Abstract The emergence of extended-spectrum β-lactamase-producing Escherichia coli (ESBL-Ec) in food animals poses a significant public health concern. While the prevalence and genetic traits of ESBL-Ec in commercial farms have been widely studied, data from backyard farms remain limited. Herein, we investigated the occurrence of ESBL-Ec among backyard animals across 12 villages in Shandong province, China. Notable variations in ESBL-Ec prevalence were observed among animal species, ranging from 78.7% in pigs, 61.5% in cattle, 50.0% in sheep, 28.6% in ducks, 14.1% in dogs, 11.5% in chickens, and 5.3% in cats. In addition, 74 ESBL-Ec were recovered from 180 flies captured in household backyards. Genomic analysis revealed substantial genetic diversity, with dominant sequence types (STs) including ST10, ST48, ST206, and ST744 identified across multiple host species. Bayesian clustering showed that all seven lineages were distributed across at least two sources, suggesting frequent inter-host transmission. Several isolates from different animal species exhibited high similarity (0–65 single nucleotide polymorphisms), indicating potential clonal spread. The bla CTX-M-14, bla CTX-M-65, and bla CTX-M-55 genes were predominant, accounting for 79.1% of detected bla CTX-M variants, and were predicted to be located on IncFIB, IncHI2, IncFII, and IncX1 plasmids. Notably, isolates from backyard animals shared STs and bla CTX-M genotypes with previously reported human and environmental isolates from the same area, suggesting potential transmission across hosts and environmental niches. These findings highlight backyard farming systems as potential reservoirs of ESBL-Ec and emphasize the need for improved antimicrobial stewardship and management practices to limit resistance spread.

ABSTRACTTools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.

An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.

Background: The health implications surrounding a mass gathering pose significant challenges to public health officials. The use of syndromic surveillance provides an ideal method for achieving the public health goals and objectives at such events. In the absence of published reports of systematic documentation of public health preparedness in mass gatherings in the local context, we describe the public health preparedness and demonstrate the operational feasibility of a tablet-based participatory syndromic surveillance among pilgrims during the annual ritual circumambulation- Panchkroshi Yatra. Methods: A real-time surveillance system was established from 2017-2019 to capture all the health consultations done at the designated points (medical camps) in the Panchkroshi yatra area of the city Ujjain in Madhya Pradesh. We also surveyed a subset of pilgrims in 2017 to gauge satisfaction with the public health measures such as sanitation, water, safety, food, and cleanliness. Results: In 2019, injuries were reported in the highest proportion (16.7%; 794/4744); most numbers of fever cases (10.6%; 598/5600) were reported in 2018, while 2017 saw the highest number of patient presentations of abdominal pain (7.73%; 498/6435). Conclusion: Public health and safety measures were satisfactory except for the need for setting up urinals along the fixed route of the circumambulation. A systematic data collection of selected symptoms among yatris and their surveillance through tablet could be established during the panchkroshi yatra, which can complement the existing surveillance for detecting early warning signals. We recommend the implementation of such tablet-based surveillance during such mass gathering events.

