Category: Antibiotics

Introduction

Production of curd by using Bacterial Probiotics

Acidification of milk is one of the methods used in preservation of milk. Acidification, gives the milk a sour taste and it is achieved by bacterial fermentation or by the addition of an acid (for example: lemon juice or vinegar). The acid causes milk to coagulate and solidify fully or partially. Coagulation of milk inhibit the growth of harmful bacteria and improves the dairy product’s shelf life. Soured milk that is produced by bacterial fermentation is more specifically called fermented milk or cultured milk. Curd is one of the famous dairy product made by Lactic Acid fermentation of milk. Cow’s milk or buffalo milk is used for the production of cured. Curd is stored in clay pots or plastic containers in the local market. As we all know metal containers are not used to store curd. Because acidic substances in curd can react with metals. It contaminates and make curd inconsumable.

Probiotics present in Curd

Curd is considered as probiotic or functional food as it possesses live lactic acid bacteria. Probiotics are live microorganisms which are harmless and beneficial to health. The Food and Agriculture Organization of the United Nations and the World Health Organization (FAO/WHO) defined a probiotic as ‘live microorganisms which when administered in adequate amounts confer a health benefit on the host’ (FAO/WHO, 2002). The definition of probiotics changes together with the development of knowledge about them. Before considering a bacterium as a probiotic, it must encounter several conditions, including the ability: To survive in the presence of acids and bile salts, to produce antimicrobial compounds, and to colonize the intestines and resist antibiotics. Some probiotics which have been already isolated from buffalo milk in India are Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus lactis and Bifidobacterium longum; from milk in Islamabad are L. acidophilus, Lactobacillus delbrueckii ssp. bulgaricus, Lactococcus lactis ssp. cremoris, L. Lactis ssp. lactis, and Streptococcus thermophilus.

Lactic Acid Bacteria (LAB)

In the production of curd specific type of probiotic bacteria known as lactic acid bacteria(LAB) are added to milk. LAB are a heterogeneous group of bacteria which can be found naturally in gastrointestinal and urogenital tracts of humans and animals. Lactic acid is produced as a result breakdown of carbohydrates by these bacteria therefore these bacterias are known as LAB. Besides lactic acid, other bi products such as acetate, ethanol, CO2, formate and succinate are also formed by these bacterias. This lactic acid lead to coagulation of milk proteins such as casein by giving a sour taste thereby producing cultured milk products such as curd.

LAB is classified into homofermentative and heterofermentative according to the end products of their glucose metabolism. The homofermentative converts glucose mainly into lactic acid by the Embden-Meyerhof pathway, while the heterofermentative transforms glucose into lactic acid, carbon dioxide, and ethanol or acetic acid by the 6-phosphogluconate pathway.

Lactic acid bacteria are not only used in food production but also in pharmaceutical and special dietary applications. The most commonly used strains of different LAB species in food including the genera of Aerococcus, Carnobacterium, Enterococcus, Lactobacillus, Lactococcus, Leuconostoc, Pediococcus, Streptococcus and Bifidobacterium A typical lactic acid bacterium is Gram-positive, non-spore forming, catalase negative, facultatively anaerobe requiring complex media, acid tolerant, fermentative and it lacks cytochromes and produces lactic acid as the major end product.

These bacterias enhances the digestibility of milk. Therefore, fermented dairy products such as curd and yogurt can be used as a substitute for the people with lactose intolerance since a large part of the milk sugar has already been digested by the lactic acid bacteria in the curdling process. As far as the microbial picture of the curd is concerned, according to the Sri Lankan Standards (SLS) regulations recommend that the curd shall be the fermented milk products obtained from coagulation of cow or buffalo milk or a mixture by the involvement of following species of organisms ; Streptococcus lactis, S. diacetylactis, S. cremoris singly or in combination with Leuconostoc spp., Laciobacillaus bulgaricus, Sireptcoccus thermophiles.

Commercial preparation of curd

Traditionally, soured milk was simply fresh milk that was left to ferment and sour by keeping it in a warm place for a day, often near a stove. Modern commercial production methods of fermented dairy products are differing from milk that has become sour naturally. Since milk can get contaminated by other types of bacteria when it left to ferment naturally. Therefore, aseptic conditions and inoculation of specific bacteria from starter culture methods are used at the present day. A starter culture is a microbial preparation with large numbers of bacterial cells of at least one microorganism to be added to a raw material to produce a fermented food by accelerating and directing its process of fermentation. Typical method for the preparation of curd is mentioned below.

Standardized milk (milk product, whose fat and/or solids-not-fat content have been adjusted to a certain pre-determined level. Under the PFA Rules) was heated to 850C for 30 minutes and cooled to 400C. The milk samples were inoculated individually at 1% level with a specific species of LAB from a starter culture sample under the aseptic condition to avoid contamination. All samples were incubated at 370C for 48 hours(this time can be vary according to the starter culture used) for activation of culture. Steps followed in the production of curd is shown in the (Figure 1) flow chart below.

Antibiotic resistant bacteria present in curd

Antibiotic resistance has become a major issue in medical field nowadays. Antibiotics which are used to feed animals (eventually get in to animal manure) and used in starter cultures contribute to additional resistance.

Most starter cultures of lactic acid bacteria have been recognized as safe by the US Food and Drug Administration (FDA) and the European Food Safety Authority (EFSA). An assessment system to analyse the pre-market safety of selected groups of microorganisms also has been proposed by EFSA. Yet, since LAB consist of antibiotic resistant (AR) genes they can act as intrinsic or extrinsic reservoirs for antibiotic resistance (AR) genes. Even though the resistance gene transfer is vertical, the external genetic factors may promote the horizontal transfer of AR genes through the food chain to pathogens (via bacteriophages). Although at present, the WHO recommends that LAB which are used in the food industry should be free of resistance, some genus of AR LAB species such as Enterococcus, Lactobacillus, Lactococcus, Leuconostoc, Pediococcus, and Streptococcus have been isolated from several fermented meat and milk products.

LAB possess a high probability of developing resistance to antibiotics. Recent studies have questioned the safety of some strains of Lactococcus lactis, Enterococci, and Lactobacillus isolated from fermented foods which showed resistance to tetracycline, erythromycin, and vancomycin.

With regard to specific antibiotics, lactobacilli are typically sensitive to the cell wall-targeting Beta-lactam antibiotics such as penicillin and to protein synthesis inhibitors such as chloramphenicol, macrolides, lincosamide, tetracycline. Beta-lactam antibiotics consist a beta-lactam ring in their chemical structure. This class includes Penicillins, cephalosporins, Carbapenems, Monobactams, Beta-lactamase inhibitors. The beta-lactam antibiotics function is to destroy bacterial by interfering with the structural crosslinking of peptidoglycans in bacterial cell walls. Production of extended-spectrum β-lactamases enzymes (ESBL) by bacteria inhibits the effect of Beta-lactam antibiotics by breaking the antibiotics’ structure through hydrolysis.

But they are more resistant to cephalosporins (which is a beta-lactam antibiotic) and vancomycin. And also LAB are generally resistance toward inhibitors of DNA synthesis such as trimethoprim, sulfonamides and fluoroquinolones. Resistance to streptomycin, clindamycin, gentamicin, oxacillin and lincosamide is also reported in some of these species. Most mutual antibiotic resistant genes found in lactobacilli are the tetracycline resistance genes. However, resistance and susceptibility are greatly varying with the different LAB species.

Health benefits of consuming curd

Curd is associated with several health benefits due to its probiotic content. One of the beneficial effects of curd are assembly of the natural antibacterial components such as nisin and acidophilin formed during the fermentation (therapeutic benefits) which has the ability to restoration of normal gut flora following oral therapy. Further it balances the faecal enzymes and intestinal micro flora, treatment of traveler’s diarrhoea, antibiotic therapy, and control of ulcer and reduction of serum cholesterol. The low pH or acidic condition that prevents the growth of putrefactive and other pathogenic organisms and possesses an increased digestibility are some other benefits of the consumption of curd. Several experimental observations have indicated a potential effect of lactic acid bacteria against the development of colon tumours.

Adverse effects of consuming curd

Sometimes antibiotic resistance bacteria can be present in curd. Consumption of curd with such bacteria may lead to antibiotic resistance as mentioned above. Other than that the major adverse effects of consumption of curd are caused by consuming contaminated curd. Since curd is a high nutritious medium many fastidious bacterias are prone to grow on curd. Curd can get contaminated by using contaminated milk, from a contaminated starter culture, in the manufacturing process (loose packing), in storing process and even by consumers. foodborne pathogens can get in to milk by several influences such as size of the farm, number of animals on the farm, hygiene management practices, variation in sample collecting methods (by hand or by machines), geographical location, and season. Milk pasteurization is regarded as an effective method to eliminate foodborne pathogens. Yet pathogens such as Listeria monocytogenes can survive and thrive even after pasteurization.

S. aureus, B. cereus, Klebsiella and coliforms like bacterias have been isolated from different curd samples around the world. According to the type of bacteria which has contaminated the curd the adverse health effects can be varied.

Isolation and identification of Antibiotic resistant bacteria present in curd.

In the process of isolation and identification of Antibiotic resistant bacteria present in curd following steps should be performed respectively.

• Collection of curd samples
• Serial dilution of samples
• Plating on a media
• Antibiotic resistant test
• DNA extraction
• Performing Polymerase Chain Reaction (PCR)
• Electrophoresis
• DNA Sequencing and identification of bacteria (using NCBI- BLAST).

