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nte
rna
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l J
o
urna
l o
f
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bli
c
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ea
lt
h Science
(
I
J
P
H
S)
Vo
l.
14
,
No
.
4
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Dec
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er
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p
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s
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v
14
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.
268
08
1866
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//
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e.
co
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M
ultidrug
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tant
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cheric
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e and
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ss
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ted
risk facto
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indiv
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uthwest
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AB
S
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RAC
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A
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ticle
his
to
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y:
R
ec
eiv
ed
J
u
l 2
0
,
2
0
2
4
R
ev
is
ed
Oct
2
3
,
2
0
2
5
Acc
ep
ted
No
v
3
,
2
0
2
5
An
ti
m
icro
b
ial
re
sista
n
c
e
(AMR
),
d
r
iv
e
n
b
y
m
u
lt
i
d
ru
g
-
re
sista
n
t
(M
DR)
Esc
h
e
ric
h
ia
c
o
li
,
p
o
se
s
a
sig
n
ifi
c
a
n
t
p
u
b
li
c
h
e
a
lt
h
t
h
re
a
t,
sile
n
tl
y
sp
re
a
d
in
g
th
ro
u
g
h
a
sy
m
p
to
m
a
ti
c
c
a
rriers
.
Li
m
it
e
d
d
a
ta
fro
m
ru
ra
l
a
re
a
s
h
ig
h
li
g
h
t
th
e
n
e
e
d
fo
r
f
o
c
u
se
d
stu
d
ies
to
g
u
i
d
e
re
sista
n
c
e
c
o
n
tro
l
e
ffo
rts.
Th
is
st
u
d
y
a
ime
d
to
iso
late
fa
e
c
a
l
Esc
h
e
ric
h
ia
c
o
li
(
E.
c
o
li
)
fro
m
a
p
p
a
re
n
tl
y
h
e
a
lt
h
y
in
d
i
v
id
u
a
ls
in
a
r
u
ra
l
c
o
m
m
u
n
it
y
in
S
o
u
th
we
ste
rn
Nig
e
ria,
d
e
term
in
e
th
e
ir
a
n
ti
m
icro
b
ial
re
sista
n
c
e
p
ro
fil
e
s,
a
n
d
e
v
a
lu
a
te
risk
fa
c
to
rs
a
ss
o
c
ia
ted
with
M
DR
E.
c
o
li
c
a
rriag
e
.
A
to
tal
o
f
3
4
7
sto
o
l
sa
m
p
les
we
re
c
o
ll
e
c
ted
fro
m
h
e
a
lt
h
y
,
c
o
n
se
n
t
in
g
in
d
iv
i
d
u
a
ls.
E.
c
o
li
wa
s
iso
late
d
a
n
d
id
e
n
ti
f
ied
u
sin
g
sta
n
d
a
rd
m
icro
b
io
l
o
g
ica
l
tec
h
n
i
q
u
e
s.
An
ti
m
icro
b
ial
re
sista
n
c
e
wa
s
a
ss
e
ss
e
d
v
ia
th
e
Kirb
y
-
Ba
u
e
r
d
isc
d
if
fu
sio
n
m
e
th
o
d
.
Iso
late
s
we
re
sc
re
e
n
e
d
p
h
e
n
o
ty
p
ica
ll
y
fo
r
t
h
e
e
x
te
n
d
e
d
s
p
e
c
tru
m
b
e
ta
-
lac
tam
a
se
(ES
BL)
p
ro
d
u
c
ti
o
n
a
n
d
g
e
n
o
ty
p
ica
ll
y
f
o
r
ES
BL
g
e
n
e
s
(CTX
-
M
,
S
HV
,
TE
M
)
.
T
h
e
d
a
ta
we
re
a
n
a
ly
z
e
d
u
si
n
g
WI
NPE
P
I
.
E.
c
o
li
wa
s
iso
late
d
fr
o
m
2
6
9
p
a
rti
c
ip
a
n
ts
(7
7
.
5
%
)
,
y
ield
in
g
5
5
5
iso
late
s
.
Hig
h
re
sista
n
c
e
ra
tes
we
r
e
o
b
se
rv
e
d
a
g
a
in
st
su
lp
h
a
m
e
th
o
x
a
z
o
le
(9
4
.
