EXTENT OF HUMAN AND ENVIRONMENTAL ANTIBIOTIC USE IN RURAL BANGLADESH

1. EXTENT OF HUMAN AND ENVIRONMENTAL ANTIBIOTIC USE IN RURAL BANGLADESH Results of qualitative research Roess AA1, Winch PJ1, Afsana A2, Afroz D2, Ali NA2, Shah R2, Seraji H2, Baqui AH1, Darmstadt GL1, Arifeen SE2 Second International Conference on Improving Use of Medicines, Chiang Mai, Thailand March 30-April 2, 2004 Funding provided by the Center for a Livable Future, JHSPH, USA Doctoral fellowship for AA Roess provided by National Institute of Child Health and Development, NIH, USA

2. Abstract Problem Statement: 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 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. Objective: 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 populations. Setting and Study Population: Between July 2002 and May 2003, interviews were conducted with 20 village doctors, local “pharmacists,” homeopaths, clinic workers, and local animal care 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 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. Outcome Measures: 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/household, average cost of drugs/child, number of animal antibiotics/household, cost of animal antibiotics/household. Results: 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 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 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 behavior, antibiotic use, and prescriber practices for both humans and animals. Conclusions: 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 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 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 the problem and make recommendations for future surveillance.

3. Increasing prevalence of antimicrobial resistant (AMR) microbes in S Asia • Community-acquired infections • Multidrugresistant pneumococci • Drug-resistant H. influenzae • FQ- and ESC-resistant Salmonella • Multidrug resistant Shigella • FQ-resistant gonococci • Multidrug-resistant M. tuberculosis • Drug-resistant malaria CHRP 2002

4. Risk factors for AMR • Antibiotic use • Recent hospital stay/visit • Crowding • Travel • Animal antibiotic use (food animal & pet)

5. Study Conceptual framework Drug Use Policy Human ab use Human Carriage AMR Human disease AMR Provider practices SES HH Crowding Town Clinic Animal Carriage AMR Animal ab use

6. AMR conceptual framework with pic 23Feb2004.doc

7. Objectives • To understand antibiotic use practices for people and animals at the household level in Sylhet • To design an instrument to quantify antibiotic use

8. Methods • Field Observations • In-depth interviews • Ministers of Fisheries and Livestock • Government veterinarians and scientists • Pharmaceutical representatives • Village doctors, drug-sellers • Semi-structured interviews • 14 human use • 24 animal use • 10 village doctors • Village doctor network

9. Crowding 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.

10. Exposure to animals -- Dhaka

11. Town 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.

12. Flooding/Infrastructure 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.

13. Human medicines in stock at home 7 1 3 8 5 2 9 7 3 14/14 5(8)/14 9/14 61

14. Care-providers/drug sellers roles 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.

15. Village doctor network • VD  multiple roles • Treatment patterns • Examination/Symptoms • Dosage

16. Animal ownership 17 13 4 5 5 12 8 4 24 19 5 4 4 1 1 24 households that owned at least 1 chicken were included to learn about animal medicine use and animal husbandry.

17. Expenditure for animal purchase 2 15 1 1 3 2 8 2 8 10 4 2 2 2 1 Animals are a large investment because they are sources of food (meat milk and eggs), and are a good source of income.

18. Animal use 100 83 75 54 54

19. Animal medicine use 29 Yes 92 Yes 100 Yes 96 Yes

20. Animal diseases • Cow—diarrhea, back pain, blisters • Goat—diarrhea, stomach swelling • Duck/Chicken—white diarrhea, fever from river, “doze” • Evil eye, bad spirits

21. Animal “medicine” • Oxytetracycline • Metronidazole • Growth promoter (2/24) • Paracetomol • Homeopathic • Injections (5/24)

22. Animal medicine cost Human medicine cost • 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.

23. Animal care expenditure • Animals  food + income • Buy animals • 5,000-18,000 Tk per cow • 0, 100-120 Tk per chicken • Treatment • 200 Tk injection • 16-60 Tk/tablet (oxytetracycline)

24. Human care expenditure • 10Tk-320Tk, m=40Tk • Vitamin • Homeopathic • Paracetomol • Antibiotics

25. Animal ab use

26. Drug sellers A 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.

27. Animal husbandry 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”.

28. Animal care-taker 13 4 3 2 0 24 Female household members take care of both chickens and children, thus they introduce to their children another source of antibiotic resistant pathogens.

29. Animals, 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.

30. Future data collection Currently we are using a survey instrument to quantify human and animal level antibiotic use, and related household and SES variables. Data will be obtained on the prevalence of human and animal carriage of AMR bacteria and the relationship of the two. This information will be shared with the Government of Bangladesh and other stakeholders with the goal of informing programs to reduce the spread of resistant microbes.

31. Survey design • AMR risk • Animal exposure (crowding, waste, ab use) • Current antibiotic use (look at available medicine) • Human waste removal • Human crowding • Antibiotic use • Human

32. JHSPH Ellen K. Silbergeld Timothy Baker Diane Lynn Francisco Mathuram Santosham Paul A. Law ICDDR,B, DSH Tamanna Sharmin Ashraful Alam Neeloy Samir K. Saha Acknowledgements Many thanks go to the Centre for a Livable Future at Johns Hopkins University School of PublicHealth and especially to Robert Lawrence and Polly Walker for their support and encouragement.