Seasonal variation and risks of potentially toxic elements in agricultural lowlands of central Cameroon.

Intensive urban agriculture is expanding in Cameroon, which increases the risks of environmental pollution, particularly in the lowlands. This study assessed the seasonal characteristics of some potentially toxic elements and their ecological risks during the dry and wet seasons in urban agricultural soils in four lowlands in Yaoundé. The area and seasonal variation of some potentially toxic elements (Cu, Pb, Zn, Cd, Cr, and Ni) were evaluated using mixed-effects modeling. The pollution status of these elements in the soil was evaluated and interpreted using parameters such as the single pollution (SPI) and Nemerow composite pollution (NCPI) indices. In addition, the effect of these metals in the environment was assessed using the potential ecological risk index (PERI). The distribution of all the studied elements showed an area effect, while a seasonal effect was only noticeable for Cu. The concentration of Cu, Pb, and Zn was higher than the recommended threshold values in one of the areas sampled, while Cr exceeded these threshold values in all areas during both seasons. Cr exhibited the highest SPI among all studied elements during the dry and wet seasons in all areas. Except for the NCPI in one area, where grade V (strong) soil pollution was recorded during the wet season, the soil from all the study areas exhibited a slight pollution level (grade III) with a mean NCPI between 1 and 2. The PERI value of all areas was below the reference values during both seasons, suggesting an overall low potential contamination risk of the soil biota. The results indicate that preventive action to limit the heavy metal contamination in the lowlands of Yaoundé needs to be taken, for instance, through the promotion of more sustainable use of agrochemicals like pesticides and mineral fertilizers.

Who could be One Health Activist at the community level?: A case for India.

BACKGROUND: Community health workers (CHWs) are the mainstay of the public health system, serving for decades in low-resource countries. Their multi-dimensional work in various health care services, including the prevention of communicable diseases and health promotion of non-communicable diseases, makes CHWs, the frontline workers in their respective communities in India. As India is heading towards the development of One Health (OH), this study attempted to provide an insight into potential OH activists (OHA) at the community level. Thus, this case study in one of India's western cities, Ahmedabad, targeted identifying OHA by exploring the feasibility and the motivation of CHWs in a local setting. METHODS: This case study explores two major CHWs, i.e., female (Accredited Social Health Activists/ASHA) health workers (FHWs) and male (multipurpose) health workers (MHWs), on their experience and motivation for becoming an OHA. The data were collected between September 2018 and August 2019 through a mixed design, i.e., quantitative data (cross-sectional structured questionnaire) followed by qualitative data (focus group discussion with a semi-structured interview guide). RESULTS: The motivation of the CHWs for liaisoning as OHA was found to be low; however, the FHWs have a higher mean motivation score [40 (36-43)] as compared to MHWs [37 (35-40)] out of a maximum score of 92. Although most CHWs have received zoonoses training or contributed to zoonoses prevention campaigns, their awareness level was found to be different among male and female health workers. Comparing the female and male health workers to act as OHA, higher motivational score, multidisciplinary collaborative work experience, and way for incentive generation documented among the female health workers. CONCLUSION: ASHAs were willing to accept the additional new liaison role of OHAs if measures like financial incentives and improved recognition are provided. Although this study documented various systemic factors at the individual, community, and health system level, which might, directly and indirectly, impact the acceptance level to act as OHA, they need to be accounted for in the policy regime.

Systemic factors for enhancing intersectoral collaboration for the operationalization of One Health: a case study in India.