0
%
),
a
m
p
icill
i
n
(
8
5
.
0
%
)
,
a
n
d
te
trac
y
c
li
n
e
(8
3
.
2
%
),
wh
il
e
imip
e
n
e
m
sh
o
we
d
t
h
e
l
o
we
st
re
sista
n
c
e
(6
.
7
%
)
.
Twe
n
ty
-
se
v
e
n
is
o
late
s
(5
%
)
we
re
c
o
n
firme
d
a
s
ES
B
L
p
r
o
d
u
c
e
rs.
Am
o
n
g
t
h
e
se
,
1
7
(
63
%
)
c
a
rried
a
t
lea
st
o
n
e
ES
B
L
g
e
n
e
—
TE
M
b
e
in
g
t
h
e
m
o
st
c
o
m
m
o
n
(4
4
.
4
%
).
Ad
d
it
io
n
a
ll
y
,
5
0
.
1
%
o
f
t
h
e
is
o
late
s
we
re
c
las
sified
a
s
M
DR,
wi
th
M
DR
E.
c
o
l
i
c
a
rriag
e
sig
n
ifi
c
a
n
t
ly
a
ss
o
c
iate
d
wit
h
se
lf
-
m
e
d
ica
ti
o
n
(p
=
0
.
0
5
).
T
h
e
wid
e
sp
re
a
d
p
re
se
n
c
e
o
f
M
DR
E.
c
o
li
a
m
o
n
g
h
e
a
lt
h
y
ru
ra
l
d
we
ll
e
rs,
c
o
u
p
led
with
it
s
a
ss
o
c
iatio
n
wit
h
se
lf
-
m
e
d
ica
ti
o
n
,
h
ig
h
li
g
h
ts
se
ri
o
u
s
p
u
b
li
c
h
e
a
lt
h
c
o
n
c
e
rn
s
a
n
d
ra
ise
s
th
e
u
rg
e
n
t
n
e
e
d
fo
r
m
o
re
e
v
id
e
n
c
e
-
b
a
se
d
stra
te
g
ies
to
c
o
m
b
a
t
AMR.
K
ey
w
o
r
d
s
:
C
ar
r
iag
e
E
s
ch
erich
ia
co
li
Mu
ltid
r
u
g
-
r
esis
tan
t
Nig
er
ia
R
u
r
al
co
m
m
u
n
ity
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
Od
eto
y
in
B
ab
atu
n
d
e
Dep
ar
tm
en
t o
f
Me
d
ical
Mic
r
o
b
io
lo
g
y
an
d
Par
asit
o
lo
g
y
,
C
o
lleg
e
o
f
Hea
lth
Scien
ce
s
Ob
af
em
i A
wo
lo
wo
Un
iv
e
r
s
ity
I
le
-
I
f
e,
Nig
er
ia
E
m
ail: o
d
eto
y
in
@
o
au
if
e
.
ed
u
.
n
g
1.
I
NT
RO
D
UCT
I
O
N
An
tim
icr
o
b
ial
r
esis
tan
ce
(
A
MR)
is
o
n
e
o
f
th
e
m
o
s
t
p
r
ess
in
g
g
lo
b
al
h
ea
lth
c
h
allen
g
es
o
f
th
e
2
1
s
t
ce
n
tu
r
y
.
I
t
is
esti
m
ated
to
h
a
v
e
d
ir
ec
tly
ca
u
s
ed
1
.
2
7
m
illi
o
n
d
ea
th
s
a
n
d
c
o
n
t
r
ib
u
ted
to
n
ea
r
ly
5
m
illi
o
n
d
ea
th
s
g
lo
b
ally
in
2
0
1
9
[
1
]
.
W
ith
o
u
t u
r
g
en
t in
ter
v
e
n
tio
n
,
AM
R
co
u
ld
lead
to
alm
o
s
t 1
0
m
illi
o
n
d
ea
th
s
an
n
u
ally
b
y
2
0
5
0
,
s
u
r
p
ass
in
g
ca
n
ce
r
as
a
lead
in
g
ca
u
s
e
o
f
m
o
r
tality
.
