Field project report submitted to In-service Applied Veterinary Epidemiology

Training (ISAVET) Program

ASSESSMENT OF AWARENESS AND UNDERSTANDING AMONG VETERINARIANS

and PARAVETERINARIANS ON AMU AND AMR IN DIRE DAWA, ETHIOPIA

By: Dr Adem Mustefa

July, 2022

Dire Dawa, Ethiopia

Abstract
Background: Antimicrobials are the drugs of choice for treating infections in humans
and animals and they have a wide range of chemical and biological properties.These

antimicrobials have been widely used in animals for disease prevention, control, and treatment,

as well as growth promoters.The global development of intensive farming has led to an upsurge

in antimicrobial use (AMU) that leads to the emergence and spread of antimicrobial resistance

(AMR). Irrational use of antibiotics in animals are considered one of the key drivers of AMR

evolution. AMR occurs when a microorganism no longer responds to a drug to which it was

originally sensitive. The general objective of this study is to assess the awareness and

understanding of veterinarians and para-veterinarian on AMU and AMR in Dire Dawa area.

METHODOLOGY:A descriptive cross sectional study was conducted from From July to

September, 2022, in Dire Dawa Administration which is located in the eastern part of Ethiopia

515 km from Addis Ababa, the capital of the country. Te total area of the administration is

128,802 hectare and the administration shares common boundaries with Ethiopian Somali

Regional States in the West, North and East, and with Oromia Regional State in the South.

RESULT: A total of 64 Respondents were participated in the study. Of the 64 Respondents who

participated in the study, 90.63% (58/64) were males and 9.38% (6/64) were females. Regarding

the age of the participants, the majority 44 (68.75%) were in the interval of 30–50 years and the

rest 14 (21.9%) and 6 (9.4%) individuals were in the age category of 21–29 and greater then 50

years,respectively.
1. BACKGROUND
Antimicrobials are the drugs of choice for treating infections in humans and animals (Marco-
Fuertes et al., 2022), and they have a wide range of chemical and biological properties (Hossain
et al., 2022). Further- more, hundreds of natural, semi-synthetic, and synthetic antimicrobial
molecules are used to treat infections in both humans and animals. These antimicrobials have
been widely used in animals for disease prevention, control, and treatment, as well as growth
promoters (Dejene, Birhanu and Tarekegn, 2022). The use of antibiotics has brought about a
revolution in human and veterinary medicine and has contributed to saving millions of lives
(Marta-costa et al., 2021). Antimicrobials are used in animal farming for a variety of reasons,
including therapeutic, metphylaxis, prophylaxis, and growth promotion (Geta and Kibret, 2021).
Antibiotics are also widely used in treatment of sick animals (Mutua et al., 2020).

The global development of intensive farming has led to an upsurge in antimicrobial use (AMU)
that leads to the emergence and spread of antimicrobial resistance (AMR). Irrational use of
antibiotics in animals are considered one of the key drivers of AMR evolution (Ahmed et al.,
2021). AMR occurs when a microorganism no longer responds to a drug to which it was
originally sensitive. Over- prescription of drugs, use of too high or too low dosages, and
incorrect duration of medication can aggravate the problem (Mutua et al., 2020). Antimicrobial
resistance (AMR) is responsible for thousands of deaths worldwide and economic loss due to the
increased hospital stays, unnecessary drug consumption, and increased burden with diagnostic
costs (Resistance, 2021). The problem of antimicrobial resistance in infectious agents has been
rising, and there is global concern that in the absence of interventions to reverse these trends, the
means to treat infectious diseases will be limited and out-of-reach for many, especially those
living in low- and middle- income countries (Government of Uganda, 2018).These problem
makes difficult to treat and control infections in both humans and animals (Ozturk et al., 2019).

