AMR at human animal interface: PGIMER research updates Dr. Neelam m Taneja Professor and In-charg ge Enteric Laboratory Postgraduate Institute of Medi ical Education and Research Chand igarh 8.2017
PGIM PGIM MER MER 2000 bed tertiary care referral centre in Chandigarh, North India Caters to patients from seven adjoining States (Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir, western parts of Uttar Pradesh, Uttaranchal, and some parts of Rajasthan) thus representing a large geographical area 2,42,3501 outpatients and 87973 admission in 2016 admission in 2016 8.2017
Enteri Enteri ic Lab ic Lab Diagnostic(conventional as well Diagnostic(conventional as well as molecular) as molecular) – Urine and Stool samples – Load- 45000 /year Load- 45000 /year – NABL accreditation Surveillance and referral servi Surveillance and referral servi ices investigating and managin ices investigating and managin outbreaks of cholera, and food p poisoning in this geographic area Research Research in the field of diarr in the field of diarr rhea , food borne infections an rhea food borne infections an urinary tract infections with spe ecial focus on epidemiology an drug resistance and pathogenes g p g sis 8.2017
Antimicrobial resistance in Ente Antimicrobial resistance in Ente eric and Uro pathogens is bein eric and Uro pathogens is bein studied at community and hosp pital level by both phenotypic an molecular assays y Conventional Culture for Salmon nella, Shigella ,Vibrio cholerae ,Campylobacter ,STEC and Yers sinia,C.difficle Antigen detection for STEC, Cam mpylobacter,C difficle Molecular tests – Multiplex PCR for diarrhoeag enic E.coli – Shigella PCR g – STEC PCR – Campylobacter PCR Campylobacter PCR Rapid dipstick for cholera and dy ysentery 8.2017
Food borne e Pathogens Vibrios, Bacillus cereus, Shigella ,Aeromonas, Pleisomonas, Yersinia Campylobacter, Staphyloccocus au Campylobacter, Staphyloccocus au ureus , Listeria, testing of milk samples ureus , Listeria, testing of milk samples by total plate counts, methylene blue e test , turbidity test , coliform tests fo milk, full water testing for coliform ms, E coli , Enterococci, V. cholerae testing of water directly for dia arrhoeagenic E.coli using in house protocols (PCR). t l (PCR) Molecular assays to detect directly f y y from food samples p Special food (RUTF) which was developed to treat malnutrition was tested by us for component analysis es ed by us o co po e a a ys s s and shelf life of the prepared food s a d s e e o e p epa ed ood Receive request from Government t labs for testing commercial food and water samples water samples .2017
Capacity for molecular epidemio ology – AFLP – PFGE – MLVA – Ribotyping – Plasmid typing Plasmid typing – Rep-PCR and RAPD – MLST MLST – WGS 8.2017
Public Health Public Health h Contribution h Contribution blic health role and surveillance Investigated 25 outbreaks of cholera and gas troenteritis. Visit the area and collect water samples sto Visit the area and collect water samples, sto ol samples and study the factors responsible ol samples and study the factors responsible cholera. Due to fast identification of source of wate Due to fast identification of source of wate er contamination, we could control the chol er contamination we could control the chol outbreaks in a week . We are also studying the molecular epid W l t d i th l l id demiology of V. cholerae causing the rec d i l f V i th h l epidemics in our region byAFLP, ribotyping a and PFGE. .2017
WHO APW project a p j and DFC rengthening district public health laboratories for la g g p aboratory surveillance of communicable diseases of y tbreak potential m of phase 1 To assist in capacity building of the district laboratories s. • Punjab‐Moga, Bhatinda, Hoshiarpur,Sangrur • Haryana‐Ambala, Faridabad, Bhiwani, Panchkula • Uttarakhand‐Dehradun, Haridwar, Tehri Garhwal,Pauri To assist in technical operations & provision of resource To assist in technical operations & provision of resource es needed to ensure required quality of laboratory es needed to ensure required quality of laboratory procedures. To formulate a framework for establishment of quality control & quality assessment schemes in these laboratories. To periodically visit the laboratories at district level & m monitor the progress 3.08.2017
