Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA)

Asiimwe, Benon B.; Kiiru, John; Mshana, Stephen E.; Neema, Stella; Keenan, Katherine; Kesby, Mike; Mwanga, Joseph R.; Sloan, Derek J.; Mmbaga, Blandina T.; Smith, V. Anne; Gillespie, Stephen H.; Lynch, Andy G.; Sandeman, Alison; Stelling, John; Elliott, Alison M.; Aanensen, David M.; Kibiki, Gibson; Sabiiti, Wilber; Holden, Matthew T. G.

doi:10.1136/bmjopen-2020-041418

Cited by 31 publications

(42 citation statements)

References 30 publications

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“…This study is nested within a wider 3-country interdisciplinary study on the drivers of AMR in East Africa (Holistic Approach to Unravel Antibacterial Resistance in East Africa—HATUA), and full details can be read elsewhere [ 28 ]. This cross-sectional community-based quantitative survey uses mystery client scenarios, sometimes called mystery clients or mystery shoppers to assess dispensing practices.…”

Section: Methodsmentioning

confidence: 99%

“…This cross-sectional study was carried out in the Mwanza (Nyamagana, Ilemela and Sengerema), Mbeya (Mbeya urban and Mbeya rural districts) and Kilimanjaro (Moshi urban and Moshi rural districts) regions of Tanzania between April and July 2019. The regions and respective districts were purposely selected based on the geographical location to cover northeastern Tanzania, northwestern Tanzania and South-western highlands of Tanzania [ 28 ]. Figure 1 shows the geographical location of regions.…”

Section: Methodsmentioning

confidence: 99%

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Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study

et al. 2021

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Worldwide, antimicrobial resistance is increasing rapidly and is associated with misuse of antimicrobials. The HATUA study (a broader 3-country study) investigated the antibiotic dispensing practices of pharmaceutical providers to clients, particularly the propensity to dispense without prescription. A cross-sectional study using a ‘mystery client’ method was conducted in 1148 community pharmacies and accredited drugs dispensing outlets (ADDO) in Mwanza (n = 612), Mbeya (n = 304) and Kilimanjaro (n = 232) in Tanzania. Mystery clients asked directly for amoxicillin, had no prescription to present, did not discuss symptoms unless asked [when asked reported UTI-like symptoms] and attempted to buy a half course. Dispensing of amoxicillin without prescription was common [88.2, 95%CI 86.3–89.9%], across all three regions. Furthermore, the majority of outlets sold a half course of amoxicillin without prescription: Mwanza (98%), Mbeya (99%) and Kilimanjaro (98%). Generally, most providers in all three regions dispensed amoxicillin on demand, without asking the client any questions, with significant variations among regions [p-value = 0.003]. In Mbeya and Kilimanjaro, providers in ADDOs were more likely to do this than those in pharmacies but no difference was observed in Mwanza. While the Tanzanian government has laws, regulations and guidelines that prohibit antibiotic dispensing without prescription, our study suggests non-compliance by drug providers. Enforcement, surveillance, and the provision of continuing education on dispensing practices is recommended, particularly for ADDO providers.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study

et al. 2021

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“…We noted few studies that integrated multiple forms of data or attempted mixed methods approaches for understanding drivers of AMR, or that focused on the implications or impacts of policy initiatives related to AMR. However, this may be changing, with studies planned that will explicitly look across social, biological and community-level drivers of AMR in Uganda and neighbouring countries [43].…”

Section: Discussionmentioning

confidence: 99%

Efforts to Identify and Combat Antimicrobial Resistance in Uganda: A Systematic Review