Collection of curd samples

There are several types of curd served in different methods in the local market. After collecting samples and separating small amounts from them to culture bottles or sterile containers serial dilution is performed.

Serial dilution of samples

In serial dilution known amount of sample is diluted with sterile water and they are pipetted to several test tubes and diluted further by increasing sterile water amount to reduce the concentration of microbes. The objective of the serial dilution method is to determine the concentration of an unknown sample by counting the number of colonies cultured from serial dilutions of the sample, and then back track the measured counts to the unknown concentration.

Plating techniques

There are several plating techniques. streak-plating, pour-plating, spread-plating are some examples for plating methods. The streak-plate procedure has been designed to isolate pure cultures of bacteria, or colonies, from mixed populations by simple mechanical separation. Pour plate method often is used to count the number of microorganisms in a mixed sample, which is added to a molten agar medium before it gets solidified. Spread plate technique is usually used to separate microorganisms confined within a small sample volume, which is spread over the surface of an agar plate. Colonies formed after plating is then subjected to antibiotic sensitivity test (ABST).

Brain Heart Infusion Broth (BHI), Man Rogosa Sharpe (MRS) agar and Luria-Bertani (LB) are some different types of medias which are used in plating. MRS is the most common broth used to culture LAB since it is a selective culture medium for Lactobacilli.

Antibiotic sensitivity test (ABST)

There are several types of Antibiotic sensitivity tests done under the principles of diffusion (qualitative methods) and dilution (quantitative methods). Kirby-Bauer disk diffusion method has been used to determine antibiotic susceptibility of some Turkish fermented dairy products. Disc diffusion method was used to screen for the antibiotic susceptibility of Lactic Acid Bacteria isolated from several Foods and Drugs in china.

Minimum inhibitory concentration (MIC) of various antimicrobial susceptibility testing are categorized by various international agencies. These MIC guidelines determine the susceptibility of organisms to particular antibiotic used.

DNA extraction

Then DNA is extracted from the bacteria obtained from antibiotic resistant colonies. According to the method of cell membrane lysis there are several methods of DNA extraction. They chemical, enzymatic and mechanical membrane lysis. In most of the methods enzymes or chemicals are used for the lysis of bacterial cell membranes (Cell wall, cell membrane and nuclear membrane). SDS, CTAB, phenol, Tris and EDTA are several common chemicals used in the solution based DNA extraction method and extraction buffers are used in enzymatic lysis.

Polymerase chain reaction

Then PCR is done to multiply obtained DNA samples or fragments. It can be LAB specific ESBCL (Extended-spectrum beta-lactamase enzymes producing bacteria which are resistant to beta lactam antibiotics) specific or universal PCR.

Electrophoresis and Identification

Then agarose gel electrophoresis is performed. If the electrophoresis results do not show a bright band again (universal) PCR is performed. Finally, the identified bacteria strands are sequenced and their specific part of genome is identified by using NCBI-BLAST.

Conclusion

Curd is very popular among Sri Lankans due to its taste and nutritional value. Curd is a fermented dairy product which can be found in almost all the super markets in Sri Lanka. Lactic Acid Bacteria is the main group of probiotic bacteria which is used to produce curd. Lactic Acid Bacteria contain antibiotic resistant genes in their genome. Antibiotic resistant bacteria contain Antibiotic resistant genes in their genome. Usually these antibiotic resistant genes transfer vertically they can be transferred horizontally by viruses (such as bacteriophage virus) through food chains and infections. Since these genes can promote antibiotic resistance presently, the WHO recommends microorganisms used in the food industry should be free of antibiotic resistant genes. The main aim of this study is to find the antibiotic resistant bacteria present in curd samples of Sri Lanka by using Plating and PCR detection. Other than Lactic acid producing bacterias there can be other bacterias grow due to contamination of curd. This research helps to discover those bacterias also.

Penicillin is still currently being used worldwide today, due to it curing many people and preventing them from dying. Alexander Fleming has made people all around the world extremely grateful for this life changing discovery. Even though Fleming did discover penicillin he did have some help from two young researchers. The researchers were called Howard Florey and Ernst Chain. The two-researchers teamed up with Fleming do make penicillin more efficient. The researchers and Fleming succeeded, and the antibiotic was used for the first time in World War II. This was to prevent the soldiers becoming sick ad hurt. The soldiers were extremely fortunate because without this antibiotic many more lives would have been lost in the war. As time progressed the antibiotic became stronger than it first was, although today the antibiotic is incredibly different. Today scientist have different tools that Fleming didn’t have access to. This allows the scientists today to adapt the antibiotic in a better way to make it more efficient. This will then benefit more people because they would become cured properly and in a small amount of time. People may seem that Fleming would be angry about other scientists adapting to the antibiotic, although if anything Fleming would be happy with this because even, he would agree that the penicillin he made wouldn’t save as many lives today. This is why the world needs to acknowledge Alexander Fleming’s work.

Alexander Flemings’ work has clearly improved society today. Due to his discovery of penicillin he has prevented millions of people from dying. This has helped societies health all around the world. With lots of diseases spreading all around the world, the world would live in complete burden due to them having no cure. Although with the input of Alexander Flemings’ discoveries the world has been benefited in many ways. This is why Alexander Flemings work has improved society today.

Overall without penicillin today the world would be in a different state. If it wasn’t thanks to Alexander Fleming accidently discovering this life changing antibiotic, we would have no idea when this antibiotic would have been discovered. It is safe to say that even Alexander Fleming became lucky, because even he himself didn’t realize what he had discovered until 10 years later. This shows that majority of the population would have suffered without this life changing antibiotic being accomplished. Although due to the antibiotic being discovered and finalized to its best sate it vital to say that Alexander Fleming’s discovery has benefited the world.

On the 6th of August 1881 Alexander Fleming was born in Darvel, the United Kingdom. Being a son of four Fleming attended school like every other boy his age. He then later went to Kilmarnok University and then later studied at St Mary’s Medical School. After his education he served the army for 14 years. His role in World War 1 was the Medical Corp Captain. This was the responsibility on keeping everyone medically safe and healthy. After the served the army then educated himself back at St Mary’s. This was the time when Fleming then became interested in bacteria. This then lead up to 1928 when Alexander Fleming discovered penicillin. Penicillin was an antibiotic to prevent people from dying and becoming sick. Alexander Fleming then later passed away on the 11th of March 1955 in London, the United Kingdom.

Introduction:

The famous philosopher Charles Darwin once said, ‘It is not the strongest of the species that survive, not the most intelligent that survive. It is the one that is the most adapted to change’. In this research project, I will be discussing the history of Tuberculosis, how it has evolved and more.

Studying evolution is vital for the knowledge of man-kinds on Tuberculosis as well as their health. Rapid evolution coupled with the migration of human populations can endanger the health of many and therefore, understanding how diseases like such evolve are important.

Vaccines are essential for the process of fighting disease-causing bacteria, however, when these types of bacteria evolve new vaccines are at a high demand. For this reason, evolution can help with the development of lifesaving technologies.

Diseases, very often, develop a resistance to these technologies. Therefore, being knowledgeable about how diseases evolve can help scientist understand how to prevent this resistance as well as help in the discovery of new sources of lifesaving drugs. (Source A)

Along with scientists gaining a greater understanding of bacteria so do the rest of the world. Individuals can be taught about bacteria and how they can evolve to help them get a larger understanding and knowledge on how they can prevent themselves from contracting diseases.

The History of Tuberculosis:

Ancient Times

The first physical proof of the existence of Tuberculosis was found in the skeletal abnormalities in the spines of mummified individuals dating back to 2400 BC. This form of Tuberculosis is now best known as Pott’s Disease and has been distinguished in early Egyptian art pieces. However, there is no evidence of diagnostics associated with Tuberculosis reported in the Egyptian scrolls.

The first written documents, bearing data related to Tuberculosis, have been discovered in India and China, which date back from around 3300 years to 2300 years ago.

In Hebraism, the word ‘Schachepheth’ is used to describe Tuberculosis in the biblical books of Deuteronomy and Leviticus. In Greece, ‘Phthisis’ provided evidence of Tuberculous lung lesion. During the same period, Isocrates was the first author claiming Tuberculosis to be an infectious disease. During the Roman period after the decline of the Roman empire, Tuberculosis was widespread in Europe during the 18th and 19th Century. (Source B & C)

Middle Ages and Renaissance Time

During these periods, a new form of Tuberculosis, known as Scrofula, had surfaced and throughout England and France it had earned the name of ‘King’s Evil’. The reasoning behind this unusual name is that many believed that those who have fallen victim to Tuberculosis could be cured by the simple touch of a Royal Family Member. During the 16th Century, the infectious nature of Tuberculosis has been clearly defined by Girolamo Fracastoro, an Italian physician. In 1735, the Health Board of the Republic (HBR) ordered the mandatory notification and isolation of those victimized by Tuberculosis.

In order to achieve this, the HBR had forbidden those suffering from being admitted into public hospitals. As a result, hospitals had been established specifically to begin the treatment process for Tuberculosis without fearing the risk of transmission and widespread across the population. (Source B)

18th and 19th Century

Tuberculosis had reached its peak by the 18th Century in Western Europe. The mortality rates of the countries within this region were estimated to be about 900 deaths among 100 000 individuals.

It was around this time that the International Union Against Tuberculosis (IUAT) had been founded and vaccinations against Tuberculosis had developed.

