Developing One Health surveillance systems.

The health of humans, domestic and wild animals, plants, and the environment are inter-dependent. Global anthropogenic change is a key driver of disease emergence and spread and leads to biodiversity loss and ecosystem function degradation, which are themselves drivers of disease emergence. Pathogen spill-over events and subsequent disease outbreaks, including pandemics, in humans, animals and plants may arise when factors driving disease emergence and spread converge. One Health is an integrated approach that aims to sustainably balance and optimize human, animal and ecosystem health. Conventional disease surveillance has been siloed by sectors, with separate systems addressing the health of humans, domestic animals, cultivated plants, wildlife and the environment. One Health surveillance should include integrated surveillance for known and unknown pathogens, but combined with this more traditional disease-based surveillance, it also must include surveillance of drivers of disease emergence to improve prevention and mitigation of spill-over events. Here, we outline such an approach, including the characteristics and components required to overcome barriers and to optimize an integrated One Health surveillance system.

Strengthening the One Health Approach in the Eastern Mediterranean Region.

One Health aims to use a multidisciplinary approach to combat health threats at animal, human, and environmental health interfaces. Among its broad focus areas are issues related to food safety, the control of zoonoses, laboratory services, neglected tropical diseases, environmental health, biosafety and biosecurity, and combatting antimicrobial resistance. A roundtable session was conducted on November 18, 2021, as part of the Eastern Mediterranean Public Health Network's (EMPHNET) seventh regional conference to highlight what role Global Health Development (GHD)|EMPHNET can play to strengthen the One Health approach. This viewpoint summarizes the findings of the roundtable discussion to highlight the experts' viewpoints on strengthening the One Health approach, including the extent of zoonotic diseases and the dynamics of pathogens and emerging diseases; the occurrence of antimicrobial-resistant pathogens as a silent pandemic; issues surrounding the globalization of trade and food safety; the importance of integrated solutions as a new norm; issues around the institutionalization and governance toward effective operationalization of the One Health approach in the region; and how the One Health approach can be operationalized at global, regional, and local levels. The panel concluded that One Health is an integrated unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems, and provided recommendations to strengthen the One Health approach. It also discussed how GHD|EMPHNET can play its role in transferring the concept of One Health from theory to practice via a solid operationalization road map guide at the Eastern Mediterranean region level. The five broad priority areas of this operational guide include (1) establishing and strengthening a governance architecture, legal framework, and policy and advocacy structure for One Health operationalization in the region; (2) fostering coordination, communication, and collaboration for One Health actions across the region and beyond; (3) building the workforce capacity for effective One Health operationalization in the region; (4) supporting regional platforms for timely, effective, and efficient data sharing and exchange on all One Health-related issues; and (5) supporting risk communication, behavior change communication, and community engagement efforts in the region.

Antibiotic usage practices and its drivers in commercial chicken production in Bangladesh.

Irrational and inappropriate use of antibiotics in commercial chicken production can contribute to the development of antimicrobial resistance. We aimed to assess antibiotic usage in commercial chicken production in Bangladesh, and identify factors associated with this practice. We conducted a large-scale cross-sectional study to collect information on antibiotic usage in commercial chickens from January to May 2021. Structured interviews were conducted with 288 broiler, 288 layer and 192 Sonali (locally-produced cross-bred) farmers in 20 sub-districts across Bangladesh. The frequency of antibiotic usage, the types of antibiotics and purpose of usage were estimated for each production type. Adjusted odds ratios (aOR) were calculated to measure the association between antibiotic usage and factors related to the characteristics of the farms and farmers using multivariable logistic regression models. The proportion of farms, irrespective of their production type, reporting usage of antibiotics in the 24 hours preceding the interview was 41% (n = 314, 95% CI: 37-44%). Forty-five percent (n = 344, 41-48%) reported antibiotic usage in the last 72 hours, 86% (n = 658, 83-88%) in the last 14 days, and almost all farms, 98% (n = 753, 97-99%), had used antibiotics since the start of their production cycle. Use of antibiotics in the 24 hours preceding an interview was more frequently reported in broiler (OR 1.91, 95% CI: 1.36-2.69) and Sonali (OR 1.94, 95% CI: 1.33-2.33) than layer farms. Oxytetracycline (23-31%, depending on production type), doxycycline (18-25%), ciprofloxacin (16-26%) and amoxicillin (16-44%) were the most frequently used antibiotics. Antibiotics were reported to be used for both treatment and prophylactic purposes on most farms (57-67%). Usage of antibiotics in the 24h preceding an interview was significantly associated with the occurrence of any illnesses in chickens (aOR broiler: 41.22 [95% CI:13.63-124.62], layer: aOR 36.45[9.52-139.43], Sonali: aOR 28.47[4.97-162.97]). Antibiotic usage was mainly advised by veterinary practitioners (45-71%, depending on production type), followed by feed dealers (21-40%) and farmers (7-13%). Improvement of chicken health through good farming practices along with changes in key stakeholders (feed dealers and practitioners) attitudes towards antibiotic recommendations to farmers, may help to reduce the levels of antibiotic usage and thus contribute to mitigate antimicrobial resistance.

