Targeted hygiene in the home and everyday life setting can reduce antibiotic prescription in children

  13 June 2020

Sumanth Gandra MD1, Sally F Bloomfield PhD2 
1. Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
2. International Scientific Forum on Home Hygiene, Somerset, UK and London School of Hygiene and Tropical Medicine, London, UK
Corresponding author:
Sumanth Gandra MD, MPH Assistant Professor of Medicine
Division of Infectious Diseases, Department of Medicine Washington University School of Medicine
Campus Box 8051
4523 Clayton Ave. St. Louis, MO 63110 Phone: 314-454-8276
Fax: 314-454-8687
Email: gandras@wustl.edu

Antimicrobial resistance (AMR) is a global public health problem with significant health and economic consequences. The most recent WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS) report reveals that a worrying number of human bacterial infections are increasingly resistant to the antibiotics at hand to treat them with higher resistance rates observed in low and middle-income countries (LMICs).1 Antibiotic overuse is one of the primary factors fueling AMR and recent data indicate rapid increase in antibiotic consumption in LMICs while antibiotic consumption rates in many high-income countries remain stable or decreasing.2 However, poor sanitation and hygiene could be playing an even greater role in promoting AMR particularly in LMICs.3 Poor hygiene and sanitation not only increase the risk of infections such as respiratory tract and diarrheal illness leading to unnecessary antibiotic prescriptions but also facilitate spread of AMR.

From their recent study, Fink G et al.4 conclude that antibiotic exposure of children in LMICs is extremely high, and that prescriptions are, to a large extent, issued inappropriately. This is often driven by demand from parents for non-prescription use of antibiotics for their children.5 Given there are more than 500 million children younger than 5 years in LMICs, the contribution to global antibiotic over-consumption is substantial. They conclude that antibiotic stewardship programmes (ASPs) need to reach far beyond regulating drug-dispensing facilities, including to the wider general population. A recently published evidence-based report,6 developed on behalf of the Global Hygiene Council, in collaboration with a group of experts in hygiene and AMR, argues that, combining ASPs with promotion of hygiene behavior change in the community could significantly reduce both the prescribing and use of antibiotics and preventing spread of resistant bacteria. The report shows that poor hygiene plays a major role in transmission of community-acquired infections. Studies suggest that handwashing alone could prevent one‐ quarter of diarrheal episodes in LMICs,7 and reduce risks of respiratory infections by 6 to 44%.8 The report also shows that, to be effective, hygiene interventions must be targeted at key moments when harmful microbes are most likely to be spreading.6 This includes not only using the toilet, coughing and sneezing, but also handling and preparing food, eating food with fingers, touching surfaces frequently touched by others, laundering of clothing, touching domestic animals, disposing of waste and caring for infected family members. Although handwashing is fundamental, it must be combined with hygiene measures targeted at hand and food contact surfaces, clothing etc. as necessary to break the chain of infection. An intervention study of 685 households in South Africa reported that children under 5 from control homes were respectively 2.99-times and 4.63-time more likely to experience respiratory tract and gastrointestinal illness than households which implemented targeted hygiene (hand washing, cleaning household surfaces at critical times, and proper waste disposal).9

Almost 120 countries have finalized AMR national action plans.10 What is striking is that these plans focus on infection prevention in healthcare facilities with limited reference to hygiene in community settings. We call on health policy makers to recognize that curbing unnecessary antibiotic consumption in LMICs cannot be achieved without also developing infection prevention strategies in community settings, and take appropriate action. We believe that e-bug (www.e- bug.eu), an interactive educational resource aimed at giving school children and teachers an understanding of AMR and the role of hygiene in reducing antibiotic prescribing, provides a cost-effective template for achieving this.

Since completing the preparation of this paper, we have seen the rapid and uncontrolled emergence of a novel highly infectious strain of coronavirus. This underlines the fact that getting people to understand and adopt effective hygiene measures in their homes and everyday lives must be restored as a key feature of public health if we are to address such emergencies and sustain access to effective antibiotics in the future.

Contributors
SG and SB contributed equally to the work
Declaration of Interests
SG and SB declare that they received consultant fees by Global Hygiene Council for development of position paper on ‘Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings’.6

References
1. World Health Organization. Global antimicrobial resistance surveillance system (GLASS) report: early implementation 2020. 2020.
2. Klein EY, Van Boeckel TP, Martinez EM, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proceedings of the National Academy of Sciences 2018: 201717295.
3. Collignon P, Beggs JJ, Walsh TR, Gand S, Laxminarayan R. Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis. The Lancet Planetary Health 2018; 2(9): e398-e405.
4. Fink G, D’Acremont V, Leslie HH, Cohen J. Antibiotic exposure among children younger than 5 years in low-income and middle-income countries: a cross-sectional study of nationally representative facility-based and household-based surveys. The Lancet infectious diseases 2019.
5. Togoobaatar G,Ikeda N et al. Survey of non-prescribed use of antibiotics for children in an urban community in Mongolia. Bulletin of the World Health Organization 2010;88:930-936. doi: 10.2471/BLT.10.079004 https://www.who.int/bulletin/volumes/88/12/10-079004/en/
6. Maillard J-Y, Bloomfield S, Courvalin P, et al. Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings: A Position Paper (https://www.ajicjournal.org/article/S0196-6553(20)30209-1/fulltext AJIC online publication April 17 2020)
7. Ejemot‐Nwadiaro RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database of systematic reviews 2008; (1).
8. Rabie T, Curtis V. Handwashing and risk of respiratory infections: a quantitative systematic review. Tropical Medicine & International Health 2006; 11(3): 258-67.
9. Cole E, Hawkley M, Rubino J, et al. Comprehensive family hygiene promotion in peri-urban Cape Town: Gastrointestinal and respiratory illness and skin infection reduction in children aged under 5. South African Journal of Child Health 2012; 6(4): 109-17.
10. World Health Organization. Seventy-Second World Health Assembly. Provisional Agenda item 11.8. 1 April 2019. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_18-en.pdf. Accessed June 19, 2019.

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