Multiple global conferences were held where the main focus was on the biological, clinical and social aspects that are associated with Tuberculosis. It is also noted that throughout this period that the global migration of populations ignited the start of the global Tuberculosis outbreak. Consequently, this period was awarded the name of ‘the most important period in history.’ (Source B)

Global Spread of Mycobacterium tuberculosis:

Tuberculosis is generally known to be an airborne disease that is spread or carried in moist air particles in the atmosphere around us, through the actions of speaking, laughing, coughing, sneezing and even singing.

Nevertheless, it is relevant to know that physical contact cannot lead to an individual contracting the Tuberculosis bacteria, whether it be on the surface of an objects or on an individual. No physical contact cannot cause the spread of the disease as it is airborne.

Throughout centuries, the spread of Mycobacterium tuberculosis seems to be associated with the global migration and distribution of mankind. Both populations, Tuberculosis and man-kind, present similarities in regards to their distribution patterns. Ever since the peak of the Tuberculosis outbreak , European countries have presented favorable conditions, in which Tuberculosis has a chance to thrive and continue to spread in. These conditions include poor housing throughout populations, poor sanitation within cities, and malnutrition and overcrowding of populations. With that said, the presence of Tuberculosis has become common in developing countries where the conditions are just as beneficial – it is also noted that within these countries, the Tuberculosis legion tends to spread more rapidly as well. (Source D)

The most common form of Mycobacterium tuberculosis has spread to Asia, Africa, and North and South America by European explorers and colonists. The poorest and socially excluded countries carry the larges amounts of global Tuberculosis cases.

Hence, Africa and Asia account for about two-thirds (2/3) of the worlds Tuberculosis cases, whereas India, Indonesia, and China account for about 43% of the global Tuberculosis cases. (Source E & F)

It is also common for Tubercular co-occurring diseases to exist. It is said that the Human Immunodeficiency Virus (HIV) has become the highest risk factor that could lead to and individual contracting Tuberculosis. The reasoning behind this is because HIV weakens one’s immune system, causing an individual to become more vulnerable to contracting multiple diseases. In cases like this, it is said that Tuberculosis is the first cause of death among those suffering from HIV. With that said, the majority of HIV-associated Tuberculosis cases and deaths tend to occur in the African region of the world. Other co-occurring diseases include those related to Diabetes mellitus, individuals who abuse nicotine and alcohol, and in countries that obtain a middle to low-income rate. As a result, individuals who fall into the above categories are at a greater risk of potentially contracting the Tuberculosis bacteria than those elsewhere. (Source F)

The following information presents the effects migration has on the transmission rates of Tuberculosis in The United States (Source G):

The relationship between Mycobacterium tuberculosis and Humankind:

Bacteria have been used in various ways that have been beneficial to mankind. However, it is still important to remember that bacteria and mankind can portray various types of relationships. This can be a relationship where either one the organisms’ benefit or a relationship where both organisms benefit. In regards to Mycobacterium tuberculosis and mankind, the Tuberculosis bacteria is known to harm the host. This is known as a Parasitic Relationship. In this beneficial relationship, the Tuberculosis bacteria resists the hosts immune defenses and starts grows at rapid rates, all at the expense of the host. The bacteria produces poisonous substances known as endotoxins and exotoxins. Endotoxins consist of lipids that are situated within the host’s body cells, whereas endotoxins are released outside the body cells. (Source H)

Diagram and Explanation on how Bacteria become Antibiotic Resistant:

Key:

• Antibiotic-Resistant Bacteria
• Normal Non-Antibiotic Resistant Bacteria
• Dead Non-Antibiotic Resistant Bacteria

How improved technology has provided an insight into the evolution of Mycobacterium tuberculosis:

Many methods and technologies have been developed throughout history that help establish the dangers of the Tuberculosis bacteria as well as the insight that scientists can use to their advantage when it comes to eliminating this disease.

Radiogram (x-ray)

Radiograms (or better known as x-rays ) are electromagnetic waves of high energy that have the ability to pass through a variety of materials. When observing the changes in one’s lungs, a chest x-ray is usually made use of to determine if those changes could possibly be associated with Tuberculosis. If the Tuberculosis bacteria has attacked the lungs then inflammation occurs, which result in a shadow being formed on the individual’s x-ray. (Nahid, Pai, and Hopewell, 2006)

Tuberculin Skin Test (TST)

The Tuberculin Skin Test (TST) usually takes place with individuals who have not yet been vaccinated for Tuberculosis with the Bacillus Calmette–Guérin (BCG) vaccine. However, it is important to note that those who have been vaccinated with the BCG vaccine must have been positively documented for a prior test. The BCG vaccine is used on foreign-born individuals and in countries with a high prevalence of Tuberculosis. Its purpose is mainly to prevent Tuberculous meningitis (meningitis caused by the Tuberculosis bacteria) and Miliary disease. The Tuberculin Skin Test (TST) takes place in two parts. During the first part, Tuberculin – a protein made from the Tuberculosis bacteria – is injected into the individual’s forearm. Then the second part will take place, where the patient’s injection site is examined after 48 to 72 hours. A raised bump will develop where the individual was injected, indicating that they carry the infectious bacteria. (Source J)

Nucleic Acid Amplification (NAA)

The Nucleic Acid Amplification (NAA) targets the nucleic acid regions, such as DNA or RNA, in an individuals body cells.

The Nucleic Acid Amplification (NAA’s) identify the small amounts of Deoxyribonucleic Acid (DNA) and Ribonucleic Acid (RNA) and uses this information to identify the Tuberculosis bacteria. The nucleic acid sequence within the DNA or RNA must first be identified in order for scientists to make probes which will attach to this sequence. The Nucleic Acid Test (NAT) will then create multiple copies of these probes through chemical reactions, which selectively amplify the signal of the nucleic acid being targeted. (Source K)

Interferon Gamma Release Assays (IGRA)

Interferon Gamma Release Assays (IGRA) are blood tests which are used to determine an individuals immune response to the Tuberculosis bacteria. ICRA detect the Interferon-Gamma Cytokines (molecules produced by the immune system) when mixed with antigens from the M. tuberculosis bacteria. (Source L)

Tuberculosis in the Present and Future:

Presently, Tuberculosis spreads rapidly due to population migration and the living conditions within developing countries. (Refer back to Global Spread of Mycobacterium tuberculosis). It is known that bacteria thrive in moist conditions. Consequently, global warming has a major effect on the rapid growth of Tuberculosis. Due to its constant increase in levels, global warming will continue to allow the rapid increase of Tuberculosis. and, in time, another outbreak will surface..

Climate-related factors, including temperature, precipitation and humidity, impact and have a major effect on the developing process and evolution of Mycobacterium tuberculosis. The quality of the earth’s air is affected by the mass pollution found in our atmosphere, where Carbon Monoxide increases the levels of Tuberculosis growth. (Source M)

The change in ultraviolet (UV) exposure from the sun seems to be another factor that contributes to the growth of Tuberculosis.

This change is brought about as a result of climate change. If an individual does not receive large enough amounts of Vitamin D, which is produced by the sun, they will develop a Vitamin D deficiency. Subsequently, this will weaken their immune system, making them more prone to contracting not only the Tuberculosis bacteria but many more diseases and viruses.

Although supplements can be taken to replace the lack of Vitamin D in an individuals body, it is important to note that there are mass amounts of individuals who are not able to get a hold of these supplements.

Many individuals, who are citizens of developing countries, could potentially not be financially stable enough to afford these costly supplements. It can also be the mere fact that it may happen where a country does not import and supply the supplements necessary to prevent such vitamin deficiencies. It is also important to note that there is a possibility that taking such supplements can interfere with one’s morals (Source N)

Conclusion:

Throughout my research project, I have discussed many aspects associated with the background of Tuberculosis, its relationship between mankind and how it has and still is evolving and aspects that contribute to its evolution.

It is vital to study the evolution of these disease-causing bacteria as they provide scientist with a better understanding on how antibiotics can be improved to prevent antibiotic resistance as well as help in the development of new vaccines against Tuberculosis.

The information obtained from these studies can also be used to educate individual more about the disease and help them gain a better understanding on it and how to prevent themselves from falling victim to the disease. In a summary, Tuberculosis was first found during ancient times, where evidence was present in skeletal abnormalities in Egypt and documents worldwide.

By the 18th Century, Tuberculosis was at its peak when European migrants had colonized to continents worldwide. Other factors that contribute to the worldwide spread of Tuberculosis includes living conditions in cities that create favorable conditions for Tuberculosis to thrive in as well as the co-occurrence of Tuberculosis and many more diseases that causes an individual’s immune system to weaken.

Climate change and global warming can also affect the growth and development of Tuberculosis. In terms of the relationship between the Tuberculosis bacteria and their host, the two organisms present a parasitic relationship where the bacteria benefits and the host is harmed. And finally, the diagnosis of Tuberculosis can be done with the use of many different tests and technologies including, skin tests (Tuberculin Skin Test/ TST), blood tests (Interferon Gamma Release Assay/ IGRA), x-rays and much more.

In the end, although many precautions and technologies such as vaccines and other various tests can be taken, Tuberculosis will continue to spread. That what we have now will soon not be enough to prevent yet another outbreak that will lead to many deaths globally.

Antibiotics are drugs or medicines used to treat bacterial infections. There are two main mechanisms that antibiotics employ to treat a bacterial infection. They can kill the bacteria or prevent it from reproducing, labeled bactericidal and bacteriostatic, respectively.

