"If You Do Not Take the Medicine and Complete the Dose It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania.

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

From policy to practice: An assessment of biosecurity practices in cattle, sheep and goats production, marketing and slaughter in Baringo County, Kenya.

Globally, biosecurity is instrumental in prevention, control and management of livestock diseases and protection of human health. It is defined, prescribed, adopted and enforced through global, regional and national frameworks, laws, policies and strategies. There is more biosecurity practice research conducted in developed countries than developing ones. Consequently, the gap between the ideals recommended in biosecurity frameworks and what is practical in under-resourced rural settings is poorly understood. This anthropological study sought to assess adoption of biosecurity practices across a cattle, sheep and goat value chains continuum to demonstrate where risks lie. The cross-sectional mixed-methods study took place in Baringo County, Kenya. Qualitatively, it utilized 26 focus group discussions with community members and 10 observational interviews with slaughter facility workers. Quantitatively, it included a household survey with 560 community members and a separate survey with 231 livestock traders. Results show that producers, traders and slaughter facility workers did observe some biosecurity practices but not others due but not limited to personal preference, limitations in veterinary service delivery and enforcement of some biosecurity measures, and lack of requisite infrastructure. The study concludes that the implementation of biosecurity measures in rural settings is more complex than envisioned in biosecurity policies and frameworks. It can be hampered by resource limitations, poor enforcement, and contestations with cultural practices. The study recommends that further studies on willingness to adopt biosecurity measures targeting community members in under-resourced settings be conducted to identify possible critical points of intervention at county and national levels.

How public health crises expose systemic, day-to-day health inequalities in low- and-middle income countries: an example from East Africa.

BACKGROUND: The current Coronavirus disease pandemic reveals political and structural inequities of the world's poorest people who have little or no access to health care and yet the largest burdens of poor health. This is in parallel to a more persistent but silent global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania. METHODS: We conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences. RESULTS: Three interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals. CONCLUSION: Entanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in 'normal' circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges.

The CINAMR (Clinical Information Network-Antimicrobial Resistance) Project: A pilot microbial surveillance using hospitals linked to regional laboratories in Kenya: Study Protocol.

Background: Antimicrobial resistance (AMR) is a global threat and is thought to be acute in low-and middle-income country (LMIC) settings, including in Kenya, but there is limited unbiased surveillance that can provide reliable estimates of its burden. Current efforts to build capacity for microbiology testing in Kenya are unlikely to result in systematic routine microbiological testing in the near term. Therefore, there is little prospect for microbiological support to inform clinical diagnoses nor for indicating the burden of AMR and for guiding empirical choice of antibiotics. Objective: We aim to build on an existing collaboration, the Clinical Information Network (CIN), to pilot microbiological surveillance using a 'hub-and-spoke' model where selected hospitals are linked to high quality microbiology research laboratories. Methods: Children admitted to paediatric wards of 12 participating hospitals will have a sample taken for blood culture at admission before antibiotics are started. Indication for blood culture will be a clinician's prescription of antibiotics. Samples will then be transported daily to the research laboratories for culture and antibiotic susceptibility testing and results relayed back to clinicians for patient management. The surveillance will take place for 6 months in each hospital. Separately, we shall conduct semi-structured interviews with frontline health workers to explore the feasibility and utility of this approach. We will also seek to understand how the availability of microbiology results might inform antibiotic stewardship, and as an interim step to the development of better national or regional laboratories linked to routine surveillance. Conclusions: If feasible, this approach is less costly and periodic 'hub-and-spoke' surveillance can be used to track AMR trends and to broadly guide empirical antibiotic guidance meaning it is likely to be more sustainable than establishing functional microbiological facilities in each hospital in a LMIC setting.

A Qualitative Study on Gendered Barriers to Livestock Vaccine Uptake in Kenya and Uganda and Their Implications on Rift Valley Fever Control.

Rift Valley fever (RVF) is a zoonotic disease of great public health and economic importance transmitted by mosquitoes. The main method of preventing the disease is vaccination of susceptible livestock before outbreaks occur. Studies on RVF vaccines have focused on the production processes, safety, and efficacy standards but those on uptake and adoption levels are rare. This study sought to understand the barriers faced by men and women farmers in the uptake of livestock vaccines to inform strategies for optimizing the use of vaccines against RVF in East Africa. The cross-sectional qualitative study utilized the pairwise ranking technique in sex disaggregated focus group discussions to identify and rank these barriers. Results indicate that men and women farmers experience barriers to vaccine uptake differentially. The barriers include the direct and indirect cost of vaccines, distances to vaccination points, availability of vaccination crushes, intra-household decision making processes and availability of information on vaccination campaigns. The study concludes that vaccine provision does not guarantee uptake at the community level. Hence, these barriers should be considered while designing vaccination strategies to enhance community uptake because vaccine uptake is a complex process which requires buy-in from men and women farmers, veterinary departments, county/district and national governments, and vaccine producers.

"We do not bury dead livestock like human beings": Community behaviors and risk of Rift Valley Fever virus infection in Baringo County, Kenya.

