 Okay, thanks a lot for joining this webinar. I'd like to welcome all of you. This is the second webinar of the One Health and Water Salutation and Hygiene Network. My name is Christina, I am working for the Swedish University of Agricultural Sciences, and we also have a few more people here from the network secretariat and members of the network. As I mentioned, this is the second webinar of the network. Our first webinar was held in March this year, and that one focused on synosis to production of the wash. But today we will focus on how effective wash can prevent the infectious and reduce the emergence of antimicrobial resistance. So we will hear three different presentations, looking at various links between antimicrobial use, antimicrobial resistance and wash, and the importance of applying a One Health approach to tackle antimicrobial resistance. As mentioned, the webinar is organized by a newly started One Health and Wash Network. People started this year. It's funded by Formas and SNU Global. The network secretariat is hosted by the Stockholm Environment Institute. And we have a Linnis Douglas Cook here from the Stockholm Environment Institute. And in addition, we have Sara Lissom here who is from the Swedish University of Agricultural Sciences, who is hosting the network secretariat in collaboration with Stockholm Environment Institute. We also have collaborating partners from Burkina Faso, from Mozambique in Kenya in the network, and our partners represent academia, governments and NGOs. And the network is holding a series of open webinars this year. There will be another one coming up in a few months time focusing on the environment. And some practicalities, please keep your microphones muted throughout the webinar. We prefer that you post questions in the chat, and you can post questions in either French or in English. Posted questions will then be read out to the presenters after the presentation, so we will open up for one or two questions after the presentations, and then we will have a session at the end for additional questions and answers. And you super welcome to post your name, your affiliation and country in the chat, so that we see who is with us today. That will be very nice. And as I mentioned, there is a link in the chat to the web page of the network where this webinar will be posted and also where our first webinar. They were calling for our first webinar is posted. So with that, I would like to start with a presentation. And first we have our first speaker is Dr David Sutherland, who is an environment health professional and is working as technical officer for food and agriculture organization of the United Nations. He has worked many years in water, sanitation and health for WHO. Before moving to quite a tight coordination on one health, and has also been acting coordinator for the MRMatic Mud Trust Fund. And they will provide an introduction to effectively wash to prevent infections that reduce the mergers of the MR. David, please. Thank you very much. Good morning and good afternoon everyone. I hope my voice is going to hold out. I have a bit of a chest infection, but very nice to be with you and just bear with me while I get the technology sorted. Okay, so thanks Christina. As Christina was saying, I've worked quite a lot with WHO and FAO and the quadripartite over the last few years, initially in wash and environmental health. And the last four years on one health and and AMR. So a lot of what I'm going to be sharing with you is from the organizations that I've worked with, but the comments, the stresses of the presentation and sort of my own personal ones based on experience. So I'm just going to really give an oversight first, sort of going through the problem. As far as wash and AMR is concerned, just showing what wash is within this context and what wash has to do with AMR. And what let's improving wash require in the context of AMR and one health. And then just a few examples of kind of things that are going on to try and address the situation. So as we all know, the AMR situation is really quite serious according to the Graham study that was published in the Lancer earlier this year. The AMR has thought already to be the leading cause of death globally with low resource settings having the highest burden, and they're going forward the financial and the social standing of millions is really going to be quite serious. And there is really growing concern on the impacts of AMR to animal health and welfare to food security and the environment. They're being driven by increased resistance and increased infections. Worst case scenario by 2050, a doubling of infections without any kind of controls in place. And the many common infections like urinary tract infections, pneumonia, bloodstream infections are without effective treatment, life threatening and increasingly becoming resistant. The diagram on the right is is adapted from a report of the Interagency Coordination Group on AMR. And what you can see on the top two boxes, the main areas are overuse and misuse. There are many contributors to antimicrobial resistance that come from wash from discharges to the environment and from infection prevention and control measures in crop production and food production. So this is a cheerful slide from WHO website. Just again, really sort of demonstrating some of the nature that one in 10 patients get an infection while receiving care in hospital. More than 50% of surgical site infections can be antibiotic resistant. And of course, this is being compounded by COVID, but has COVID has also presented many opportunities when it comes to management of health facilities. The Director General of UN said do not call a healthcare facility a healthcare facility if there is no wash. This is a birthing room in a small healthcare facility with no wash whatsoever. So what do we mean by wash wash really has inputs. It has internal processes, and it has output. So the inputs primarily a water supply. The internal processing and management is related to hygiene. And we're looking at human facilities, whether that's housing offices or recreational facilities, human healthcare facilities and agricultural production facilities or farms, whether this is livestock crops or aquaculture. And then the outputs from the facilities that are in questions or sanitation and wastewater out into the environment. So this is essentially what we mean by wash. Wash has its own targets under the Sustainable Development Goals. The huge contribution, important contribution that wash takes has in ensuring improved health and well-being of the global population is understood. So there's targets for safe use, safely managed drinking water services, safely managed sanitation and hand washing services, and safely treated wastewater. So one of the areas just want to sort of show, we call these shit flow diagrams. This is quite a lot of work is being done to