Although AMR is a global health concern, people in low- and middle-income countries bear the
brunt of the consequences (Hossain et al., 2022). Antimicrobial-resistant pathogens can circulate
in populations of humans and animals, through food, water, and the environment. Transmission
of AMR is facilitated by trade, travel, and both human and animal movement (Gebeyehu et al.,
2021). In many sub-Saharan African countries, including Ethiopia, there is a paucity of data on
the prevalence of both AMR and AMU, as the combined realities of underfunded veterinary
healthcare systems, limited regulatory capacities and lack of systematic, national, or regional
surveillance systems undermine efforts to promote prudent AMU and control AMR (Kemp et al.,
2021). To make effective and sustainable strategies, recommendations and treatment guidelines
to maximize the therapeutic efficacy and reduce (Vijay et al., 2021) AMR in both human and
animals, assessing the knowledge, attitude and practice (KAP) of veterinary practitioners are
pertinent(Sarker et al., 2021). As there were no previous studies to investigate the assessment of
awareness and understanding regarding to AMU and AMR among veterinarians and para-
veterinarian in Ethiopia, particularly Dire Dawa area, I undertake this research which will be
used as a baseline for researchers to fill the gaps of AMR challenges.

General objective

The general objective of this study is to assess the awareness and understanding of veterinarians
and para-veterinarian on AMU and AMR in Dire Dawa area

Specific objectives
 To determine the current level of awareness of veterinarian and para-veterinarian on

AMR

 To describe antibiotic-related practice of animal health worker on AMR

 To identify major gaps of the veterinary drugs regulatory system in the country
2. METHODOLOGY

2.1. Study design, period and setting

A descriptive cross sectional study was conducted from From July to September, 2022, in Dire
Dawa Administration which is located in the eastern part of Ethiopia 515 km from Addis Ababa,
the capital of the country. Te total area of the administration is 128,802 hectare and the
administration shares common boundaries with Ethiopian Somali Regional States in the West,
North and East, and with Oromia Regional State in the South. The Dire Dawa administrative
composed of 9 urban and 38 rural kebele Administrations. In Dire Dawa Administration, there
are 1 regional laboratory, 1 type B clinic, 4 type C clinic and 26 type D clinics centers serving
the community. Written consent was obtained from study respondents before they completed the
questionnaire. Data collection was performed between July to September, 2022.

2.2 SOURCE POPULATION

All Government-appointed veterinarians and para-veterinarian working in Dire Dawa

Administration were source population for the study.

2.3 Study population

A total of 64 veterinarians and para-veterinarian stafs who volunteered were included in this

study
2.4. Data collection and processing
Structured questionnaire interviews were conducted to assess the awareness and understanding
of antimicrobial use and resistance among government-appointed veterinarians and para-
veterinarian in dire dawa administration. The questionnaire will be developed after reviewing
the literature on how to conduct a kap survey as well as global antimicrobial studies. The
questions veterinarians and para-veterinarian were grouped into four sections: The first one
consist demographic information of the veterinarians, second section include 8 questions on
animal health service provision, third section contain 6 questions on diagnosis, treatment and
type of job aids for treating animals and fourth section had 11 questions on antimicrobials use,
resistance prevention and containment, challenges and suggested solutions. The majority of the
answers were in multiple choice.

2.3. Data analysis

Te entire data was entered into a computer and analyzed using SAS version 9.1. Frequency and
percentages among descriptive statistics were used to describe the data.

3. RESULT

Socio -Demographic Character of Study Participants

Socio-demographic data and professional of the participants were described in Table 1. A total
of 64 Respondents were participated in the study. Of the 64 Respondents who participated in the
study, 90.63% (58/64) were males and 9.38% (6/64) were females. Regarding the age of the
participants, the majority 44 (68.75%) were in the interval of 30–50 years and the rest 14
(21.9%) and 6 (9.4%) individuals were in the age category of 21–29 and greater then 50
years,respectively. From the participants by profession, majority 42 (65.63%) were Animal
Health Diploma, followed by DVM 16(25%), Animal Health Degree 5 (7.81%) and MSc
1(1.56%). All of the respondents (n = 64) worked in different government sector in Dire Dawa
Administration. Work area (department) of the studied veterinarians and para-veterinarian
showed that 84.4% (n =54) animal health care provision, 7.8% (n =5) were animal
health/medicines regulation or management, 4.7% (n =3) were inspection of food establishments
or slaughter/ abattoir houses, and , 3.1% (n =2) were quarantine. In this study, work
characteristics of the studied healthcare workers showed that most of them (57.81%) were in the
interval of 1-10 years and the rest were greater than 11 working year experience (42.18%)
and average work load per month was 24 days. Most of the respondents (56%, n = 246) had
not received any training on antimicrobial use and AMR at the time of the current study.

