Characteristics of a Nationwide Voluntary Antibiotic Resistance Awareness Campaign in India; Future Paths and Pointers for Resource Limited Settings/Low and Middle Income Countries.

Antibiotic resistance has reached alarming proportions globally, prompting the World Health Organization to advise nations to take up antibiotic awareness campaigns. Several campaigns have been taken up worldwide, mostly by governments. The government of India asked manufacturers to append a 'redline' to packages of antibiotics as identification marks and conducted a campaign to inform the general public about it and appropriate antibiotic use. We investigated whether an antibiotic resistance awareness campaign could be organized voluntarily in India and determined the characteristics of the voluntarily organized campaign by administering a questionnaire to the coordinators, who participated in organizing the voluntary campaign India. The campaign characteristics were: multiple electro-physical pedagogical and participatory techniques were used, 49 physical events were organized in various parts of India that included lectures, posters, booklet/pamphlet distribution, audio and video messages, competitions, and mass contact rallies along with broadcast of messages in 11 local languages using community radio stations (CRS) spread all over India. The median values for campaign events were: expenditure-3000 Indian Rupees/day (US$~47), time for planning-1 day, program spread-4 days, program time-4 h, direct and indirect reach of the message-respectively 250 and 500 persons/event. A 2 min play entitled 'Take antibiotics as prescribed by the doctor' was broadcast 10 times/day for 5 days on CRS with listener reach of ~5 million persons. More than 85%ofcoordinators thought that the campaign created adequate awareness about appropriate antibiotic use and antibiotic resistance. The voluntary campaign has implications for resource limited settings/low and middle income countries.

Trends in Resistance to Extended-Spectrum Cephalosporins and Carbapenems among Escherichia coli and Klebsiella spp. Isolates in a District in Western India during 2004-2014.

Surveillance data on the level of resistant bacteria is needed to inform strategies to reduce the development and spread of antibiotic resistance. The aim of this study was to determine the non-susceptibility trends to extended-spectrum cephalosporins and carbapenems among Escherichia coli and Klebsiella spp. isolates from the district of Nashik in Western India during the period 2004-2014. Antibacterial susceptibility testing of clinical isolates was performed using Kirby-Bauer disc diffusion method to determine inhibitory zone diameters. The change in proportions of non-susceptible bacteria over calendar time was investigated with spline transformations in a logistic regression model. For the extended-spectrum cephalosporins, the proportions of non-susceptible E. coli and Klebsiella spp. isolates were above 78.4% and 84.9% throughout the study period, respectively. E. coli and Klebsiella spp. isolates exhibited carbapenem non-susceptibility levels as high as 76.9% and 84.1% respectively. The proportions of extended-spectrum betalactamase (ESBL)-producing isolates ranged from 38.3-85.9% in E. coli and from 45.1-93.1% in Klebsiella spp. Significantly higher proportions of non-susceptible and ESBL-producing isolates were found among isolates from inpatients compared to isolates from outpatients for both E. coli and Klebsiella spp. (p < 0.050). The high proportions of non-susceptible isolates observed show that there is great need to focus on optimal use of antibiotics to reduce the development of antibiotic resistance.

High Proportions of Multidrug-Resistant Acinetobacter spp. Isolates in a District in Western India: A Four-Year Antibiotic Susceptibility Study of Clinical Isolates.

The purpose of the study was to determine the proportions of multidrug-resistant (MDR) Acinetobacter spp. isolates from the district of Nashik in Western India during the period from 2011-2014. Antibacterial susceptibility testing of isolates from inpatients and outpatients was performed using Kirby-Bauer disc diffusion method to determine inhibitory zone diameters. Proportions of non-susceptible isolates were calculated from the antibacterial susceptibility data. MDR was defined as an isolate being non-susceptible to at least one antibacterial agent in at least three antibacterial categories. The change in proportions of MDR isolates; extended-spectrum ß-lactamase (ESBL)-producing isolates; and non-susceptible isolates to specific antibacterial categories over calendar time was investigated by logistic regression. The proportions of MDR and ESBL-producing isolates ranged from 89.4% to 95.9% and from 87.9% to 94.0%; respectively. The proportions of non-susceptible isolates to aminoglycosides; carbapenems; antipseudomonal penicillins/ß-lactamase inhibitors; cephalosporins; folate pathway inhibitors; or penicillins/ß-lactamase inhibitors exceeded 77.5%. Proportions of fluoroquinolone and tetracycline non-susceptible isolates ranged from 65.3% to 83.3% and from 71.3% to 75.9%; respectively. No changes in trends were observed over time; except for a decreasing trend in fluoroquinolone non-susceptible isolates (OR = 0.75 (95% CI, 0.62-0.91)). Significantly higher proportions of non-susceptible; MDR and ESBL-producing isolates were found among isolates from the respiratory system compared to isolates from all other specimen types (p < 0.05). High proportions of MDR Acinetobacter spp. isolates were observed in the period from 2011-2014. Antimicrobial stewardship programmes are needed to prevent the emergence and spread of antibiotic resistance.

Impact of Integrated Watershed Management on Complex Interlinked Factors Influencing Health: Perceptions of Professional Stakeholders in a Hilly Tribal Area of India.