WHO APW project a WHO APW project a and DFC-Phase 2 and DFC Phase 2 Stool referral system :A total of 336 stool samples were colle Stool referral system :A total of 336 stool samples were colle ected and submitted from the following centers‐ Moga (N=58 ected and submitted from the following centers Moga (N=58 , Ambala (N=38), Sangrur (N=17), Panchkula (N=72) and Pau uri (N=32) DPHLs. These samples were collected from PHC and DPHL level by active surveillance Most of the samples (231, 68%) were sent by local couriers a and 95% were received in proper conditions, though some were not sent in double packaging t t i d bl k i Outbreaks of cholera were reported from Ambala, Moga an nd Panchkula ,samples were also submitted from suspected cases from Sangrur Uttarakhand and Chandigarh for confir cases from Sangrur , Uttarakhand and Chandigarh for confir rmation rmation . Fourteen outbreaks of diarrhoea / food poisoning occurred d in 2010 and 2011 followed by 4 outbreaks each of dengue chickenpox, measles and viral fever , 3 of jaundice , 2 of ty yphoid one each of viral encephalitis and rubella . Tool for assessment of biosafety in laboratory y y The culture facilities were established at the following cent tres‐ Ambala, Bhiwani, Haridwar , Pauri. Quality assurance panels were sent and responded 3.08.2017
Food born ne illnesses F Foodborne illness are of serious conce db ill f i ern to public health worldwide bli h l h ld id 90% bacterial infections followed by p parasitic and viral Major bacterial pathogens : Campyl lobacter, Salmonella, Diarrhoeagenic coli, Listeria, Yersinia, Shigella, Vibrio , etc. Salmonella is the leading cause of death followed by Campylobacter (C Alert;2008) Al t 2008) Both occur in intestinal tract of sheep Both occur in intestinal tract of sheep p goat pigs and poultry p, goat, pigs and poultry
E. coli is commensal microbiota b ut some may be pathogenic strain i.e. EPEC, ETEC , EAEC, EIEC, STEC Transfer of virulence genes can occ g cur through lateral gene transfer g g Diarrhoeagenic E. coli caused maxi Diarrhoeagenic E. coli caused maxi imum hospitalizations imum hospitalizations Contaminated food and water are Contaminated food and water are main sources of infections main sources of infections
Indian s scenario Burden of foodborne diseases is un Burden of foodborne diseases is un nknown nknown No surveillance system y No national database of epide miology of common food borne pathogens Foodborne infections occur as spo db f radic cases and also as outbreaks d d l b k U d Underreporting ti of f foodborne f db outbreaks tb k and d cause i is rarely l established. Foodborne gastroe enteritis is clubbed with acute diarrhoea and is not notifiable
In our region too foodborne illn In our region too foodborne illn nesses are very common but no nesses are very common but no investigated or reported In a study conducted by us, in colla aboration with WHO, we found tha every year 1,400 to 31,000 cases o y y , , of suspected food‐ and‐water‐borne p infections were being reported at the district public health lab (DPHLs) across Punjab, Haryana an nd Uttarakhand Every year one to three outbre eaks of food poisoning reportedly occurred at the DPHLs (Unpublishe d t th DPHL (U bli h ed data PGIMER) Almost all of these d d t PGIMER) Al t ll f th go uninvestigated
How antibiotics in li ivestock affect us used for prophylactic, therapeutic and g used for prophylactic therapeutic and g rowth promotion rowth promotion suppress gut flora leaving more nutrien nts to be absorbed by animal leading to greater gain in weight greater gain in weight Most of the antibiotic classes are the on es used for humans Overuse has lead to emergence of antib Overuse has lead to emergence of antib iotic resistance iotic resistance Residues of these antibiotics remain ac ctive in animals for certain time and are also excreted in faeces Consumption of trace levels of these res sidues in foods may alter human intestina microflora and cause resistance gene tra ansfer Low levels of abs released in environm ment accumulate and affect bacteria and cause transfer of resistance genes 2017
Global antimicrobial consumption in livestock (Van Bockerel; 2015)
What we la ack in India Guidelines on antibiotic use in feed G id li tibi ti i f d are available, but not implemente d d il bl b t t i l t Antibiotics used for human dise Antibiotics used for human dise ase treatment are used in growt ase treatment are used in growt promoters No monitoring of residue limits in food meat in Indian markets We do not know the antibiotic re esistance pattern or resistance gen p pool in food animals We are unaware of the rate of tra ansmission of antibiotic resistance t humans
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