BACKGROUND: Rift Valley Fever (RVF), is a viral zoonotic disease transmitted by Aedes and Culex mosquitoes. In Kenya, its occurrence is associated with increased rains. In Baringo County, RVF was first reported in 2006-2007 resulting in 85 human cases and 5 human deaths, besides livestock losses and livelihood disruptions. This study sought to investigate the county's current RVF risk status. METHODOLOGY AND PRINCIPAL FINDINGS: A cross-sectional study on the knowledge, attitudes and practices of RVF was conducted through a mixed methods approach utilizing a questionnaire survey (n = 560) and 26 focus group discussions (n = 231). Results indicate that study participants had little knowledge of RVF causes, its signs and symptoms and transmission mechanisms to humans and livestock. However, most of them indicated that a person could be infected with zoonotic diseases through consumption of meat (79.2%) and milk (73.7%) or contact with blood (40%) from sick animals. There was a statistically significant relationship between being male and milking sick animals, consumption of milk from sick animals, consuming raw or cooked blood, slaughtering sick livestock or dead animals for consumption (all at p≤0.001), and handling sick livestock with bare hands (p = 0.025) with more men than women engaging in the risky practices. Only a few respondents relied on trained personnel or local experts to inspect meat for safety of consumption every time they slaughtered an animal at home. Sick livestock were treated using conventional and herbal medicines often without consulting veterinary officers. CONCLUSIONS: Communities in Baringo County engage in behaviour that may increase their risk to RVF infections during an outbreak. The authors recommend community education to improve their response during outbreaks.

Effect of climatic variability on malaria trends in Baringo County, Kenya.

BACKGROUND: Malaria transmission in arid and semi-arid regions of Kenya such as Baringo County, is seasonal and often influenced by climatic factors. Unravelling the relationship between climate variables and malaria transmission dynamics is therefore instrumental in developing effective malaria control strategies. The main aim of this study was to describe the effects of variability of rainfall, maximum temperature and vegetation indices on seasonal trends of malaria in selected health facilities within Baringo County, Kenya. METHODS: Climate variables sourced from the International Research Institute (IRI)/Lamont-Doherty Earth Observatory (LDEO) climate database and malaria cases reported in 10 health facilities spread across four ecological zones (riverine, lowland, mid-altitude and highland) between 2004 and 2014 were subjected to a time series analysis. A negative binomial regression model with lagged climate variables was used to model long-term monthly malaria cases. The seasonal Mann-Kendall trend test was then used to detect overall monotonic trends in malaria cases. RESULTS: Malaria cases increased significantly in the highland and midland zones over the study period. Changes in malaria prevalence corresponded to variations in rainfall and maximum temperature. Rainfall at a time lag of 2 months resulted in an increase in malaria transmission across the four zones while an increase in temperature at time lags of 0 and 1 month resulted in an increase in malaria cases in the riverine and highland zones, respectively. CONCLUSION: Given the existence of a time lag between climatic variables more so rainfall and peak malaria transmission, appropriate control measures can be initiated at the onset of short and after long rains seasons.

Lay knowledge and management of malaria in Baringo county, Kenya.

BACKGROUND: Malaria, a disease caused by protozoan parasites of the genus Plasmodium and transmitted by female anopheline mosquitoes, is a major cause of morbidity, mortality and loss in productivity in humans. Baringo County is prone to seasonal transmissions of malaria mostly in the rainy seasons. METHODS: This cross-sectional study used a mixed methods approach to collect data on knowledge and lay management of malaria. A questionnaire survey was administered to 560 respondents while qualitative data was collected through 20 focus group discussions in four ecological zones covering Baringo North, Baringo South and Marigat sub-Counties of Baringo County. Analyses were done through summary and inferential statistics for quantitative data and content analysis for qualitative data. RESULTS: The study communities were knowledgeable of malaria signs, symptoms, cause and seasonality but this biomedical knowledge co-existed with other local perceptions. This knowledge, however, did not influence their first (p = 0.77) or second choice treatments (p = 0.49) and compliance to medication (p = 0.84). Up to 88 % of respondents reported having suffered from malaria. At the onset of a suspected malaria case community members reported the following: 28.9 % visited a health facility, 37.2 % used analgesics, 26.6 % herbal treatments, 2.2 % remnant malaria medicines, 2.2 % over the counter malaria medicines, 1 % traditional healers and 1.8 % other treatments. Nearly all respondents (97.8 %) reported visiting a health facility for subsequent treatments. Herbal treatments comprised of infusions and decoctions derived from roots, barks and leaves of plants believed to have medicinal value. Compliance to conventional malaria treatment regime was, however, identified as a challenge in malaria management. Quick relief from symptoms, undesirable qualities like drug bitterness and bad smell, undesirable side-effects, such as nausea and long regimen of treatment were some of the contributors to non-compliance. Men and women exhibited different health-seeking behaviours based on the cultural expectations of masculinity, femininity, gender roles and acceptability of health services. CONCLUSIONS: While knowledge of malaria is important in identifying the disease, it does not necessarily lead to good management practice. Treatment-seeking behaviour is also influenced by perceived cause, severity of disease, timing, anticipated cost of seeking treatment and gender, besides the availability of both traditional and conventional medicines.