identify what is safely treated, what is safely managed and what isn't when trying to assess progress against the targets. So what we have here is a flow diagram for this is for a small town. These diagrams hundreds, maybe thousands have been prepared for towns and cities and localities. Looking at the source, the containment of sanitation waste, the emptying and transport treatment, and the reuse and disposal. And depending on how that is managed, that could be seen as safely managed or not safely managed. This is water closet, sewerage centralized systems, on-site facilities or open discharge and open defecation and going into a domestic environment into agricultural fields or into receiving waters. So these, those shit flow diagrams in many ways, the antimicrobials follow that wash flow. So you have antimicrobials going into animal populations and into human populations and then being processed by humans and going out as unmetabolized, well, maybe unmetabolized antimicrobials from human waste, active antimicrobial residues from pharmaceutical industries and unmetabolized antimicrobials from animal agriculture and crops going out into the environment, water environment in particular. So in the context of AMR, what does wastewater contain? So the main areas of interest to us when it comes to AMR is that there are disease causing pathogens within the wastewater. There are lots of humans and plants and animals requiring treatment with antimicrobial agents. Hundreds of millions of cases of diarrhea each year in humans are treated with antimicrobials. Universal access to wash could reduce this by at least 60%. And then there's resistant microorganisms with low pathogenicity infecting vulnerable populations or transferring their genes to pathogens causing infection. So this figure is slightly out of date now and likely to have increased but the last survey done was 14% of humans carry globally carry ESBL producing E. coli in their feces. And then when and then the third component of interest is the active residues. It's not known about the wastewater from pharmaceutical manufacturing. But it's studies have shown that up to 80% of antimicrobial agents taken by humans and animals are excreted as active residues. The challenge here is that wastewater treatment is often insufficient or not possible. The level of treatment required is not possible for context. So in practical terms, what does wash cover in different contexts? We're looking here really at community wash wash in healthcare facilities and wash in agriculture and aquaculture. So in terms of water supply, this is very much looking at standard of service, which is looking at facilities for water supply plus what is the drinking water quality sources are protected. And what is the quality of the water going in. So this is for drinking and hygiene usage in human facilities could also be in food production facilities but also is irrigation water fisheries water for sanitation. Again, looking at standard of facilities plus on and off site use collection transport and disposal. On the agriculture side is also looking at wastewater from livestock production and processing. Hygiene is not really just and hygiene, although that is an extremely important element of infection prevention and control. But it's really seen as hygiene of the facility as well. It includes hand washing facilities and services that community level and in healthcare facilities and also looking at the presence and implementation of IPC protocols for staff and would include biosecurity measures in wash in agriculture and aquaculture. The waste management is really looking at solid waste and so again similar to sanitation is looking at disposal collection transport and the off site disposal with healthcare facilities. This also looks at infectious waste and sharps. And on the agriculture side this can as well as production it can include the animal remains from slaughterhouses or wet markets and then environmental cleaning is looking at the cleaning of the facilities. So looking at having protocols in place, responsibilities and schedules for management and standing operating procedures for workers and for facilities. So in terms of prevention and control of AMR prevention refers to strategies and interventions to prevent emergence transmission and spread of AMR. It can refer to the prevention of infections overall, as well as across one health interfaces. Control refers to minimizing transmission and spread of AMR within and across species and or the environment. So source control relates to strategies and interventions designed to prevent potentially harmful pollutants entering wastewater systems. This can also include the disposal of unused antibiotics into wastewater systems. I think a lot of us are familiar with the concept of one health. This is the quadripartite's own perspective. Quadripartite being FAO UNEP World Health Organization and the World Organization for Animal Health. So it's integrated in a unifying approach that aims to sense sustainably balance and optimize the health of people animals and ecosystems. So really the one health approach is saying that there are definitely specific settings, specific issues, specific concerns that relate to agriculture in terms of the location in terms of disease issues and issues such as prudent use in animals and access to vet services. And similarly within human health sector that there are specific settings, specific issues and specific concerns. The main issue around one health is looking at those shared settings, shared issues, especially related to the potential for horizontal gene transfer and shared concerns in terms of waste management and uncontrolled spillover. So having worked in WASH for 20, 30 years, WASH is really, as a sector, it's really extremely used to intersectoral working. And so in many ways, those involved in WASH are very active and very open to engagement. So I think you will find in many cases those who are working in WASH are very responsive when trying to look at some of these issues. There is however very rarely, if ever a ministry for WASH, the WASH components tend to be very disparate and spread out amongst many agencies. So water supply could include local government, private sector or domestic. Hygiene is often facilities management can be lying ministry agencies, under health industry and agriculture. Water and waste management is also tends to be local government, but quite often will be a different agency or institution from water supply and private and domestic. But it's very much a sector ready and willing to engage. So just want to finish off with a few slides really about what is being done to address some of these issues. So there was quite a significant publication produced a couple of years ago now. There's a technical brief on WASH and waste water management to prevent infections and reduce the spread of antimicrobial resistance. So