Leishmania vaccine development: A comprehensive review.

Infectious diseases like leishmaniasis, malaria, HIV, tuberculosis, leprosy and filariasis are responsible for an immense burden on public health systems. Among these, leishmaniasis is under the category I diseases as it is selected by WHO (World Health Organization) on the ground of diversity and complexity. High cost, resistance and toxic effects of Leishmania traditional drugs entail identification and development of therapeutic alternative. Since the natural infection elicits robust immunity, consistence efforts are going on to develop a successful vaccine. Clinical trials have been conducted on vaccines like Leish-F1, F2, and F3 formulated using specific Leishmania antigen epitopes. Current strategies utilize individual or combined antigens from the parasite or its insect vector's salivary gland extract, with or without adjuvant formulation for enhanced efficacy. Promising animal data supports multiple vaccine candidates (Lmcen-/-, LmexCen-/-), with some already in or heading for clinical trials. The crucial challenge in Leishmania vaccine development is to translate the research knowledge into affordable and accessible control tools that refines the outcome for those who are susceptible to infection. This review focuses on recent findings in Leishmania vaccines and highlights difficulties facing vaccine development and implementation.

Natural-Product-Inspired Microwave-Assisted Synthesis of Novel Spirooxindoles as Antileishmanial Agents: Synthesis, Stereochemical Assignment, Bioevaluation, SAR, and Molecular Docking Studies.

Leishmaniasis is a neglected tropical disease, and there is an emerging need for the development of effective drugs to treat it. To identify novel compounds with antileishmanial properties, a novel series of functionalized spiro[indoline-3,2'-pyrrolidin]-2-one/spiro[indoline-3,3'-pyrrolizin]-2-one 23a-f, 24a-f, and 25a-g were prepared from natural-product-inspired pharmaceutically privileged bioactive sub-structures, i.e., isatins 20a-h, various substituted chalcones 21a-f, and 22a-c amino acids, via 1,3-dipolar cycloaddition reactions in MeOH at 80 °C using a microwave-assisted approach. Compared to traditional methods, microwave-assisted synthesis produces higher yields and better quality, and it takes less time. We report here the in vitro antileishmanial activity against Leishmania donovani and SAR studies. The analogues 24a, 24e, 24f, and 25d were found to be the most active compounds of the series and showed IC50 values of 2.43 µM, 0.96 µM, 1.62 µM, and 3.55 µM, respectively, compared to the standard reference drug Amphotericin B (IC50 = 0.060 µM). All compounds were assessed for Leishmania DNA topoisomerase type IB inhibition activity using the standard drug Camptothecin, and 24a, 24e, 24f, and 25d showed potential results. In order to further validate the experimental results and gain a deeper understanding of the binding manner of such compounds, molecular docking studies were also performed. The stereochemistry of the novel functionalized spirooxindole derivatives was confirmed by single-crystal X-ray crystallography studies.

Oxidant-Switched Palladium-Catalyzed Regioselective Mono- versus Bis-ortho-Aroylation of 1-Aryl-1H-indazoles with Aldehydes via C-H Bond Activation.

A highly efficient oxidant-switched palladium-catalyzed regioselective C(sp2)-H/C(sp2)-H cross-dehydrogenative coupling (CDC) for direct mono/bis-ortho-aroylation of substituted 1-phenyl-1H-indazoles 1a-j with various substituted aldehydes 3a-t via C(sp2)-H bond activation has been developed. In this study, Pd-catalyzed chelation-assisted mono- or bis-aroylation of substituted 1-phenyl-1H-indazoles depends on the type of oxidant being used for the CDC reaction. While mono-ortho-aroylation of substituted 1-phenyl-1H-indazole was obtained using dicumylperoxide (DCP) as the oxidant, the bis-ortho-aroylation product has been afforded by the use of tert-butyl hydroperoxide (TBHP). Regardless of the greater activity at the C-3 position of 1H-indazoles, the greater coordinating capacity of the N atom directed the aroylating group to the ortho position, leaving behind the nondirected metalation pathway. The Pd-catalyzed operationally simplified methodology proceeded in the presence of oxidants with either DCP or TBHP in dichloroethane as the solvent at 110 °C for 16 h, which generated a miscellaneous variety of monosubstituted o-benzoyl/acyl-1-aryl-1H-indazoles 4a-t/5a-i and bis-substituted o-benzoyl-1-aryl-1H-indazoles 6a-j in ≤88% yields. The probable mechanistic pathway involves a free radical chelation-assisted approach that could be accomplished by the addition of an in situ-generated oxidant-promoted benzoyl/acyl radical to the ortho position of 1-phenyl-1H-indazoles. A wide range of substrates, a high functional group tolerance, gram-scale synthesis, control/competitive experiments, and a variety of synthetic applications further exemplify the versatility of the developed methodology.

