Globally, antimicrobial resistance (AMR) and climate change (CC) are two of the top health emergencies, and can be considered as two interlinked public health priorities. The complex commonalities between AMR and CC should be deeply investigated in a One Health perspective. Here, we provided an overview of the current knowledge about the relationship between AMR and CC. Overall, the studies included pointed out the need for applying a systemic approach to planetary health. Firstly, CC increasingly brings humans and animals into contact, leading to outbreaks of zoonotic and vector-borne diseases with pandemic potential. Although it is well-established that antimicrobial use in human, animal and environmental sectors is one of the main drivers of AMR, the COVID-19 pandemic is exacerbating the current scenario, by influencing the use of antibiotics, personal protective equipment, and biocides. This also results in higher concentrations of contaminants (e.g., microplastics) in natural water bodies, which cannot be completely removed from wastewater treatment plants, and which could sustain the AMR spread. Our overview underlined the lack of studies on the direct relationship between AMR and CC, and encouraged further research to investigate the multiple aspects involved, and its effect on human health.

/pdf/how-antimicrobial-resistance-is-linked-to-climate-change-an-24d5j3vb.pdf

How Antimicrobial Resistance Is Linked to Climate Change: An Overview of Two Intertwined Global Challenges

Diarrheal diseases remain a serious global public health threat, especially for those populations lacking access to safe water and sanitation infrastructure. Although association of several diarrheal diseases, e.g., cholera, shigellosis, etc., with climatic processes has been documented, the global human population remains at heightened risk of outbreak of diseases after natural disasters, such as earthquakes, floods, or droughts. In this review, cholera was selected as a signature diarrheal disease and the role of natural disasters in triggering and transmitting cholera was analyzed. Key observations include identification of an inherent feedback loop that includes societal structure, prevailing climatic processes, and spatio-temporal seasonal variability of natural disasters. Data obtained from satellite-based remote sensing are concluded to have application, although limited, in predicting risks of a cholera outbreak(s). We argue that with the advent of new high spectral and spatial resolution data, earth observation systems should be seamlessly integrated in a decision support mechanism to be mobilize resources when a region suffers a natural disaster. A framework is proposed that can be used to assess the impact of natural disasters with response to outbreak of cholera, providing assessment of short- and long-term influence of climatic processes on disease outbreaks.

Natural Disasters and Cholera Outbreaks: Current Understanding and Future Outlook

Summary Shortages of vaccines for epidemic diseases, such as cholera, meningitis, and yellow fever, have become common over the past decade, hampering efforts to control outbreaks through mass reactive vaccination campaigns. Additionally, various epidemiological, political, and logistical challenges, which are poorly documented in the literature, often lead to delays in reactive campaigns, ultimately reducing the effect of vaccination. In June 2015, a cholera outbreak occurred in Juba, South Sudan, and because of the global shortage of oral cholera vaccine, authorities were unable to secure sufficient doses to vaccinate the entire at-risk population—approximately 1 million people. In this Personal View, we document the first public health use of a reduced, single-dose regimen of oral cholera vaccine, and show the details of the decision-making process and timeline. We also make recommendations to help improve reactive vaccination campaigns against cholera, and discuss the importance of new and flexible context-specific dose regimens and vaccination strategies.

Adapting to the global shortage of cholera vaccines: targeted single dose cholera vaccine in response to an outbreak in South Sudan.

An ethnographic exploration of diarrheal disease management in public hospitals in Bangladesh: From problems to solutions.

A comprehensive targeted intervention (CTI) was designed and deployed in the neighborhoods of cholera cases in the Kathmandu Valley with the intent of reducing rates among the neighbors of the case. This was a feasibility study to determine whether clinical centers, laboratories, and field teams were able to mount a rapid, community-based response to a case within 2 days of hospital admission. Daily line listings were requested from 15 participating hospitals during the monsoon season, and a single case initiated the CTI. A standard case definition was used: acute watery diarrhea, with or without vomiting, in a patient aged 1 year or older. Rapid diagnostic tests and bacterial culture were used for confirmation. The strategy included household investigation of cases; water testing; water, sanitation, and hygiene (WASH) intervention; and health education. A CTI coverage survey was conducted 8 months postintervention. From June to December of 2016, 169 cases of Vibrio cholerae O1 were confirmed by bacterial culture. Average time to culture result was 3 days. On average, the CTI Rapid Response Team (RRT) was able to visit households 1.7 days after the culture result was received from the hospital (3.9 days from hospital admission). Coverage of WASH and health behavior messaging campaigns were 30.2% in the target areas. Recipients of the intervention were more likely to have knowledge of cholera symptoms, treatment, and prevention than non-recipients. Although the RRT were able to investigate cases at the household within 2 days of a positive culture result, the study identified several constraints that limited a truly rapid response.