this is available on the WHO website and I think on other quadripartite sites as well. And there are various other pieces of work that have been done by tripartite and by tripartite partners on issues around AMR in environment crops and biocides on AMR relevant legislation on impact of the climate crisis and how that affects it and environmental dimensions as well as specific management tools and reporting for facilities such as WASH fit and the practical steps for WASH in health care facilities. So there are many initiatives for working with health care facilities and these have been very much stepped up as a response of COVID. And the recognition of the importance of all sorts of measures to prevent the spread of infection and the management of hospital waste. So in many ways COVID has been a huge burden but it has demonstrated the huge need for dealing with these issues at facility level. So going back to the sort of original diagram of contributed contributors to AMR. Key improvements required are to increase access to clean water, sanitation and hygiene and to improve these prevention and control practices in health care facilities and farms. To treat discharge of waste from health care facilities, pharmaceutical manufacturing and farms and to improve infection and disease prevention and control and reduced transmission of resistant pathogens in food production and storage distribution and preparation. So just a few examples of kind of work that's being done in both the human and the agricultural sector. This is information from a global progress report on WASH in health care facilities. The practical steps that were set up there were eight steps that were felt to be absolutely essential to ensure effective management at health care facilities. The goal is to conduct situation analysis and assessment, set targets and define a roadmap for improvements, establish national standards and accountability mechanisms, improve infrastructure and maintenance, monitor and review data, develop the health workforce, engage with communities. Very important at a small level health care facilities and conduct operational research and share learning. Work is being done in many countries in this area on embedding WASH standards, international quality efforts, on risk based WASH improvements, on monitoring and reviewing data and implications for policy and practice and engaging with communities. And on the agriculture side, primarily examples now from the poultry industry, there's a lot of quite a lot of work that is being done by Fleming Fund and the AMR multi-partner trust fund. The multi-purpose trust for partner trust fund is fairly new. So there are new initiatives that are underway. There is an IPC and WASH network. So participating countries are sharing experience. But somewhere that has been started and is getting going is from Indonesia, where FAO RAP drafted and the government in Indonesia finessed an assessment tool, which was a merger of WHO's infection prevention and control assessment framework and FAO's layer farm assessment tools. And importantly, this was used as a starting point for national certification of production facilities. In Kenya, farm biosecurity guidelines for dairy poultry and pig value chains have been developed and veterinarians and paraprofessionals have been trained on their use. And also given instructions and guidance on how to disseminate those guidelines to stakeholders within their respective networks and areas of responsibility. In Zimbabwe, farmer field schools are used to promote adoption of good animal husbandry practices. This is improving biosecurity and the hygiene standards and broiler value chain. So there's a lot of work that is sort of getting underway and there are other countries that are interested to participate in that developing in this area. So that's it really from my side as an overview. I just want to give you a quick advertisement for I'm not I'm sure most of you may have seen it but in case you haven't. The quadripartite is starting later today. That 2pm Central European time, a series on antimicrobial resistance in the environment. So it'll be a webinar series I think it's a four webinars. So the first one is understanding the basics for national action. This will go into a lot more detail than I have done. I think it's a one and a half hour webinar and substantial presentation on the basics of environmental AMR and the risks and the overall principles and terminologies. Understanding of key sources and approaches to prevent control and strategies to strengthen the involvement environment. I would strongly recommend that as more detailed follow up to this presentation. That's all from me for now. Thank you very much. Thank you very much David for a very interesting presentation. I don't see any questions yet in the chat but I see that Linus is raising his hand. Please Linus over to you for questions. Thank you David for that super comprehensive presentation. I'm from the wash the wash sector and also working with the increased reuse and recycling circular economy. At the moment and you know, I mean it's concerning that we have these active residues in human excreta. As you said, up to 80% of the antibiotics are found in in the urine and the thesis and then different sanitation systems either will transmit these active substances to water or to soil. So if we if we recycle, could you say something about what happens to these active residues in water and soil if there would be a pressure preference to have it to soil. Compared to water. Very good question. I mean, neither, neither is ideal. I mean, I would have to say that the 80% is very much an estimate. But I think really what we could say is that a significant proportion is there as active residues. I think one of the issues is very much about the the half life of the the residues. And that would have an impact in terms of of management is I don't feel confident to give you a specific answer as you can probably tell but what I'm speaking. I would encourage you to attend the meeting later in the day, where there are some significant experts there who would have more information to give on that side. I think, certainly, I think that they, there are a whole series of symposia that have been going on over the years on the environmental dimension of AMR. And a huge proportion of that work has been on agricultural waste. The last one was in Hong Kong the next one is in Sweden later this year, and a whole series of fascinating papers that came out of that. A lot of that was looking at the impact of composting and of effective sort of treatment before putting onto soil and to contaminating to fertilizing crops and others. I think that there is certainly a strong argument for containment before going for fertilizing and use on that side, but I can't give you a definitive answer I'm afraid three three hours time you'll get a much more definitive