Antibiotic resistance is becoming an ever-growing issue all around the globe. The rate of bacterial evolution far exceeds our current rate of development of antibacterial agents. If bacteria become completely resistant to our antibiotics then we will have to survive like we did in the past – where any infection could kill. What is being done to prevent this? New antibiotics are being researched and developed, and this is getting the attention of investors and large pharmaceutical companies. Unfortunately, “there’s not been a new class of antibiotics discovered since the 1980s.” Scientists are working on developing new organic compounds – even nanotechnology (tiny machines that will fight bacteria one by one inside your body).

Europe has banned giving antibiotics to farm animals to boost their growth, however this still happens in some places e.g. China, which is why some super-resistant bugs have surfaced there.

China’s overuse of antibiotics is severe and is one of the reasons why China has the world’s most rapid growth rate of resistance (22% average growth in a study spanning 1994 to 2000). In China, antibiotics are regarded as a cure-all medicine, a panacea, and is overprescribed. Viral infections such as the common cold are not affected by antibiotics however an estimated 75% of patients with seasonal influenza are prescribed antibiotics, and the rate of antibiotics prescription to inpatients is 80%. This is one of the main reasons for high antibiotic resistance in China. Pathogens such as MRSA superbug are able to thrive as they adapt to China’s antibiotic heavy environment.

There are many factors behind China’s overuse of antibiotics. Firstly, the perception of antibiotics as a cure-all drug causes many Chinese patients to demand them even when they are not necessary. Additionally, they may request the newest antibiotics, perceiving them to be more effective. This causes problems because misusing antibiotics is what leads to the development of antibiotic resistance, which claims an estimated 33,000 lives a year within the EEA. Financial incentives also play a significant role in antibiotic overprescriptions. In many hospitals, doctors’ incomes are closely linked to their prescription of specific drugs, and bonuses from hospitals and kickbacks from companies augment their incomes.

An audit study suggested that “antibiotics abuse in China is not driven by patients actively demanding antibiotics, but is largely a supply-side phenomenon.” Tackling the problem of antibiotic-resistant bacteria has already cost us billions of pounds. Progressively fixing one of many causes of antibiotic resistance growth will help to reduce the amount of effort and time required to overcome this issue. In China, the problem of antibiotic overuse is not just a technical problem but also a social problem, which will require re-educating the public and the doctors on antimicrobial usage. According to Dr. Chen Zhu, Minister of Health, P.R China, “The ultimate solution to this problem is to undertake health reform which is to improve the compensation mechanism for public hospitals, to increase the income of doctors, to gradually eliminate the practice of hospitals subsidizing their medical services with drug sales and to promote the basic drug system.” Once public health reforms have been consolidated in China, the rigamarole of minimizing antibiotic resistance will have been greatly reduced and hopefully, we will begin to see a reversal in the increasing number of antibiotic-resistance bacterial infections in the future.

Methicillin (aka meticillin) is an antibiotic that is used to treat bacterial infections caused by organisms of the genus Staphylococcus. It was developed in 1959 as a type of antibiotic called a ‘penicillinase-resistant penicillin’, which means it was modified to make it resistant to penicillinase (a bacterial enzyme that can inactivate the antimicrobial effect of the drug). Methicillin-resistant strains of bacteria were initially detected in Europe, as early as the 1960s, which eventually rendered the drug useless for clinical purposes. Some naturally-resistant strains were detected in some countries even before the use of methicillin. It is likely that these original strains initially spread through natural populations of S.aureus via horizontal transfer and recombination, which is where DNA from one organism is transferred to another organism that is not its offspring. It is thought that these original strains went on to develop into unique and diverse strains within hospitals, as a result of “selection by exposure to antibiotics and by cross-infection”. This problem still persists almost 60 years later; a strain known as Methicillin-resistant S.aureus (MRSA) is pandemic, causing infection in tens of thousands of hospital patients and healthy individuals worldwide each year. The article published by Ayliffe in 1997 reported that all MRSA strains were “currently susceptible to vancomycin or teicoplanin”, however the first reports of VRSA (vancomycin-resistant S.aureus) were reported in the US in 2002. Vancomycin was originally planned to be a last resort drug for complicated infections caused by Staph bacteria. In the span of 16 years, one of our most potent treatments was rendered useless by some strains of the bacteria.

A bacteriophage is a virus which infects and replicates within bacteria and archaea. They are the most abundant organism within the biosphere with an estimated viral population of “greater than 1031 or approximately 10 million per cubic centimeter of any environmental niche where bacteria or archaea reside”. Bacteriophages were discovered by Frederick Twort in 1915 and independently in 1917 by Felix D’Herelle. D’Herelle observed them and realized that phages had the potential to kill bacteria that cause disease in humans, as well as in plants and animals and advocated for the use of phages as therapeutic agents pre-antibiotic era (before the discovery of penicillin). In 1933, he co-founded an institute for phage research in the Soviet Republic of Georgia. In the West, scientific efforts turned to the miraculous discovery of penicillin and research on phage therapy was abandoned. However, with the recent development of antibiotic resistance, phage therapy is regaining a lot more attention. Several reports have indicated the effectiveness of bacteriophages against pathogenic bacteria that causes infections in humans or animals via phage therapy.

In addition to bacteriophages, phage lytic proteins also provide successful elimination of pathogenic bacteria. The two main classes of phage lytic proteins are VALs and VAPGHs. These virion-associated lysins (VAL) are produced toward the end of the lytic cycle. Endolysins are highly specialised enzymes produced by the phage to digest the bacterial cell wall and are responsible for the progeny phage release. They have high specificity, don’t harm the natural flora and have a low chance of bacterial resistance, making them ideal for fighting against antibiotic-resistant bacteria. (Fischetti, 2010) On the other hand, Virion-associated peptidoglycan hydrolases (VAPGH) act in the first step of the phage lytic cycle. They locally degrade the peptidoglycan of the bacterial cell wall during infection. Unlike, lysins, VAPGHs create a small hole through which the phage tail can eject its genetic material (the start of the phage lytic cycle). Paul et al. identified a phage’s gene that encoded a muralytic enzyme, which was lethal to S.aureus (the aforementioned bacteria). They experimented with the gene until they produced a protein that retained the antistaphylococcal activity. Then, they combined their new gene with a staphylococcal cell wall-binding protein to produce chimeric protein P128. (Paul et al., 2011) P128 showed potent antistaphylococcal activity on clinical isolates of S.aureus including MRSA and against the genus Staphylococcus in general. It was even effective against MRSA in a rat nasal colonization model. Not only was this a success, it also demonstrates how VAPGHs and VALs could be developed for other pathogenic bacteria. A later study into P128 found that it was bactericidal against every S.aureus strain tested, including many clinically relevant S.aureus strains. Perhaps, most interesting of all was that the P128 protein was able to kill S.aureus, which was recovered from healthy people, under conditions representing physiological conditions. These results are promising for the future prospects of bacteriophages and their clinical applications.

Parfitt highlights the importance of distinguishing between lytic and lysogenic bacteriophages. When lysogenic phages insert their genetic material into the bacteria, their genes are integrated into the bacteria’s genome. When the bacteria divides, the phage’s genes are also replicated, however this presents problems as they could cause ‘horizontal’ spread of antibiotic resistance genes among related bacteria. These lysogenic phages are unlikely to get approval due to their evident disadvantages. Nonetheless this should not detract from the positive effects of lytic phages, which can not spread this antibiotic resistance.

Compared to antibiotics, the price of getting treatment appears to be a significant barrier to inclusive access to phage therapy. At the Phage Therapy Centre, the estimated cost of out-patient care is USD $3000-$5000, which can vary depending on the complexity of the condition. (Phagetherapycenter.com, 2018) Despite its expensive costs, this has improved a lot in just over 12 years, as a course of treatment used to cost between USD $8000 and $20,000 and even these exorbitant prices might outdo conventional antibiotics in the case of multidrug-resistant bacteria eg MRSA. According to an article published by Health Leaders, the average treatment costs for drug-resistant staph infections were about USD $38,500 and more than USD $40,700 for MSSA-associated (methicillin susceptible S.aureus) pneumonias. These estimates may not be accurate as an article in the Clinical Infectious Diseases journal estimates the average costs to be roughly USD $34,526 for MSSA-related hospitalization costs and USD $34175 for MRSA-related hospitalization costs. Furthermore, patients with MRSA-related infections had a higher mortality rate than patients with MSSA-related infections. This may imply that the actual cost of treatment may be higher for these patients and reinforces the idea that multi-drug resistant bacteria are a major problem in current medicine.

Antibiotics are key for treating bacterial infections such as pneumonia, skin and soft tissue infections. Antibiotic use makes surgery, and use of medical devices in patients possible by greatly reducing mortality risk due to infection. Antibiotic resistance is a global natural phenomenon. Strains of bacteria can evolve to develop defence mechanisms to antibiotic exposure, resulting in failure of the antibiotic. Although this is a natural process the rate at which this occurs is increasing due to inappropriate use of antibiotics.1 This means in the future treatment for common infections will be rendered ineffective, increasing mortality. It is estimated that by 2050, 10 million deaths per year may result from antibiotic resistance if interventions are not put in place. 2 With the discovery of new antibiotics declining in the past twenty years and an increase in antibiotic use, antibiotic resistance poses a great threat to public health globally. Many factors contribute to antibiotic resistance such as inappropriate prescribing and poor adherence to treatment guidelines. With studies being carried out and a greater understanding of the antibiotic resistance threat, there is a great urge to tackle the increasing resistance rate. The community setting accounts for approximately 90% of antibiotic use, with respiratory tract infections (RTI) making up majority of antibiotic prescriptions, followed by skin infections.3,4

What contributes to antibiotic resistance?