Evidence for Reversal of Immunosuppression by Homeopathic Medicine to a Predominant Th1-type Immune Response in BALB/c Mice Infected with Leishmania donovani.

BACKGROUND: Visceral leishmaniasis (VL) is a neglected tropical disease that is fatal if treatment is not given. The available chemotherapeutic options are unsatisfactory, and so complementary therapies like homeopathy might be a promising approach. METHODS: A nosode from a pure axenic culture of Leishmania donovani was prepared and screened for its anti-leishmanial potential both in an in-vitro and an in-vivo experimental approach. RESULTS: Leishmania donovani amastigote promastigote nosode (LdAPN 30C) exhibited significant anti-leishmanial activity against the promastigote forms of Leishmania donovani and was found to be safe. A study conducted on VL-infected mice revealed that LdAPN 30C resolved the disease by modulating the host immune response toward the Th1 type through upregulating the pro-inflammatory cytokines (IFN-γ and IL-17) and inducing nitric oxide (NO) levels in the infected macrophages. The hepatic parasite load was also found to be significantly decreased. The nosode was found to be safe, as no histological alterations in the liver or kidney were observed in the animals treated with the LdAPN 30C. CONCLUSION: This is the first study in which an axenic culture of Leishmania donovani has been used for the preparation of a homeopathic medication. The study highlights the anti-leishmanial and immunomodulatory potential of a homeopathic nosode in experimental VL.

Antimicrobial Resistance Surveillance in Low- and Middle-Income Countries: Progress and Challenges in Eight South Asian and Southeast Asian Countries.

Antimicrobial resistance (AMR) is a serious global health threat and is predicted to cause significant health and economic impacts, particularly in low- and middle-income countries (LMICs). AMR surveillance is critical in LMICs due to high burden of bacterial infections; however, conducting AMR surveillance in resource-limited settings is constrained by poorly functioning health systems, scarce financial resources, and lack of skilled personnel. In 2015, the United Nations World Health Assembly endorsed the World Health Organization's Global Action Plan to tackle AMR; thus, several countries are striving to improve their AMR surveillance capacity, including making significant investments and establishing and expanding surveillance networks. Initial data generated from AMR surveillance networks in LMICs suggest the high prevalence of resistance, but these data exhibit several shortcomings, such as a lack of representativeness, lack of standardized laboratory practices, and underutilization of microbiology services. Despite significant progress, AMR surveillance networks in LMICs face several challenges in expansion and sustainability due to limited financial resources and technical capacity. This review summarizes the existing health infrastructure affecting the establishment of AMR surveillance programs, the burden of bacterial infections demonstrating the need for AMR surveillance, and current progress and challenges in AMR surveillance efforts in eight South and Southeast Asian countries.

Effects of phosphite as a plant biostimulant on metabolism and stress response for better plant performance in Solanum tuberosum.

Food availability represents a major worldwide concern due to population growth, increased demand, and climate change. Therefore, it is imperative to identify compounds that can improve crop performance. Plant biostimulants have gained prominence because of their potentials to increase germination, productivity and quality of a wide range of horticultural and agronomic crops. Phosphite (Phi), an analog of orthophosphate, is an emerging biostimulant used in horticulture and agronomy. The aim of this study was to uncover the molecular mechanisms through which Phi acts as a biostimulant with potential effects of overall plant growth. Field and greenhouse experiments, using 4 potato cultivars, showed that following Phi applications, plant performance, including several physio-biochemical traits, crop productivity, and quality traits, were significantly improved. RNA sequencing of control and Phi-treated plants of cultivar Xingjia No. 2, at 0 h, 6 h, 24 h, 48 h, 72 h and 96 h after the Phi application for 24 h revealed extensive changes in the gene expression profiles. A total of 2856 differentially expressed genes were identified, suggesting that multiple pathways of primary and secondary metabolism, such as flavonoids biosynthesis, starch and sucrose metabolism, and phenylpropanoid biosynthesis, were strongly influenced by foliar applications of Phi. GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of Genes and Genomes) enrichment analyses associated with defense responses revealed significant effects of Phi on a plethora of defense mechanisms. These results suggest that Phi acted as a biostimulant by priming the plants, that was, by triggering dynamic changes in gene expression and modulating metabolic fluxes in a way that allowed plants to perform better. Therefore, Phi usage has the potential to improve crop yield and health, alleviating the challenges posed by the need of feeding a growing world population, while minimizing the agricultural impact on human health and environment.