answer. David, we have two additional questions in the chat, I think we can group them in one. It's, it's one question about if is the sanitation safety planning tool a good approach to AMR for small towns and rural areas, especially. And also, so a follow up question, is the sanitation safety tool same as the wash fit tool for health facilities by W and show. Yeah, excellent questions. Certainly, I was quite closely involved with sanitation safety planning in India while based in Delhi and the tool is an extremely good approach, because it looks at all the various risk groups. And the nature of the risk and to address those risks so that would include farmers that would include those working in markets it would include those consuming the product. So it's very broad ranging in its risk assessment. So it's extremely good. We were doing one of the areas where we do some training and piloting was the East Caucasus wetlands. What's interesting there is that there was a wastewater treatment plant installed, and farmers were begging the operators the wastewater treatment plan to release a significant proportion of the wastewater in an untreated condition, because it's an extremely valuable resource before is treated by the time is treated an awful lot of the nutrients and goodness is has gone. So as well as the, the pathogens and the antimicrobials, you also have many many good things in there so it is a, it is a real challenge and with the increase in fertilizer prices going on now. The, the free fertilizer that comes from wastewater is is hugely attractive to farmers so it is a real challenge but the sanitation safety planning definitely identifies the risk groups and the nature of the risk. So yes they are very good. And it's a similar approach wash fit is similar in many ways and you are identifying the risks, and then you are seeking then how to manage those risks. Thanks a lot David I think with that we don't have more time for questions right now, but I know that you're staying with us until the end, and we hope that there will be some additional time for questions at the very end of the webinar. So thanks a lot and with that I would like to move on to our next presenter, which is Dr Innocentio Chonko from the National Institute of Health in Mozambique. Dr Innocentio is a veterinarian he's also a PhD fellow in tropical diseases and global health, and he is coordinator for the National One Health Platform in Mozambique. And Dr Innocentio will present to us under microbial use in intensive farming and resulting persistence in the environment. So you already started with your presentation Innocentio please move on and the floor is yours. Thank you Kristen. Good, good, good, good, good morning everyone. I'm going to start this presentation from Mozambican team. It's real about sharing the small stats that we have regarding the antibiotic use in intensive farming and the resulting resistance in the environment that we think that it's a potential public health implication in Mozambique. Moving. Right. So, this is Mozambique who doesn't know Mozambique we are in southern of Africa. We have the population approximately a million, where 45 its population young than 15 years old, and we have this representative in terms of different species of animals. We bring this just to focus on the bold number. So, Mozambique is a particularly vulnerable to the effect of disease, because approximately 81% of the country levels, it's basic to an agriculture. So, they are continuous contact with the animals and the soil. So, we have some water disease that are representing very big hospitalization cases in Mozambique. This information needs according to the annual reports and some studies that are already floppy in Mozambique, regarding to the watch and the disease that our water our tabone. So, we have issues regarding to the poor water supply system, the weak sanitation and drainage system and the lack of personal hygiene. It's important to say that this is not only for Mozambique. It's, we can find across all the Sahara Africa. We have the shortage of portable water as improved water sources are limited to the urban area. Even these water that are limited to the urban areas. We have some studies and the annual reports that showing us that they are not facing the quality that is recommended for human construction. So the cell of home bottled water, the reuse of the boat list, which are the often collected in garbage and containers. It's important to say that in a different seat in a different capital of the city in Mozambique. Many people they use to sell the reuse a bottle. So the process of watching those boat list and the bottling water for sale does not follow the minimum IGN criteria and several stats even here in Mozambique. They have shown that the most bottled water that are sold the are not can present a good physical quality but in terms of chemical and the microbiological quality is are not following the human consumption. So the consumption of this water can contribute to the increase of water-borne disease. It's important to mention that Mozambique, the mainly farming, mainly for poultry, the higher number of farming mainly for poultry are not automatically are still manual. And the main of them they use those reuse bottling. So increasing the higher rates of occurrence of the disease in the animals and consequently the use of antibiotics to treat the disease. So we have another issue relating to the approximate of people and the animals. As I said that 81% of people they practice agriculture and they use the animals to prepare the soil. So we have issues regarding the climate change. When we talk about climate change, we know that Mozambique for example was hit by the two cyclones in 2019. And main of places out of the seeds, mainly in the rural areas, they use the water well supplies to have the water to drink. So during this period, the risk of water contamination and the risk of developing the water-borne disease. So we have issues regarding to hygienic food replenish and the consumption practice. I will not take along this picture because it seems like the one that we presented with the previous speak showing the very important role of the people that take the drugs while they are seeking. And the animals that they be administrating the antibiotic when they are seeking. And those antibiotics when they are not be used, they can be discard and contaminate the soil or contaminate the plant. So it becomes the risk for the human. I will not take a long time was explained. So I'm bringing this picture just to show this very important issues. This is a Mozambican picture. We can see this area. This is any area where they discard the solid resets. So these solid resets, they come from different ways. And while there's a rain, we can see here the source of water. So this source of water is visually with people and the animals. So it is a high risk