Conference Material > Slide Presentation
Finger F, Mimbu N, Ratnayake R, Meakin S, Bahati JB, et al.
MSF Scientific Day International 2024. 16 May 2024; DOI:10.57740/tC1av3293
Conference Material > Abstract
Finger F, Mimbu N, Ratnayake R, Meakin S, Bahati JB, et al.
MSF Scientific Day International 2024. 16 May 2024; DOI:10.57740/hfok99y
INTRODUCTION
The risk of cholera outbreaks spreading rapidly and extensively is substantial. Case-area targeted interventions (CATI) are based on the premise that early detection can trigger a rapid, localised response in the high-risk radius around case-households to reduce transmission sufficiently to extinguish the outbreak or reduce its spread, as opposed to relying on resource-intensive mass interventions. Current evidence supports intervention in a high-risk spatiotemporal zone of up to 200 m around case- households for 5 days after case presentation. Médecins Sans Frontières (MSF) started delivering CATI to people living within these high-risk rings during outbreaks in the Democratic Republic of the Congo in April 2022. We present the results of a prospective observational study designed to evaluate the CATI strategy, measuring effectiveness, feasibility, timeliness, and resource requirements, and we extract operational learnings.
METHODS
Between April 2022 and April 2023, MSF delivered the holistic CATI package in five cholera-affected regions. The package incorporated key interventions combining household-level water, sanitation, and hygiene measures, health promotion, antibiotic chemoprophylaxis, and single-dose oral cholera vaccination (OCV). We conducted a survey in each ring roughly 3 weeks after the intervention to estimate coverage and uptake of the different components. We measured effectiveness by comparing cholera incidence in the first 30 days between rings with different delays from primary case presentation to CATI implementation, using a Bayesian regression model and adjusting for covariates such as population density, age, and access to water and sanitation.
RESULTS
During the study, four MSF operational sections implemented 118 CATI rings in five sites. The median number of households per ring was 70, the median OCV coverage was 85%, and the median time from presentation of the primary case to CATI implementation and to vaccination was 2 days and 3 days, respectively. These characteristics varied widely across sites and between rings. No secondary cases were observed in 81 (78%) of 104 rings included in the analysis, and we noted a (non- significant) decreasing trend in the number of secondary cases with decreasing delay to CATI implementation, e.g. 1.3 cases [95% CrI 0.01–4.9] for CATI implementation starting within 5 days from primary case presentation, and 0.5 cases [0.03–2.0] for CATI starting within 2 days.
CONCLUSION
Our results show that rapid implementation of CATI with vaccination is feasible in complex contexts. The number of secondary cases was low when CATI was implemented promptly. This highly targeted approach may be an effective strategy to quickly protect people most at risk and is resource- efficient if implemented early to extinguish localised outbreaks before they require mass interventions.
The risk of cholera outbreaks spreading rapidly and extensively is substantial. Case-area targeted interventions (CATI) are based on the premise that early detection can trigger a rapid, localised response in the high-risk radius around case-households to reduce transmission sufficiently to extinguish the outbreak or reduce its spread, as opposed to relying on resource-intensive mass interventions. Current evidence supports intervention in a high-risk spatiotemporal zone of up to 200 m around case- households for 5 days after case presentation. Médecins Sans Frontières (MSF) started delivering CATI to people living within these high-risk rings during outbreaks in the Democratic Republic of the Congo in April 2022. We present the results of a prospective observational study designed to evaluate the CATI strategy, measuring effectiveness, feasibility, timeliness, and resource requirements, and we extract operational learnings.
METHODS
Between April 2022 and April 2023, MSF delivered the holistic CATI package in five cholera-affected regions. The package incorporated key interventions combining household-level water, sanitation, and hygiene measures, health promotion, antibiotic chemoprophylaxis, and single-dose oral cholera vaccination (OCV). We conducted a survey in each ring roughly 3 weeks after the intervention to estimate coverage and uptake of the different components. We measured effectiveness by comparing cholera incidence in the first 30 days between rings with different delays from primary case presentation to CATI implementation, using a Bayesian regression model and adjusting for covariates such as population density, age, and access to water and sanitation.