Antibiotics usage practices in aquaculture in Bangladesh and their associated factors.

Background: Irrational and inappropriate use of antibiotics in aquaculture can contribute to the development of antibiotic resistance. Objectives: In this study, we aimed to assess antibiotic usage in inland and coastal fish farms in Bangladesh and identify factors associated with this practice. Methods: We conducted a cross-sectional study to collect antibiotic usage information from 672 fish farmers in Bangladesh. The frequency of use, the types of antibiotics, the purpose of usage, and antibiotic prescribing practices were estimated. Adjusted odds ratios (aOR) were calculated to measure the association between antibiotic usage and factors related to the characteristics of the farms and farmers using multivariable logistic regression models. Results: Twenty-two farms reported using antibiotics in the last 24 h preceding the interview (3%, 95% CI: 2-5%); 36 farms (5%, 95% CI: 4-7%) in the last 72 h, 141 farms (21%, 95% CI: 18-24%) in the last 14 days, and 478 farms (71%, 68-75%) reported antibiotic usage at least once since the start of their production cycle. Antibiotics usage in the last 14 days preceding the interviews was higher in freshwater fish farms (98%) than in brackish water farms (2%). Oxytetracycline, ciprofloxacin, and amoxicillin were the most frequently used antibiotics. Most of the antibiotics were reported to be used for both therapeutic and prophylactic purposes (71%, 95% CI: 63-78%). Antibiotics used within the last 14 days were mainly advised by feed dealers or drug sellers (51%, 95% CI: 43-60%), followed by farmers themselves (31%, 95% CI: 23-38%) and local service providers (18%, 95% CI, 12-25%). Fish farms having history of antibiotic use within the last 14 days preceding interviews was significantly associated with illness in fish (aOR 1.98, 95% CI:1.21-3.29) compared to farms with healthy fish and fishes cultured in ponds (aOR 9.34, 95% CI: 3.69-23.62) compared to enclosure cultures. Conclusions: Improvement of fish health through better farming practices and changes in feed dealers' and farmers' attitudes towards self-prescription of antibiotic without veterinarian diagnostics may help to reduce the levels of antibiotic usage and thus contribute to mitigating antimicrobial resistance.

Identifying Benefits, Challenges, and Options for Improvement of Veterinary Work-Based Learning in Bangladesh.

Work-based learning (WBL) provides relevant contemporary experience of working environments. Potential benefits for students include developing invaluable skills (clinical, personal, cultural, and professional) and gaining greater awareness of the profession and future career opportunities. However, there are also challenges related to running and sustaining a successful WBL program. In the context of this study, WBL refers to external placements undertaken by final-year students. The aims of the study were to identify ways to optimize the benefits while managing the challenges in delivering WBL in a veterinary curriculum. An in-depth study was undertaken at Chattogram Veterinary and Animal Sciences University (CVASU), Bangladesh, where a WBL program has been in place for 20 years. Final-year veterinary students at CVASU were surveyed to ascertain WBL experiences; survey findings were further explored in focus groups with students, recent graduates, faculty, and placement providers. Most agreed that they had sufficient opportunities to observe, assist, and directly handle pet and farm animals with top skills learned, including clinical diagnosis and communication, and recognized the value of learning in professional workplaces. Based on suggested areas of improvement, the following recommendations can be made: carefully selecting placements, adjusting time allocation, improving communication and building strong collaborations with placement providers, allowing students to customize more placements to align with their career preferences, and staffing adequately to arrange placements and manage a WBL program. Overall, results suggest the current WBL arrangements at CVASU are reasonably good, but there are some specific areas for improvement.

Measures, Gaps, and Mitigation Strategies in Bangladesh's COVID-19 Response.