Unnecessary antibiotic use

Unnecessary prescribing of antibiotics is a major contributor to antibiotic resistance. This involves exposing patients to antibiotics for self-limiting or viral infections for which antibiotics are ineffective. A study carried out in the Republic of Ireland (ROI) evaluated antibiotic prescribing by health care professionals, paying particular attention to the necessity of antibiotic prescriptions. The study has shown that the majority of antibiotics were issued for upper respiratory tract infections, coughs and sore throats accounting for more than 60% of the antibiotic prescriptions studied. 4 These conditions are generally identified to be viral and self-limiting, therefore many of these prescriptions may have been avoidable. Taking antibiotics for a viral infection will not resolve the patients’ symptoms nor speed up the process. This increases patient exposure to antibiotics unnecessarily, while increasing the risk of adverse reactions such as C.difficile infection.5,6 It needs be noted that this study carried out in ROI cannot be representative of the global scale of antibiotic use. As stated in the study, certain patient groups have to pay for a GP consultation which may result in an increased expectation for antibiotic treatment. The prescribers’ decision may be influenced by this pressure from patients.

Prescriber and public attitudes

The idea of prescribers being influenced to prescribe antibiotics is a recurrent theme that has appeared when investigating antibiotic use. If the attitudes of the public and prescribers can be changed this may help tackle an important area that contributes to antibiotic resistance. A questionnaire study investigated the idea of ‘pressure to prescribe’ by looking at the attitude of patients and prescribers’ towards antibiotics. The paper demonstrates that of those who thought they had an infection, over 70% wanted and expected an antibiotic to be prescribed. The patients view were compared with the prescribers opinion, who felt antibiotics were ‘definitely indicated’ in only one fifth of the patients who received antibiotics. ‘Patient pressure’ influenced the prescriber’s decision in 20-40% of cases.7 Another survey-based paper explored patient satisfaction in consultations for respiratory tract infections. Prescribers were of the opinion that patients who expected an antibiotic would be left unsatisfied if they did not receive one, and that they were more likely to revisit for a second consultation. The study revealed that there was in fact no difference in satisfaction for those who received antibiotics and those who did not receive treatment.8 Patient satisfaction depended on the information and reassurance they received during the consultation. This study provides important evidence surrounding attitudes towards antibiotic prescriptions. Doctors may overestimate the influence of antibiotic prescriptions on patient satisfaction, centering on a treatment strategy rather than providing factual information to the patient about the harm of inappropriate antibiotic use and resistance. This plays a role in the over prescribing of antibiotics. Education to the public about antibiotic use and resistance would be beneficial in combating the emerging resistance rate.9 An increased public awareness of the future threat antibiotic resistance may reduce the expectation of patients to receive an antibiotic, this would also increase patient confidence when the prescriber feels treatment is not necessary.

Adherence to guidelines

Appropriate antibiotic selection, dose and duration of treatment are very important in ensuring safe antibiotic use that will protect the public from the future threat of antibiotic resistance. A cross sectional study carried out in the English primary care sector considered the connection between compliance to antibiotic guidelines and antibiotic resistance. It was identified that a considerable proportion of prescriptions for respiratory indications were outside the recommended treatment duration, in more than 80% of cases. This study provides alarming figures, highlighting that respiratory tract infections accounts for approximately ‘1.1 million excess treatment days’ with antibiotics, which could have been avoided if appropriate guidelines had been followed. It is positive to see however, that other non-respiratory conditions such as pyelonephritis only exceeded recommended guidelines in less than 20% of cases.6 Other studies also reported that 80% of antibiotic prescriptions were not strictly in accordance with guidelines.4 There is a clear trend of large numbers of prescriptions deviating from duration guidelines. It should also be noted that a deviation in antibiotic choice can also be seen, with second and third line agents being selected rather than first line as expected.4 It is clear that guidelines and recommendations are in place however they are not being followed as closely as required in order to reduce the risk of antibiotic resistance. A qualitative study carried out in Australia looked at GP prescribing against guidelines and how they help them make a clinical decision.10 GPs agreed that guidelines played an important role in standardization of healthcare provided to patients which was important. Experienced GPS didn’t feel the need to check guidelines with some of them having a ‘preference’ to antibiotics they prescribed for certain indications. This is a common trend among prescribers with many having a go to antibiotic for certain indications. Although this may be suitable for the treatment of infection it can result in an increase in second and third line agents being used, were as first line agents are preferable in order to reduce the risk of antibiotic resistance.

Self-medicating with antibiotics

A questionnaire study carried out in China explores another issue contributing to antibiotic resistance. It looks at ‘self-medicating’ with antibiotics, with particular focus on treatment of children. This is a perfect example of antibiotic misuse that contributes to antibiotic resistance. The study found that ‘almost half of respondents kept antibiotics at home for children’, with approximately 30% of these using antibiotics to treat illnesses such as cold, sore throat and fever, illnesses which do not warrant antibiotic use. These antibiotics were left over from previous prescriptions and some pharmaceutical purchases. 11 This study only looks at the use of leftover antibiotics in China however it is extremely likely that this is a problem globally. Another study carried out in Rwanda also provides evidence of students self-medicating with antibiotics, of those who chose to self-medicate, 50% of these used antibiotics for a common cold.12 Lack of patient knowledge is a contributing factor to inappropriate antibiotic use. A questionnaire carried out in Serbia found that surprisingly over 50% of people thought antibiotics could treat a common cold. A lack of knowledge lead to a three times greater chance of self-medicating with antibiotics in comparison to those with adequate knowledge.13 Education if extremely important in tacking antibiotic resistance and could be regarded as the ‘best approach’ to improving antibiotic prescribing.9

Occurrence of Infections

Otitis media in pediatrics is a common ailment seen in a community setting that carries a significant amount of antibiotic prescribing.4,14 In many cases otitis media is a self-limiting condition, however some patients require antibiotic treatment. In a move to reduce antibiotic use, antibiotic prescribing for otitis media has reduced in the UK. A cohort study carried out in the United Kingdom investigated the impact of reduced prescribing on the incidence of mastoiditis, a complication of otitis media. The paper found that the declining use of antibiotics over the course of this study was not linked to any increase in the incidence of mastoiditis. The paper identifies that in order to reduce one case of mastoiditis which is rare, a significant number of otitis media cases would need treated with antibiotics which would not be feasible. The benefit of reduced antibiotic use in this scenario outweighs the risk of mastoiditis.14 This paper is positive as it provides evidence that reducing patient exposure to antibiotics for self-limiting conditions does not increase their risk of complications, and this should be taken by example. This study does mention however that although this is positive to see, prescribers need to be aware of signs of complications when the do occur in order to reduce serious consequences for the patient.

As mentioned previously, a reduction in antibiotic use in self-limiting conditions is beneficial in reducing antibiotic resistance, however antibiotics play a very important role in treating infection and are life-saving. A study carried out in England looked at the increasing rate of antibiotic prescribing for Staphylococcus aureus skin infections. Over approximately a 10 year period this study found an over 60% increase in ‘antistaphylococcal’ drug prescription rates. The paper however found that the increase in prescribing wasn’t due to ‘treatment drift from other antibacterial drugs’, but may indicate an increasing prevalence of staph infection. 15 Throughout the study Flucloxacillin which is the drug of choice for this indication which is positive to see. This study highlights that the need for antibiotics have been increasing over time, and in order to tackle antibiotic resistance, prevention measures should be put in place to reduce the incidence of infection, which in turn will reduce the number of antibiotics required.

Antibiotic resistant organisms

Although treatment of many common infections are being threatened by the emergence of antibiotic resistance, there are a number of bacterial organisms that are particularly high risk. Gonorrhoea is the second most common bacterial STI globally. The bacteria Neisseria Gonorrhoeae has the ability to mutate rapidly resulting in many strains become resistant to antibiotic treatment. A study in the US in 2017 found that ‘50% of isolates are resistant to one or more antibiotics’.16 Gonorrhoea if left untreated can lead to many complications such as pelvic inflammatory disease and infertility.17 The increasing incidence of gonorrhoea infection, and the increase in antibiotic resistance of the causative agent Neisseria Gonorrhoeae bacteria is of great concern to global public health. The pathogen has a great ability to adapt leading to resistance resulting in a global epidemic.18 This bacteria is found to have ‘widespread’ resistance to many antibiotics classes such as penicillin, tetracycline, cephalosporin.17 Main target to reduce the spread of antibiotic resistant pathogens is to prevent transmission of the infection. Education to public on safe sex, methods to prevent spread of STIs and the importance of getting screened regularly may help reduce the spread of resistant organisms. Treatment for gonorrhoea has progressed from effective use of oral penicillin to dual therapy and IM injection of third generation cephalosporins.18,19

Stewardship

Antimicrobial stewardship is a term that refers to ways in which antimicrobial use can be optimized in order to reduce the risk of resistance. This includes interventions and programmes to promote safe and effective use of antibiotics to preserve their use for future generations.20 The community pharmacy plays a key role in tackling antibiotic resistance and promoting antibiotic stewardship as it is usually the first interaction a patient has with a healthcare professional. This is therefore a key area to carry out antibiotic stewardship with patients, in order to reduce antibiotic burden. The pharmacist has an important role in targeting causes of resistance, by counselling patients on taking their antibiotic appropriately by following the dose and duration recommended, which increases patient compliance. Pharmacists can also advise the patient on alternative treatment for viral and self-limiting conditions which may help the number of visits to the GP for antibiotics. A qualitative study carried out in England and Wales analysed the role the community pharmacy has in antimicrobial stewardship. The focal point of this study is the issues pharmacists feel limit them in carrying out antimicrobial stewardship. 21 It is clear that pharmacists have adequate knowledge of what antibiotic resistance is and the importance of it, however there was a lack of awareness of any antimicrobial stewardship initiatives in the local community. The study mentions that GPs were confident in the pharmacists’ ability ‘to deal with minor respiratory tract infections’. Pharmacists did have uncertainty whether patients in more vulnerable groups such as elderly and very young needed an antibiotic or not, and were more likely to refer to the GP in these cases. Time and accessibility to information was a key limitation identified by pharmacists in this study. The vital role the pharmacists’ plays in dispensing of medicines can leave little time for over the counter consultations with patients. There was concern that less experienced pharmacy staff may be providing misinformation to patients when it comes to antibiotics. Another limitation highlighted in the study is the lack of access pharmacists have to patient medical records therefore they have no indication for infection when dispensing an antibiotic. Having patient records would be very beneficial as it would allow pharmacists intervention when inappropriate antibiotics are prescribed. This could increase the number of 1st line antibiotics being prescribed rather than second and third line agents. This may greatly help the effort to reduce antibiotic resistance.