RESULTS
During the study, four MSF operational sections implemented 118 CATI rings in five sites. The median number of households per ring was 70, the median OCV coverage was 85%, and the median time from presentation of the primary case to CATI implementation and to vaccination was 2 days and 3 days, respectively. These characteristics varied widely across sites and between rings. No secondary cases were observed in 81 (78%) of 104 rings included in the analysis, and we noted a (non- significant) decreasing trend in the number of secondary cases with decreasing delay to CATI implementation, e.g. 1.3 cases [95% CrI 0.01–4.9] for CATI implementation starting within 5 days from primary case presentation, and 0.5 cases [0.03–2.0] for CATI starting within 2 days.
CONCLUSION
Our results show that rapid implementation of CATI with vaccination is feasible in complex contexts. The number of secondary cases was low when CATI was implemented promptly. This highly targeted approach may be an effective strategy to quickly protect people most at risk and is resource- efficient if implemented early to extinguish localised outbreaks before they require mass interventions.
Conference Material > Poster
Teklehaimanot BF, Filina Y, Keating P, Morales AM, Sahelie B, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/QJQJ8Q
Journal Article > ResearchFull Text
PLOS One. 27 July 2019; Volume 14; DOI:10.1371/journal.pone.0219002
Nair MM, Tripathi S, Mazumdar S, Mahajan R, Harshana A, et al.
PLOS One. 27 July 2019; Volume 14; DOI:10.1371/journal.pone.0219002
Background
Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal.
Materials and methods
We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner.
Results
Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another.
Conclusions
A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.
Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal.
Materials and methods
We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner.
Results
Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another.
Conclusions
A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.
Conference Material > Abstract
Mahajan R, Edwards T, Shandilya C, Kashyap V, Marino E, et al.
MSF Scientific Days International 2021: Research. 19 May 2021
INTRODUCTION
Limited data exist to inform community management of children with moderate acute malnutrition (MAM), who are normally excluded from severe acute malnutrition (SAM) treatment programmes. This study was conducted to generate evidence of longitudinal outcomes in children aged 6-59 months with MAM (defined as mid-upper arm circumference, MUAC, 115-124mm), without interventional supplementary feeding. In this study, children in India with MAM were followed up for six months to better understand their long-term nutritional outcomes.
METHODS
We carried out a multicentre prospective longitudinal observational study, nested within a randomized trial, in Jharkhand, India. Children with MAM were enrolled over a 12-month period in 46 centres in Jharkhand state, and followed up for six months while attending government integrated child development services. Anthropometric, clinical and sociodemographic characteristics were recorded at enrolment. The primary outcome was deterioration to SAM (MUAC <115 or bilateral pitting oedema) or death within six months. Risk factors for this outcome were investigated.
ETHICS
This study was approved by the MSF Ethical Review Board and by the ethics review boards of the Rajendra Institute of Medical Sciences, Ranchi and Jawaharlal Nehru University, New Delhi, India, and London School of Hygiene & Tropical Medicine, UK. Clinical Trial Registry-India number, CTRI/2017/12/010743.
RESULTS
Of 971 children enrolled, 98 (10.0%) were lost to follow-up, mainly linked with seasonal migration; 12 were seen outside of the six-month window (three before day 168 and nine after day 210). Of 861 children included in the analysis, 595 (61.3%) were female, with a mean age of 16.0 months (standard deviation 9.7). At enrolment 333 (34.3%) had MUAC 115-119mm, 430 (44.3%) had weight-for-height z-score (WHZ) <-3 and 431 (44%) had a WHZ of -2 to-3. Within six months, 133 (15.5%) deteriorated to SAM or died (95% confidence interval, CI: 13.1-18.0%; five deaths), of whom 97 children deteriorated to poor outcome (SAM or death) by three months (11.3%, with one death; representing over two thirds of those deteriorating to poor outcome by six months). In an adjusted logistic regression model, with an interaction between MUAC at enrolment (115-119, 120-124mm) and age (6-11, 12-23, ≥24 months), significantly increased odds of deterioration to SAM or death were seen amongst those with MUAC 115-119mm in all age groups (p≤0.02) and in those under one year with MUAC<125mm. After adjustment, there was no evidence of associations with socio-demographic factors, breastfeeding or WHZ<-3.
CONCLUSION
Children aged under 1 year and children with MUAC 115-119mm should be closely monitored, considering high MAM burdens in India. Increasing the MUAC admission criterion and/or targeted interventions for MAM children at higher risk could be considered. WHZ<-3 not already MUAC<115mm does not appear to be a risk factor for deterioration.