The Coronavirus Disease 2019 (COVID-19) spread rapidly from China to most other countries around the world in early 2020 killing millions of people. To prevent virus spread, world governments implemented a variety of response measures. This paper's objectives were to discuss the country's adopted measures to combat the virus through June 2020, identify gaps in the measures' effectiveness, and offer possible mitigations to those gaps. The measures taken included screening device deployment across international air and land ports, flight suspensions and closures from COVID-19 affected countries, and declaration and extension of a national public holiday (equivalent to lockdowns in other countries). Identified gaps were test kit, PPE, ICU beds, and ventilator shortages, limited public awareness, and insufficient coordination and collaboration among national and international partners. Proper and timely risk mapping, preparedness, communication, coordination, and collaboration among governments and organizations, and public awareness and engagement would have provided sufficient COVID-19 mitigation in Bangladesh.

Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh.

For supporting antibiotic stewardship interventions, the World Health Organization (WHO) classified antibiotics through the AWaRe (Access, Watch, and Reserve) classification. Inappropriate use of antimicrobials among hospital-admitted patients exposes them to the vulnerability of developing resistant organisms which are difficult to treat. We aimed to describe the proportion of antibiotic use based on the WHO AWaRe classification in tertiary and secondary level hospitals in Bangladesh. A point prevalence survey (PPS) was conducted adapting the WHO PPS design in inpatients departments in 2021. Among the 1417 enrolled patients, 52% were female and 63% were from the 15-64 years age group. Nearly 78% of patients received at least one antibiotic during the survey period. Third-generation cephalosporins (44.6%), penicillins (12.3%), imidazoles (11.8%), aminoglycosides (7.2%), and macrolides (5.8%) were documented as highly used antibiotics. Overall, 64.0% of Watch, 35.6% of Access, and 0.1% of Reserve group antibiotics were used for treatment. The use of Watch group antibiotics was high in medicine wards (78.7%) and overall high use of Watch antibiotics was observed at secondary hospitals (71.5%) compared to tertiary hospitals (60.2%) (p-value of 0.000). Our PPS findings underscore the need for an urgent nationwide antibiotic stewardship program for physicians including the development and implementation of local guidelines and in-service training on antibiotic use.

Pattern of Antibiotic Dispensing at Pharmacies According to the WHO Access, Watch, Reserve (AWaRe) Classification in Bangladesh.

The WHO Essential Medicines List Access, Watch, and Reserve (AWaRe) classification could facilitate antibiotic stewardship and optimal use. In Bangladesh, data on antibiotic dispensing in pharmacies according to the AWaRe classification are scarce. We aimed to explore antibiotic dispensing pattern in pharmacies according to the WHO AWaRe classification to aid pharmacy-targeted national antibiotic stewardship program (ASP). From January to July 2021, we interviewed drug-sellers from randomly selected pharmacies and randomly selected customers attending the pharmacies. We collected data on demographics and medicines purchased. We classified the purchased antibiotics into the Access, Watch, and Reserve groups among 128 pharmacies surveyed, 98 (76.6%) were licensed; 61 (47.7%) drug-sellers had pharmacy training. Of 2686 customers interviewed; 580 (21.6%) purchased antibiotics. Among the 580 customers, 523 purchased one, 52 purchased two, and 5 purchased three courses of antibiotics (total 642 courses). Of the antibiotic courses, the Watch group accounted for the majority (344, 53.6%), followed by the Access (234, 36.4%) and Reserve (64, 10.0%) groups. Approximately half of the antibiotics (327/642, 50.9%) were purchased without a registered physician's prescription. Dispensing of non-prescribed antibiotics was higher in the Access group (139/234, 59.4%), followed by Watch (160/344, 46.5%) and Reserve (28/64, 43.8%) groups. These findings highlight the need to implement strict policies and enforce existing laws, and pharmacy-targeted ASP focusing on proper dispensing practices to mitigate antimicrobial resistance in Bangladesh.

Avian influenza transmission risk along live poultry trading networks in Bangladesh.

Live animal markets are known hotspots of zoonotic disease emergence. To mitigate those risks, we need to understand how networks shaped by trading practices influence disease spread. Yet, those practices are rarely recorded in high-risk settings. Through a large cross-sectional study, we assessed the potential impact of live poultry trading networks' structures on avian influenza transmission dynamics in Bangladesh. Networks promoted mixing between chickens sourced from different farming systems and geographical locations, fostering co-circulation of viral strains of diverse origins in markets. Viral transmission models suggested that the observed rise in viral prevalence from farms to markets was unlikely explained by intra-market transmission alone, but substantially influenced by transmission occurring in upstream network nodes. Disease control interventions should therefore alter the entire network structures. However, as networks differed between chicken types and city supplied, standardised interventions are unlikely to be effective, and should be tailored to local structural characteristics.