of consumption of water that are contaminated with pathogens or with antibiotics. So this picture shows the floods that Mozambique were hit in 2019. As we can see all the soil is covered by the water and the source of the water. As we said that many of people they are using the water supply wells. It's covered by this water that it can bring the risk of the people. We bring this picture just to show and to make sure that we have some people that are preparing the milk in the rural areas. And then we can see this milk is prepared in the field. And there's no very good condition of the water. So they are using the water that are coming from the wells and increase the risk of antibiotic resistance. So this picture, it's a real picture that we took and unfortunately I can't show the source of the water. So sometimes those people when they are selling the chicken in the market. When the chicken, I send the chicken the market, they because of the lack of information, they are using antibiotic in the drinking water for the chicken and the chicken and be sold for the people. The same thing I call in the goats as you can see in this picture. Those pictures are taken from any municipal market. We have issues regarding to the floods as I said I mentioned before that Mozambique it's currently heated by the cyclone. And we have the condition of the contamination of the source of the water. So some studies that shows us that many, many, many well supply, many water well supply were contaminated and we they found a higher rate of a call in that well water. We are coming to the antibiotic resistance. It's better to say that as we know all of us, the antibiotic, they are be used in the human or in the animals. In the animals, many of them they are using for the disease treatment or some they are using for the growing the animals. Unfortunately, these it's common in many developing camps to use the antibiotic for to promote the growing of the animals. So in agriculture at the global level, we found the class the same class of drugs that are be used in the animals like tetracycline and better lactams etc etc are the same that we we find in the in the in the in the human and the animals. So, we have approximately 700,000 people that are dying each year. And if we don't control this, the, the, the, the estimated for 2005, showing that the number they will, it will increase. So Mozambique applied to develop the National Action Plan for antimicrobial resistance. And then we have those strategy objectives, we highlight these that say that the reduce of the incidence of infection through effective sanitation hygiene and infection prevention measure that recognize that we if we have the good. If we follow the procedure for the water sanitation and hygiene, we can reduce the use of anti antibiotic because we will reduce the risk of infection, and that will reduce automatically the use of antibiotics or reducing the risk of resistance to the antibiotic. So Mozambique it's a member of the glass since the 2008 we started to share the data from AMR. So those are some studies that we developed in Mozambique, we have quite a good number of the studies that have been developed in Mozambique and the majority of those studies, they are showing us that there are big relation between the quality of the water, the risk of contamination and the use of antibiotic. What we have in Mozambique and in the main African countries is people when they get sick, they go to the health facility and the main health facility. They are using empirical treatment for antibiotic. It means when they go as they don't have the capacity to develop the different methods of diagnosis mainly for those cases that are not common. They just perform malaria diagnosis. So if malaria it's negative and they prefer to use the antibiotic so increasing the risk of antibiotic resistance. Instead of that people they used to do their own treatment so they just take the antibiotic and not following the procedure. So it means if we have very good quality of the water we can reduce the risk of drinking contaminated water and develop the disease and reduce the use of antibiotic. In a sense, one minute remaining? So the antibiotic are used in a large stock where they are used to treat the disease as I said previously, many developing countries use it for growing. So we can find this antibiotic, it depends by the food of animal, the intensive and extensive farming. It's important to say that Mozambique is not so well for intensive farming but for poultry, different people they use the intensive farming that increase the use of antibiotic. We have commercial and industrial in Mozambique we are doing the same and we have the lack of clean legislation. It means we have the documents that people they need to follow to use the antibiotic but not all of them they are following it. This is a start that we developed in Mozambique that's a focus focusing on our workshop that shows us the resistance that we found in a different place in the supermarket, informal supermarket or formal supermarket in the slot house. Those results show us that there's a resistance that a resistance that are coming from the consumption of or the use of the antibiotic that are the same group that can be used in the animal. So it's important to say that the article mentioned that mainly this contamination can be related with the type of the water that will be used during the production in the farming. So those are the results that show us that up to 50% they found the resistance to this group of the farmers. So we had in for the supermarket showed the higher resistance profiles and then the slaughter house and there's no difference that we were noted. In conclusion, we would like to say that the antibiotic are good to be used it, but we needed to follow the procedure that can come from the veterinary that can come to medical doctor and we avoid to use the antibiotic by ourselves because we can pollute the environment by discarding the antibiotic or by using not using well this antibiotic. This is what we would like to present for Mozambican team. Thank you. Thank you very much in a sense of very interesting comprehensive presentation. I think we have time for one short question. I don't see any questions in the chat, but there might be someone in the audience wants to ask a quick question. I don't see any hands. Please over to you. Yeah, hi, you know, I could just ask the question since, since you have identified wash as one of the strategic axis for your a more working in Mozambique has that also translated into strengthening wash budgets or strengthening action in the fields. I mean, is it translated into more money for for the wash sector in Mozambique, you know, if you come again, I did not hear well sorry. Yeah, sorry, I was wondering if since the wash wash as a prevention tool for for infections and reducing the use of antimicrobials has been identified