Mo
s
t
o
f
th
ese
b
u
r
d
en
s
wo
u
ld
f
all
o
n
lo
wer
-
in
co
m
e
r
eg
io
n
s
,
p
ar
ticu
lar
ly
s
u
b
-
Sah
ar
a
n
Af
r
ica
[
2
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Mu
ltid
r
u
g
-
r
esis
ta
n
t E
s
ch
erich
ia
co
li c
a
r
r
ia
g
e
a
n
d
r
is
k
fa
cto
r
s
a
mo
n
g
h
ea
lth
y
…
(
Od
eto
yi
n
B
a
b
a
tu
n
d
e
)
1867
Am
o
n
g
t
h
e
m
o
s
t
co
n
ce
r
n
in
g
r
esis
tan
t
p
ath
o
g
en
s
is
E
s
ch
erich
ia
co
li
(
E
.
c
o
li
)
,
a
v
er
s
atile
b
ac
ter
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m
th
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ts
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s
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h
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r
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co
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m
en
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al
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d
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p
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p
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th
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o
r
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r
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ar
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tio
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em
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ce
o
f
m
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ltid
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MD
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.
co
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p
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th
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s
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ef
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co
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ates
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im
al,
a
n
d
e
n
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ir
o
n
m
en
tal
h
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[
3
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.
Als
o
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a
g
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a
l
m
eta
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an
aly
s
is
p
u
b
lis
h
ed
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2
0
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5
f
o
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n
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th
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th
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p
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led
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ev
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ce
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o
f
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p
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ci
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c
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li
was
2
5
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%,
with
2
3
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4
%
in
h
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lth
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m
m
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ity
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em
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er
s
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d
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in
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s
p
italis
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ts
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in
d
icatin
g
wid
esp
r
ea
d
asy
m
p
t
o
m
atic
co
lo
n
is
atio
n
[
4
]
.
T
h
e
p
o
s
t
-
C
OVI
D
-
1
9
er
a
h
as
s
ee
n
a
s
u
r
g
e
in
r
esis
t
an
t
g
r
a
m
-
n
e
g
ativ
e
o
r
g
an
is
m
s
,
lik
ely
d
r
iv
e
n
b
y
in
cr
ea
s
ed
an
d
o
f
te
n
in
ap
p
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o
p
r
iate
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tib
io
tic
p
r
escr
ip
tio
n
s
d
u
r
in
g
th
e
p
an
d
e
m
ic
[
5
]
.
T
h
is
s
ilen
t
s
p
r
ea
d
o
f
r
esis
tan
ce
g
en
es
th
r
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g
h
asy
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to
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atic
ca
r
r
ier
s
co
m
p
licates
in
f
ec
tio
n
co
n
tr
o
l
an
d
i
n
cr
ea
s
es
th
e
r
is
k
o
f
d
ev
elo
p
in
g
u
n
tr
ea
tab
le
in
f
ec
ti
o
n
s
.
T
h
e
ac
q
u
is
itio
n
o
f
MD
R
E
.
c
o
li
b
y
h
ea
lth
y
c
o
m
m
u
n
ity
m
e
m
b
er
s
is
d
r
iv
en
b
y
v
ar
io
u
s
f
a
cto
r
s
.
Prio
r
an
tib
io
tic
u
s
e
s
elec
ts
f
o
r
r
esis
t
an
t
g
u
t
s
tr
ain
s
.
Hea
lth
ca
r
e
co
n
tact,
ev
en
with
o
u
t
ac
tiv
e
i
n
f
ec
tio
n
,
in
c
r
ea
s
es
r
is
k
d
u
e
to
co
n
tam
in
ated
en
v
ir
o
n
m
en
ts
.
I
n
ter
n
atio
n
al
tr
av
el
to
ar
ea
s
with
h
ig
h
AM
R
p
r
ev
ale
n
ce
also
co
n
tr
ib
u
tes
to
co
lo
n
iz
atio
n
.
W
ith
in
co
m
m
u
n
ities
,
p
o
o
r
f
o
o
d
h
y
g
ie
n
e,
s
u
ch
as
th
e
co
n
s
u
m
p
tio
n
o
f
u
n
d
er
co
o
k
e
d
p
o
u
ltr
y
o
r
u
n
wash
ed
p
r
o
d
u
ce
,
an
d
an
i
m
al
h
an
d
lin
g
,
s
er
v
e
as
k
ey
tr
an
s
m
is
s
io
n
r
o
u
tes.