Antibiotic stewardship interventions such as prescribing guidelines and periodic feedback on antibiotic prescribing, can positively influence prescribing behaviour among physicians. Similarly, the volume and type of antibiotics prescribed in veterinary settings could be improved by implementing such interventions. An interrupted time-series study design was implemented to evaluate the impact on antibiotics prescribing rate among veterinarians, upon receipt of antibiotic stewardship interventions generated by a web-based platform (OPEN Stewardship).A total of 41 veterinarians were enrolled in Canada and Israel and their antibiotic prescribing data between 2019 and 2021 were obtained. After a brief pre-intervention period, veterinarians periodically received three OPEN Stewardship generated interventions in the form of feedback reports that provided relevant prescribing guidelines and feedback on the participants’ antibiotic prescribing. A multi-level generalized linear mixed-effect negative binomial model was used to compare the change in the level and the trend of antibiotic prescribing after the administration of the intervention.A decline in antibiotic prescribing rate was found among the Canadian and the Israeli veterinarians who received the feedback reports. After the receipt of the first (incidence rate ratios [IRR] = 0·88; 95% confidence interval: 0·79, 0·98), and second (IRR = 0·85; 95% confidence interval: 0·75, 0·97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. In general, after the receipt of the feedback reports, decline in antibiotics prescribing was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, following the receipt of feedback reports, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0·39 compared to that of Israeli veterinarians.This study shows that antibiotic prescribing can be improved in a veterinary setting by antibiotic stewardship interventions such as feedback on antibiotic prescribing and prescribing guidelines. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.Funding Information: This work was supported by the funding from the Canadian Institutes of Health Research (CIHR) (grant # AMR352 155212) and the Israeli Ministry of Health (grant #8762491), under the European Commission's Joint Programming Initiative on Antimicrobial Resistance (5th Joint Call).Declaration of Interests: The authors have no conflict of interest to declare.Ethics Approval Statement: This study was approved by research ethics boards in both Canada (University of Guelph REB #19-03-006), and Israel (Internal Research Review Committee of the Koret School of Veterinary Medicine – Veterinary Teaching Hospital #KSVM-VTH/05_2019).

Introduction Antimicrobial resistance (AMR) impacts the health and well-being of animals, affects animal owners both socially and economically, and contributes to AMR at the human and environmental interface. The overuse and/or inappropriate use of antibiotics in animals has been identified as one of the most important drivers of the development of AMR in animals. Effective antibiotic stewardship interventions such as feedback can be adopted in veterinary practices to improve antibiotic prescribing. However, the provision of dedicated financial and technical resources to implement such systems are challenging. The newly developed web-based Online Platform for Expanding Antibiotic Stewardship (OPEN Stewardship) platform aims to automate the generation of feedback reports and facilitate wider adoption of antibiotic stewardship. This paper describes a protocol to evaluate the usability and usefulness of a feedback intervention among veterinarians and assess its impact on individual antibiotic prescribing. Methods and analysis Approximately 80 veterinarians from Ontario, Canada and 60 veterinarians from Israel will be voluntarily enrolled in a controlled interrupted time-series study and their monthly antibiotic prescribing data accessed. The study intervention consists of targeted feedback reports generated using the OPEN Stewardship platform. After a 3-month preintervention period, a cohort of veterinarians (treatment cohort, n=120) will receive three feedback reports over the course of 6 months while the remainder of the veterinarians (n=20) will be the control cohort. A survey will be administered among the treatment cohort after each feedback cycle to assess the usability and usefulness of various elements of the feedback report. A multilevel negative-binomial regression analysis of the preintervention and postintervention antibiotic prescribing of the treatment cohort will be performed to evaluate the impact of the intervention. Ethics and dissemination Research ethics board approval was obtained at each participating site prior to the recruitment of the veterinarians. The study findings will be disseminated through open-access scientific publications, stakeholder networks and national/international meetings.

IntroductionAntimicrobial resistance undermines our ability to treat bacterial infections, leading to longer hospital stays, increased morbidity and mortality, and a mounting burden to the healthcare system. Antimicrobial stewardship is increasingly important to safeguard the efficacy of existing drugs, as few new drugs are in the developmental pipeline. While significant progress has been made with respect to stewardship in hospitals, relatively little progress has been made in the primary care setting, where the majority of antimicrobials are prescribed. OPEN Stewardship is an international collaboration to develop an automated feedback platform to improve responsible antimicrobial prescribing among primary care physicians and capable of being deployed across heterogeneous healthcare settings. We describe the protocol for an evaluation of this automated feedback intervention with two main objectives: assessing changes in antimicrobial prescribing among participating physicians and determining the usability and usefulness of the reports.Methods and analysisA non-randomised evaluation of the automated feedback intervention (OPEN Stewardship) will be conducted among approximately 150 primary care physicians recruited from Ontario, Canada and Southern Israel, based on a series of targeted stewardship messages sent using the platform. Using a controlled interrupted time-series analysis and multilevel negative binomial modelling, we will compare the antimicrobial prescribing rates of participants before and after the intervention, and also to the prescribing rates of non-participants (from the same healthcare network) during the same period. We will examine outcomes targeted by the stewardship messages, including prescribing for antimicrobials with duration longer than 7 days and prescribing for indications where antimicrobials are typically unnecessary. Participants will also complete a series of surveys to determine the usability and usefulness of the stewardship reports.Ethics and disseminationAll sites have obtained ethics committee approval to recruit providers and access anonymised prescribing data. Dissemination will occur through open-access publication, stakeholder networks and national/international meetings.