in Mozambique. Has that also been, do you see any effect in the in the work that the wash sector is carrying out are they do they get strengthened the budgets for example from from from this recognition. Yes, very good question. I see that that it's, it's a very big issues in Mozambique. Because in instead of the advocacy activity that will be developed by the government sector. We have applied the in 2016 for the global health security agenda, and they developed the national plan for secret health. And the one of the point, it's the water hygiene sanitation and the food security. So it means that it's something that we are taking as priority in Mozambique. For the budgets, this plan will we, we are we are doing the review now, and they will be submitted within September to the Council of Ministers. So they can be found the all the activities using the government budget. So this it's a really issue to that will be taken by the government. Thank you very much in a sense that was a good addition to the presentation. And I see that there was one additional question in the chat. We don't have time for that now, but this stay on with us after the next presentation will be hope that there is some time is efficient time for additional questions. I would like to invite Dr Florence Motua from the International Livestock Research Institute with our last presenter for today. And Dr Florence is a scientist she is working on animal health and safety, and she will talk to us about sustaining handwashing post COVID, and what this means for infection control and AMR. With that, I would like to say over to you Florence. Thank you for that introduction. You will allow me to put off my video because of the collection. Yes, so my talk is about sustaining handwashing post COVID, and what this means for infection control and AMR. So, as a way of saying how my presentation will flow, I will have a small introduction, which I will just be very brief because much has been said by the previous presenters. And then I'll give some highlight from the work we did on COVID-19 mitigation and implications for food safety. A few slides on the hand hygiene and try that to do a combio usage and AMR, and then one slide on to conclude. We know that AMR is a present significant threat to public health globally. And the burden has been demonstrated and shown in previous studies. And we know that from the global action plan on AMR, reducing the incidence of infection through effective sanitation, hygiene and infection prevention measures is one of the key points highlighted there. Overall, looking at the bigger picture, Washington interventions can address several of the sustainable development goals whose target is 2030, the year 2030. And thinking more of the line of food safety where I work a lot on, we know that the area is a serious public health problem. And this is more of a problem, a serious problem in developing countries. But the good thing is that we know that hygiene can reduce the real health results. And these have been demonstrated in a number of studies, including the one that I given there in the reference. The real disease agents are frequent cause of foodborne diseases. And we know that based on the studies by the world organization and the World Bank. The burden associated with these diseases is quite huge. And it's more affects the developing countries in Africa, regions in Africa and Asia, and it's more so in the children under the age of five years. So there's that not equal distribution when it comes to the burden of these diseases. So I'll tell you a little bit about the study that we did on COVID-19 mitigation and effects on food safety. I'll start by saying that COVID-19 is not transmitted through food. There has not been any evidence to link that so far. But we know that frequent hand washing, social distancing and face masks were among the available strategies that were promoted at the time when this problem started. And at the same time, we know this helped a lot in containing the spread of the infection as more work on vaccine studies continued. So our study looked at how enforcement of the COVID-19 mitigation measures impacted on food safety in the region of East Africa. So we contacted the food safety experts in the region. These are experts we had worked with in previous food safety projects here at Tehran. We were able to book appointments and interview five experts from out of the six experts that we worked on in the countries. We were not able to talk to people in Rwanda. And as a summary of what we found out from this study, I leave out the problems that touch on the bigger food safety, food systems disruption and just focus on the ones that are on food safety. So one of the things that we came up with them links to food safety was the issue around bulk purchasing during that time. And this was a problem because the people not have enough spaces to store the products. And then also the issue of having and trust with the suppliers. These are people that the suppliers that made it increase the risk of consumers buying foods that were not safe and therefore increasing the risk of getting foodborne infections. And then the issues around transport delays and this is especially the transport and the border points, because the people that were transporting transporting these products needed to stay for a long time to do the COVID testing. And then also again, the disposal of products that got spoiled, it wasn't clear how that was dealt with. Of course, because of working from home, there were limitations in ensuring the issue food inspections were done. So my talk is more on the hand washing. So I picked a few of the things that came out relating to hand washing and hygiene. So, for example, in Kenya, there were regulations that businesses, especially the food outlets, including the food outlets and the restaurants needed to install hand washing facilities. So it was a must that they do that. And then also we saw a lot from the government, both the national government but also the county government and the partners coming out and providing water tanks just to facilitate and make it easier for people to access water and therefore wash their hands. So these are just some pictures and materials that I got from online resources as I was preparing for this presentation. And then it's not just in the public places where we saw changes in the hand washing behavior, even the families themselves at home. We got some experts saying that some of the families were keen on installing hand washing stations in their homes. And this was more so for them to wash hands, especially when they go out of the compounds and come into their homes. The resources were also recommended and mentioned by these experts, but they were thought to be expensive, especially to the low income categories. In Burundi, there was a mention of the government coming in with the partners