Exogenous phosphite application alleviates the adverse effects of heat stress and improves thermotolerance of potato (Solanum tuberosum L.) seedlings.

Phosphite (Phi), an analog of phosphate (Pi) anion, is emerging as a potential biostimulator, fungicide and insecticide. Here, we reported that Phi also significantly enhanced thermotolerance in potatoes under heat stress. Potato plants with and without Phi pretreatment were exposed to heat stress and their heat tolerance was examined by assessing the morphological characteristics, photosynthetic pigment content, photosystem II (PS II) efficiency, levels of oxidative stress, and level of DNA damage. In addition, RNA-sequencing (RNA-Seq) was adopted to investigate the roles of Phi signals and the underlying heat resistance mechanism. RNA-Seq revealed that Phi orchestrated plant immune responses against heat stress by reprograming global gene expressions. Results from physiological data combined with RNA-Seq suggested that the supply of Phi not only was essential for the better plant performance, but also improved thermotolerance of the plants by alleviating oxidative stress and DNA damage, and improved biosynthesis of osmolytes and defense metabolites when exposed to unfavorable thermal conditions. This is the first study to explore the role of Phi in thermotolerance in plants, and the work can be applied to other crops under the challenging environment.

The Effect of Iodium 30c on Experimental Visceral Leishmaniasis.

BACKGROUND: Leishmaniasis is one of several neglected tropical diseases that warrant serious attention. A disease of socio-economically poor people, it demands safer and cheaper drugs that help to overcome the limitations faced by the existing anti-leishmanials. Complementary or traditional medicines might be a good option, with an added advantage that resistance may not develop against these drugs. Thus, the present investigation was performed to evaluate the anti-leishmanial efficacy of an ultra-diluted homeopathic medicine (Iodium 30c) in experimental visceral leishmaniasis (VL). METHODS: Compliant with strict ethical standards in animal experimentation, the study was performed in-vivo in inbred BALB/c mice which were injected intravenously with 1 × 107 promastigotes of Leishmania donovani before (therapeutic) or after (prophylactic) treatment with Iodium 30c for 30 days. In other groups of mice (n = 6 per group), amphotericin B served as positive control, infected animals as the disease control, while the naïve controls included normal animals; animals receiving only Iodium 30c or Alcohol 30c served as sham controls. The anti-leishmanial efficacy was assessed by determining the hepatic parasite load and analysing percentages of CD4+ and CD8+ T cells. Biochemical analysis and histological studies were performed to check any toxicities. RESULTS: Iodium-treated animals showed a significantly reduced parasite load (to 1503 ± 39 Leishman Donovan Units, LDU) as compared with the infected controls (4489 ± 256 LDU) (p < 0.05): thus, the mean therapeutic efficacy of Iodium 30c was 66.5%. In addition, the population of CD4+ and CD8+ T cells was significantly increased (p < 0.05) after treatment. No toxicity was observed, as evidenced from biochemical and histopathological studies of the liver and kidneys. Efficacy of Iodium 30c prophylaxis was 58.3%, while the therapeutic efficacy of amphotericin B was 85.9%. CONCLUSION: This original study has shown that Iodium 30c had significant impact in controlling parasite replication in experimental VL, though the effect was less than that using standard pharmaceutical treatment.

Assessment of genetic variability and structuring of riverine buffalo population (Bubalus bubalis) of Indo-Gangetic basin.

The buffalo population of Uttar Pradesh (UP) constitutes 26.1% of the total buffalo population of India, yet this population has not been classified into distinct breeds or subpopulations due to lack of systematic study. Genetic variation at 30 microsatellite loci was examined and statistical analysis was carried out to reveal genetic diversity, demographic parameters of these buffaloes and to investigate the existence of population substructures underlying geographical distribution. The mean number of alleles per locus was 13.26 and mean effective number of alleles was 3.74, whereas mean observed and expected heterozygosities were found to be 0.57 and 0.67 in UP buffaloes. Principal component analysis (PCA) based on allele frequency data revealed subclustering of UP buffalo population. Bayesian analysis result also revealed clear membership of individuals into five clusters indicating a genetic subdivision within the UP buffalo population. The buffaloes of Western and Central regions of UP were subtly separated while buffaloes of Tarai area and Bhadawari buffaloes revealed distinctive population structure. The buffaloes of Mau, Ballia and Ghazipur districts of Eastern region also had a distinctive genetic structure. The analysis of data on buffaloes of Indo-Gangetic plains revealed that population was in mutation drift equilibrium. The observed mean M ratio in the population was above the critical significance value (Mc) suggesting that it has not suffered any severe reduction in effective population size. The statistical tests revealed a historical constancy of size of buffalo in this geographical area. The high level of genetic variability indicates UP buffalo population is a vast reservoir of genetic diversity and this shall help in taking informed conservation decisions and sustainable utilization.