BACKGROUND: The rapidly increasing dissemination of carbapenem-resistant Enterobacteriaceae (CRE) in both humans and animals poses a global threat to public health. However, the transmission of CRE between humans and animals has not yet been well studied. OBJECTIVES: We investigated the prevalence, risk factors, and drivers of CRE transmission between humans and their backyard animals in rural China. METHODS: We conducted a comprehensive sampling strategy in 12 villages in Shandong, China. Using the household [residents and their backyard animals (farm and companion animals)] as a single surveillance unit, we assessed the prevalence of CRE at the household level and examined the factors associated with CRE carriage through a detailed questionnaire. Genetic relationships among human- and animal-derived CRE were assessed using whole-genome sequencing-based molecular methods. RESULTS: A total of 88 New Delhi metallo-beta-lactamases-type carbapenem-resistant Escherichia coli (NDM-EC), including 17 from humans, 44 from pigs, 12 from chickens, 1 from cattle, and 2 from dogs, were isolated from 65 of the 746 households examined. The remaining 12 NDM-EC were from flies in the immediate backyard environment. The NDM-EC colonization in households was significantly associated with a) the number of species of backyard animals raised/kept in the same household, and b) the use of human and/or animal feces as fertilizer. Discriminant analysis of principal components (DAPC) revealed that a large proportion of the core genomes of the NDM-EC belonged to strains from hosts other than their own, and several human isolates shared closely related core single-nucleotide polymorphisms and bla(NDM)( )genetic contexts with isolates from backyard animals. CONCLUSIONS: To our knowledge, we are the first to report evidence of direct transmission of NDM-EC between humans and animals. Given the rise of NDM-EC in community and hospital infections, combating NDM-EC transmission in backyard farm systems is needed.

Livestock-associated meticillin-resistant Staphylococcus aureus (LA-MRSA) is an increasingly important public health concern worldwide; however, data on LA-MRSA from Asian countries is scarce. As such, a comprehensive molecular epidemiological survey of S. aureus along a pork production chain and in the community was undertaken in Shandong Province, China. spa typing and whole-genome sequencing were used to survey the occurrence and potential transmission of S. aureus in various sectors, including 899 porcine samples (snout or skin swabs, carcass swabs and pork portions), 845 human nasal samples and 239 environmental samples from commercial farms, a slaughterhouse, a pork wholesale market and the surrounding community. MRSA was detected in higher frequencies in samples from two commercial pig farms (pigs, 49%; farm workers, 64%; environmental samples, 16%) than in samples from the slaughterhouse (fatteners, 8.2%; carcasses, 1.1%; operation workers, 0%; environmental samples, 3.8%), the pork wholesale market (pork, 14%; sellers, 0%) and individuals in the community (6.8%). There were significant differences in population structures, antimicrobial susceptibility profiles, and the presence of resistance and virulence genes between human- and pig-associated isolates. The phylogenetic analysis confirmed the dissemination of LA-MRSA between various segments along the pork production chain. However, MRSA of the same sequence type was not found to be disseminated between the commercial farms and the surrounding communities. Furthermore, one MRSA ST398 was observed, and a novel CC9 variant ST3597 was detected within the chain. The high MRSA carriage rates and the emergence of a new MRSA CC9 variant identified in this study highlight the need for MRSA surveillance.