and trying to lower the cost of the soap, just to make it more accessible because it doesn't make a lot of sense to pass the message that people need to wash their hands running water and soap when the soap itself and other ingredients that are required are not available. And then there was also indications that the informal markets were not well supplied with again with water and soap. So it was difficult for people living in those settings to be able to practice proper hand hygiene and washing. And then also there were a mention about compliance issues, including even people coming out and refusing just plainly to wash their hands when requested to do so by people running these hand washing stations, especially in the public places. And just so some of them using the water for non-intended purposes, although good purposes, like for example, people, I think there was a mention of people wanting to just to use the water provided to wash their hands when they are going to eat, but not for frequent washing of their hands when they come out. And then of course in Kenya there were complaints over the management of the water tanks that were supplied by this national government, because it wasn't clear who, whether it was now still the national government who was supposed to take care of these water tanks or it was the county governments who helped take care of the tanks that the national central government provided. So then the statistical on the hand hygiene itself, this slide is just to highlight that there are many opportunities that our hearts get contaminated with a pathogen that could impact on our health, both at home, in school, in hospitals and other places. So this slide was just to demonstrate that I just to say that a hard washing is an opportunity to present and bring to break the transmission on this pathogen. So hand washing is a simple measure, but not everyone can access it. I saw this document from the UNICEF website that three people in ten do not have a place in their homes to wash their hands with water and soap. So this is a message that needs to be borne in mind as we go out to sensitize people to, or as initiatives are developed to sensitize people to comply with the proper hand washing with water and soap. My little side on the internet, I found that there are quite a number of initiatives meant to encourage or promote hand washing behavior. So one of them is the global hand washing day. I wasn't able to confirm whether this is the same one that I think was celebrated this year, or I saw it was celebrated this year, and May 5th. And then there's also a very good hand washing handbook, which is a very good resource, especially for people that are training people to adopt this hand washing practices. Next. And then there is also another comprehensive initiative on hand hygiene for all, which is promoted or driven by WHO and UNICEF. It defines short, medium and long term measures that can be adopted to ensure hand hygiene in the communities. And it covers a number of areas, political behavior change, promoting supply, supply of hand hygiene products and services, policies and strategies by governments, institutional arrangement, looking again at the financing, monitoring to measure usage and take capacity building. And what this initiative covers is hand hygiene, both at homes, schools, healthcare, public places, places where we work and other places. So this is quite a compressive document and I put a link there for those that might want to read more about it. I am not so sure how much has been done, but maybe people in the audience are more familiar with the initiative. So as I am just about to finish, I just want to say that frequent hand washing with soap can reduce risk of infection and lower transmission, disease transmission rates, and therefore avoid unnecessary use of antimicrobials. Again at microbial use we know is a key driver of microbial resistance, but I think what is missing more is just emphasizing on the linkage between AMR and hand hygiene and clarifying that it's for those that are promoting this. And then AMR is best addressed through one health approach, I think David clarified that. So hand washing should be promoted as an approach that can be utilized at all settings to prevent spread of infection. And I take note that the hygiene is not just hand hygiene, but also the environment where all this is happening, transmission failure. So just to conclude, I just want to say that the level of hand hygiene, which we all witnessed during the pandemic is what we are proposing to prevent future pandemics or disease outbreaks, but also ensure we prevent also other infections including the ones that are related to food safety. So already we have seen that there is a rich resource base, which we can use, which can be used to promote hand hygiene, the ones specifically for hand hygiene, but also the ones that David explained overall on the wash. So to address AMR, we need to prioritize hand hygiene as we do for the other wash intervention. We need to think different because this is something that is so close to us, yet not so many people have access to it. And we need to consider approaches that particularly encourage behavioral change at home with communities, hospitals and other places. There was a list that I gave earlier from one of the initiative. I think prioritizing what should come first in that list will be key so that as resources are limited, then a key target starting point can be realized. And I think that was my last slide. So thank you so much and over to you Christina. Thank you a lot Florence for that presentation. I haven't managed to follow the chat. If there are any specific questions I think we can now take a few questions for Florence first and then we can open up the floor for additional ones. Are there any questions specifically focusing on the presentation from Florence. I see that David Hartman, you have your hand up. Please David, I think we'll leave the floor to you to start with that. Thank you Christina and thank you very much Florence for a really clear and interesting presentation. And I work in Myanmar and I work in the animal health sector and certainly during the pandemic. In Myanmar we saw some really good initiatives to encourage better hand hygiene, you know, even communities, widely putting up hand wash basins at bus stops, for example with running water and soap and that was that was good. Very I'm particularly concerned with in my work is improving this kind of practice on farms, you know the livestock human interface. And it's a struggle because especially nowadays with increasing costs of inputs and pressure on farmers, you know how to work for farm workers. It's difficult to actually bring about the behavior change, which you are suggesting is required. So I wonder if you have any thoughts on what can be done to actually achieve that behavior change, especially in the