Ad
d
iti
o
n
ally
,
i
n
ad
eq
u
ate
s
an
itatio
n
,
in
clu
d
in
g
co
n
tam
in
ated
wastewate
r
s
y
s
tem
s
,
f
ac
il
it
ates
f
ae
ca
l
-
o
r
al
s
p
r
ea
d
,
m
ak
i
n
g
MD
R
E
.
co
li
a
s
ilen
t a
n
d
p
er
s
is
ten
t th
r
ea
t [
6
]
,
[
7
]
.
MD
R
E
.
co
li
is
a
m
ajo
r
p
u
b
lic
h
ea
lth
c
o
n
ce
r
n
in
Nig
er
ia,
wh
er
e
h
ig
h
r
ates
h
av
e
b
ee
n
c
o
n
s
is
ten
tly
f
o
u
n
d
in
f
o
o
d
,
wate
r
,
an
d
h
u
m
an
an
d
a
n
im
al
p
o
p
u
latio
n
s
.
Pre
v
io
u
s
r
esear
ch
in
u
r
b
an
a
n
d
h
o
s
p
ital
s
ettin
g
s
ac
r
o
s
s
th
e
co
u
n
tr
y
h
as
h
ig
h
lig
h
ted
s
ig
n
if
ican
t
r
esis
tan
ce
.
Fo
r
in
s
tan
ce
,
s
tu
d
ies
i
n
L
a
g
o
s
an
d
Ab
u
ja
f
o
u
n
d
th
at
alm
o
s
t
all
E
.
co
li
f
r
o
m
b
ee
f
c
attle
an
d
th
eir
h
an
d
le
r
s
wer
e
MD
R
[
8
]
,
an
d
s
im
ilar
h
ig
h
r
e
s
is
tan
ce
lev
els
h
av
e
b
ee
n
n
o
ted
in
c
o
m
m
u
n
ity
an
d
h
o
s
p
ital
s
ettin
g
s
in
Ad
o
-
E
k
iti
[
9
]
,
as
well
as
in
d
r
i
n
k
in
g
wate
r
an
d
h
ea
lth
y
in
d
iv
id
u
als
in
Osu
n
an
d
Oy
o
States
[
1
0
]
,
[
1
1
]
.
T
h
is
b
o
d
y
o
f
wo
r
k
estab
lis
h
es
th
e
clea
r
p
r
esen
ce
o
f
MD
R
E
.
co
li
in
Nig
er
ia'
s
u
r
b
an
an
d
h
ea
lth
ca
r
e
s
y
s
tem
s
.
D
esp
ite
th
is
ev
id
en
ce
,
th
er
e
is
a
cr
itical
g
ap
in
u
n
d
er
s
tan
d
i
n
g
th
e
ca
r
r
ia
g
e
o
f
MD
R
E
.
co
li
in
h
ea
lth
y
i
n
d
iv
i
d
u
als
with
in
Nig
er
ia'
s
r
u
r
al
co
m
m
u
n
ities
,
wh
er
e
a
lar
g
e
p
o
r
tio
n
o
f
th
e
p
o
p
u
latio
n
r
esid
es.
T
h
e
u
n
iq
u
e
in
te
r
p
la
y
b
etwe
en
h
u
m
an
s
,
an
im
als,
a
n
d
th
e
en
v
ir
o
n
m
en
t
in
th
ese
ar
ea
s
cr
ea
tes
a
s
ig
n
if
ican
t
r
eser
v
o
ir
f
o
r
r
esis
tan
t
b
ac
ter
ia,
wh
ich
ca
n
ea
s
ily
s
p
r
ea
d
f
r
o
m
r
u
r
al
to
u
r
b
an
ce
n
ter
s
an
d
ac
r
o
s
s
in
ter
n
atio
n
al
b
o
r
d
e
r
s
v
ia
th
e
m
o
v
e
m
en
t
o
f
p
e
o
p
le,
a
n
im
als,
an
d
ag
r
ic
u
ltu
r
al
p
r
o
d
u
cts.