Limited data exist to inform community management of children with moderate acute malnutrition (MAM), who are normally excluded from severe acute malnutrition (SAM) treatment programmes. This study was conducted to generate evidence of longitudinal outcomes in children aged 6-59 months with MAM (defined as mid-upper arm circumference, MUAC, 115-124mm), without interventional supplementary feeding. In this study, children in India with MAM were followed up for six months to better understand their long-term nutritional outcomes.
METHODS
We carried out a multicentre prospective longitudinal observational study, nested within a randomized trial, in Jharkhand, India. Children with MAM were enrolled over a 12-month period in 46 centres in Jharkhand state, and followed up for six months while attending government integrated child development services. Anthropometric, clinical and sociodemographic characteristics were recorded at enrolment. The primary outcome was deterioration to SAM (MUAC <115 or bilateral pitting oedema) or death within six months. Risk factors for this outcome were investigated.
ETHICS
This study was approved by the MSF Ethical Review Board and by the ethics review boards of the Rajendra Institute of Medical Sciences, Ranchi and Jawaharlal Nehru University, New Delhi, India, and London School of Hygiene & Tropical Medicine, UK. Clinical Trial Registry-India number, CTRI/2017/12/010743.
RESULTS
Of 971 children enrolled, 98 (10.0%) were lost to follow-up, mainly linked with seasonal migration; 12 were seen outside of the six-month window (three before day 168 and nine after day 210). Of 861 children included in the analysis, 595 (61.3%) were female, with a mean age of 16.0 months (standard deviation 9.7). At enrolment 333 (34.3%) had MUAC 115-119mm, 430 (44.3%) had weight-for-height z-score (WHZ) <-3 and 431 (44%) had a WHZ of -2 to-3. Within six months, 133 (15.5%) deteriorated to SAM or died (95% confidence interval, CI: 13.1-18.0%; five deaths), of whom 97 children deteriorated to poor outcome (SAM or death) by three months (11.3%, with one death; representing over two thirds of those deteriorating to poor outcome by six months). In an adjusted logistic regression model, with an interaction between MUAC at enrolment (115-119, 120-124mm) and age (6-11, 12-23, ≥24 months), significantly increased odds of deterioration to SAM or death were seen amongst those with MUAC 115-119mm in all age groups (p≤0.02) and in those under one year with MUAC<125mm. After adjustment, there was no evidence of associations with socio-demographic factors, breastfeeding or WHZ<-3.
CONCLUSION
Children aged under 1 year and children with MUAC 115-119mm should be closely monitored, considering high MAM burdens in India. Increasing the MUAC admission criterion and/or targeted interventions for MAM children at higher risk could be considered. WHZ<-3 not already MUAC<115mm does not appear to be a risk factor for deterioration.
Journal Article > ResearchFull Text
PLoS Curr. 2 February 2018; Volume 10; ecurrents.dis.bb5f22928e631dff9a80377309381feb.; DOI:10.1371/currents.dis.bb5f22928e631dff9a80377309381
Pereira AL, Southgate R, Ahmed H, Oconner P, Cramond V, et al.
PLoS Curr. 2 February 2018; Volume 10; ecurrents.dis.bb5f22928e631dff9a80377309381feb.; DOI:10.1371/currents.dis.bb5f22928e631dff9a80377309381
In 2015, following an influx of population into Kobanê in northern Syria, Médecins Sans Frontières (MSF) in collaboration with the Kobanê Health Administration (KHA) initiated primary healthcare activities. A vaccination coverage survey and vaccine-preventable disease (VPD) risk analysis were undertaken to clarify the VPD risk and vaccination needs. This was followed by a measles Supplementary Immunization Activity (SIA). We describe the methods and results used for this prioritisation activity around vaccination in Kobanê in 2015.
Conference Material > Abstract
Burza S, Mahajan R, Edwards T, Shandilya C, Pereira AL, et al.
MSF Scientific Days International 2021: Research. 19 May 2021
INTRODUCTION
Most interventions for community-based management of severe acute malnutrition (CM-SAM) worldwide utilise mid-upper arm circumference (MUAC) <115mm for eligibility and ≥125mm for discharge. However, this discharge criterion is based on very limited evidence, with no data from the Indian subcontinent. India, home to over one-third of malnourished children globally, provides facility-based care based on weight-for-height with no guidelines for CM-SAM. Previous observational data suggests relapse in children reaching ≥120mm is similar to that for ≥125mm, whilst duration of treatment required to achieve ≥125mm is nearly doubled, with higher default rates. This trial in the state of Jharkhand, India investigated whether discharge with MUAC ≥120mm is non-inferior to MUAC ≥125mm for risk of relapse to SAM or death.