Due to the elevated use of antibiotics in variety of products and in anthropogenic activities the concentration of AB become higher in waste water and fresh water bodies. The presence of antibiotics especially Fluoroquinolones pose adverse impacts on public health as well as on aquatic life through developing antibiotic-resistant genes. To overcome these impacts, the use of antibiotics should cut down and a proper and safe disposal of effluents having antibiotics in it should ensure.

Risk assessment is the mean of evaluating hazard or risk associated with a process, chemical, situation and its influence on public health and surroundings. Hazard identification, Dose-response assessment, Exposure assessment, Risk characterization are the steps to carry out the process of risk assessment.

In this review paper we will discuss about the risk associated with the antibiotics especially fluoroquinolones, their impacts on aquatic life, on public health and possible treatment technologies for the removal of FQs.

As a developing bunch of natural and man-made contaminants, anti-microbial have pulled in developing consideration due to their potential undesirable impacts on human wellbeing and on their environments. anti-microbial are broadly utilized to treat irresistible illnesses for both people and animals, and to advance the development of aquaculture, horticulture and many more. The emerging contaminants/pollutants comprise Pharmaceutical active compounds (PhAC) especially antibiotics, personal care products (PPCP), disinfection byproducts (DBP), hormones, insecticides, pesticides, explosive, endocrine disrupting chemicals etc.

A study was conducted in Beijing china where they analyzed 11 personal care product and a metabolite in different vegetables grown in filed irrigated with wastewater. The results showed the presence of some PPCPs higher than its threshold limit and some were under the threshold limit. The amount of N4-acetylsulfamethoxazole and Triclosan were greater than the others.

Due to the water deficiency reclaimed wastewater is used for the irrigation purposes which increases the risk of crop contamination by antibiotics and other emerginging contaminants present in wastewater. The contaminated crops can affect harmfully on human health upon the consumption. The manifestation of antibiotics in reclaimed wastewater and the practice of this water for irrigation purpose can develop the antibiotic resistance in already prevailing microbe in the topsoil, Due to the application of wastewater and animal manure continuously onto the lands.

The usage of Fluoroquinolones is generally for the antimicrobial and antifungal illnesses associated to urinary tract and respiratory tract infections. The higher intake of these types of antibiotics results in severe and everlasting nerve impairment which is known as peripheral neuropathy. (Miller, 27 August 2013) Norfloxacin, Ofloxacin, Levofloxacin and Ciprofloxacin are some most commonly used fluoroquinolones antibiotics mostly used for the cure of traveler’s diarrhea in grownups.

Due to high amount of FQs in Pakistan the antibiotic resistance to Salmonella Typhi and Salmonella Paratyphi is already developed among the citizen. A research study was conducted in Lahore Pakistan for the detection of Fluoroquinolones in wastewater of two famous hospitals in Lahore and it was concluded that the greater amount of Ofloxacin and Ciprofloxacin were presented in the waste water of the both hospitals. Another research done in USA showed that the high consumption of fluoroquinolones by United States people and high usage in poultry medicine developed antibiotic resistance to campylobacter specie due to intake of poultry products by the citizens of America.

Nearly 1600 persons in United States of America may have the campylobacter jejuni due to high intake of fresh and old beef which showed that elevated resistance is established in campylobacter jejuni against fluoroquinolones. A study in California showed that fluoroquinolones resistant Neisseria gonorrhea was increased exponentially among the people of California in the course of 2000 and 2003 because the patients with QRNG were highly resilient to fluoroquinolones.

The continuous use of FQs also increases their extent in waste of industrial effluents, municipal waste, hospital waste etc. The ultimate destination of the waste is water bodies and the unprocessed wastewater comprise higher sum of FQs in it which can generate catastrophic impacts on aquatic biome. The accumulation of FQs in the bodies of aquatic creature give rise to bioaccumulation of FQs in them. A research was directed in the industrial areas of Pakistan, Hattar and Kahuta in which the wastewater and sludge of the industrial waste was assessed. The results showed that the Ciprofloxacin, Enrofloxacin and Levofloxacin were greater in the industrial wastewater of Kahuta while the quantity of these FQs were greater in the slurry of Hattar industrial sector.

It was also concluded that Enrofloxacin has numerous potential to cause catastrophic effects to green algae. It can also pose adverse impacts to cyanobacteria and invertebrates followed by green algae. (Riaz, 2017) in every water body FQs are present from higher to lower concentration depending on the location of water body. It was also assessed that the higher dose and lower dose of FQs in water bodies both have adverse impact on aquatic life. The smaller amount of FQs in water bodies can affect the reproduction of fish and other aquatic creatures due to longer exposure to FQs.

According to the study done in China revealed that the conformist treatment is not efficient for the removal of antibiotics from the wastewater. The exploration was done for the detection of destiny of eight quinolones nine sulfonamides and five macrolides. The results exposed that the amongst the all antibiotics the quinolones prerequisite secondary treatment and the other two categories were tenacious throughout traditional treatment.

One of the great technology for the deletion of fluoroquinolones antibiotics from waste water is using bamboo biochar through course of adsorption. This process showed 90% removal of FQs from the wastewater. (Yanbin Wang, 2015) there are many technologies developed for the removal of FQs from the wastewater but not a single process can remove the FQs 100% from the wastewater.

Fluoroquinolones are the antibiotics used for the infectious diseases especially associated with UTI and RT infections. The release of FQs in water bodies can cause catastrophic affects to aquatic biota. The usage of wastewater for the irrigation having FQs in it can also cause adversely to the public health. The removal of FQs are not an easy task but there are variety of technologies that can remove FQs from wastewater to some extent. More and more research is needed to conduct regarding the FQs and their safe disposal. Also in many countries the awareness is desirable for the safe disposal and regarding the adverse impacts due to usage of FQs antibiotics continuously.

Antibiotics are a category of drugs that are commonly used for the treatment of bacterial infections. Commercial antibiotic use in farms started in the 1940’s, and over time the uses have progressed to aid animal growth and to stop animal illness in small quarters. This development of antibiotics in farming may be a valuable economically, however there are drawbacks that have seen little attention. This emphasis on profit from antibiotic use, over animal welfare and human health, is becoming a risk. It was found that 80% of antibiotics in the U.S. are used in meat and poultry products. The risk associated with this statistic is this use of antibiotics in food is widespread, threatening public health as it builds antibiotic resistance. For example, 81% of beef contains one type of resistant bacteria [footnoteRef:0]. The use of antibiotics in farming has become an unsustainable practice because of its widely unmonitored effects on the environment and human health.To resolve this issue, action must be taken through congress, academic studies, and the FDA, in order to have more information and regulations on this issue.

The initial use of antibiotics in farms was for treating sick animals which is sustainable, as the usage is in moderation. However today farms are using unsustainable and possibly dangerous practices that are affecting the animal’s wellbeing and the environment. It is common now in industrial farming for antibiotics to be put in the animals feed and water. This is for more growth, feeding efficiency and to prevent diseases among animals. There are many FDA approved antibiotics for agricultural use such as penicillin, however almost none of the over the counter uses have been reviewed by the FDA to ensure they are safe in regards to antibiotic resistance. This is distressing as the FDA allows the use of antibiotics for the intended purpose of making sure animals are “clean” and safe, even though they have not investigated all the effects that antibiotics in food have on people[footnoteRef:1]. In effort for efficiency , antibiotics are now necessary to keep an excess of animals in one shared space healthy, since they combat the issues of the rapid spread of disease among animals in crowded spaces. This claim is reflected in the finding that as the number of farms raising animals have decreased, the amount of animals housed in them are the same[footnoteRef:2]. Another reason antibiotics are becoming crucial for efficiency is they are used as a growth supplement in animals. Since the antibiotics are regularly implemented into the feed to aid growth, the animal waste contains excessive nutrients, farm chemicals, antibiotics and hormones. The large groups of animals in small spaces, leads to a large manure output with elements that contaminate the soil, contaminate nearby water sources and threatens wildlife.