Studies on the protective efficacy of second-generation vaccine along with standard antileishmanial drug in Leishmania donovani infected BALB/c mice.

It is well established that visceral leishmaniasis (VL; also known as Kala azar) causes immunosuppression, and a successful drug treatment is associated with the development of cell-mediated immunity. Therefore combining a drug with an immune enhancer can provide a better approach for the treatment of the disease. Keeping this in mind, the in vivo antileishmanial efficacy of immunochemotherapy was evaluated with the use of a 78 kDa antigen with or without monophosphoryl lipid A (MPL-A) along with a traditional drug sodium stibogluconate (SSG) in Leishmania donovani infected BALB/c mice. Mice were infected intracardially with promastigotes of L. donovani, and 30 days after infection, these animals were given specific immunotherapy (78 kDa/78 kDa+MPL-A) or chemotherapy (SSG) or immunochemotherapy (SSG+78 kDa/SSG+78 kDa+MPL-A). Animals were euthanased on 1, 15 and 30 post-treatment days. The antileishmanial potential of the immunochemotherapy was revealed by significant reduction in the parasite burden (P<0·001). These animals were also found to exhibit increased delayed type hypersensitivity (DTH) responses, higher IgG2a levels, lower IgG1 levels and greater cytokine (IFN-γ and IL-2) concentrations compared with chemotherapy or immunotherapy alone, pointing towards the generation of a strong protective (Th1) type of immune response. Immunochemotherapy with SSG+78 kDa+MPL-A was found to be most effective in protecting mice against VL and therefore can be an alternative option for treatment of VL.

Control strategy for current limitation and maximum capacity utilization of grid connected PV inverter under unbalanced grid conditions.

Under grid voltage sags, over current protection and exploiting the maximum capacity of the inverter are the two main goals of grid-connected PV inverters. To facilitate low-voltage ride-through (LVRT), it is imperative to ensure that inverter currents are sinusoidal and remain within permissible limits throughout the inverter operation. An improved LVRT control strategy for a two-stage three-phase grid-connected PV system is presented here to address these challenges. To provide over current limitation as well as to ensure maximum exploitation of the inverter capacity, a control strategy is proposed, and performance the strategy is evaluated based on the three generation scenarios on a 2-kW grid connected PV system. An active power curtailment (APC) loop is activated only in high power generation scenario to limit the current's amplitude below the inverter's rated current. The superior performance of the proposed strategy is established by comparison with two recent LVRT control strategies. The proposed method not only injects necessary active and reactive power but also minimizes overcurrent with increased exploitation of the inverter's capacity under unbalanced grid voltage sag.

Multiple signals converge on a differentiation MAPK pathway.

An important emerging question in the area of signal transduction is how information from different pathways becomes integrated into a highly coordinated response. In budding yeast, multiple pathways regulate filamentous growth, a complex differentiation response that occurs under specific environmental conditions. To identify new aspects of filamentous growth regulation, we used a novel screening approach (called secretion profiling) that measures release of the extracellular domain of Msb2p, the signaling mucin which functions at the head of the filamentous growth (FG) MAPK pathway. Secretion profiling of complementary genomic collections showed that many of the pathways that regulate filamentous growth (RAS, RIM101, OPI1, and RTG) were also required for FG pathway activation. This regulation sensitized the FG pathway to multiple stimuli and synchronized it to the global signaling network. Several of the regulators were required for MSB2 expression, which identifies the MSB2 promoter as a target "hub" where multiple signals converge. Accessibility to the MSB2 promoter was further regulated by the histone deacetylase (HDAC) Rpd3p(L), which positively regulated FG pathway activity and filamentous growth. Our findings provide the first glimpse of a global regulatory hierarchy among the pathways that control filamentous growth. Systems-level integration of signaling circuitry is likely to coordinate other regulatory networks that control complex behaviors.

Genetic variation and phylogenetic relationships of Indian buffaloes of uttar pradesh.