Table 1: Socio-demographic characteristics of study participants

# Sociodemographic characteristic Number %
1 Age (years)
21-29 14 21.9
30-50 44 68.75
>50 6 9.4
2 Gender
Male 58 90.63
Female 6 9.38
3 Education
DVM+MSc 1 1.56

DVM 16 25
Animal Health Degree 5 7.81
Animal Health Diploma 42 65.63
4 Work Area (department)

Animal health care provision 54 84.4

Inspection of food establishments 3 4.7

or slaughter/ abattoir houses
Animal health/medicines 5 7.8
regulation or management
Quarantine 2 3.1
 No. of years in service

1-10 years 37 57.81

> 10 years 27 42.18
Non‐trained 85.93

Training on antimicrobial use

Trained 14.06

Average work load per month 24 days

Animal Health Service Provision .

The most common animal health problems were reported by respondents elaborated in Table 2.
From a total of 64 participants, 37.50% of them (24 respondents) considered Salmonellosis,
followed by Bloody diarrhea or Dysentery, Respiratory disease, Mastitis, Anthrax and Viral
diseases were the major animal health problem reported.

Table2 : The most common animal health problems encounters reported by respondents
Variable Number %

1 Mastitis 6 9.38
2 Bloody diarrhea or Dysentery 15 23.44
3 Respiratory disease 7 10.94
4 Black leg 2 3.13
5 Salmonellosis 24 37.50
6 Anthrax 4 6.25
7 Viral diseases 4 6.25
8 Others 1 1.56
Estimated Recurrence of animal diseases being 50 78.13
treated
The most commonly used antibiotics by animal owners were oxytetracycline (100%), followed
by Ivermectin, (91.67%) and Albendazole (83.33%) then multivitamin(66.67%). The least used
antibiotics was sulphonamides (41.17%) as reported by HCPs. The table 3 showed that the most
frequent source of antibiotics used was Veterinary pharmacy (41.67%) followed by Private vet
clinic (33.33%), Government vet clinic (16.67%) and Buy from any shop or open market
(8.33).

Table 3: Self-selection (self-medication or over the counter use) of antimicrobials by owners

reported by HCPs
Variable Number %
Frequency of self-selection of 12 18.75
antimicrobials by owners n= 12
Top 5 antimicrobials self-selected recalled by
HCPs
1 Oxytetracycline 12 100

2 Ivermectin, 11 91.67

3 Albendazole 10 83.33

4 multivitamin 8 66.67

5 Sulfa drug 5 41.67

Sources of self-selected antimicrobials by

owners

1 Government vet clinic 2 16.67

2 Private vet clinic 4 33.33
3 Veterinary pharmacy 5 41.67
4 Buy from any shop or open market 1 8.33

Regarding what aids the veterinarians’ and para-veterinarians decisions to prescribe

antimicrobials, most of the respondents (60.93%, 39/64) agreed that they always Used own
experiences for treating animals. On the other hand, 15.62% (10/64) of the respondents agreed
that they prescribe antibiotics based on veterinary standard treatment guideline (VSTG)
(management and treatment of diseases), followed by 9.37% (6/64) Veterinary Medicines
Formulary (VMF) (detailed information about vet medicines) , then Use List of Veterinary
Medicines and Others method were used for treating animals diseases.

Table: 4 Job aids followed in treating animals

Type of job aids for treating animals no %

1 Use own experiences 39 60.93

2 Use veterinary standard treatment guideline (VSTG) 10 15.62

(management and treatment of diseases)

3 Use Veterinary Medicines Formulary (VMF) (detailed 6 9.37

information about vet medicines)

4 Use List of Veterinary Medicines 5 7.81

5 Others 4 6.25

 15.62% of the Vet clinics have STG and that 100% and 93.75% believed that STG
and Vet formulary are essential for their services.