BACKGROUND: One Health is a collaborative, multisectoral, and transdisciplinary approach-working at the local, regional, national, and global levels-with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. Operationalization of the One Health approach is still unclear for various local health systems with their respective targets. In this scenario, the empirical study of intersectoral collaboration between the human and animal health systems provides an opportunity to investigate the appropriate strategies and their enabling factors at the local health system level. Thus, this study documented and validated the innovative strategy for intersectoral collaboration, focusing on effectual prevention and control of zoonotic diseases with its enabling factors for a city in western India, Ahmedabad. METHODS: This case study was conducted in three phases: phase I (qualitative data collection, i.e., vignette interview), phase II (quantitative data collection through modified policy Delphi), and phase III (participatory workshop). The vignette data were handled for content analysis, and the Delphi data, like other quantitative data, for descriptive statistics. The participatory workshop adapts the computerized Sensitivity Model® developed by Vester to analyse the health system dynamics. RESULT: Out of the possible 36 strategies, this study validated the top 15 essential (must-have) and five preferred (should-have) strategies for the study area. For operationalization of the One Health approach, the enabling factors that were identified through the systems approach are micro-level factors at the individual level (trust, leadership, motivation, knowledge), meso-level factors at the organizational level (human resource, capacity-building, shared vision, decision-making capacity, laboratory capacity, surveillance), macro-level factors at the system level (coordinated roles, relationships, common platform), and external factors outside of the system (guidelines/policies, community participation, a specific budget, political will, smart technology). DISCUSSION: This study reveals that the micro-level factors at the individual level are potential levers of the health system. More attention to these factors could be beneficial for the operationalization of the One Health approach. This study recommends a systems approach through a bottom-up exploration to understand the local health system and its enabling factors, which should be accounted for in formulating future One Health policies.

Health System Contact and Awareness of Zoonotic Diseases: Can it Serve as One Health Entry Point in the Urban Community of Ahmedabad, India?

One Health (OH) is emphasized globally to tackle the (re)emerging issues at the human-animal-ecosystem interface. However, the low awareness about zoonoses remain a challenge in global south, thus this study documented the health system contact and its effect on the awareness level of zoonoses in the urban community of Ahmedabad, India. A community-based household survey was conducted between October 2018 and July 2019. A total of 460 households (HHs) were surveyed from two zones and 23 wards of the city through cluster sampling. A structured, pilot-tested, and researcher-administered questionnaire in the vernacular language was used to collect the information on demographic details, socio-economic details, health-seeking behavior for both the humans and their animals, human and animal health system contact details and the participants' awareness on selected zoonotic diseases based on the prioritization (rabies, brucellosis, swine flu, and bird flu). Out of 460 surveyed households, 69% of HHs and 59% of HHs had a health system contact to the human and animal health system respectively at the community level. There are multiple health workers active on the community level that could potentially serve as One Health liaisons. The investigation of the knowledge and awareness level of selected zoonotic diseases revealed that 58.5%, 47.6%, and 4.6% know about rabies, swine and/or bird flu, and brucellosis, respectively. The mixed-effect linear regression model indicates that there is no significant effect on the zoonotic disease awareness score with the human health system contact; however, a minimal positive effect with the animal health system contact was evident.

COVID-19 in India: Making a case for the one health surveillance system.

Pandemics like COVID-19 warrant an urgent implementation of the one health surveillance (OHS) system to the focus on multisectoral, multidisciplinary, multi-institutional, and multispecialty coordination, in all aspects of the response to outbreaks that might involve humans, animals, and their environment. The Indian system so far has evolved in conducting surveillance and monitoring of parameters within the domain of human health, animal health, and the environment, but in silos. This commentary piece provides an opinion to boost the existing surveillance activities for early detection and ways to develop an integrated OHS to prevent future COVID-19 like pandemics in India. It also attempts to provide possible solutions at the interface of human-animal-environment, from the simpler to the complex system integration with the principles of one health.

Correction to: Convergence model for effectual prevention and control of zoonotic diseases: a health system study on 'One Health' approach in Ahmedabad, India.

It was highlighted that the original article [1] contained an error in the Methods section, specifically in Study Section. The number urban health centres should be 72 instead of 6. This Correction article shows the incorrect and correct statement in the Methods section.

Convergence model for effectual prevention and control of zoonotic diseases: a health system study on 'One Health' approach in Ahmedabad, India.

