No abstract

BackgroundInfluenza infections result in both inappropriate and appropriate antibiotic prescribing. There is a huge burden of both influenza and infections caused by antimicrobial-resistant pathogens in Africa. Influenza vaccines have the potential to reduce appropriate antibiotic use, through reduction of secondary bacterial infections, as well as to reduce levels of influenza misdiagnosed and treated as a bacterial infection (inappropriate).ObjectivesTo estimate potential reductions in antibiotic use that are achievable by introducing an influenza vaccine into various African settings.MethodsInfluenza incidence was combined with population size, vaccine and health system characteristics.ResultsWe estimated that the direct impact of vaccination could avert more than 390 prescriptions per 100 000 population per year if a 50% efficacious influenza vaccine at 30% coverage was introduced to adults >65 years old in South Africa or children 2–5 years old in Senegal. Across Africa, purely through reducing the number of severe acute respiratory infections, the same vaccine characteristics could avert at least 24 000 antibiotic prescriptions per year if given to children <5 years old.ConclusionsThe introduction of an influenza vaccine into multiple African settings could have a dramatic indirect impact on antibiotic usage. Our values are limited underestimates, capturing only the direct impact of vaccination in a few settings and risk groups. This is owing to the huge lack of epidemiological information on antibiotic use and influenza in Africa. However, it is likely that influenza vaccination in Africa could substantially impact antibiotic usage in addition to influenza-related mortality and morbidity.

Background A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals’ use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high. Methods The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs. Results Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability. Conclusion There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

ObjectiveThe emergence of infectious diseases pose major global health threats. Estimates of total in-country human pathogen diversity, and insights as to how and when species were described through history, could be used to estimate the probability of new pathogen discoveries. Data from the Lao People’s Democratic Republic (Laos) were used in this proof-of-concept study to estimate national human pathogen diversity and to examine historical discovery rate drivers.MethodsA systematic survey of the French and English scientific and grey literature of pathogen description in Laos between 1874 and 2017 was conducted. The first descriptions of each known human pathogen in Laos were coded according to the diagnostic evidence available. Cumulative frequency of discovery across time informed the rate of discovery. Four distinct periods of health systems development in Laos were identified prospectively and juxtaposed to the unmodelled rate of discovery. A model with a time-varying rate of discovery was fitted to these data using a Markov-Chain- Monte-Carlo technique.ResultsFrom 6456 pathogen descriptions, 245 discoveries of known human pathogens in Laos, including repeat discoveries using different grades of evidence, were identified. The models estimate that the Laos human pathogen species diversity in 2017 is between 169 and 206. During the last decade, there has been a 33-fold increase in the discovery rate coinciding with the strengthening of medical research and microbiology.ConclusionDiscovery curves can be used to model and estimate country-level human pathogen diversity present in a territory. Combining this with historical assessment improves the understanding of the factors affecting local pathogen discovery.PROSPERO registration numberA protocol of this work was registered on PROSPERO (ID:CRD42016046728).