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- Hassell, James M., et al.
(författare)
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Clinically relevant antimicrobial resistance at the wildlife-livestock-human interface in Nairobi : an epidemiological study
- 2019
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Ingår i: The Lancet Planetary Health. - : ELSEVIER SCI LTD. - 2542-5196. ; 3:6, s. E259-E269
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Tidskriftsartikel (refereegranskat)abstract
- Background: Antimicrobial resistance is one of the great challenges facing global health security in the modern era. Wildlife, particularly those that use urban environments, are an important but understudied component of epidemiology of antimicrobial resistance. We investigated antimicrobial resistance overlap between sympatric wildlife, humans, livestock, and their shared environment across the developing city of Nairobi, Kenya. We use these data to examine the role of urban wildlife in the spread of clinically relevant antimicrobial resistance.Methods: 99 households across Nairobi were randomly selected on the basis of socioeconomic stratification. A detailed survey was administered to household occupants, and samples (n=2102) were collected from the faeces of 75 wildlife species inhabiting household compounds (ie, the household and its perimeter; n=849), 13 livestock species (n=656), and humans (n=333), and from the external environment (n=288). Escherichia coli, our sentinel organism, was cultured and a single isolate from each sample tested for sensitivity to 13 antibiotics. Diversity of antimicrobial resistant phenotypes was compared between urban wildlife, humans, livestock, and the environment, to investigate whether wildlife are a net source for antimicrobial resistance in Nairobi. Generalised linear mixed models were used to determine whether the prevalence of antimicrobial resistant phenotypes and multidrug-resistant E coli carriage in urban wildlife is linked to variation in ecological traits, such as foraging behaviour, and to determine household-level risk factors for sharing of antimicrobial resistance between humans, wildlife, and livestock.Findings: E coli were isolated from 485 samples collected from wildlife between Sept 6,2015, and Sept 28, 2016. Wildlife carried a low prevalence of E coli isolates susceptible to all antibiotics tested (45 [9%] of 485 samples) and a high prevalence of clinically relevant multidrug resistance (252 [52%] of 485 samples), which varied between taxa and by foraging traits. Multiple isolates were resistant to one agent from at least seven antimicrobial classes tested for, and a single isolate was resistant to all antibiotics tested for in the study. The phenotypic diversity of antimicrobial-resistant E coli in wildlife was lower than in livestock, humans, and the environment. Within household compounds, statistical models identified two interfaces for exchange of antimicrobial resistance: between both rodents, humans and their rubbish, and seed-eating birds, humans and their rubbish; and between seed-eating birds, cattle, and bovine manure.Interpretation: Urban wildlife carry a high burden of clinically relevant antimicrobial-resistant E coli in Nairobi, exhibiting resistance to drugs considered crucial for human medicine by WHO. Identifiable traits of the wildlife contribute to this exposure; however, compared with humans, livestock, and the environment, low phenotypic diversity in wildlife is consistent with the hypothesis that wildlife are a net sink rather than source of clinically relevant resistance. Wildlife that interact closely with humans, livestock, and both human and livestock waste within households, are exposed to more antimicrobial resistant phenotypes, and could therefore act as conduits for the dissemination of clinically relevant antimicrobial resistance to the wider environment. These results provide novel insight into the broader epidemiology of antimicrobial resistance in complex urban environments, characteristic of lower-middle-income countries.
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| 3. |
- Liyanage, Prasad, et al.
(författare)
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Evaluation of intensified dengue control measures with interrupted time series analysis in the Panadura Medical Officer of Health division in Sri Lanka : a case study and cost-effectiveness analysis
- 2019
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Ingår i: The Lancet Planetary Health. - : Elsevier. - 2542-5196. ; 3:5, s. e211-e218
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Tidskriftsartikel (refereegranskat)abstract
- Background: Dengue has become a major public health problem in Sri Lanka with a considerable economic burden. As a response, in June, 2014, the Ministry of Health initiated a proactive vector control programme in partnership with military and police forces, known as the Civil-Military Cooperation (CIMIC) programme, that was targeted at high-risk Medical Officer of Health (MOH) divisions in the country. Evaluating the effectiveness and cost-effectiveness of population-level interventions is essential to guide public health planning and resource allocation decisions, particularly in resource-limited health-care settings.Methods: Using an interrupted time series design with a non-linear extension, we evaluated the impact of vector control interventions from June 22, 2014, to Dec 29, 2016, in Panadura, a high-risk MOH division in Western Province, Sri Lanka. We used dengue notification and larval survey data to estimate the reduction in Breteau index and dengue incidence before and after the intervention using two separate models, adjusting for time-varying confounding variables (ie, rainfall, temperature, and the Oceanic Niño Index). We also assessed the cost and cost-effectiveness of the CIMIC programme from the perspective of the National Dengue Control Unit under the scenarios of different levels of hospitalisation of dengue cases (low [25%], medium [50%], and high [75%]) in terms of cost per disability-adjusted life-year averted (DALY).Findings: Vector control interventions had a significant impact on combined Breteau index (relative risk reduction 0·43, 95% CI 0·26 to 0·70) and on dengue incidence (0·43, 0·28 to 0·67), the latter becoming prominent 2 months after the intervention onset. The mean number of averted dengue cases was estimated at 2192 (95% CI 1741 to 2643), and the total cost of the CIMIC programme at 2016 US$271 615. Personnel costs accounted for about 89% of the total cost. In the base-case scenario of moderate level of hospitalisation, the CIMIC programme was cost-saving with a probability of 70% under both the lowest ($453) and highest ($1686) cost-effectiveness thresholds, resulting in a net saving of $20 247 (95% CI −57 266 to 97 790) and averting 176 DALYs (133 to 226), leading to a cost of −$98 (−497 to 395) per DALY averted. This was also the case for the scenario with high hospitalisation levels (cost per DALY averted −$512, 95% CI −872 to −115) but with a higher probability of 99%. In the scenario with low hospitalisation levels (cost per DALY averted $690, 143 to 1379), although the CIMIC programme was cost-ineffective at the lowest threshold with a probability of 77%, it was cost-effective at the highest threshold with a probability of 99%.Interpretation: This study suggests that communities affected by dengue can benefit from investments in vector control if interventions are implemented rigorously and coordinated well across sectors. By doing so, it is possible to reduce the disease and economic burden of dengue in endemic settings.Funding: None.
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