METHODS
We conducted a multicentre randomized controlled noninferiority trial for SAM children aged between six and 59 months across 46 centres in Jharkhand, India. Over 12 months, children with MUAC<115mm and without oedema at admission were randomly allocated to be discharged either at MUAC ≥120 mm or MUAC ≥125mm. Endpoints were status at three months (primary) and six months (secondary) after reaching their allocated discharge MUAC. Non-inferiority was concluded if the upper bound (UB) of a one-sided 95% confidence interval was within a pre-defined 13% margin, based on pragmatic operational indicators.
ETHICS
This study was approved by the MSF Ethics Review Board and by the Ethical Review Boards of the Rajendra Institute of Medical Sciences, Ranchi and Jawaharlal Nehru University, New Delhi, India, and London School of Hygiene & Tropical Medicine, UK. Clinical Trials Registry – India number, CTRI/2017/12/010743.
RESULTS
Of 633 children enrolled, 316 were allocated to the standard of care arm (discharge at ≥125mm) and 317 to the ≥120mm arm. No significant clinical-epidemiological differences were detected between cohorts not reaching their allocated discharge MUAC, however there was a higher proportion of treatment non-response (17.5% vs 9%) in the 125mm arm. Of 194 and 236 children reaching discharge criteria in each arm respectively, 176 and 216 were eligible for intention-to-treat analysis. For the standard of care arm, 42% of children were male, with a mean age of 12.6 months (standard deviation, SD; 7.9); for the ≥120mm arm, 41% were male, with a mean age of 12.1 months (SD; 7.1). Overall, non-inferiority was observed within three months; unadjusted risk difference (RD) 6.4%, 95% UB=11.6%, ≥125mm: n=14 (8.0%; 14 relapse, 0 death), ≥120mm: n=31 (14.4%; 30 relapse, 1 death). In pre-specified stratified analyses, non-inferiority was observed in children with MUAC 110-114mm at enrolment (N=285, RD 2.0%, 95% UB 7.5%); however, inferiority was observed with MUAC<110mm (N=107, RD 17.5%, 95% UB 29.0%). In stratified secondary outcome analyses at six months, conclusions were similar.
CONCLUSION
Using a non-inferiority margin of 13%, results support ≥120mm as a discharge criterion in children admitted with MUAC 110-114mm, but not in those with MUAC<110mm. This margin in children discharged earlier needs to be balanced against greater capacity for programmatic coverage. Considering over two thirds of children are admitted with MUAC 110-114mm, defining discharge criteria by admission MUAC may have important implications on increasing capacity and cost-effectiveness of CM-SAM programming in India.
Most interventions for community-based management of severe acute malnutrition (CM-SAM) worldwide utilise mid-upper arm circumference (MUAC) <115mm for eligibility and ≥125mm for discharge. However, this discharge criterion is based on very limited evidence, with no data from the Indian subcontinent. India, home to over one-third of malnourished children globally, provides facility-based care based on weight-for-height with no guidelines for CM-SAM. Previous observational data suggests relapse in children reaching ≥120mm is similar to that for ≥125mm, whilst duration of treatment required to achieve ≥125mm is nearly doubled, with higher default rates. This trial in the state of Jharkhand, India investigated whether discharge with MUAC ≥120mm is non-inferior to MUAC ≥125mm for risk of relapse to SAM or death.
METHODS
We conducted a multicentre randomized controlled noninferiority trial for SAM children aged between six and 59 months across 46 centres in Jharkhand, India. Over 12 months, children with MUAC<115mm and without oedema at admission were randomly allocated to be discharged either at MUAC ≥120 mm or MUAC ≥125mm. Endpoints were status at three months (primary) and six months (secondary) after reaching their allocated discharge MUAC. Non-inferiority was concluded if the upper bound (UB) of a one-sided 95% confidence interval was within a pre-defined 13% margin, based on pragmatic operational indicators.
ETHICS
This study was approved by the MSF Ethics Review Board and by the Ethical Review Boards of the Rajendra Institute of Medical Sciences, Ranchi and Jawaharlal Nehru University, New Delhi, India, and London School of Hygiene & Tropical Medicine, UK. Clinical Trials Registry – India number, CTRI/2017/12/010743.