The complexity and increasing burden of zoonotic diseases create challenges for the health systems of developing nations. Public health systems must therefore be prepared to face existing and future disease threats at the human-animal interface. The key for this is coordinated action between the human and the animal health systems. Although some studies deal with the question of how these two systems interact during unforeseen circumstances such as outbreaks, a dearth of literature exists on how these systems interact on early detection, prevention and control of zoonotic diseases; assessing this problem from the health system perspective in a developing nation adds further complexity. Systems thinking is one of the promising approaches in understanding the factors that influence the system's complexity and dynamics of health maintenance. Therefore, this study aims to understand the generic structure and complexity of interaction between these actors within the domain of One Health for the effectual prevention and control of zoonotic diseases in India.The present study will be executed in Ahmedabad, located on the Western part of India, in Gujarat state, using a mixed methods approach. For the first step, zoonotic diseases will be prioritised for the local context through semi-quantitative tools. Secondly, utilising semi-structured interviews, stakeholders from the human and animal health systems will be identified and ranked. Thirdly, the identified stakeholders will be questioned regarding the current strength of interactions at various levels of the health system (i.e. managerial, provider and community level) through a quantitative network survey. Fourthly, utilising a vignette method, the ideal convergence strategies will be documented and validated through policy Delphi techniques. Finally, through a participatory workshop, the factors that influence convergence for the control and prevention of zoonotic diseases will be captured.This study will provide a comprehensive picture of the current strength of collaboration and network depth at various levels of the health system. Further, it will assist different actors in identifying the relevance of possible One Health entry points for participation, i.e. it will not only contribute but will also develop a system convergence model for the effectual prevention and control of zoonotic diseases.

Urban park qualities driving visitors mental well-being and wildlife conservation in a Neotropical megacity.

Green infrastructure has been widely recognized for the benefits to human health and biodiversity conservation. However, knowledge of the qualities and requirements of such spaces and structures for the effective delivery of the range of ecosystem services expected is still limited, as well as the identification of trade-offs between services. In this study, we apply the One Health approach in the context of green spaces to investigate how urban park characteristics affect human mental health and wildlife support outcomes and identify synergies and trade-offs between these dimensions. Here we show that perceived restorativeness of park users varies significantly across sites and is mainly affected by safety and naturalness perceptions. In turn, these perceptions are driven by objective indicators of quality, such as maintenance of facilities and vegetation structure, and subjective estimations of biodiversity levels. The presence of water bodies benefited both mental health and wildlife. However, high tree canopy coverage provided greater restoration potential whereas a certain level of habitat heterogeneity was important to support a wider range of bird species requirements. To reconcile human and wildlife needs in green spaces, cities should strategically implement a heterogeneous green infrastructure network that considers trade-offs and maximizes synergies between these dimensions.

One Health Risk and Disease (OHRAD): a tool to prioritise the risks for epidemic-prone diseases from One Health perspective.

BACKGROUND: The rise in epidemic-prone diseases daily poses a serious concern globally. Evidence suggests that many of these diseases are of animal origin and contribute to economic loss. Considering the limited time and other resources available for the animal and human health sectors, selecting the most urgent and significant risk factors and diseases is vital, even though all epidemic-prone diseases and associated risk factors should be addressed. The main aim of developing this tool is to provide a readily accessible instrument for prioritising risk factors and diseases that could lead to disease emergence, outbreak or epidemic. METHODS: This tool uses a quantitative and semi-quantitative multi-criteria decision analysis (MCDA) method that involves five steps: Identifying risk factors and diseases, Weighting the criteria, Risk and disease scoring, Calculating risk impact and disease burden score, and Ranking risks and diseases. It is intended to be implemented through a co-creation workshop and involves individual and group activities. The last two steps are automated in the MS Excel score sheet. RESULTS: This One Health Risk and Disease (OHRAD) prioritisation tool starts with an individual activity of identifying the risks and diseases from the more extensive list. This, then, leads to a group activity of weighing the criteria and providing scores for each risk and disease. Finally, the individual risk and disease scores with the rankings are generated in this tool. CONCLUSIONS: The outcome of this OHRAD prioritisation tool is that the top risks and diseases are prioritised for the particular context from One Health perspective. This prioritised list will help experts and officials decide which epidemic-prone diseases to focus on and for which to develop and design prevention and control measures.

Changes in eating habits and lifestyle during the first year of the COVID-19 pandemic across metropolitan regions in Brazil and Germany: A survey-based cross-sectional study.

