Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel.

BACKGROUND: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics. METHODS: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings. RESULTS: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course. CONCLUSIONS: We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Acceptability and Feasibility of Sharing a Soapy Water System for Handwashing in a Low-Income Urban Community in Dhaka, Bangladesh: A Qualitative Study.

Handwashing with soap at key times is an effective means of reducing pathogen transmission. In a low-income community in urban Dhaka, we piloted and evaluated the acceptability and feasibility of a shared handwashing intervention. This included promotion by community health promoters of a homemade solution of detergent powder mixed with water and stored in a 1.5-L reclaimed mineral water bottle. Community health promoters encouraged sharing of the recurrent detergent cost among compound members. Of 152 participating compounds, fieldworkers randomly selected 60 for qualitative assessment. Fieldworkers conducted 30 in-depth interviews and five focus group discussions among purposively selected compound members. The reclaimed bottles served as an easily accessible dispenser for the soapy water, which could feasibly be retained next to the toilet and kitchen areas for communal use. Bottles functioned as a positive reminder for handwashing at recommended key times. Most compounds (45/60, 75%) shared a common soapy water system and its associated costs. There was reluctance to prepare soapy water for shared use in the remaining 25%. Soapy water was an acceptable hand cleaning agent, with the bottle as a feasible dispenser. It was simple in design, cost-effective, replicable, popular with intervention recipient, and neighboring nonrecipients, and commonly shared among nonrelated households. The need to share expenses and product preparation served as a barrier. Developing a sustainable maintenance system, therefore, is critical to ensuring the public health benefits of handwashing with soap.

Provision versus promotion to develop a handwashing station: the effect on desired handwashing behavior.

BACKGROUND: Diarrhea prevalence increases from around the time that complementary foods are introduced. Improving caregiver's hand hygiene during food preparation could reduce complementary food contamination and enteric pathogen transmission. Washing hands with soap is more common when water and soap are together at a convenient location. We conducted a three-month pilot intervention to evaluate two options for setting up handwashing stations: i) provide a handwashing station, or ii) help the family to make their own from available materials. Additionally, we assessed the feasibility of this intervention to be integrated with a child feeding program. METHODS: We conducted the intervention among two groups; 40 households received a free of cost handwashing station and another 40 households were motivated to place their own soap/soapy-water and water vessel near the food preparation and child feeding area. Community health workers encouraged caregivers to wash hands with soap/soapy-water before food preparation and feeding a child. They either assisted study participants to install the study-provided handwashing station at the recommended place or encouraged caregivers to develop their own. Field researchers assessed placement and composition of handwashing stations and the feasibility of integrating handwashing and nutrition messages. RESULTS: By end of the trial, 39/40 households developed their own handwashing station, comprising a bucket, mug and bar soap/soapy-water of which 60% (6/10) households were observed with a functional and complete handwashing station set. Observed handwashing with soap was detected among 8/10 households from the study-provided handwashing station group and 5/10 among households who had made their own handwashing station. Sixty-seven of the 76 caregivers recalled integrated intervention messages on social and health benefits of infant and young child feeding correctly; and all recalled key handwashing with soap times, before food preparation and feeding a child. CONCLUSION: Encouraging households to develop their own handwashing station with soap and water to place at a food preparation/child feeding location is feasible over the short term. In the absence of large-scale provision of handwashing stations, caregivers can be encouraged to create and use their own. Integrating handwashing with soap into a nutrition intervention was feasible and acceptable and should be considered by policy makers.

Outbreaks of campylobacteriosis in Australia, 2001 to 2006.

The objective of this study was to examine the frequency of Campylobacter outbreaks in Australia and determine common transmission routes and vehicles. Summary and unit data on Campylobacter outbreaks that occurred between January 2001 and December 2006 were systematically collected and analyzed. Data from Campylobacter mandatory notifications for the same period were used for comparison. During the study period there were 33 Campylobacter outbreaks reported, affecting 457 persons. Of these, 147 (32%) had laboratory-confirmed infections, constituting 0.1% of notified Campylobacter cases. Campylobacter outbreaks most commonly occurred during the Australian Spring (September to November; n = 14, 45%), when notifications generally peaked. Transmission was predominantly foodborne or suspected foodborne (n = 27, 82%), commercial settings (n = 15, 55%) being most commonly involved. There were eight foodborne outbreaks (30%) attributed to food prepared or eaten at institutions; four (15%) at aged care facilities and three (11%) at school camps. A vehicle or suspected vehicle was determined for 16 (59%) foodborne outbreaks; poultry (chicken or duck) was associated with 11 (41%) of these, unpasteurized milk and salad were associated with two outbreaks each. Three potential waterborne outbreaks were detected, and one was due to person-to-person transmission. Campylobacter outbreaks were more commonly detected during this study period compared to a previous 6-year period (n = 9) when prospective recording of information was not undertaken. However, outbreak cases continue to constitute a very small proportion of notifications. Improved recognition through subtyping is required to enhance outbreak detection and investigation so as to aid policy formulation for prevention of infection. In addition to detection of chicken as a common source of outbreaks, these data highlight the importance of directing policy at commercial premises, aged care facilities, and school camps to reduce Campylobacter disease burden.

Age-specific risk factors for sporadic Campylobacter infection in regional Australia.