T
o
ad
d
r
ess
th
is
cr
u
cial
g
a
p
,
th
is
s
tu
d
y
was
co
n
d
u
cted
to
i
n
v
esti
g
ate
th
e
ca
r
r
iag
e
o
f
MD
R
E
.
co
li
i
n
h
ea
lth
y
in
d
iv
id
u
als
in
a
r
u
r
al
s
ettin
g
,
aim
in
g
to
id
en
tify
E
.
co
li
f
r
o
m
f
ae
ca
l
s
am
p
les,
d
eter
m
i
n
e
th
eir
r
esis
tan
ce
p
r
o
f
iles
,
an
d
ev
alu
ate
ass
o
ciate
d
r
is
k
f
ac
to
r
s
.
2.
M
E
T
H
O
D
2
.
1
.
St
ud
y
lo
c
a
t
io
n
T
h
is
cr
o
s
s
-
s
ec
tio
n
al
s
tu
d
y
was
co
n
d
u
cted
at
th
e
Dep
ar
tm
en
t
o
f
Me
d
ical
Mic
r
o
b
io
lo
g
y
a
n
d
Par
asit
o
lo
g
y
,
Ob
a
f
em
i
Awo
l
o
wo
Un
iv
e
r
s
ity
,
I
le
-
I
f
e,
Osu
n
State,
Nig
er
ia.
Sam
p
les
we
r
e
co
llected
f
r
o
m
a
r
u
r
al
s
ettlem
en
t
in
Ay
ed
aa
d
e
L
o
ca
l
Go
v
er
n
m
e
n
t
Ar
ea
(
7
°
3
7
′0
″
N,
4
°3
1
′
0
″
E
)
,
p
r
ed
o
m
in
an
tly
in
h
a
b
ited
b
y
Oy
o
-
s
p
ea
k
in
g
p
eo
p
le
with
a
p
r
o
jecte
d
p
o
p
u
latio
n
o
f
ap
p
r
o
x
im
ately
3
,
0
3
7
[
1
2
]
.
T
h
e
co
m
m
u
n
ity
’
s
wate
r
s
u
p
p
ly
r
elies
o
n
two
m
etallic
tan
k
s
th
at
d
is
tr
ib
u
te
p
ip
e
-
b
o
r
n
e
wate
r
an
d
th
r
ee
s
tr
ateg
ically
p
lace
d
b
o
r
e
h
o
les.
Acc
ess
to
th
e
co
m
m
u
n
ity
is
o
f
ten
h
in
d
e
r
ed
b
y
p
o
o
r
r
o
ad
c
o
n
d
itio
n
s
,
esp
ec
ially
d
u
r
in
g
th
e
r
ain
y
s
ea
s
o
n
,
wh
e
n
f
lo
o
d
in
g
an
d
o
v
e
r
f
lo
win
g
r
i
v
er
s
r
en
d
er
th
e
r
o
ad
s
im
p
ass
ab
le.
Hea
lth
ca
r
e
s
er
v
ices
ar
e
l
im
ited
to
a
s
in
g
le
p
r
im
ar
y
h
ea
lth
ca
r
e
ce
n
tr
e,
s
taf
f
ed
b
y
p
r
o
f
ess
io
n
als
wh
o
co
m
m
u
te
f
r
o
m
I
le
-
I
f
e,
an
a
n
cien
t
to
wn
lo
ca
ted
r
o
u
g
h
ly
ten
k
ilo
m
et
r
es
awa
y
.
No
tab
ly
,
th
is
co
m
m
u
n
ity
lack
s
a
d
ed
icate
d
d
r
u
g
d
is
p
en
s
ar
y
.
T
h
is
co
m
m
u
n
ity
is
ty
p
ical
o
f
m
a
n
y
r
u
r
al
co
m
m
u
n
ities
in
Nig
er
ia
an
d
was th
u
s
s
elec
ted
f
o
r
th
is
s
tu
d
y
.
2.
2.
Sa
m
ple a
nd
da
t
a
co
llect
io
n
A
to
tal
o
f
3
4
7
ap
p
ar
en
tly
h
ea
lth
y
r
esid
en
ts
wer
e
r
ec
r
u
it
ed
f
o
r
th
is
cr
o
s
s
-
s
ec
tio
n
al
s
tu
d
y
u
s
in
g
r
an
d
o
m
s
am
p
lin
g
.