COVID-19 caused profound societal changes to cope rapidly with the new circumstances. The food market changed its quantity, quality, form, and frequency dynamics. Consequently, food-eating habits and lifestyles like physical exercise likely experienced changes. An online-based survey was conducted between June 2020 and January 2021 in the metropolitan regions of Rhine Ruhr Metropolis (RRM), Greater São Paulo (GSP), other metropolitan regions in São Paulo state (oMRSP), other Brazilian metropolitan regions (oBRMR), and the remaining urban areas in both countries (oUA), representing different contexts of Brazil and Germany. We assessed self-reported changes in physical activity level, diet quality, self-reported eating habits, and buying groceries during the first year of the pandemic. In Germany, indoor and outdoor activities increased for 34% of the respondents, while in Brazil, there was a decrease in physical activity for 50% of the participants. The Healthy Eating Index (HEI) scored higher among Brazilians (16.8) than Germans (15.2) on a 0-29 HEI scale. Increased awareness of healthy and sustainable eating habits was observed in GSP (0.7), oMRSP (0.63), oBRMR (0.7), and oUA (0.68) on a scale from no change (0) to change (1). In RRM, an increase in convenience foods was noticed (0.86). Participants reported discomfort with food purchasing due to hygiene measures and avoided going to the supermarket (0.7 on average in Brazil and 0.58 for females using the same 0-1 scale). Also, food supply at the grocery shops was reported to be often unavailable and in lower quantities. A real-time assessment of self-reported changes in eating habits and lifestyle during the lockdown in 2020 in different contexts is insightful for rethinking strategies to improve conditions in the post-COVID-19 era and prepare for future pandemics.

Effect of portable HEPA filters on COVID-19 period prevalence: an observational quasi-interventional study in German kindergartens.

OBJECTIVES: The aim of the study was to evaluate the effect of high-efficiency particulate air (HEPA) filters on COVID-19 period prevalence in kindergartens. DESIGN: The observational study follows an intervention design with the intervention group using HEPA filters and the control group not. SETTING: The study was conducted in 32 (10 intervention, 22 control) kindergartens (daycare centres) in Rhineland Palatinate (Germany). PARTICIPANTS: Data of 2360 children (663 intervention, 1697 control) were reported by the kindergarten heads. Data were collected on institutional level without any identifying information on individuals. Thus, all children of all facilities were included; however, no demographic data were recorded. INTERVENTIONS: The study followed a quasi-interventional design, as no formal intervention was conducted. A charity foundation equipped kindergartens with HEPA filters. These kindergartens were enrolled as intervention group. The control group was recruited from the neighbouring communities and districts. OUTCOME MEASURES: The primary outcome measure was the number of COVID-19 cases reported by the kindergarten heads, converted into period prevalence rates per 1000 population. RESULTS: The mean COVID-19 period prevalence rates of the control and intervention groups were 186 (95% CI: 137.8 to 238.9) and 372 (95% CI: 226.6 to 517.6) per 1000 children, respectively. The one-sided Wilcoxon rank-sum test indicates a p value of 0.989; thus, the hypothesised preventive effect of HEPA filters could not be confirmed in the kindergarten setting. CONCLUSIONS: While HEPA filters can significantly reduce the viral load in room air, this does not lead to reduced COVID-19 prevalence in the selected kindergartens in Germany. It is known that contagion mainly occurs via direct face-to-face air exchange during play and that the contaminated air does not necessarily pass through the filter prior to air exchange between children. The use of HEPA filters may also lead to a sense of security, leading to reduced preventive behaviour.

Agroecosystem exploration for Antimicrobial Resistance in Ahmedabad, India: A Study Protocol.