India possesses a total buffalo population of 105 million out of which 26.1% inhabit Uttar Pradesh. The buffalo of Uttar Pradesh are described as nondescript or local buffaloes. Currently, there is no report about the genetic diversity, phylogenetic relationship and matrilineal genetic structure of these buffaloes. To determine the origin and genetic diversity of UP buffaloes, we sequenced and analysed the mitochondrial DNA D-loop sequences in 259 samples from entire Uttar Pradesh. One hundred nine haplotypes were identified in UP buffaloes that were defined by 96 polymorphic sites. We implemented neutrality tests to assess signatures of recent historical demographic events like Tajima's D test and Fu's Fs test. The phylogenetic studies revealed that there was no geographic differentiation and UP buffaloes had a single maternal lineage while buffaloes of Eastern UP were distinctive from rest of the UP buffaloes.

Outcomes of Ayurvedic care in a COVID-19 patient with hypoxia - A case report.

This paper reports for the first time, the outcomes of Ayurvedic intervention in a COVID-19 patient with hypoxia requiring supportive oxygen therapy. Patient developed fever, severe cough, loss of smell, loss of taste, nasal block, anorexia, headache, body ache, chills, and fatigue and was hospitalised when she developed severe breathing difficulty. Later, she tested positive for COVID-19 by RT-PCR. The patient sought Ayurvedic treatment voluntarily when her SPO2 remained at 80% even after being given oxygen support. The patient was administered Ayurvedic medicines while undergoing oxygen therapy at the hospital. The patient refused to take Fabiflu recommended by the treating physician and discontinued other Allopathic drugs except for Vitamin C. The patient showed clinical improvement within a day of administration of Ayurvedic medicines and was able to talk, eat, and sit on the bed without breathing difficulty and her SPO2 became stable between 95 and 98%. In the next two days, she was asymptomatic without oxygen support and was discharged from the hospital in the following week. Since obesity and high plasma C-Reactive Protein (CRP) levels indicated high risk for progression to severe disease, the favourable outcomes with Ayurvedic treatment in this patient is significant and warrants further studies. Ayurvedic care may be considered as a first-line cost-effective alternative for COVID-19 patients presenting with symptomatic hypoxia in an integrative setup.

Unwelcome prevalence of leishmaniasis with several other infectious diseases.

Co-infection among leishmaniasis and other infectious diseases is common among natural populations especially in the endemic areas of the disease. It depends on the environmental factors, vector availability, host-parasite interactions and above all geographical boundaries. Leishmaniasis being an immunosuppressive disease empowers the invading opportunistic infections to invade and successfully colonize. A variety of infections coexist with leishmaniasis like HIV, leprosy, tuberculosis, schistosomiasis etc. With the different pathology and immune status, co-infection in most cases leads to disease severity and increased mortality.Inevitably, co-infection increases the complexity and poses a threat in the cure and control programmes. This is the first review which highlights the existing co-infections of leishmaniasis with other infectious diseases. The review also focuses on the immunology of co-infections together, diagnosis and the treatment options available for treating such cases. With the changing environment and the overlapping endemic areas of leishmaniasis with other diseases, it becomes difficult to treat a disease without accurate diagnosis. Thus, the review insists on the need for more research on development of newer and differential diagnostic methods for co-infected individuals with theoverlapping symptoms.

Irrigation Effect on Yield, Skin Blemishes, Phellem Formation, and Total Phenolics of Red Potatoes.

Dark Red Norland is an important potato cultivar in the fresh market due to its attractive bright, red colour, and good yield. However, skin blemishes such as silver patch, surface cracking, and russeting can negatively influence the tuber skin quality and marketability. It is well known that potato is a drought-sensitive plant. This study was conducted to determine whether irrigation would affect Dark Red Norland's yield and skin quality. A three-year field trial was conducted by Peak of the Market in Manitoba, Canada. Plants were treated under both irrigation and rainfed conditions. The results show that irrigation increased the total yield by 20.6% and reduced the severity of surface cracking by 48.5%. Microscopy imaging analysis demonstrated that tubers from the rainfed trials formed higher numbers of suberized cell layers than those of the irrigated potatoes, with a difference of 0.360 to 0.652 layers in normal skins. Surface cracking and silver patch skins had more suberized cell layers than the normal skins, with ranges of 7.805 to 8.333 and 7.740 to 8.496, respectively. A significantly higher amount of total polyphenols was found in the irrigated samples with a mean of 77.30 mg gallic acid equivalents (GAE)/100 g fresh weight (fw) than that of the rainfed samples (69.80 mg GAE/100 g fw). The outcome of this study provides a better understanding of the water regime effect causing these skin blemishes, which could potentially be used to establish strategies to improve tuber skin quality and minimize market losses.