Nestle told The Nation’s Health , “It is going to enforce existing environmental quality laws and regulate industrial animal farms as thoroughly as other industries to avoid public health and environmental risks.” However Nestle also notes that these facilities have been given a pass on pollution. This is a concern as it would be unacceptable if a city, home to thousands of people, chose not to treat its waste, and yet pig and cattle ranches contain open lagoons filled with untreated waste that threaten local water and land sources[footnoteRef:3]. Even though companies like Nestle make statements wanting to avoid public health and environmental damage, they will still continue unsustainable practices in these areas as long as they are meeting the regulations. In order for improvements in public health and the environment, stricter regulations are needed in order to reform big business practices.

Since antibiotic usage in farming is now standard practice, people are becoming more resistant to certain antibiotics making the treatment of an illness through alternatives to these antibiotics more expensive, as well as causing more side effects. 60 percent of all antibiotics on the farm are used in human medicine, which means humans and animals are taking the same antibiotics, resulting in resistance to this medicine. The Consumers Union has made a statement recognizing that antibiotic use in farming practices today is a threat to human health. Antibiotic resistance bacteria are called superbugs. These superbugs are found in meat and poultry, and they have the capacity to transmit their resistance to other bacteria in the environment, causing a spread of new strains of harmful bacteria. In a study of 200 American supermarket meat samples “ 20% contained Salmonella; 84% were resistant to at least one antibiotic. Another report found resistant bacteria in 81% of ground turkey meat, 69% of pork chops, 55% of ground beef and 39% of chicken breasts, wings and thighs found in US supermarkets Another study samples from 36 US supermarkets. Almost 25% tested positive for the resistant bacteria’. Based on this data over 25% of all bacteria found in supermarket meat had resistant bacteria. This risk of antibiotic resistance is clearly tied to accessible food and and consumers are not informed well enough to avoid this potential health threat. Cipro is an chloroquine antibiotic that treated the anthrax attack. The use of antibiotics in poultry was common from 1995 to 2005, so FDA monitored that that resistance to cipro in human illnesses was increasing from 12.9% to 21.7 percent in 2005.. In response, the FDA began the process to remove fluoroquinolones from routine use in poultry in 2000. The drug class was banned from routine poultry use in 2005 after protracted legal challenges. with 2 million people suffering from a resistant infection annually and an 8.8 percent increase in resistance. The legal use of antibiotics use has certainly shown to affect certain antibiotic resistance in people, this is especially bad for the young and old. They depend on these antibiotics to work because alternative medicines include more side effects and are more expensive.

The most effective action would be to put a ban on all antibiotics used for non-therapeutic reasons and to create stricter farm environmental laws through congress, to protect human health and the environment. Though public ad campaigns still help educate the public, it is still not enough to make an impact on the issue. Some progress is that the FDA banned the use of fluoroquinolone (class of antibiotics) in 2005, when 30% of e coli found in chicken breasts were already resistant to one or more types of antibiotics. Also, in 2012, the FDA stated “Misuse and overuse of antimicrobial drugs creates selective evolutionary pressure that enables antimicrobial resistant bacteria to increase in numbers more rapidly than antimicrobial susceptible bacteria and thus increases the opportunity for individuals to become infected by resistant bacteria.” Also in 2012, the FDA banned certain uses of cephalosporin, a antimicrobial drug in certain animals, stating “In regard to antimicrobial drug use in animals, the Agency considers the most significant risk to the public health associated with antimicrobial resistance to be human exposure to food containing antimicrobial-resistant bacteria resulting from the exposure of food-producing animals to antimicrobials(The Overuse of Antibiotics in Food Animals Threatens Public Health, 2). The FDA is taking initiative to fix this problem but they need to study more of these antibiotics to stop more of them due to the increasing numbers of antimicrobial resistant bacteria. Another problem is that the FDA is banning antibiotics usage too late after it has already affected the health of many like the consequences of fluoroquinolones. It is necessary that congress steps in and pass the preservation of antibiotics for medical treatment act to directly end antibiotic issues because the FDA’s progress to stop the overuse of antibiotics has been deterred for the past 30 years (Antibiotic Resistance and the Use of Antibiotics in Animal Agriculture,1). Denmark has successfully been raising animals using antibiotics only for medical reasons. The ban started in 1998 and the world health organization found there was no decrease in feed efficiency and the ban reduced human health risk without significantly harming animal health or farmers income. Danish government data shows that livestock production has increased since the ban which antibiotic resistance has declined (Antibiotic Resistance and the Use of Antibiotics in Animal Agriculture,3). The Danish government has set an example for America, exemplifying how a ban on antibiotics will eliminate human health risk with little consequences to farmers and the animals. If a direct ban on antibiotics in livestock was passed, this would force the farmers to put less animals in more space to prevent the spread of disease (which was originally prevented from antibiotics), this would cause less animal waste, and in result it would stop waste containing farm chemicals, antibiotics and hormones from running off into local water sources, contaminating soil, and threatening wildlife. While there is no antibiotic ban in the US, in North Carolina, environmental advocates and farmers took on issues associated with the state’s 10 million hogs, which is the first state to ban new hog waste lagoons and require new waste systems to protect the environment. The law included money to fix contaminated water wells and help farmers convert existing lagoons into cleaner systems, and requiring that utilities use renewable energy provided by hog waste to combat the environmental issues caused by large amounts of animals waste.

Many other people view the use of antibiotics as not affecting human health because it is applied in small doses and most of the antibiotics used are not applied in human medicine. Even though the vast majority of antibiotics are not extensively used in both people and animals (Antibiotic Resistance and the Use of Antibiotics in Animal Agriculture, 2)all of the drugs except ionophores are still used by both animals and humans no matter the percentage, which builds up antibiotic resistance for Americans. The industry says that 40 percent of all the antibiotics used on the farm are drugs (called ionophores) not used in human medicine, (The Overuse of Antibiotics in Food Animals Threatens Public Health, 4) This statement does not give farmers a viable reason to use antibiotics because still 60% of all antibiotics used on the farm are used in human medicine, also supporting antibiotic resistance. Some argue that the amount of antibiotics used in food is extremely low and there is no evidence that antibiotics in food is harming people directly because humans still take antibiotics annually. However numerous studies have have demonstrated that routine use of antibiotics on a farm promotes drug-resistant superbugs in those facilities, after a long fight in the courts, FDA finally banned use of the drug in 2005, when nearly 30 percent of C. coli found in chicken breasts were ciprofloxacin resistant increasing from 20% in 1999. By 2010, resistance to ciprofloxacin had declined to 13.5 percent to 12%.(The Overuse of Antibiotics in Food Animals Threatens Public Health, 1) This study has shown the correlation between the use of antibiotics and human health because the resistance to c.coli decrease from 13.5 to 12 percent after the ban was in act and the amount of chicken breasts that were ciprofloxacin resistant increased 10% before the ban. This goes to show that the small doses of antibiotics still negatively affect human health.

Antibiotics have become commonly used in farming which leads to negative effects on human health and the environment. Since the use of antibiotics is still legal, it encourages farmers to keep a majority of animals in small spaces because antibiotics stop the spread of disease. This leads to environmental issues such as large amounts of waste in small spaces which waste runs off into bodies of water. Antibiotics are shown by many studies to negatively affect human health, but there is no direct evidence due to a lack of constants in the studies and the controversy on if humans or animals cause antibiotic resistance. Measures such as direct action in Congress, more FDA research and environmental initiatives have not been taken. Every day that the FDA and Congress delay implementing legislation to ban antibiotic usage, the risks for human health increases unless an action is taken.

Overuse and inappropriate use of antibiotics in agriculture has been implicated in the development of antibiotic resistant bacteria, which is a significant and growing public health threat. Antibiotics are used in the agricultural as growth promoters as well as treatment and prevention of infections. Some of the popular antibiotics used as growth promoters are those related to Vancomycin such as Avopricin. These antibiotics are administered to animals orally, through injection or mixed into animal food. Spraying of antibiotics on plants is also a common practice that helps treat infections. However, the use of antibiotics has its implications both in the economical and the biological aspect. Biologically, antibiotics lead to the emergence of antibiotic-resistant strains. Economically, it lowers the production cost.

Use of antibiotics as growth promoters has resulted in antibiotic-resistant strains. These resistant antibiotics can be transmitted to humans and other animals. The transmissions occur when contaminated animal products are ingested or through direct contact. Animal and human bacteria can also transfer genes leading to human infections. Some studies suggest that Campylobacter jejuni infections became resistant towards fluoroquinolone due to contamination from beef in the US. An investigation was done on chicken using antibiotic growth promoters also added up to the findings as it was discovered that campylobacter infections were connected to chicken. The results led to the banning of fluoroquinolone use in poultry farming.

Exposure of human to resistant bacterial strains from agriculture has been reported in most parts of the world. A staphylococcus strain resistant has been found to transmit from livestock to humans. In the Netherlands ST398 was published, Denmark reported a CC93 strain whereas Europe reported an ST130 methicillin resistant staphylococcus. Cases of these resistant strains have been reported with no contact between animals and humans. The fact suggests that the infections might have occurred due to human contact, or by contact with pets, contaminated foods or contaminated environment. Animals are zoonotic reserves. Hence, animal to human transmissions is at a very high rate compared to other transmission routes.

Economically, antibiotic use has both long and short-term effects. Short term impacts of antibiotic use in the agricultural sector are that of the reduced cost of production and a rise in production volumes. However, due to the health risks posed by the use of antibiotics in the agricultural sector, most government has been forced to ban the use of reported antibiotics in the farming sector. The banning has economic implications as it will increase the cost of production. It will call for farmers changing their production processes such as changing the type of equipment’s, housing and looking for medical alternatives to the banned antibiotics. Feed formulations also need adjustment, including switching to biosecurity techniques like selective breeding. The antibiotic-producing industries might also encounter lose as their purchase rate will drop. Animal products will also be produced in smaller quantities due to the absence of growth promoters. A decrease in production volumes leads to the hiking of prices of farm products, making it unaffordable.