Introduction: Antimicrobial resistance (AMR) has emerged as one of the leading threats to public health. AMR possesses a multidimensional challenge that has social, economic, and environmental dimensions that encompass the food production system, influencing human and animal health. The One Health approach highlights the inextricable linkage and interdependence between the health of people, animal, agriculture, and the environment. Antibiotic use in any of these areas can potentially impact the health of others. There is a dearth of evidence on AMR from the natural environment, such as the plant-based agriculture sector. Antibiotics, antibiotic-resistant bacteria (ARB), and related AMR genes (ARGs) are assumed to present in the natural environment and disseminate resistance to fresh produce/vegetables and thus to human health upon consumption. Therefore, this study aims to investigate the role of vegetables in the spread of AMR through an agroecosystem exploration in Ahmedabad, India. Protocol: The present study will be executed in Ahmedabad, located in Gujarat state in the Western part of India, by adopting a mixed-method approach. First, a systematic review will be conducted to document the prevalence of ARB and ARGs on fresh produce in South Asia. Second, agriculture farmland surveys will be used to collect the general farming practices and the data on common vegetables consumed raw by the households in Ahmedabad. Third, vegetable and soil samples will be collected from the selected agriculture farms and analyzed for the presence or absence of ARB and ARGs using standard microbiological and molecular methods. Discussion: The analysis will help to understand the spread of ARB/ARGs through the agroecosystem. This is anticipated to provide an insight into the current state of ARB/ARGs contamination of fresh produce/vegetables and will assist in identifying the relevant strategies for effectively controlling and preventing the spread of AMR.

Integrated Pest Management (IPM) and One Health - a call for action to integrate.

One Health (OH) has gained considerable prominence since the beginning of the 21st century, among others, driven by the recent epidemics and the increasing importance of zoonotic diseases. Yet, despite the holistic and multidimensional nature of OH, to date, most emphasis has been on the interactions between animal and human health, with considerably less attention to environmental and plant health. However, there is growing evidence that the challenges of climate change, growing food and nutritional insecurity, and biodiversity loss can best be addressed within the context of the OH framework. Conceptionally, Integrated Pest Management (IPM) could perfectly fit into such an approach, but historically, IPM has been practiced very much in a compartmentalized manner. New approaches such as Regenerative Agriculture and Sustainable Intensification offer solutions to how to successfully embed IPM into a OH framework.

Associations between socio-spatially different urban areas and knowledge, attitudes, practices and antibiotic use: A cross-sectional study in the Ruhr Metropolis, Germany.

Inappropriate and excessive antibiotic use fuels the development of antibiotic resistance. Determinants of antibiotic use, including knowledge and attitudes, are manifold and vary on different spatial scales. The objective of this study was to examine the associations between socio-spatially diverse urban areas and knowledge, attitudes, practices and antibiotic use within a metropolitan city. A cross-sectional survey was conducted in the general population in socio-spatially different areas in Dortmund, Germany, in February and March 2020. Three urban areas were chosen to represent diverse socio-spatial contexts (socio-spatially disadvantaged: A, intermediate: B, socio-spatially disadvantaged: C). Participants were selected via simple random sampling. The questionnaire comprised knowledge and attitude statements and questions around antibiotic use and handling practices. Differences between the areas were examined by estimating odds ratios (OR) and corresponding 95% confidence intervals by multiple logistic regression. Overall, 158 participants were included. Participants of Area C showed the lowest proportions of correct knowledge statements, indicated more often attitudes contrary to common recommendations, lower risk awareness and reported more often antibiotic use (C: 40.8%; A: 32.7%; B: 26.5%) and potential mishandling practices (C: 30.4%; A: 9.6%; B: 17.3%). The multiple logistic regression confirmed these differences. Around 42.3% (C), 33.3% (A) and 20.0% (B) of the diseases mentioned for which an antibiotic was used are mainly caused by viral pathogens. A common misconception across all areas was the perception of antibiotic resistance as an individual rather than a universal issue. This study reveals distinct differences between socio-spatially diverse urban areas within a metropolitan city, regarding knowledge, attitudes and practices around antibiotics and ABR. Our findings confirm that enhanced efforts are required to better inform the population about the adequate use and handling of antibiotics. This study emphasizes the need for future interventions to be tailored to the specific local socio-economic context.

Changing dietary patterns is necessary to improve the sustainability of Western diets from a One Health perspective.