Feasibility of a Comprehensive Targeted Cholera Intervention in The Kathmandu Valley, Nepal

The 2010 earthquake in Haiti and the subsequent cholera outbreak taught us multiple lessons on how we might better avert cholera outbreaks, beyond simply improving access to clean water and sanitation [1]. Post-earthquake Nepal is now a test of how well we learned these lessons (Fig 1). Earthquake-associated mortality generally progresses in well-defined phases that ultimately give way to longer-lasting periods of new and complex health needs. The first phase is caused by the immediate kinetic trauma. The second is a product of infectious complications from the bodily trauma. The third is linked to infectious disease outbreaks enabled by the destroyed infrastructure; many of these latter diseases are now vaccine preventable, including cholera.

/pdf/is-a-cholera-outbreak-preventable-in-post-earthquake-nepal-4issso3ubi.pdf

Is a Cholera Outbreak Preventable in Post-earthquake Nepal?

Background: Acute diarrhoeal disease management often requires rehydration alone without antibiotics. However, antibiotics are frequently used inappropriately and this is an important driver of antimicrobial resistance. The mHDM trial was conducted to determine if electronic decision-support improves rehydration and antibiotic guideline adherence in resource-limited settings.

Methods: A cluster randomized controlled trial was conducted at ten district hospitals in Bangladesh. Inclusion criteria were patients two-months of age or older with uncomplicated acute diarrhoea. Admission orders were observed without intervention followed by randomization to electronic ('Rehydration Calculator') or paper formatted World Health Organization guidelines. Generalized linear mixed-effect models, accounting for hospital clustering, served as the analytical framework.

Findings: Of 6,577 screened patients, 4,975 were enrolled. There was no statistical difference between electronic and paper decision-support for IV fluids ordered (interaction p=0.31). Among severely dehydrated patients, volumes were 29.2% higher (0.014 L/kg) for electronic compared to paper decision-support (0.062 L/kg, 95%CI 0.051-0.076 vs 0.048 L/kg, 95%CI 0.039-0.058; interaction p=0.01). Inappropriate antibiotics decreased with electronic decision-support, including a 28.5% decrease for electronic (97.2%, 95%CI 90.3-99.3 to 68.7%, 95%CI 40.9-87.4) compared to a 23.8% increase for paper (43.1%, 95%CI 19.8-70.0 to 66.9%, 95%CI 39.8-86.1) among children under 5 years (interaction p<0.001). Class-switching from non-indicated (ciprofloxacin, metronidazole; interaction p values <0.001) to indicated (azithromycin; interaction p<0.001) antibiotics occurred for both decision-support methods.

Interpretation: Electronic decision-support, and paper to a lesser extent, improved guideline adherence with a prominent reduction of inappropriate antibiotic orders. The accessibility of the electronic medium offers scalability to improve guideline adherence for acute diarrhoeal disease management and combat antibiotic resistance globally.

Trial Registration: This trial was registered at clinicaltrials.gov (NCT03154229).

Funding Statement: This work was supported by the National Institutes of Health [DP5OD019893; R21TW010182] to EJN. Internal support was provided by the University of Florida and Stanford University.

Declaration of Interests: The authors declare no competing interests.

Ethics Approval Statement: Research ethics boards at the IEDCR (IEDCR/IRB/2017/10), icddr,b (ERC and RRC PR-17036) and University of Florida (IRB201601762) approved this study. A Data and Safety Monitoring Board (DSMB) was assembled at the icddr,b. The protocol received independent evaluation by three international experts. The US Department of Health and Human Services human experimentation guidelines were followed during this research.

Electronic Decision-Support Improves Diarrhoeal Disease Guideline Adherence ((mHealth Diarrhoeal Management, mHDM, Trial): A Cluster Randomized Controlled Trial

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Is a Cholera Outbreak Preventable in Post-earthquake Nepal?

Electronic Decision-Support Improves Diarrhoeal Disease Guideline Adherence ((mHealth Diarrhoeal Management, mHDM, Trial): A Cluster Randomized Controlled Trial

A method, apparatus and computer program product for personal identification and electronic data management