ObjectiveTo develop, evaluate, and implement a universal online platform - termed OPEN Stewardship - to promote responsible antimicrobial prescribing (antimicrobial stewardship).IntroductionAntibiotic resistance is a mounting public health threat calling for action on global, national and local levels. Antibiotic use has been a major driver of increasing rates of antibiotic resistance. This has given rise to the practice of antibiotic stewardship, which seeks to reduce unnecessary antibiotic use across different care settings. Antibiotic stewardship has been increasingly applied in hospital settings, but adoption has been slow in many ambulatory care settings including primary care of humans. Uptake of antibiotic stewardship in veterinary care has been similarly limited. Audit and feedback systems of antibiotic use coupled with patterns of antibiotic use and best practice guidelines have proven useful in outpatient settings, but scale-up is limited by heterogeneous systems of care and limited resources.MethodsA multi-sectoral team with partners from Canada, Israel and Sweden is developing a web-based platform for administering antibiotic stewardship across multiple care settings and sectors, for human and animal prescribers. There are several interventions which support behaviour change and can be applied to antibiotic stewardship programs. Systematic reviews have found beneficial effects of numerous behaviour change interventions for optimizing clinical practice such as computerized reminders [1], opinion leaders as champions for change [2], and audit and feedback [3]. A recent Cochrane review [4] found that interventions to enable correct use of antibiotics improved policy compliance, and that enabling interventions that included feedback were more likely to be effective. We will use antibiotic prescribing benchmarking, focused guidelines, and local patterns of antibiotic resistance as key components that can be deployed as feedback through this antibiotic stewardship platform.The OPEN Stewardship platform will be hosted on an AWS cloud-based server using industry standard encryption. The platform will function with a central administrator who will enroll and deliver feedback to participating prescribers. This platform will be evaluated prospectively in two countries (Canada and Israel) to evaluate user experience of the feedback as well as impact on antimicrobial prescribing. The evaluation will include prescribers from both human and animal health. After the prospective evaluation, the platform will be made available online for broad multi-sectoral use.ResultsWe have designed the interface for a web-based platform for antibiotic stewardship which will be used in a multinational prospective primary care stewardship intervention in 2019 and 2020 and subsequently rolled out for broad public use (www.openasp.org). The platform layout can be seen in Figure 1. Data capture for aggregate prescriber level antibiotic use and local guidelines will be possible through both a manual graphical user interface and a dataset template upload. Antibiotic resistance data will be pulled from a companion database (www.resistanceopen.org). Administrators will be able to generate unique feedback forms containing visualizations and snapshots from antibiotic use, guidelines, and antibiotic resistance data (Figure 2). These can then be delivered by email on an individual or scheduled basis for one or multiple prescribers simultaneously. Participating prescribers will also have the option to login to view their own profile and browse antibiotic use, resistance and guidelines.ConclusionsAntibiotic stewardship needs to be adopted in a fashion that is country and context specific and not administered from the top down. With our approach we seek to empower groups from any country or care setting to provide regional and tailored stewardship feedback through an open interface. We have here demonstrated the design of an web-based antibiotic stewardship platform which will be evaluated prospectively and subsequently made available for open and broad multi-sectoral use - in keeping with a One Health approach.References1. Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD001096.2. Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD009255.3. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012 Jun 13;(6):CD000259.4. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD003543.

Introduction To effectively minimise the emergence and dissemination of antibiotic resistant bacteria, a holistic One Health approach is called for. The Sino-Swedish Integrated Multisectoral Partnership for Antibiotic Resistance Containment is a cross-sectoral and integrated project on antibiotic resistance, conducted in Shandong Province in China. This paper outlines the overall study protocol for the project. To our knowledge, this is the first research programme aiming to take a true holistic approach across multiple sectors simultaneously in China, and the first to incorporate both antibiotic use and infection prevention and control in addition to antibiotic resistance patterns. The project aims to address gaps in current knowledge and seeks to improve the situation through a system-wide intervention. By using a One Health approach we can address important research questions that individual discipline investigations are unable to. The results obtained should thus more closely reflect the world in which human health, animal health and the environment are inextricably and intimately interlinked. Methods and analysis Both quantitative and qualitative studies are included for households from 12 villages, their surrounding environment and a tertiary care hospital in a nearby town. The studies include analyses of antibiotic consumption for humans and pigs; qualitative and quantitative data on perceptions, knowledge and attitudes; faecal carriage of extended spectrum β-lactamase and carbapenemase-producing Enterobacteriaceae from pigs and humans, and occurrence in household drinking water, surface water, waste water and clinical bacterial isolates from the hospital. Carriage of methicillin-resistant Staphylococcus aureus in humans, household pigs and clinical bacterial isolates is also investigated. Furthermore, potential inter-relationships between these sources are analysed. A multifaceted One Health intervention is designed and implemented in 6 of the 12 villages. Repeated and continuous data collections take place over 2 years, where the repeated data collection is performed after 1 year of intervention. Comparisons are made between intervention and control villages, before and after the intervention. Ethics Ethics approval was obtained from the first Affiliated Hospital, College of Medicine, Zhejiang University, China, reference number 2015#185 and 2015#283.