Kivumbi

Standley

2021

TropicalMed

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The global burden of antimicrobial resistance is on the rise, resulting in higher morbidity and mortality in our communities. The spread of antimicrobial resistance in the environment and development of resistant microbes is a challenge to the control of antimicrobial resistance. Approaches, such as antimicrobial stewardship programmes and enhanced surveillance, have been devised to curb its spread. However, particularly in lower- and middle-income countries, the overall extent of antimicrobial resistance and knowledge on ongoing surveillance, stewardship or investigation efforts, are often poorly understood. This study aimed to look at the efforts that have been undertaken to detect and combat antimicrobial resistance in Uganda as a means of establishing an overview of the situation, to help inform future decisions. We conducted a systematic literature review of the PubMed database to assess these efforts. A search combining keywords associated with antimicrobial resistance were used to find relevant studies between 1995 and 2020 on surveillance of antimicrobial resistance in Uganda, and susceptibility of microbes to different drugs. The search yielded 430 records, 163 of which met the inclusion criteria for analysis. The studies were categorized according to country and region, the type of antimicrobial resistance, context of the study, study design and outcome of the study. We observed that antibacterial resistance and antimalarial resistance had the most published studies while antiviral and antifungal resistance were represented by very few studies each. Most studies were conducted in humans and hospital settings, with few in veterinary and One Health contexts, and only one that included environmental sampling. The majority of studies have focused on surveillance, susceptibility testing or resistance genes; none of our included papers had a policy or stewardship focus. The results from our work can inform public health policy on antimicrobial stewardship as it contributes to understanding the status of antimicrobial resistance surveillance in Uganda, and can also help to guide future research efforts. Notably, a One Health approach needs to be followed with respect to surveillance of antimicrobial resistance to better understand the mechanisms of resistance transfer across the human-animal–environment interface, including additional investigation in antiviral and antifungal resistance.

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“…Notwithstanding this evidence of non-compliance with national regulations, there is little evidence on how antibiotic dispensing and sales have been affected by the COVID-19 pandemic. This study builds on an earlier, pre-COVID-19, project on the drivers of AMR in East Africa [32] to explore pandemic-era drug seller behaviours and practices in Tanzania and Uganda. The study was conducted in mid-2021, when healthcare facilities were struggling to cope with COVID-19 alongside the usual burden of disease, mitigation measures were still evolving, and both governments and citizens were attempting to adjust to the unprecedented conditions.…”

Section: Introductionmentioning

confidence: 99%

Antibiotic dispensing practices during COVID-19 and implications for Antimicrobial Resistance (AMR): Parallel mystery client studies in Uganda and Tanzania

Olamijuwon

Konje

Kansiime

et al. 2022

Preprint

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Background: Over-the-counter antibiotic access is common in low-and-middle-income countries, including Tanzania and Uganda, and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller-client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in countries with different government responses to the pandemic.Methods: Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms= 415, nADDOs= 116) and Mbarara, Uganda (nPharms= 440, nDSs= 67), from June 10-July 30, 2021. The mystery clients (who held no prescription) sought advice for simulated COVID-19 symptoms from the drug sellers, documented the quality of their interaction with sellers and the type of drugs dispensed.Results: Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms= 36%, DSs= 35%, p-value= 0.947) compared to Mwanza (Pharms= 9%, ADDOs= 4%, p-value= 0.112) identified the client’s symptoms as possibly COVID-19. More than three-quarters of drug sellers in both Mbarara (Pharms= 86%, DSs= 89%) and Mwanza (Pharms= 93%, ADDOs= 97%) sold prescription-only medicines without asking for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms= 51%, ADDOs= 67%) compared to Mbarara (Pharms= 31%, DSs= 42%) sold a partial course without any objection. Among the drug sellers who sold antibiotics, more drug sellers in Mbarara (Pharms= 73%, DSs= 78%, p-value= 0.580) compared to Mwanza (Pharms= 40% ADDOs= 46%, p-value= 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.Conclusion: Our study highlights low levels of awareness of and vigilance towards COVID-19 symptoms and widespread propensity to dispense prescription-only antibiotics without a prescription and to dispense partial doses of antibiotics. The implications of these for antimicrobial resistance are further discussed. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to the current pandemic and to prepare them for future health emergencies.

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Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA)

Cited by 31 publications

References 30 publications

Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study

Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study

Efforts to Identify and Combat Antimicrobial Resistance in Uganda: A Systematic Review

Antibiotic dispensing practices during COVID-19 and implications for Antimicrobial Resistance (AMR): Parallel mystery client studies in Uganda and Tanzania

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