Ho
u
s
eh
o
ld
s
th
at
p
r
o
v
i
d
ed
in
f
o
r
m
e
d
co
n
s
en
t
wer
e
in
clu
d
ed
,
wh
ile
in
d
iv
id
u
als
wh
o
h
ad
tak
en
an
tib
io
tics
o
r
h
ad
b
e
e
n
ill
with
in
th
e
p
r
ev
io
u
s
2
1
d
ay
s
wer
e
ex
clu
d
ed
.
A
v
a
lid
ated
,
s
tr
u
ctu
r
ed
q
u
esti
o
n
n
air
e
was
u
s
ed
t
o
c
o
llect
d
em
o
g
r
ap
h
ic
d
ata
an
d
in
f
o
r
m
atio
n
o
n
th
e
p
a
r
ticip
an
ts
'
wate
r
s
o
u
r
ce
s
an
d
waste
d
is
p
o
s
al
p
r
ac
tices.
Sto
o
l
s
am
p
les
wer
e
co
llected
d
aily
th
r
o
u
g
h
h
o
u
s
e
-
to
-
h
o
u
s
e
v
is
its
,
p
r
i
m
ar
ily
in
th
e
m
o
r
n
in
g
wh
en
p
ar
ticip
an
t
av
aila
b
ilit
y
was
o
p
tim
al.
E
ac
h
p
ar
ticip
an
t
r
ec
ei
v
ed
a
s
ter
ile
co
n
tain
er
with
a
s
co
o
p
,
a
n
d
d
etailed
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
8
66
-
1
8
75
1868
p
icto
r
ial
in
s
tr
u
ctio
n
s
f
o
r
asep
t
ic
co
llectio
n
wer
e
p
r
o
v
id
ed
t
o
p
r
ev
e
n
t
u
r
i
n
e
co
n
tam
in
atio
n
.
All
s
am
p
les
wer
e
tr
an
s
p
o
r
t
ed
to
th
e
Me
d
ical
Mic
r
o
b
io
lo
g
y
L
ab
o
r
at
o
r
y
at
Ob
af
em
i
Awo
lo
wo
Un
iv
er
s
ity
with
in
two
h
o
u
r
s
o
f
co
llectio
n
to
en
s
u
r
e
s
am
p
le
in
t
eg
r
ity
f
o
r
m
icr
o
b
ial
an
aly
s
is
.
2.
3.
B
a
ct
er
i
a
l
i
s
o
la
t
io
n
Sto
o
l
s
p
ec
im
en
s
wer
e
s
tr
ea
k
e
d
o
n
to
eo
s
in
m
eth
y
len
e
b
l
u
e
(
E
MB)
ag
ar
p
lates
an
d
in
cu
b
ated
at
3
7
°C
f
o
r
2
4
h
o
u
r
s
.
Pre
s
u
m
p
tiv
e
E
.
co
li
co
lo
n
ies
wer
e
id
en
tifie
d
b
y
th
eir
ch
a
r
ac
ter
is
tic
g
r
ee
n
m
etallic
s
h
ee
n
o
r
p
u
r
p
le
co
lo
u
r
atio
n
.
T
o
o
b
tain
p
u
r
e
cu
ltu
r
es,
th
r
ee
to
f
i
v
e
m
o
r
p
h
o
lo
g
ically
d
is
tin
ct
co
lo
n
ies
ex
h
ib
itin
g
th
ese
tr
aits
we
r
e
s
u
b
cu
ltu
r
ed
o
n
s
ter
ile
n
u
tr
ien
t
ag
ar
.
T
h
is
ap
p
r
o
ac
h
was
in
ten
d
ed
to
ca
p
tu
r
e
a
b
r
o
ad
er
d
i
v
er
s
ity
o
f
s
tr
ain
s
with
p
o
ten
tially
v
ar
ied
r
esis
tan
ce
p
r
o
f
iles
.
Pu
r
e
is
o
lates
wer
e
f
u
r
th
er
id
en
tifie
d
u
s
in
g
s
tan
d
ar
d
b
io
ch
em
ical
test
s
,
in
clu
d
in
g
in
d
o
le
p
r
o
d
u
ctio
n
a
n
d
citr
ate
u
ti
lis
atio
n
.
E
.
co
li
AT
C
C
2
5
9
2
2
was
em
p
lo
y
ed
as
a
p
o
s
itiv
e
co
n
tr
o
l
[
1
3
]
.