In a case-control study in the Hunter region of New South Wales, Australia, 354 cases and 593 controls were recruited to investigate meat, other food, and environmental exposures as potential risk factors for domestically acquired Campylobacter illness. In a multivariable model, illness was significantly associated with household exposure to diarrheal illness, consumption of restaurant chicken or beef, eating two or more "fast" food meals in a week, and overseas travel. Comparing exposures for the 0- to 4-year and 5-year and older age groups allowed detection of additional risk factors. Eating restaurant-prepared red meat and swimming were significantly associated with Campylobacter illness in the older group only. These findings demonstrate age-specific differences in risk factors for campylobacteriosis.

Clonal complexes of Campylobacter jejuni identified by multilocus sequence typing are reliably predicted by restriction fragment length polymorphism analyses of the flaA gene.

Multilocus sequence typing (MLST) has provided important new insights into the population structure of Campylobacter jejuni and is rapidly becoming the gold standard for typing this species. However, the methodology is comparatively costly and slow to perform for the routine surveillance testing of large numbers of isolates required by public health laboratories. Restriction fragment length polymorphism analysis of the flaA gene (RFLP-flaA) and sequencing of the variable region in the fla locus (SVR-fla) were compared to MLST to determine if a low cost alternative could be found that reliably predicts clonal lineage (as determined by MLST). An isolate of C. jejuni from each of 153 patients from New South Wales, Australia, collected sequentially over a period of 30 months from 1999 to 2001 and comprising 40 sequence types (ST) from 15 clonal complexes (CC) was examined. Of 15 CC, 12 were represented by more than one isolate and a predominant RFLP-flaA type was found for 10 (83%). Of these, seven (70%) correctly predicted the predominant MLST CC with a probability of >0.8. Of 40 STs detected, 19 were reported for the first time, 9 of which were represented by more than one isolate. Eight of these were represented by a single RFLP-flaA type. Only two of eight major SVR-fla types were able to predict CC with a probability of >0.8, indicating that flaA-RFLP is a more reliable predictor of CC than SVR-fla and thus offers an alternative to MLST for use in routine surveillance.

Low-level fluoroquinolone resistance among Campylobacter jejuni isolates in Australia.

BACKGROUND: Ciprofloxacin-resistant Campylobacter jejuni isolates obtained from infected patients in Australia have not been detected in studies of isolates from specific geographic areas. The Australian government has prohibited the use of fluoroquinolone in food-producing animals. To assess the impact of this policy, we have examined the antimicrobial susceptibility of isolates from 5 Australian states. METHODS: We conducted a period-prevalence survey of the susceptibility of C. jejuni isolates to 10 antimicrobial agents. C. jejuni isolates obtained from 585 patients from 5 Australian states (Queensland, South Australia, Tasmania, Victoria, and Western Australia) were identified by means of notifiable disease databases and were systematically selected from September 2001 to August 2002. RESULTS: Among locally acquired infections, only 2% of isolates (range, 0%-8% in different states) were resistant to ciprofloxacin. The locally acquired isolates also exhibited resistance to sulfisoxazole (55%), ampicillin (46%), roxithromycin (38%), tetracycline (7%), nalidixic acid (6%), chloramphenicol (3%), erythromycin (3%), gentamicin (2%), and kanamycin (0.2%). Treatment with antimicrobial agents in the 4 weeks before onset was not associated with ciprofloxacin resistance. CONCLUSIONS: The very low level of ciprofloxacin resistance in C. jejuni isolates likely reflects the success of Australia's policy of restricting use of fluoroquinolones in food-producing animals.

Laboratory surveillance of Shiga toxin producing Escherichia coli in South Australia and the Hunter Health Area, New South Wales, Australia.

To estimate the prevalence of Shiga toxin producing Escherichia coli in Australia, bloody stool samples from two Australian locations were screened for the presence of Shiga toxin genes, stx1 and stx2. Four of 126 (3.2%) and 139 of 5,829 (2.4%) patients from the two locations had a positive polymerase chain reaction for Shiga toxin genes.

An outbreak of gastrointestinal illness associated with the consumption of escolar fish.

An outbreak of gastrointestinal illness occurred amongst attendees of a conference lunch in the Hunter area, New South Wales, in October 2001. A distinctive symptom reported by many ill persons was the presence of oily diarrhoea. The Hunter Public Health Unit investigated the outbreak by conducting a telephone interview of the cohort of conference attendees using a standard questionnaire. Twenty persons out of 44 attendees (46%) became ill following the conference. The median incubation period was 2.5 hours (range 1-90 hours). The most common symptoms reported were; diarrhoea (80%)-38 per cent of these reported oily diarrhoea; abdominal cramps (50%); nausea (45%); headache (35%) and vomiting (25%). For analyses, a case was defined as a person who developed oily diarrhea, or diarrhoea within 48 hours, or had at least two other symptoms of gastroenteritis within 6 hours, of the conference lunch. Seventeen persons had symptoms that met the case definition. None of the foods or beverages consumed were significantly associated with illness, however, all cases had consumed fish and none of those who did not eat fish (4 persons) became ill. Moreover, only 'fish' or 'potato chips' could explain a significant proportion of the illness. Analysis of the oil composition of the fish consumed was consistent with the known profile of the species marketed as 'escolar'. Among those who consumed fish the following potential risk factors did not have a significant association with the illness; Body Mass Index, age, health status and the amount of fish consumed. We concluded that consumption of fish within the marketing group escolar can cause severe abdominal cramping, nausea and vomiting, in addition to incontinent diarrhoea.