Objective: To develop, test and study tablet-based participatory syndromic surveillance system for common infectious disease conditions at community level in Simhashta religious mass gathering in Ujjain, India, 2016.Introduction: Infectious disease surveillance for generating early warnings to enable a prompt response during mass gatherings has long been a challenge in India 1,2 as well as in other parts of the world 3,4,5. Ujjain, Madhya Pradesh in Central India hosted one of the largest religious festival in the world called ‘Simhasth kumbh mela’ on the banks of River Kshipra, where more than 50 million attendees came for holy dip during April 22 to May 21, 2016. The attendees included pilgrims (residents and visitors), observers, officials and volunteers. We developed an android application with automated summary reports and an interactive dashboard for syndromic surveillance during the gathering.Methods: We established the participatory surveillance at all 22 sectors of the festival area, and at 20 out-patient hospitals and 12 pharmacies. We trained 55 nursing and social work graduate trainees to collect data from all these settings. The data collectors visited designated spots daily during a fixed time and collected age, gender, residence and self-reported symptoms from consenting attendees during the festival period. The application automatically added date, time and location of interview to each record and data was transmitted to a web server. We monitored the data in the interactive dashboard and prepared summary report on a periodic basis. Daily summary report of self-reported symptoms by time, place and person was shared daily evening with the festival surveillance authority.Results: Of the total 93,020 invited pilgrims, 91% participated in the surveillance. Almost 90% of those were from outside the festival city, 60% were men and 57% were aged 15 to 44 years. Almost 50% of them self-reported presence of at least one symptom. Most frequently reported symptoms were dehydration due to heat (13%), cold (13%), fever (7%) and loose stool (5%). During the festival period of over one month, surveillance data indicated increasing trends of self-reported cough and fever and declining trends of self-reported dehydration (Figure-1). The designated public health authorities for the festival did make use of the information for appropriate action. This tablet-based application was able to collect, process and visualise around 2500 records per day from the community without any data loss.Conclusions: To our knowledge, this is the first report from India documenting real-time surveillance of the community using hand-held devices during a mass gathering. Despite some implementation issues and limitations in the approach and data collected, the use of digital technology provided well-timed information avoiding tedious manual work and reduced a good amount of human resources and logistics involved in reporting symptoms with a traditional paper-based method in such a large population. In retrospect, the main utility of the surveillance output was that of giving reassurance to the officials, as no major outbreaks occurred during the event. We believe that this experience and further analyses will provide input for the establishment and use of such a surveillance system during mass gatherings. The team of investigators propose improving the methods and tools for future use.

Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Veterinary Medicine, China Agricultural University, Beijing 100193, China; Public Health Agency of Sweden, Stockholm, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Animal Health and Antimicrobial Strategies, National Veterinary Institute (SVA), Uppsala, Sweden; Shandong Center for Disease Control and Prevention, Jinan, China; Institute of Microbiology and Epizootics, Centre for Infection Medicine, Department of Veterinary Medicine, Freie Universit€ at Berlin, Berlin, Germany

Abstract Objectives To characterize the mobile colistin resistance gene mcr-5 in Aeromonas hydrophila from backyard pigs in rural areas of China. Methods Pig faecal samples from 194 households were directly tested for the presence of mcr-5 by PCR assay and the phenotypic antimicrobial susceptibility profiles of the mcr-5-positive isolates were determined using the broth dilution method. The genomic location and transferability of mcr-5 were analysed by S1-PFGE with Southern blotting and DNA hybridization, and natural transformation, respectively. One strain isolated from an mcr-5-positive sample was subjected to WGS and the stability of the mcr-5-harbouring plasmid over successive generations was examined by subculturing. Results One mcr-5-positive A. hydrophila isolate showing resistance, with a colistin MIC of 4 mg/L, was isolated from a backyard pig faecal sample. mcr-5 was located on a 7915 bp plasmid designated pI064-2, which could naturally transform into a colistin-susceptible A. hydrophila strain of porcine origin and mediated colistin resistance in both the original isolate and its transformants. The plasmid backbone (3790 bp) of pI064-2 showed 81% nucleotide sequence identity to the corresponding region of the ColE2-type plasmid pAsa1 from Aeromonas salmonicida, while similar replication primases are widely distributed among aeromonads, Enterobacteriaceae and Pseudomonas species. Conclusions To the best of our knowledge, this is the first identification of the novel colistin resistance gene mcr-5 in an A. hydrophila isolate from the faeces of a backyard pig. mcr-5 is expected to be able to disseminate among different bacterial species and genera.

This study investigated the prevalence of MRSA in samples taken in households, with and without backyard pigs in villages in a rural area of Shandong Province, China. Community-associated MRSA and livestock-associated MRSA, belonging to ST59 and ST9, respectively, were identified in both humans and pigs. The genotypic and phenotypic comparison of isolates indicates that bidirectional transmission of MRSA has occurred between humans and pigs in the villages.

T he continual rise of antimicrobial resistance (AMR) was recognised by the United Nations in 2016 as a serious threat to global health and human development. Surveillance of AMR and monitoring antibiotic usage are complementary and fundamental to everyday clinical practice. They are also central to monitoring the effectiveness of national AMR prevention and containment programmes. The extent of AMR (eg, prevalence and trends, public health significance of resistance phenotypes or species) can be determined through quality laboratories interconnected in a well organised national surveillance network. Building this surveillance network remains a challenge in most countries, including those of the World Health Organization’s (WHO) South East Asia region (SEAR). A lack of information technology (IT) infrastructure is often cited as a barrier to comprehensive AMR surveillance and antibiotic usage programmes. Surveillance of AMR and antibiotic usage is complex as data generated from one single patient require analysis of several organisms. These must be tested for susceptibility to several antibiotics and combined with antibiotic treatment regimens. When surveillance data are captured by networks of clinical laboratories, only IT systems can readily manage and consolidate the information to allow timely and thorough analyses nationally and locally. Computers can be used efficiently to study the emergence of resistant genes and in systems to detect an outbreak within a hospital or nationally; for analysis of AMR clusters through antibiotic resistance profiles; for automated or manual entry of data for web based reporting that allows real time integration and timely analysis; and to provide automated reporting with the ability for space-time visualisation. Surveillance specialists in the region understand the potential benefits of automation offered through software, hardware, and communication infrastructure, although ways to set up an IT system are unclear. Major barriers to improving the quality of work are the costs of software and hardware, of maintaining systems, and of employing staff. Inadequate infrastructure also leads to limited/slow internet connectivity. We present here strategic directions and practical solutions for setting up an IT system to improve the AMR surveillance network for countries in the South East Asia region—developing their full participation in the Global AMR Surveillance System (GLASS).

Antibiotic resistance is a complex global health challenge. The recent Global Action Plan on antimicrobial resistance highlights the importance of adopting One Health approaches that can cross traditional disciplinary boundaries. We report on the early experiences of a multisectoral Sino-Swedish research project that aims to address gaps in our current knowledge and seeks to improve the situation through system-wide interventions. Our research project is investigating antibiotic use and resistance in a rural area of China through a combination of epidemiological, health systems and laboratory investigations. We reflect here on the challenges inherent in conducting long distance cross-disciplinary collaborations, having now completed data and sample collection for a baseline situation analysis. In particular, we recognise the importance of investing in aspects such as effective communication, shared conceptual frameworks and leadership. We suggest that our experiences will be instructive to others planning to develop similar international One Health collaborations.

