Many factors, including lack of knowledge, influence diagnosis and reporting of disease in Sub-Saharan Africa. Health Care workers (HCWs) are in constant interaction with communities and play an important role in the prevention, diagnosis and treatment of infectious diseases, including zoonoses. We determined knowledge of HCWs regarding cause, vector, transmission, diagnosis and clinical symptoms of five zoonotic diseases: anthrax, brucellosis, rabies as well as Ebola and marburg haemorrhagic fevers in endemic western Uganda. This was a descriptive cross-sectional study among HCWs based at health centres in and around Queen Elizabeth Conservation Area, Western Uganda. A self-administered questionnaire was used to measure knowledge of these five most common zoonoses recently recorded in the area. Data were captured as true if the responses were correct or false if incorrect. Analyses were in STATA and inferential statistics by cross-tabulation, and a chi-square P-value of less than 0.05 was considered significant. A majority (114/140; 81.4%) of the respondents had heard about zoonoses. The most accurately identified zoonoses were anthrax (128/140; 91.4%) closely followed by rabies (126/140; 90%), while only 21 (15%) respondents knew that cryptosporidiosis was zoonotic. Up to 20% (28/140) and 12.8% (18/140) thought that malaria and HIV, respectively, were zoonotic. There was poor overall knowledge of the endemic diseases brucellosis among all the participants, where only 1.4% (2/140) knew its causative agent, clinical symptoms and transmission. There was a total lack of knowledge (0%) about anthrax and Ebola whereby none of the 140 HCWs knew all the three above aspects required to be knowledgeable for each of the two diseases. Generally, there was poor knowledge of the five zoonoses. We recommend that medical curricula incorporate training on zoonotic and other emerging diseases, and continuing medical education regarding zoonoses should be designed for the HCWs practicing in hotspot zones.

Introduction: Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviours, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. Methods: The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from 6,827 adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Among 6,388 patients we analysed patterns of self-reported treatment seeking behaviours (patient pathways) using process mining and single-channel sequence analysis. Of those with microbiologically confirmed UTI (n=1,946), we used logistic regression to assessed the relationship between treatment seeking behaviour, AB use, and likelihood of having a multi-drug resistant (MDR) UTI. Results: The most common treatment pathways for UTI-like symptoms included attending health facilities, rather than other providers (e.g. drug sellers). Patients from the sites sampled in Tanzania and Uganda, where prevalence of MDR UTI was over 50%, were more likely to report treatment failures, and have repeated visits to clinics/other providers, than those from Kenyan sites, where MDR UTI rates were lower (33%). There was no strong or consistent relationship between individual AB use and risk of MDR UTI, after accounting for country context. Conclusion: The results highlight challenges East African patients face in accessing effective UTI treatment. These challenges increase where rates of MDR UTI are higher, suggesting a reinforcing circle of failed treatment attempts and sustained selection for drug resistance. Whilst individual behaviours may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of ABR.

IntroductionAntimicrobial resistance (AMR) is a global health threat that requires urgent research using a multidisciplinary approach. The biological drivers of AMR are well understood, but factors related to treatment-seeking and the social contexts of antibiotic (AB) use behaviours are less understood. Here we describe the Holistic Approach to Unravelling Antibacterial Resistance in East Africa (HATUA), a multi-centre consortium that investigates the diverse drivers of drug-resistance in urinary tract infections (UTIs) in East Africa.Methods and AnalysisThis study will take place in Uganda, Kenya and Tanzania. We will conduct geospatial mapping of AB sellers, and conduct mystery client studies and in-depth interviews (IDI) with drug sellers to investigate AB provision practices. In parallel, we will conduct IDIs with doctors, alongside community focus groups. Clinically diagnosed UTI patients will be recruited from healthcare centres, provide urine samples, and complete a questionnaire capturing retrospective treatment pathways, socio-demographic characteristics, attitudes and knowledge. Bacterial isolates from urine and stool samples will be subject to culture and antibiotic susceptibility testing (C&AST). Genomic DNA from bacterial isolates will be extracted with a subset being sequenced. A follow-up household interview will be conducted with 1800 UTI-positive patients, where further environmental samples will be collected. A sub-sample of patients will be interviewed using qualitative tools. Questionnaire data, microbiological analysis and qualitative data will be linked at the individual level. Quantitative data will be analysed using statistical modelling including Bayesian network analysis, and all forms of qualitative data analysed through iterative thematic content analysis.Ethics and DisseminationApprovals have been obtained from all national and local ethical review bodies in East Africa and the UK. Results will be disseminated in communities, with local and global policy stakeholders, and in academic circles. They will have great potential to inform policy, improve clinical practice and build regional pathogen surveillance capacity.