress of IPC and hand hygiene programmes. Clean and safe care should be universally available to every person worldwide. It can be achieved through improved IPC practices and monitoring everywhere, driving the foundation for quality care in the UHC era. This work is supported by WHO, Geneva, Switzerland, and the Infection Control Programme and WHO Collaborating Centre on Patient Safety (SPCI/WCC), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland. Hand hygiene research activities at the SPCI/WCC are supported by the Swiss National Science Foundation (grant 32003B_163262). DP works with WHO on the Private Organizations for Patient Safety—Hand Hygiene initiative. The aim of this WHO initiative is to harness industry strengths to align and improve implementation of WHO recommendations for hand hygiene in health care in different parts of the world, including in the least developed countries. In this instance, companies/industry with a focus on hand hygiene and infection control-related advancement have the specific aim of improving access to affordable hand hygiene products, as well as through education and research. All other authors declare no competing interests. The opinions expressed in this Article are those of the authors and do not reflect the official position of WHO. WHO takes no responsibility for the information provided or the views expressed in this Article. We thank Rosemary Sudan for the professional editing assistance and Maraltro for the figure design. We also thank Safiah Mai for providing background documentation about universal health coverage.

The emergence of antimicrobial resistance (AMR) in foodborne bacteria is a growing concern worldwide. AMR surveillance is a key element in understanding the implications resulting from the use of antibiotics for therapeutic as well as prophylactic needs. The emergence and spread of AMR in foodborne human pathogens are indirect health hazards. This surveillance study reports the trend and pattern of AMR detected in Vibrio species isolated from molluscs harvested in Canada between 2006 and 2012 against 19 commonly used antibiotics. Five common antibiotics, ampicillin, cephalothin, erythromycin, kanamycin, and streptomycin, predominantly contributed to AMR, including multidrug resistance (MDR) in the molluscan Vibrio spp. isolated in 2006. A prospective follow-up analysis of these drugs showed a declining trend in the frequency of MDR/AMR Vibrio spp. in subsequent years until 2012. The observed decline appears to have been influenced by the specific downturn in resistance to the aminoglycosides, kanamycin, and streptomycin. Frequently observed MDR/AMR Vibrio spp. in seafood is a potential health concern associated with seafood consumption. Our surveillance study provides an indication of the antibiotics that challenged the marine bacteria, sourced to Canadian estuaries, during and/or prior to the study period.

Clinical microbiology laboratories in low-resource settings, it is not only about equipment and reagents, but also good governance for sustainability

Extending political will into action in African LMICs: abating global antimicrobial resistance

The nutritional and economic potentials of livestock systems are compromised by the emergence and spread of antimicrobial resistance. A major driver of resistance is the misuse and abuse of antimicrobial drugs. The likelihood of misuse may be elevated in low- and middle-income countries where limited professional veterinary services and inadequately controlled access to drugs are assumed to promote non-prudent practices (e.g., self-administration of drugs). The extent of these practices, as well as the knowledge and attitudes motivating them, are largely unknown within most agricultural communities in low- and middle-income countries. The main objective of this study was to document dimensions of knowledge, attitudes and practices related to antimicrobial use and antimicrobial resistance in livestock systems and identify the livelihood factors associated with these dimensions. A mixed-methods ethnographic approach was used to survey households keeping layers in Ghana (N = 110) and Kenya (N = 76), pastoralists keeping cattle, sheep, and goats in Tanzania (N = 195), and broiler farmers in Zambia (N = 198), and Zimbabwe (N = 298). Across countries, we find that it is individuals who live or work at the farm who draw upon their knowledge and experiences to make decisions regarding antimicrobial use and related practices. Input from animal health professionals is rare and antimicrobials are sourced at local, privately owned agrovet drug shops. We also find that knowledge, attitudes, and particularly practices significantly varied across countries, with poultry farmers holding more knowledge, desirable attitudes, and prudent practices compared to pastoralist households. Multivariate models showed that variation in knowledge, attitudes and practices is related to several factors, including gender, disease dynamics on the farm, and source of animal health information. Study results emphasize that interventions to limit antimicrobial resistance should be founded upon a bottom-up understanding of antimicrobial use at the farm-level given limited input from animal health professionals and under-resourced regulatory capacities within most low- and middle-income countries. Establishing this bottom-up understanding across cultures and production systems will inform the development and implementation of the behavioral change interventions to combat antimicrobial resistance globally.

The nutritional and economic potentials of livestock systems are compromised by the emergence and spread of antimicrobial resistance. A major driver of resistance is the misuse and abuse of antimicrobial drugs. The likelihood of misuse may be elevated in low- and middle-income countries where limited professional veterinary services and inadequately controlled access to drugs are assumed to promote non-prudent practices (e.g., self-administration of drugs). The extent of these practices, as well as the knowledge and attitudes motivating them, are largely unknown within most agricultural communities in low- and middle-income countries. The main objective of this study was to document dimensions of knowledge, attitudes and practices related to antimicrobial use and antimicrobial resistance in livestock systems and identify the livelihood factors associated with these dimensions. A mixed-methods ethnographic approach was used to survey households keeping layers in Ghana (N = 110) and Kenya (N = 76), pastoralists keeping cattle, sheep, and goats in Tanzania (N = 195), and broiler farmers in Zambia (N = 198), and Zimbabwe (N = 298). Across countries, we find that it is individuals who live or work at the farm who draw upon their knowledge and experiences to make decisions regarding antimicrobial use and related practices. Input from animal health professionals is rare and antimicrobials are sourced at local, privately owned agrovet drug shops. We also find that knowledge, attitudes, and particularly practices significantly varied across countries, with poultry farmers holding more knowledge, desirable attitudes, and prudent practices compared to pastoralist households. Multivariate models showed that variation in knowledge, attitudes and practices is related to several factors, including gender, disease dynamics on the farm, and source of animal health information. Study results emphasize that interventions to limit antimicrobial resistance should be founded upon a bottom-up understanding of antimicrobial use at the farm-level given limited input from animal health professionals and under-resourced regulatory capacities within most low- and middle-income countries. Establishing this bottom-up understanding across cultures and production systems will inform the development and implementation of the behavioral change interventions to combat antimicrobial resistance globally.