RESULTS
Of 633 children enrolled, 316 were allocated to the standard of care arm (discharge at ≥125mm) and 317 to the ≥120mm arm. No significant clinical-epidemiological differences were detected between cohorts not reaching their allocated discharge MUAC, however there was a higher proportion of treatment non-response (17.5% vs 9%) in the 125mm arm. Of 194 and 236 children reaching discharge criteria in each arm respectively, 176 and 216 were eligible for intention-to-treat analysis. For the standard of care arm, 42% of children were male, with a mean age of 12.6 months (standard deviation, SD; 7.9); for the ≥120mm arm, 41% were male, with a mean age of 12.1 months (SD; 7.1). Overall, non-inferiority was observed within three months; unadjusted risk difference (RD) 6.4%, 95% UB=11.6%, ≥125mm: n=14 (8.0%; 14 relapse, 0 death), ≥120mm: n=31 (14.4%; 30 relapse, 1 death). In pre-specified stratified analyses, non-inferiority was observed in children with MUAC 110-114mm at enrolment (N=285, RD 2.0%, 95% UB 7.5%); however, inferiority was observed with MUAC<110mm (N=107, RD 17.5%, 95% UB 29.0%). In stratified secondary outcome analyses at six months, conclusions were similar.
CONCLUSION
Using a non-inferiority margin of 13%, results support ≥120mm as a discharge criterion in children admitted with MUAC 110-114mm, but not in those with MUAC<110mm. This margin in children discharged earlier needs to be balanced against greater capacity for programmatic coverage. Considering over two thirds of children are admitted with MUAC 110-114mm, defining discharge criteria by admission MUAC may have important implications on increasing capacity and cost-effectiveness of CM-SAM programming in India.
Conference Material > Abstract
Nair MM, Tripathi S, Mazumdar S, Mahajan R, Harshana A, et al.
MSF Scientific Days UK 2019: Research. 9 May 2019
INTRODUCTION
Inappropriate antibiotic use is thought to be widespread, particularly in less well-regulated healthcare systems, and contributes to antimicrobial resistance. Patients may interact with both formal and informal healthcare providers in accessing primary healthcare, but the level of knowledge, attitudes, and practices (KAP) of both providers and patients in relation to appropriateness of prescribing has not been well documented in India.
METHODS
We aimed to use a mixed methods approach to explore the prescribing patterns of informal and formal healthcare providers in West Bardhaman district of West Bengal, India. We surveyed 384 participants using convenience sampling (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) using a validated KAP questionnaire, adapted to the local context. In order to triangulate data, we also conducted 28, semi-structured, in-depth interviews with providers and community members. Qualitative data was analysed using the framework method in an inductive and deductive manner, while quantitative data was collated in Excel and analysed using SPSS. Questions used 5-point Likert scales, with maximum possible scores of 32, 45, and 20 in the knowledge, attitudes, and practice sections respectively, and a maximum total composite score of 97. We calculated a percent composite score across all categories by dividing the mean score with the maximum possible score, and used multivariate logistic regression analysis to estimate the odds of having a low composite score (<60) based on occupation by comparing allopathic doctors (referent category) with all other study participants, adjusted for age and gender.
ETHICS
This study was approved by the Ethics Committee of the Calcutta School of Tropical Medicine, Kolkata, India, and the MSF Ethics Review Board.
RESULTS
We found substantial dissonance between knowledge and practice amongst allopathic doctors, who scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed worst regarding practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n=82) reported prescribing them in this situation.
19 (6.6%) non-doctors (including eight informal health providers, 8.3%), three nurses (3.1%), and eight pharmacy workers (8.3%) received low overall composite scores for KAP, as compared to doctors (n=1; 1%; OR 10.4, 95% CI 5.4-20.0, p<0.01). Over 95% of informal health providers, nursing staff and pharmacy shopkeepers stated knowledge of antibiotics was important, even though none were legally permitted to prescribe. Only 42 (43.8%) doctors and 17 (17.7%) pharmacy shopkeepers correctly identified gentamicin as an antibiotic contraindicated in pregnancy. 30.8% (118) of all providers and 56 out of 96 (58%) of all informal providers described pharmaceutical company representatives as a major source of information about antibiotics. Healthcare providers described company representatives as having extensive networks, with informal providers reporting that attendance at antibiotic marketing conferences was common. Community members reported actively seeking “potent” medicines from providers, and frequent switching of providers if they perceived medications to be inadequate.