Lack of access to water has a significant impact on the health of people in tribal areas, where water in households as well as for productive purposes is essential for life. In resource-limited settings such as hilly tribal areas, implementation of an integrated watershed management programme (IWMP) can have a significant impact on public health by providing a solution to water scarcity and related problems. The professional stakeholders in rural healthcare and development administration are important pillars of the system that implements various programmes and policies of government and non-government organizations, and act as facilitators for the improvement of public health in tribal areas. Information about the perceptions of these stakeholders on public health implications of the integrated watershed management programme is important in this context. A qualitative study was conducted using face to face semi-structured interviews and focus group discussions (FGDs) with stakeholders involved in healthcare provision, education and development administration. The transcripts of interviews and FGDs were analyzed using manifest and latent content analysis. The perceptions and experiences shared by healthcare and development administration stakeholders suggest that implementation of IWMP in tribal areas helps efficient water and agriculture management, which results in improved socio-economic conditions that lead to positive health outcomes.

Draft Genome Sequence of Enterotoxigenic Escherichia coli Strain E24377A, Obtained from a Tribal Drinking Water Source in India.

Enterotoxigenic Escherichia coli (ETEC) is a major cause of diarrheal disease in humans and animals. Its dissemination can occur through water sources contaminated by it. Here, we report for the first time the draft genome sequence of ETEC strain E24377A, obtained from a tribal drinking water source in India.

Can integrated watershed management contribute to improvement of public health? A cross-sectional study from hilly tribal villages in India.

Tribal people living in hilly areas suffer from water scarcity in many parts of the world, including India. Water scarcity adversely impacts all aspects of life, including public health. Implementation of an Integrated Watershed Management Programme (IWMP) can help solve the problems arising out of water scarcity in such areas. However, the knowledge about and views of the water scarcity sufferers on the public health implications of IWMP have not been well documented. This cross-sectional study was performed in six purposively selected tribal villages located in Maharashtra, India. In three of the villages IWMP had been implemented (IWMV), but not in the other three (NWMV). The head of each household in all villages was interviewed using a questionnaire covering various public health aspects relevant to the villages. A total of 286/313 (92%) households participated in the study. Compared to NWMV, respondents in IWMV experienced significantly lesser prolonged water scarcity (OR=0.39), had greater number of toilets (OR=6.95), cultivated more variety of crops (OR=2.61), had lower migration (OR=0.59), higher number of girls continuing education (OR=3.04) and better utilized modern healthcare facilities in the antenatal, natal and postnatal period (OR=3.75, 2.57, 4.88 respectively). Thus, tribal people in IWMP-implemented villages reported advantages in many aspects of public health.

Quality of water and antibiotic resistance of Escherichia coli from water sources of hilly tribal villages with and without integrated watershed management-a one year prospective study.

In many hilly tribal areas of the world, water scarcity is a major problem and diarrhoea is common. Poor quality of water also affects the environment. An integrated watershed management programme (IWMP) aims to increase availability of water and to improve life conditions. Globally, there is a lack of information on water contamination, occurrence of diarrhoea and antibiotic resistance, a serious global concern, in relation to IWMP in hilly tribal areas. Therefore, a prospective observational study was conducted during 2011­2012 in six villages in a hilly tribal belt of India, three with and three without implementation of an IWMP, to explore quality of water, diarrhoeal cases in the community and antibiotic resistance of Escherichia coli from water sources. The results showed that physico-chemical quality of water was within limits of safe consumption in all samples. The odds of coliform contamination in water samples was 2.3 times higher in non-watershed management villages (NWMV) compared to integrated watershed management villages (IWMV) (95% CI 0.8­6.45, p = 0.081). The number of diarrhoeal cases (18/663 vs. 42/639, p < 0.05) was lower in IWMV as compared to NWMV. Overall E. coli isolates showed high susceptibility to antibiotics. Resistance to a wider range of antibiotics was observed in NWMV.

Improvement in health and empowerment of families as a result of watershed management in a tribal area in India - a qualitative study.

BACKGROUND: Tribal people in India, as in other parts of the world, reside mostly in forests and/or hilly terrains. Water scarcity and health problems related to it are their prime concern. Watershed management can contribute to resolve their health related problems and can put them on a path of socio-economic development. Integrated management of land, water and biomass resources within a watershed, i.e. in an area or a region which contributes rainfall water to a river or lake, is referred to as watershed management. Watershed management includes soil and water conservation to create water resources, management of drinking water, improving hygiene and sanitation, plantation of trees, improving agriculture, formation of self-help groups and proper utilisation and management of available natural resources. For successful implementation of such a solution, understanding of perceptions of the tribal community members with regard to public health and socioeconomic implications of watershed management is essential. METHODS: A qualitative study with six focus group discussions (FGDs), three each separately for men and women, was conducted among tribal community members of the Maharashtra state of India. The data collected from the FGDs were analyzed using manifest and latent content analysis. RESULTS: "Improvement in health and empowerment of families as a result of watershed management" was identified as the main theme. Participants perceived that their health problems and socio-economic development are directly and/or indirectly dependent upon water availability. They further perceived that watershed management could directly or indirectly result in reduction of their public health related challenges like waterborne diseases, seasonal migration, alcoholism, intimate partner violence, as well as drudgery of women and may enhance overall empowerment of families through agricultural development. CONCLUSIONS: Tribal people perceived that water scarcity is the main reason for their physical, mental and social health problems and a major obstacle for their overall development. The perceptions of tribal participants indicate that infectious diseases, migration, alcoholism, intimate partner violence and drudgery of women are end results of water scarcity and efforts to increase water availability through watershed management may help them to achieve their right to health which is embedded in their right to access to water.