Almost all animal health professionals (95 %) identified the lack of diagnostic facilities in study

area. In addition, available laboratory facilities are not adequately equipped and veterinarians

mostly depend on (50%)Clinical symptoms and signs (empiric treatment) used as diagnostic

methods followed for treating animals. Bacteriological lab tests used some times. Antimicrobial

susceptibility testing is only performed where failure or low response to initial therapy is

observed (and therefore not considered in routine diagnosis of cases)

Table:5 Diagnostic methods followed/used or threating of animals
Diagnostic methods followed for treating animals Yes %

1 Clinical symptoms and signs (empiric treatment) 32 50

2 Culture and Sensitivity tests 19 29.68

3 Bacteriological lab tests 11 17.18

4 Other 2 3.12

Antimicrobial s Use, Resistance Prevention and Containment, Challenges and Suggested

Solutions

Out of 64 participants who reported on AMU , the majority (46.87%) of the participants used
antimicrobials for treatment purposes. Other reported uses of antimicrobials included
growth promotion(21.87%), prevention of diseases(17.18%) and feed additives for animal
production (14.06%).

Table 6: Purpose of antimicrobials use

Purpose of antimicrobials use Frequency Percent
Treatment of sick animals 30 46.87
Prophylaxis/ metaphylaxis of animal 11 17.18
diseases
Perceived growth promotion/fattening of 14 21.87
animals
Others 9 14.06
All results obtained on the general level of knowledge of antibiotics use and some of the care (or
lack of care) that respondents took with antibiotics are shown in Table 7. Among all 64 survey
respondents, 79.68% of them (51respondents) considered antibiotic resistance to be a major
public health problem. Seventy-seven respondents (17%) belonging to the various professional
groups surveyed even indicated that antibiotics should be administered for any type of infection,
whether bacterial, viral, or fungal, although 53% (n = 34) of respondents thought antibiotics
should be administered for bacterial infection.
Participants frequently mentioned mastitis (68.0%), bloody diarrhea or dysentery (53.4%),
brucellosis (48.5%) and (45.2%) (CBPP/CCPP)as the health conditions frequently treated by
antimicrobials.

Table 7: Evaluation of antimicrobials prescribing practices

# Animal Diseases Medicines of your choice in this order Comments

A What are your First Second Third based on

choices of medicines VSTG,

for the following Rational or

diseases not

1 Bloody diarrhea or Sulpha Albendazo Ivermectin Rational

dysentery medicines le

2 Mastitis Penistrip Amoxicilli Oxytetracycline Rational

3 Trypanosomiasis Pentmidine Suramin Berenil Not rational

4 Fever No need of Amoxicilli Oxytetracyclin Not rational

treatment n

5 Brucellosis Oxytetracycli Rifampicin Pencillin+streptomyc Not rational

ne in

6 Contagious bovine Oxytetracycli Amoxicilli Rifampicin Not rational

pleuropneumonia
 /contagious caprine ne n
pleuropneumonia
(cbpp/ccpp)

Antibiotics prescription practices of health workers were elaborated in Table 8. Out of the total
study participants (N = 64), 55 (85.93%) were practicing antibiotic prescription. The majority,
39(60%) of the participants Responded that standard treatment guidelines were not available in
their office. 15.7% of the prescribes responded they ‘always’ referred the standard treatment
guideline while almost half of them, 49.3% referred ‘some times’. Regarding the frequency of
reviewing antimicrobial stewardship, less than one-third (n = 21, 32.81%) of respondents knew
what the treatment, while more than two-thirds (n = 43 67.18%) had never heard about it (Table
7). We provided the definition of AMS in the questionnaire before asking the respondents about
the potential influence of implementing AMS guidelines on various important sectors of the
current AMR situation.
The types of antimicrobials that were known to participants included amoxicillin (66.0%),
Oxytetracycline (39.1%), Pencillin+Streptomyci (20.7%), Pen G (14.9%) and Sulpha medicines.