Western diets are associated with multiple environmental impacts and risks to human health. European countries are gradually taking action towards the Farm to Fork Strategy, embracing a Life Cycle Assessment (LCA) perspective to promote the sustainability of food production and consumption. Although LCA enables the comprehensive assessment of environmental impacts, diet-related human health and animal welfare impacts are often underrepresented. This study proposes integrating additional indicators into LCA to evaluate the sustainability of diets under the One Health (OH) approach, which holistically considers interlinked complex health issues between humans, animals and the environment. Human health loss is estimated according to risk factors for non-communicable diseases; while animal welfare is measured as animal life years suffered, loss of animal lives and loss of morally-adjusted animal lives. The extended LCA framework is applied to men and women's reference diets in the German federal state of North Rhine-Westphalia (NRW); compared to three optimized dietary scenarios under nutritional constraints: 1) the national dietary guidelines, 2) a vegan diet (VD) and 3) a Mediterranean diet (MD). Men's reference diet causes greater impacts than women's across OH dimensions due to the higher food consumption, especially of ready-to-eat meals, sausages, meat, and sweetened and alcoholic beverages. Both reference diets are associated with risk factors for cardiovascular diseases, diabetes, stroke and neoplasms. Besides meat, consumption of honey, fish and seafood has the greatest impact on animal welfare, because of the high number of individuals involved. Alternative diets improve the sustainability of food consumption in NRW, although trade-offs arise: MD worsens animal suffering due to the higher fish intake; water use increases in both VD and MD due the higher intake of nuts and vegetables. Results highlight the importance of including animal welfare and human health indicators in LCA to better elucidate the potential impacts of diets characterized by the high intake of animal products, from a OH perspective.

The Regeneration of Urban Blue Spaces: A Public Health Intervention? Reviewing the Evidence.

Research in recent years has demonstrated that urban surface waters ("urban blue spaces") can provide beneficial effects on human health and wellbeing. Despite blue spaces prevailing on urban development agendas across the world, little investigation has been done whether and how the regeneration of such spaces is used as a (community-based) public health intervention. Therefore, a review was conducted to analyze urban blue space regeneration projects in terms of their significance for public health. Results show that the regeneration of urban blue spaces displays a diversity of intervention types and follows certain development trends seen in general urban regeneration: Similarities mainly arise in relation to objectives (multi-dimensional goals with increasing focus on environmental sustainability and economic interests), stakeholders (shift to multi-actor governance with a rise of partnerships and community participation), and funding (prevalence of mixed financial schemes and increasing reliance on external funding sources). Although threefold public health effects have been noted across the projects (i. behavioral changes toward healthier lifestyles, ii. healthier urban environments, iii. health policy changes), results of this review indicate that the potential to use urban blue regeneration as a community-based health intervention has yet to be realized.

Intersectoral collaboration shaping One Health in the policy agenda: A comparative analysis of Ghana and India.

Intersectoral collaborations are an integral component of the prevention and control of diseases in a complex health system. On the one hand, One Health (OH) is promoting the establishment of intersectoral collaborations for prevention at the human-animal-environment interface. On the other hand, operationalising OH can only be realized through intersectoral collaborations. This work contributes to broadening the knowledge of the process for operationalising OH by analysing the governance structures behind different initiatives that tackle health problems at the human-animal-environment interface. The cases taken as examples for the analysis are the control and response to rabies and avian influenza under "classical OH", and the management of floods and droughts for insights into "extended OH". Data from Ghana and India were collected and compared to identify the key elements that enable ISC for OH. Despite the case studies being heterogeneous in terms of their geographic, economic, social, cultural, and historical contexts, strong similarities were identified on how intersectoral collaborations in OH were initiated, managed, and taken to scale. The actions documented for rabies prevention and control were historically based on one sector being the leader and implementer of activities, while avian influenza management relied more on intersectoral collaborations with clearly defined sectoral responsibilities. The management of the impact of flood and droughts on health provided a good example of intersectoral collaborations achieved by sectoral integration; however, the human health component was only involved in the response stage in the case of Ghana, while for India, there were broader schemes of intersectoral collaborations for prevention, adaptation, and response concerning climate change and disaster.

Prevalence of multidrug-resistant and extended-spectrum beta-lactamase-producing Escherichia coli in urban community wastewater.