Aims: The aim of this study was to estimate the self-reported domestic incidence of acute gastrointestinal illness in the Swedish population irrespective of route of transmission or type of pathogen causing the disease. Previous studies in Sweden have primarily focused on incidence of acute gastrointestinal illness related to consumption of contaminated food and drinking water. Methods: In May 2009, we sent a questionnaire to 4000 randomly selected persons aged 0–85 years, asking about the number of episodes of stomach disease during the last 12 months. To validate the data on symptoms, we compared the study results with anonymous queries submitted to a Swedish medical website. Results: The response rate was 64%. We estimated that a total number of 2744,778 acute gastrointestinal illness episodes (95% confidence intervals 2475,641–3013,915) occurred between 1 May 2008 and 30 April 2009. Comparing the number of reported episodes with web queries indicated that the low number of episodes during the first 6 months was an effect of seasonality rather than recall bias. Further, the result of the recall bias analysis suggested that the survey captured approximately 65% of the true number of episodes among the respondents. Conclusions: The estimated number of Swedish acute gastrointestinal illness cases in this study is about five times higher than previous estimates. This study provides valuable information on the incidence of gastrointestinal symptoms in Sweden, irrespective of route of transmission, indicating a high burden of acute gastrointestinal illness, especially among children, and large societal costs, primarily due to production losses.

BackgroundInfectious disease surveillance has long been a challenge for countries like India, where 75% of the health care services are private and consist of both formal and informal health care providers. Infectious disease surveillance data are regularly collected from governmental and qualified private facilities, but not from the informal sector. This study describes a mobile-based syndromic surveillance system and its application in a resource-limited setting, collecting data on patients' symptoms from formal and informal health care providers.DesignThe study includes three formal and six informal health care providers from two districts of Madhya Pradesh, India. Data collectors were posted in the clinics during the providers' working hours and entered patient information and infectious disease symptoms on the mobile-based syndromic surveillance system.ResultsInformation on 20,424 patients was collected in the mobile-based surveillance system. The five most common (overlapping) symptoms were fever (48%), cough (38%), body ache (38%), headache (37%), and runny nose (22%). During the same time period, the government's disease surveillance program reported around 22,000 fever cases in one district as a whole. Our data – from a very small fraction of all health care providers – thus highlight an enormous underreporting in the official surveillance data, which we estimate here to capture less than 1% of the fever cases. Additionally, we found that patients from more than 600 villages visited the nine providers included in our study.ConclusionsThe study demonstrated that a mobile-based system can be used for disease surveillance from formal and informal providers in resource-limited settings. People who have not used smartphones or even computers previously can, in a short timeframe, be trained to fill out surveillance forms and submit them from the device. Technology, including network connections, works sufficiently for disease surveillance applications in rural parts of India. The data collected may be used to better understand the health-seeking behaviour of those visiting informal providers, as they do not report through any official channels. We also show that the underreporting to the government can be enormous.

SUMMARY An evaluation was conducted to determine which syndromic surveillance tools complement traditional surveillance by serving as earlier indicators of influenza activity in Sweden. Web queries, medical hotline statistics , and school absenteeism data were evaluated against two traditional surveillance tools. Cross-correlation calculations utilized aggregated weekly data for all-age, nationwide activity for four influenza seasons, from 2009/2010 to 2012/2013. The surveillance tool indicative of earlier influenza activity, by way of statistical and visual evidence, was identified. The web query algorithm and medical hotline statistics performed equally well as each other and to the traditional surveillance tools. School absenteeism data were not reliable resources for influenza surveillance. Overall, the syndromic surveillance tools did not perform with enough consistency in season lead nor in earlier timing of the peak week to be considered as early indicators. They do, however, capture incident cases before they have formally entered the primary healthcare system.