Antibiotics Use and Its Knowledge in the Community: A Mobile Phone Survey during the COVID-19 Pandemic in Bangladesh.

The general population has been excessively using antibiotics during the COVID-19 pandemic. Therefore, the use of antibiotics for any reported illnesses in the preceding four weeks and knowledge of antibiotics among the general population in the community were assessed for possible interventions. A mobile phone survey among a general population across eight administrative divisions of Bangladesh was conducted during January-March 2021. Reported illness episodes irrespective of COVID-19 in the preceding four weeks of the interview, use of antibiotics for the illnesses, and knowledge on antibiotics among the general population were recorded. Descriptive analyses were performed. We randomly interviewed 1854 participants, with a mean age of 28.5 years (range: 18-75 years); 60.6% were male. Among all participants, 86.3% (95% CI: 84.7-87.8) heard names of antibiotics, but only 12.1% reported unspecified harmful effects, and 3.5% reported antimicrobial resistance when antibiotics were taken without a physician's prescription. Among 257 (13.9%) participants, who consumed medicines for their recent illness episode, 32.7% (95% CI: 27.2-38.6) reported using antibiotics. Of those who could recall the names of antibiotics prescribed (n = 36), the most frequently used was azithromycin (22.2%) followed by cefixime (11.1%) and ciprofloxacin (5.6%). Our findings show an increased antibiotic use for illnesses reported in the preceding four weeks and an elevated knowledge at the community level during the COVID-19 pandemic compared with the pre-pandemic period.

Risk Areas for Influenza A(H5) Environmental Contamination in Live Bird Markets, Dhaka, Bangladesh.

We evaluated the presence of influenza A(H5) virus environmental contamination in live bird markets (LBMs) in Dhaka, Bangladesh. By using Bernoulli generalized linear models and multinomial logistic regression models, we quantified LBM-level factors associated with market work zone-specific influenza A(H5) virus contamination patterns. Results showed higher environmental contamination in LBMs that have wholesale and retail operations compared with retail-only markets (relative risk 0.69, 95% 0.51-0.93; p = 0.012) and in March compared with January (relative risk 2.07, 95% CI 1.44-2.96; p<0.001). Influenza A(H5) environmental contamination remains a public health problem in most LBMs in Dhaka, which underscores the need to implement enhanced biosecurity interventions in LBMs in Bangladesh.

Creating the Next Generation of Evidence-Based Veterinary Practitioners and Researchers: What are the Options for Globally Diverse Veterinary Curricula?

Veterinary educators strive to prepare graduates for a variety of career options with the skills and knowledge to use and contribute to research as part of their lifelong practice of evidence-based veterinary medicine (EBVM). In the veterinary curriculum, students should receive a grounding in research and EBVM, as well as have the opportunity to consider research as a career. Seeing a lack of a cohesive body of information that identified the options and the challenges inherent to embedding such training in veterinary curricula, an international group was formed with the goal of synthesizing evidence to help curriculum designers, course leaders, and teachers implement educational approaches that will inspire future researchers and produce evidence-based practitioners. This article presents a literature review of the rationale, issues, and options for research and EBVM in veterinary curricula. Additionally, semi-structured interviews were conducted with 11 key stakeholders across the eight Council for International Veterinary Medical Education (CIVME) regions. Emergent themes from the literature and interviews for including research and EBVM skills into the curriculum included societal need, career development, and skills important to clinical professional life. Approaches included compulsory as well as optional learning opportunities. Barriers to incorporating these skills into the curriculum were grouped into student and faculty-/staff-related issues, time constraints in the curriculum, and financial barriers. Having motivated faculty and contextualizing the teaching were considered important to engage students. The information has been summarized in an online "toolbox" that is freely available for educators to inform curriculum development.

Improvement of DVM Curriculum to Meet OIE Recommendations at Chattogram Veterinary and Animal Sciences University, Bangladesh.