In conclusion, the use of antibiotics in the agricultural sector poses more disadvantages than advantages. Its use should, therefore, be discouraged for the sake of human and animal health as well as economic stability.

Antibiotics have become an indispensable part of the medical procedure to treat various diseases. Children, being in the most active phase of life, play in the gardens inhabited by all sorts of insects, slide on the railings laden with dust, sail paper boats in the muddy puddles on a rainy day and what not! We, the parents, are often on our toes running to the doctors with their cuts and wounds, infections and ailments due to their fearless fun-loving attitude.

Though the side effects of various drugs are a major concern for parents, less do they know about their toxic effects on the Central Nervous System of their children. The neurotoxic side effects of the antibiotics are not that well recognized until now – [1]. According to an article published by University of Oxford, July 22,2020, experiments on mice show that antibiotic treatment during infancy impedes brain signalling pathways that function in social behaviour and pain regulation. If the same is true for humans also, still needs to be established.

A lot of factors increase the susceptibility to neurotoxicity like genetic factors, nutritional status, renal efficiency, blood flow, tissue- uptake, status of blood-brain barrier rate of medicine absorption, target tissues of the antibiotic, route of the drug-delivery, elimination of medicine’s metabolites and Central nervous system penetration – [2] [3]. Antibiotic induced neurotoxic side effects can have a whole gamut of neurological implications. So, these wonderful life savers, as the antibiotics are known as, can become the villains for our brain and can affect our thinking too!

To our surprise, the first anti-depressant was discovered by serendipity in a sanatorium made to treat Tuberculosis – [4]. It was observed that an antibiotic used for tuberculosis (TB) treatment (isoniazid) induced a strange behaviour in the patients. The normally quiet patients also started laughing and dancing around. Now, this was just a curtain-raiser on how the anti-microbial drug could affect the functioning of our brain.

Many studies show that a lot of antibiotics have a structure that mimics the neurotransmitter GABA and if they can breach the blood-brain barrier, they may clog up GABA receptors, eventually causing a wide variety of mental complications, for example, the use of Penicillin has been associated with disrupted brain function in people since 1945. The visible symptoms include aphasia, spasms, seizures, psychosis, confusion, lethargy anxiety, and coma. Though unclear about what causes the brain malfunction, the studies reveal a diminishment of the neurotransmitter GABA, making apparent that antibiotics contribute to brain-related issues. Another serious disruption in brain function, called Delirium, may be linked with the usage of even common antibiotics in which a person is in a state of mental confusion accompanied by hallucinations and agitation.

Coming back to the effects on children, one would be surprised to know that most mothers, knowingly or unknowingly pass on much more than their own genes to their children. Maternal antibiotic use during pregnancy is usually associated with an increased rate of anxiety, autism, schizophrenia, and depression later in the child’s life. [5]. The Broad-spectrum antibiotics may damage the useful micro-organisms in a way that can have a long-term effect on the child.

Being a parent, we need to know that the first thousand days of childhood are very important. During this period, the child’s immune system is trained to tolerate the beneficial bacteria, Also, the appropriate microbiota in their body helps their brain to develop normally. So, administering these so-called life-saving antibiotics, kill the useful bacteria during this critically important accommodation period in a child’s growth period.

In the experiment done on mice, the lack of useful bacteria was seen to cause an abnormal stress reaction. When the mice were provided with a healthy microbiota, it put them back on track, but only if they were younger than 3-weeks period. After that their stress response couldn’t recover showing how important is useful microbiota for the normal functioning of the brain, especially during the initial period of development of an infant.

Infants who have to be given antibiotics end up having a less diverse microbiota, making them prone to IBD and depression as adults. So, if your child needs them, don’t hold back, but do your best to make this early training period of the body as normal as possible. – [6]. Excessive use of antibiotics in children is also noted to cause anxiety, personality changes and bad temper. This may be due to Edema in brain or pH change in the gut due to death of useful gut bacteria. The antibiotic-treated mice showed impaired anxiety-like social behaviours and displayed aggression.

The experimental evidence adds concern as it suggests that early exposure to antibiotics lead to long-term behavioural changes in children. Not only does the overuse kills useful bacteria but also makes the harmful bacteria to become resistant to our drugs. We have a lot of research done on antibiotic usage vs. change in gut bacteria, leading to an increased risk of several diseases like inflammably bowel disease, colorectal cancer, and obesity. Just another reason to be careful with the use of antibiotics.

With all these research results, one thing is clear that antibiotics can have a surprising impact on the brain. Hence, with antibiotics being capable of affecting my child’s thinking, immune system, and behaviour, I would definitely consider the next time she gets an infection.

Antibiotic was working as magic bullet against infection causing bacteria since discovery in 1928. By evolution, some bacteria fight back against antibiotic and become resistant. In 21st century, antimicrobial resistance is one of the biggest threats for the world. All over the world, antibiotic resistant bacteria infect a huge number of people and cause death of a certain number of them. Due to resistance to antibiotics, it is very tough to treat these infections. Abuse of antibiotics is proved a leading cause of forming resistance and there are lots of severe cases reported due to antibiotic resistance for respiratory infections. Resistance can occur by mutation in gene to alter target protein, change membrane permeability etc. or by acquiring resistant gene from different bacterium. These genes can be carried by plasmid or bacterial chromosome. Chromosomal resistant genes generally transfer mother to daughter by vertical transmission, can also be transferred horizontally by conjugation. But plasmid can be transferred other surrounding cells as well as daughter cells. By horizontal transfer, resistant gene can be transferred to a bacterium of a different species. Moreover, poultry and animal farmers use antibiotics for better production which eventually enter into human body through food chain. There is no circumspection to control the market of medicines. So, it has become mandatory to control purchase of drugs and make people aware of antibiotic resistance to ameliorate the situation.

Antibiotic Resistance in Bangladesh

Here I have collected data from various research studies to realize: 1) which antibiotics are used mostly in our country in various diseases; 2) in which cases antibiotics are used, and 3) the situation of antibiotic resistance in our country.

A survey on antibiotics practices in Chittagong conducted by IIUC in 2015 revealed that antibiotics were prescribed for 69.49% of patients and azithromycin (30.49%), cefixime and ciprofloxacin are widely used. Staphylococcus aureus and Staphylococcus pneumoniae are proved to be liable for acute respiratory tract infection in our country by a study conducted by GARP (Global Antibiotic Resistant Partnership)-Bangladesh and CDDEP along with icddr,b. Samples taking from Enam medical college during 2014-2015 period showed that these two pathogens are largely resistant to amoxicillin and cotrimoxazole. Another research of icddr,b shows that rotavirus and E.coli, 2 major pathogens for diarrhea are resistant to TMP-STX and erythromycin, nalidixic acid respectively.

Causes of Antibiotic Misuse in Bangladesh

There are many reasons for misuse of antibiotics in our country:

1. Many people buy antibiotics from medicine shops without prescription. Most of them don’t complete the course and treat themselves with antibiotics by their previous experience.
2. People think antibiotics can recover them from any disease quicker than other drugs.
3. Many rural people are dependent upon village doctors. They recommend high dose of antibiotics at the early stages of the disease. According to a survey from 10 villages in 2019 conducted by ABACUS (Antibiotic Access and Use) project in Matlab, villagers generally don’t take facilities of doctors and pharmacies from district medical colleges due structural corruption, stock out, etc. They buy antibiotics from rural pharmacies at low price motivated by family members and are reluctant to know the harmful effects.
4. Here the prices of antibiotics are much less than abroad.
5. Rural pharmacies were the preferred and trusted source of antibiotics for self-treatment.
6. People don’t know which drugs are antibiotics and also don’t finish the course. Around 1.5 million people are taking antibiotics daily without prescriptions.
7. Antibiotics are used at random in meat and milk production to increase yield. Farmers have a wrong notion that more antibiotic, more production. Those antibiotics enter our body through consumption. This sub-lethal level of antibiotic triggers bacteria to create mutation on multiple regions of the chromosome and causes multiple antibiotic resistance. According to the Daily Star, a study conducted by Bangladesh Agricultural Research Council (BARC) and Patuakhali Science and Technology University showed that nearly 50% of poultry feed of 14 brands contain antibiotics.

Possible Solutions to Overcome Antibiotic Misuse in Bangladesh

We should follow some steps through both social activities and law enforcement:

1. Doctors should advice people not to take antibiotics for silly sickness. Besides pharmacy owners should be punished under National Drug Policy-2005 and other laws if they sell antibiotics without checking prescription.
2. In 90s, BTV and other electronic media broadcast TVCs on HIV and tuberculosis that created a huge impact on making awareness. Now we can also make and broadcast TVCs to promote awareness on antibiotic resistance.
3. We can celebrate World Antibiotic Resistance Awareness Week in educational institutions specially in schools.
4. People of rural areas should be encouraged to follow hygiene instead of using antibiotics indiscriminately for diarrheal diseases.

Conclusion

In our country, acute respiratory tract diseases and diarrheal diseases cause lots of deaths. At present antibiotic resistance has become an alarming problem for people suffering from lower respiratory tract infection and so on. It is high time we made people conscious of the consequences of misuse of antibiotics. It will lead to the lessen of preventable death caused by infectious diseases which is one of the targets of SDG Goal 3.