animal production sector, because we, we sort of know the need for better wash but it's proving quite difficult at least in Myanmar for us to bring about that change at farm level. So grateful for your thoughts on that. Thank you. No response now, Christina. Yes, please, Florence, go on and respond. Yeah, so yeah, you're right. There's what we see and there is also the challenges that they are when you talk about the real digital change for actual for us to see the actual thing happening. So one of the things that I came up when we were doing these work, the coffee, the study work was a somebody told me some of the from the Kenya dairy, working with the Kenya dairy border. He told me one thing that they've always advocated for outlets to keep hand washing station outside just to know, but it never, they never thought to ever happen. But coffee to make them know that it is possible. So I think with that is just saying that it is possible for people to practice the highest item level at home, especially now the hand washing that we are talking about. And the authorities know it's COVID made it, made it clear that it can happen. So I think it's now for the authorities and the others that are working to improve these improve wash and other practices to see because they don't have to push them. What is what are what is it that we need to consider in the interventions that will come up with that would allow for a progressive change. We may not want to, we may not be able to go there right away, but that would be a progressive approach that can be promoted and help us to get to where we want to see, maybe it will take time over. Thanks a lot Florence I think we are all struggling with behavior change. How do you bring about that. How do you make sure that your target audience is seeing incentives for changing their behavior. And we have additional questions in the chat and I'm now opening up to all our presenters. We have a question if there is a cost effective way of testing for AMR processing and consumption points. I don't know if David in a sensual Florence if either of you would like to respond to that question. In a sensual do you want to say a few words on that. In response, David. Yeah, I just wanted to make one point I had actually deleted a slide to save on time. But the big challenges that we have in water resource, scarce areas. The point of wash is interlinked and they're not separate things. And that's in order to have effective hand washing gene you need to have water. And without water close to the point of use then it is really difficult to, to, to manage. It's really a general point not necessarily specific to this, the farm point. But really, it's a real challenge in some areas where water is, is, is in short supply to manage hand hygiene. And it's really to make hand work you need water as close to the point of use as possible. It's not quite lazy, and we don't want to walk anywhere to get hold of water. But yeah, so it's just general. Thanks David and I know that there are some trials there to make sure that you can pass by, or you have to pass by the hand washing station and that we that we kind of remind you to wash your hands I mean there are ways to building more frequent hand washing in facilities and so on. But I think there's much more that can be done on improving the access to the hand washing. In a sense you do want to say a few words on on testing for a more processing consumption points. Yeah, yes. Hi Christina hi everyone. So we, we, we don't have any testing for a more at the processing or consumption point right now. Yeah we don't, we don't, we don't have, we don't perform here in Mozambique so I don't have a quiet experience. I don't know if it the ocusiano I think it's here in the call it needs to comment on deal. Hi the ocusiano. There seem to be no response. Yeah, but we don't have any experience regarding the testing for a more at the construction point. But I think even we developed these without any education information and communication package. So it can be a big challenge because you can do the testing for MR at the processing or consumption point but you have the chain of the, the food or the water until the, the people that today are going to have the construction to have the construction of that product so it's a big challenge we don't have here in Mozambique and I don't have experience or getting to this and I fully agree with the previous speaker we're getting to the corner. Thanks a lot in a sense I think what we are all finding challenging is that there is no fast testing, neither for bacterial diseases or for amr they takes time, and that means that you normally get the results in a few days delay. And that that is an issue we're all facing when it comes to guiding treatments. And I know there's a lot of research ongoing and finding types of rapid testing, and that can assist physicians and veterinarians in guiding the treatment. And we have another very tricky question out. And that is, is there a fit for purpose treatment considering amr and I think the purpose treatment considering amr to, would that make sense, or would make sense wouldn't it. David or Florence do you want to respond to that. Well yeah. Excuse me. It is a tricky question. I guess you've got the three components of the requirement is whether it's the pathogens, or whether it's the low level. Pathogenic or whether it's the empty. It's the active antimicrobials beating. I think if you if you're taking out the active antimicrobials then you're looking at normal wastewater treatment in any other situation. Well, I guess it's a more complicated question than it even appears by itself so it's quite tricky but I think, you know, if you're looking at bacteria, bacterial waste and then composting and then some form of treatment and then before use is quite effective. The real truth with the active antimicrobials, which is not only is it difficult to test for extremely difficult and very expensive to treat. And so really the question there is, is stopping the active antimicrobials from getting into the environment in the first place. Humans have to poop. They have no choice. But if you're looking at manufacturers, then you need to be looking there at more efficient processes. Thanks David, I think it's samurai. This is that prevention is better than cure right this saving a lot of money if we can invest more in the infection prevention. I think with that it's already quarter past 12. So we've come to the end of the webinar. I would like to say special thanks to our presenters, David in a sense your Florence for sharing data in the webinar today really helpful very informative. I would like to say thanks to all of you who participated in the webinar today and I hope to see you in our next webinar and to know what's going on next please check out our website. And I hope to see you next time. Thanks a lot. Thanks. Bye. Thank you. Bye.