CONCLUSION
Current initiatives aimed at tackling antimicrobial resistance in Asia focus on surveillance systems, regulation of antibiotic sales, and on national guidelines for use, but fail to take into account patient perceptions and the relationships between different providers and the role of pharmaceutical company representatives. We highlight ways in which pharmaceutical company representatives play roles in networking with informal providers.
CONFLICTS OF INTEREST: None declared.
Mohit Nair is a qualitative research manager with MSF, India, and holds a Master’s in Public Health from Harvard T.H. Chan School of Public Health. Previous work has focused on perceptions of care amongst advanced HIV patients in Bihar, drivers of antibiotic use in West Bengal, and quality of life for HIV-kala-azar patients in Bihar. Prior to joining MSF, Mohit was a consultant for Save the Children, in Laos, assessing gaps in primary healthcare and developing action plans for children with disabilities.
Inappropriate antibiotic use is thought to be widespread, particularly in less well-regulated healthcare systems, and contributes to antimicrobial resistance. Patients may interact with both formal and informal healthcare providers in accessing primary healthcare, but the level of knowledge, attitudes, and practices (KAP) of both providers and patients in relation to appropriateness of prescribing has not been well documented in India.
METHODS
We aimed to use a mixed methods approach to explore the prescribing patterns of informal and formal healthcare providers in West Bardhaman district of West Bengal, India. We surveyed 384 participants using convenience sampling (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) using a validated KAP questionnaire, adapted to the local context. In order to triangulate data, we also conducted 28, semi-structured, in-depth interviews with providers and community members. Qualitative data was analysed using the framework method in an inductive and deductive manner, while quantitative data was collated in Excel and analysed using SPSS. Questions used 5-point Likert scales, with maximum possible scores of 32, 45, and 20 in the knowledge, attitudes, and practice sections respectively, and a maximum total composite score of 97. We calculated a percent composite score across all categories by dividing the mean score with the maximum possible score, and used multivariate logistic regression analysis to estimate the odds of having a low composite score (<60) based on occupation by comparing allopathic doctors (referent category) with all other study participants, adjusted for age and gender.
ETHICS
This study was approved by the Ethics Committee of the Calcutta School of Tropical Medicine, Kolkata, India, and the MSF Ethics Review Board.
RESULTS
We found substantial dissonance between knowledge and practice amongst allopathic doctors, who scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed worst regarding practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n=82) reported prescribing them in this situation.
19 (6.6%) non-doctors (including eight informal health providers, 8.3%), three nurses (3.1%), and eight pharmacy workers (8.3%) received low overall composite scores for KAP, as compared to doctors (n=1; 1%; OR 10.4, 95% CI 5.4-20.0, p<0.01). Over 95% of informal health providers, nursing staff and pharmacy shopkeepers stated knowledge of antibiotics was important, even though none were legally permitted to prescribe. Only 42 (43.8%) doctors and 17 (17.7%) pharmacy shopkeepers correctly identified gentamicin as an antibiotic contraindicated in pregnancy. 30.8% (118) of all providers and 56 out of 96 (58%) of all informal providers described pharmaceutical company representatives as a major source of information about antibiotics. Healthcare providers described company representatives as having extensive networks, with informal providers reporting that attendance at antibiotic marketing conferences was common. Community members reported actively seeking “potent” medicines from providers, and frequent switching of providers if they perceived medications to be inadequate.
CONCLUSION
Current initiatives aimed at tackling antimicrobial resistance in Asia focus on surveillance systems, regulation of antibiotic sales, and on national guidelines for use, but fail to take into account patient perceptions and the relationships between different providers and the role of pharmaceutical company representatives. We highlight ways in which pharmaceutical company representatives play roles in networking with informal providers.
CONFLICTS OF INTEREST: None declared.
Mohit Nair is a qualitative research manager with MSF, India, and holds a Master’s in Public Health from Harvard T.H. Chan School of Public Health. Previous work has focused on perceptions of care amongst advanced HIV patients in Bihar, drivers of antibiotic use in West Bengal, and quality of life for HIV-kala-azar patients in Bihar. Prior to joining MSF, Mohit was a consultant for Save the Children, in Laos, assessing gaps in primary healthcare and developing action plans for children with disabilities.
Conference Material > Slide Presentation
Mahajan R, Edwards T, Shandilya C, Kashyap V, Marino E, et al.
MSF Scientific Days International 2021: Research. 19 May 2021