Antibiotic resistance (ABR) and the spread of multidrug-resistant and extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli via wastewater to environmental compartments are of rapidly growing global health concern. Health care facilities, industries and slaughterhouses discharge high loads of ABR bacteria with their wastewater. However, the general community is often the biggest indirect discharger. Yet, research focusing explicitly on this important diffuse source is rather scarce raising questions about variations in the occurrence of ESBL-producing E. coli in wastewater from different communities and over time. Between April 2019 and March 2020, wastewater from three socio-spatially different districts in the Ruhr Metropolis, Germany, and the receiving wastewater treatment plant was sampled monthly and analysed for the occurrence of ESBL-producing E. coli via culture-based methods. Isolates were validated with matrix assisted laser desorption ionization time of flight mass spectrometry and antibiotic resistance profiles were analysed via microdilution. Results were interpreted using the European Committee on Antimicrobial Susceptibility Testing criteria. The German Commission for Hospital Hygiene and Infection Prevention criteria were used for multidrug-resistance categorization. Phenotypic ESBL-producing E. coli could be isolated from every wastewater sample demonstrating that the general community is an important indirect discharger. The socio-spatially disadvantaged area displayed higher absolute loads of ESBL-producing E. coli compared to the other two areas, as well as higher adjusted loads for domestic discharge and inhabitants, particularly during winter, indicating a higher ABR burden. Thirty-two isolates (28.6%) were characterized as multidrug-resistant Gram-negative bacteria (3MRGN). Resistance profiles varied only for those antibiotics, which can be administered in outpatient care. Resistance levels tended to be around 10% lower in the socio-spatially advantaged area. This study shows that spatial and seasonal influences regarding the occurrence of ESBL-producing E. coli in wastewater from socio-spatially different communities are identifiable.

'One Health' Actors in Multifaceted Health Systems: An Operational Case for India.

The surging trend of (re)emerging diseases urges for the early detection, prevention, and control of zoonotic infections through the One Health (OH) approach. The operationalization of the OH approach depends on the contextual setting, the presence of the actors across the domains of OH, and the extent of their involvement. In the absence of national operational guidelines for OH in India, this study aims to identify potential actors with an attempt to understand the current health system network strength (during an outbreak and non-outbreak situations) at the local health system of Ahmedabad, India. This case study adopted a sequential mixed methods design conducted in two phases. First, potential actors who have been involved directly or indirectly in zoonoses prevention and control were identified through in-depth interviews. A network study was conducted as part of the second phase through a structured network questionnaire. Interest and influence matrix, average degree, network density, and degree of centralization were calculated through Atlas.Ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany), UCINET (Analytic Technologies, Lexington, KY, USA) software. The identified actors were categorized based on power, administrative level (either at the city or district level), and their level of action: administrative (policy planners, managers), providers (physicians, veterinarians), and community (health workers, community leaders). The matrix indicated that administrative actors from the district level were 'context setters' and the actors from the city level were either 'players' or 'subjects'. The network density showed a strength of 0.328 during the last outbreak of H5N1, which decreased to 0.163 during the non-outbreak situation. Overall, there was low collaboration observed in this study, which ranged from communication (during non-outbreaks) to coordination (during outbreaks). The private and non-governmental actors were not integrated into collaborative activities. This study concludes that not only collaboration is needed for OH among the sectors pertaining to the human and the animal health system but also better structured ('inter-level') collaboration across the governance levels for effective implementation.

What drives antibiotic use in the community? A systematic review of determinants in the human outpatient sector.

Inadequate and excessive use of antibiotics in humans, animals, and plants has been identified among the key drivers of antibiotic resistance (ABR). In human medicine, the great majority of antibiotics are prescribed in the outpatient sector with profound differences in antibiotic consumption across various geographical scales and between health care sectors; raising questions around the underlying drivers. Moving beyond individual patient-related determinants, determinants of antibiotic use in the outpatient sector were categorized as compositional, contextual and collective, enabling an analysis of potential area effects on antibiotic use. 592 variables identified in 73 studies were sorted into 46 determinant groups. Compositional determinants provided the strongest evidence with age, education, employment, income, and morbidity exhibiting a clear influence on antibiotic use. Regarding contextual and collective determinants, deprivation, variables around health care services, Hofstede's dimensions of national culture and regulation affect antibiotic use. The results are biased towards high-income and western countries, often relying on secondary data. However, the findings can be used as signposts for associations of certain variables with antibiotic use, thereby enabling further research and guiding interventions.