A veterinary education twinning project between Chattogram Veterinary and Animal Sciences University (CVASU) and Tufts Cummings School of Veterinary Medicine (TCSVM) was supported by the World Organisation for Animal Health (OIE) to align CVASU's veterinary curriculum with OIE's recommended Core Curriculum and Day 1 Competencies. The major objectives were curriculum development with improvement to the internship program, introduction of problem-based learning (PBL), and implementation of continuing education (CE). Major activities to achieve these objectives involved several workshops and seminars at CVASU and establishing student exchange and CVASU faculty training programs. Major accomplishments were (a) implementation of a revised Doctor of Veterinary Medicine (DVM) curriculum at CVASU aligned with the OIE-recommended curriculum and Day 1 Competencies; (b) incorporation of PBL into the curriculum and development of 23 PBL cases relevant to Bangladesh-specific diseases; (c) improvement of the internship program by including Day 1 Competencies; (d) development and implementation of 11 structured CE sessions including hands-on training; (e) improvement of curriculum, teaching, and clinical training at CVASU following training of CVASU faculty and students at TCSVM; and (f) three peer-reviewed publications from summer research projects by TCSVM students at CVASU. The twinning project allowed CVASU to improve its DVM curriculum by aligning with OIE's recommended curriculum and Day 1 Competencies. The impact of the project went beyond CVASU as evidenced by other veterinary schools adopting the CVASU curriculum and PBL, veterinary school deans engaged in improving veterinary curriculum and clinical training, and implementation of a national CE program for veterinarians.

Qualitative risk assessment of transmission pathways of highly pathogenic avian influenza (HPAI) virus at live poultry markets in Dhaka city, Bangladesh.

Analysis of environmental samples obtained from the Live Poultry Markets (LPMs) of Dhaka City, Bangladesh, has revealed that the highest degree of prevalence of highly pathogenic avian influenza A (HPAI, H5N1), besides other subtypes of the LPAI virus, poses the plausible risk of transmission of these viruses between human and poultry species. The present study was conducted using the OIE risk analysis framework to assess the risk level of each pathway successively. The estimated risk parameters were integrated towards to obtain the overall risk level for each specific HPAI transmission pathway using the matrix adapted by Cristobel Zepeda accompanying other expert consultations. The relevant data obtained from published and unpublished sources, together with survey data of field observations, were used to formulate and confirm the risk pathways and their associated risks. The results revealed that the risk of the release of the HPAI virus was medium when exposure was high. Additionally, the consequence would be considered very high with a medium degree of uncertainty for all parameters. Ultimately, the overall risk for transmission was estimated as medium with a medium degree of uncertainty. The findings of this study reveal that there is a significant threat that HPAI virus transmission could occur among poultry and humans and effectively sustain within the environment of the LPMs. Our findings are primarily focused on public health considerations, the hygienic slaughter of poultry and the relevant cleaning and sanitation practices conducted in the LPMs to support evidence-based decision-making processes. The findings of the study have the potential to be used to formulate effective risk reduction measures and can be further adapted in low-resource settings without major infrastructural changes required of the LPMs. All of which would reduce the risk of HPAI virus release and further lessen the degree of exposure and transmission in established LPMs.

Practising co-production and interdisciplinarity: Challenges and implications for one health research.

We review the nature of interdisciplinary research in relation to One Health, a perspective on human-animal health which would appear to merit close interdisciplinary cooperation to inform public health policy. We discuss the relationship between biological sciences, epidemiology and the social sciences and note that interdisciplinary work demands attention be given to a range of often neglected epistemological and methodological issues. Epidemiologists may sometimes adopt social science techniques as "bolt-ons"1 to their research without having a complete understanding of how the social sciences work. The paper introduces a range of social science concepts and applies them to the challenges of understanding and practicing participatory and local epidemiology. We consider the problem of co-production of knowledge about One Health and zoonotic diseases in relation to funding structures, working in large international teams and explore some of the often-neglected realities of working across disciplines and cultures. We do this in part by applying the concept of value-chain to the research process.

Trends and clinico-epidemiological features of human rabies cases in Bangladesh 2006-2018.

Vaccinating dogs against rabies is an effective means of reducing human rabies. We subjected 1327 clinically diagnosed human rabies death and mass dog vaccination (MDV) data during 2006-2018 to quantify the impacts of MDV on human rabies incidence in Bangladesh and a subset of rabies death data (422) for clinico-epidemiological analysis. A positive and increasing trend of MDV (p = 0.01 and tau = 0.71) and a negative and declining trend (p < 0.001 and tau = -0.88) of human rabies cases (Correlation coefficient: -0.82) have been observed. Among 422 deaths, the majority (78%) of the victims sought treatment from traditional healers, and 12% received post-exposure prophylaxis (PEP). The mean incubation period of rabies in cases with exposure sites on the head & neck (35 days) was shorter than the upper limb (mean = 64 days, p = 0.02) and lower limb (mean = 89 days, p < 0.01). MDV has been found to be effective for reducing human rabies cases in Bangladesh. Creating awareness among the animal bite victims to stop reliance on traditional healers rather seeking PEP, addressing the role of traditional healers through awareness education programme with respect to the treatment of dog bites, ensuring availability of PEP, and continuing to scale up MDV may help to prevent human rabies deaths.