Ayurvedic management of persistent hypoxia in a diabetic and hypertensive COVID-19 patient in the post-hospitalization period-A case report.

COVID-19 patients may require supplemental oxygen therapy at home after recovery from COVID-19. We report benefits of add on Ayurvedic intervention in a 75-year-old gentleman who was oxygen dependent post hospitalisation. He was earlier treated for COVID-19 related bilateral pneumonitis, Acute Respiratory Distress Syndrome and Acute Renal Failure. Patient reported breathing difficulty, generalized weakness, reduced appetite and severe constipation. The Pulse Oximetry readings with oxygen support fluctuated between 80 and 85 %, Blood Pressure was 150/100 mm Hg, LDH raised at 463 IU/L and HbA1c at 8.7%. The patient was administered micro-doses of Rasasindura sublingually every 10 min for one day followed by administration of Indukanta Ghrita and Suvarnamalinivasanta Rasa. The oxygen saturation improved to 95 % in 12 hrs of initiating treatment, oxygen support was weaned off on the third day of starting the Ayurvedic treatment, three weeks earlier than prescribed at the time of discharge. The patient is ambulant and maintaining oxygen saturation between 95 and 98 %. This case report highlights the potential of Ayurvedic intervention to manage patients with persistent hypoxia in post hospitalization phase. Well-designed studies are warranted to confirm the benefits of integrating such interventions with standard of care in COVID-19.

Molecular and morphological identification of frog species collected at Rara Lake in Rara National Park, Nepal.

This study seeks to clarify the taxonomic identity of three adult frogs and two tadpoles from Rara Lake situated in Rara National Park, Mugu district, Western Nepal, using both phenotypic and mitochondrial sequence data (16S rRNA gene). Based on the molecular data, we determined our specimens belonged to two species; Paa cf. ercepeae (Dubois, 1974) and Paa rarica (Dubois, Matsui, and Ohler, 2001), and this assignment is also supported by morphology. Principal component analysis of phenotypic data clustered species into large-bodied (SVL > 55 mm) and small-bodied (SVL < 55 mm) groups. The molecular data suggest that Paa rarica belonged to a group that contains several undescribed lineages and that Paa liebigii (Gnther, 1860) hosts extensive cryptic diversity. Our study also documents that Paa species in the Himalayan region are more widely distributed than previously believed.

Thrombosis and thromboembolism: Brighton collaboration case definition and guidelines for data collection, analysis, and presentation of immunization safety data.

This is a Brighton Collaboration case definition of thrombosis and thromboembolism to be used in the evaluation of adverse events following immunization, and for epidemiologic studies for the assessment of background incidence or hypothesis testing. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of SARS-CoV-2 vaccines. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected expert reviewers prior to submission.

Over-the-counter sale of antibiotics - Using Net-Map to identify and segment stakeholders as the first step towards the development of smart regulation.

INTRODUCTION: Antimicrobial resistance (AMR) is a complex public health problem requiring coordinated efforts by a multitude of public and private sector stakeholders. Over-the-counter (OTC) antibiotics sale is contributing to rising AMR. We applied NetMap, a research tool to identify, prioritize and assess relationships among stakeholders, also to identify the stakeholders that must be engaged for regulating antibiotic OTC sale for humans in India. METHODS: Through a one-day workshop, a team of expert facilitators engaged with a mixed group of stakeholders-regulators, drug manufacturers, retailers and consumers of antibiotics to identify and rank stakeholders based on their role, power/interest and influence. Stakeholders were listed and grouped as per the type of agency represented. Carrom discs were stacked against each stakeholder with the height of stack reflecting perceived power. RESULTS: A total of 25 stakeholders were identified from government, non-government, private/corporate, academic and research agencies and the general public. Based on the stacking exercise, a power/interest matrix was developed with six stakeholders having high power and high interest, five having high power but low interest, six having low power but high interest and eight having low power. A visual NetMap was developed to position the stakeholders as proximal, middle and distal based on their perceived influence. CONCLUSIONS: NetMap can be used with stakeholders with varying skill sets. It is a useful project initiation tool that was successfully used to prioritize stakeholders for reaching out, for targeted outreach and development of customized tools for developing innovative regulation for tackling OTC sale of antibiotics. It also pre-empted any conflict of interests.