Table 8: Evaluation of antimicrobials prescribing practices (medicines indications)

# Medicines Medicines indications for Diseases 1, 2, 3 Comments based on

VSTG, Rational or

not

1 2 3

1 Amoxicillin pasteurellosis urinary track CCPP/CPP Not rational

infection

2 Oxytetracycline urinary track Pneumonia salmonella rational

infection

3 Pencillin+Streptomycin Mastitis urinary Not rational

 (CBPP/CCPP) track

infection

4 Pen G Blackleg Mastitis Skin Not rational

infection

5 Sulpha medicines Bloody GIT infection Mastitis Not rational

diarrhea or

Dysentery

Based on the respondents survey results of frequency of difficulty in treating animal infectious
diseases and possible reasons, concerning the causes of antimicrobial resistance, the common causes
for antimicrobial resistance were patient poor adherence, 210 (96.5%), self prescription, 207 (95%), and
empiric choice of antibiotics, 206 (94.5%). Of the respondents, 202 (92.7%) considered that each
widespread/overuse of antibiotics, inappropriate duration of antibiotic courses and poor infection control
contributed for antimicrobial resistance. Prescribers poor awareness, sub-standard quality of antibiotics
and microbes mutation promote antimicrobial resistance as responded by 196 (89.9%), 195 (89.4%) and
195 (89.4%) of the participants, respectively. Respectively, 136 (62.4%) and 127 (58.3%) of the
participants answered that the use of broad spectrum antibiotics and promotion by pharmaceutical
representatives for antibiotics promotes antimicrobial resistance (Table 9).
Table 9: Frequency of difficulty in treating animal infectious diseases and possible reasons
Number %
Frequency of difficulty encounters in the treatment of bacterial
infectious animal diseases (n=64)
Possible reasons for difficulty in treating diseases Yes # (%) No # (%)
1 Do not know 62.71 37.29
2 Owners self-prescription of medicines for their animals 34.48 65.52
3 Wrong diagnosis or use of the wrong antimicrobial 87.93 12.07
4 Antimicrobials resistance 93.10 6.90
5 Sharing of antimicrobials that are prescribed for some other 36.21 63.79
animal
6 Use of Counterfeit or poor quality antimicrobials 86.21 13.79
7 Not following correct administration and full course of 86.21 13.79
antimicrobials
8 Overcrowding and poor hygiene and sanitation 51.72 48.28
 9 Poor animal feeding practices 98. 1.72
10 Others (specify)

Three-fourth of the respondents (75%, 48/64) correctly answered that antibiotics are used

to treat bacterial infection while 23%, 15/64) of them mentioned that it could be used to treat

all types of infections.

Table 10: Suggested solution to prevent and contain AMR

Suggested solution to prevent and contain AMR Number %

Improve hygiene and proper animal feeding 55 85.94

Proper diagnosis of infectious diseases and antimicrobials treatment 62 99.88

adherence

Use of quality or legal source antimicrobials 34 53.13

Fight counterfeit/contraband medicines use 34 53.13

Proper animal waste disposal 57 89.06

Clearance of antimicrobials from body of animals before their food 53 82.81

products are used

Develop new medicines, vaccines, fast diagnostics 58 90.63

Others (specify)

Discussion
We conducted a questionnaire-based survey of the level of awareness and understanding of

healthcare workers on AMU and antimicrobial resistance, prescribing behavior, and the source of

information on AMR in in dire dawa administration. The awareness of antimicrobial resistance

among veterinarians and para-veterinarians practitioners has risen during the past few years and

has been demonstrated by studies across the globe.

few studies have focused on opinions and attitudes on antimicrobial use and
stewardship in the veterinary profession
Antimicrobial resistance is global public health agenda
due to inappropriate and irrational use of antibiotics

AWARENESS AND UNDERSTANDING AMONG VETERINARIANS and

PARAVETERINARIANS ON AMU AND AMR IN DIRE DAWA,

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