Fin
ally
,
th
e
is
o
lates
wer
e
p
r
eser
v
ed
in
1
6
%
g
ly
ce
r
o
l
b
r
o
th
an
d
s
to
r
ed
at
2
–
8
°C
f
o
r
f
u
tu
r
e
a
n
aly
s
is
.
2.
4.
Ant
im
icr
o
bia
l
s
us
ce
ptib
ility
t
esting
An
tim
icr
o
b
ial
s
u
s
ce
p
tib
ili
ty
test
in
g
was
co
n
d
u
cted
o
n
th
e
is
o
lates
u
s
in
g
th
e
Kir
b
y
-
B
au
er
d
is
c
d
if
f
u
s
io
n
m
eth
o
d
o
n
M
u
eller
-
Hin
to
n
Ag
ar
(
MH
A)
,
f
o
llo
wi
n
g
th
e
C
lin
ical
an
d
L
ab
o
r
ato
r
y
Stan
d
ar
d
I
n
s
titu
te
(
C
L
SI)
g
u
id
elin
es
[
1
4
]
.
A
s
tan
d
ar
d
ized
b
ac
ter
ial
in
o
c
u
lu
m
(
0
.
5
Mc
Far
lan
d
s
tan
d
ar
d
)
w
as
p
r
ep
ar
e
d
f
o
r
ea
c
h
is
o
late
an
d
s
p
r
ea
d
o
n
to
M
HA
p
lates.
A
p
an
el
o
f
ten
an
tib
io
tic
d
is
cs,
in
clu
d
in
g
ce
f
tazid
im
e
(
3
0
μ
g
)
,
g
en
tam
icin
(
1
0
μ
g
)
,
n
alid
ix
ic
ac
id
(
3
0
μ
g
)
,
s
u
lf
am
eth
o
x
az
o
l
e
(
3
0
μ
g
)
,
ch
lo
r
am
p
h
e
n
ico
l
(
3
0
μ
g
)
,
tr
im
eth
o
p
r
im
(
5
μ
g
)
,
cip
r
o
f
lo
x
ac
in
(
5
μ
g
)
,
c
ef
o
tax
im
e
(
3
0
μ
g
)
,
im
i
p
en
em
(
1
0
μ
g
)
,
a
n
d
am
p
icillin
(
1
0
μ
g
)
,
was
th
en
ap
p
lied
.
Mu
ltid
r
u
g
r
esis
tan
ce
(
MD
R
)
was
d
ef
in
ed
as
r
esi
s
tan
ce
to
at
least
o
n
e
an
tib
io
tic
in
th
r
e
e
o
r
m
o
r
e
d
if
f
er
e
n
t
class
es.
2
.
6
.
P
heno
t
y
pic det
er
m
ina
t
i
o
n
o
f
ex
t
ended
-
s
pect
rum
bet
a
-
la
ct
a
m
a
s
e
pro
du
ce
rs
E
SB
L
p
r
o
d
u
ce
r
s
wer
e
id
en
tifi
ed
u
s
in
g
ce
f
o
tax
im
e
(
C
T
X
3
0
μ
g
)
a
n
d
ce
f
tazid
im
e
(
C
AZ
3
0
μ
g
)
d
is
cs,
test
ed
in
d
iv
id
u
ally
a
n
d
i
n
co
m
b
in
atio
n
with
clav
u
lan
ic
ac
id
(
1
0
μ
g
)
o
n
Mu
eller
-
Hin
to
n
ag
ar
.
A
p
o
s
itiv
e
co
n
f
ir
m
ato
r
y
test
was
d
ef
in
ed
as
a
≥
5
m
m
in
cr
ea
s
e
in
t
h
e
zo
n
e
o
f
in
h
ib
itio
n
f
o
r
th
e
co
m
b
in
atio
n
d
is
c
co
m
p
ar
ed
to
th
e
s
in
g
le
an
tib
i
o
tic
d
is
c
[
1
4
]
.
K
leb
s
iella
p
n
e
u
mo
n
ia
e
AT
C
C
7
0
0
6
0
3
3
s
er
v
ed
as
th
e
p
o
s
itiv
e
co
n
tr
o
l f
o
r
E
SB
L
p
r
o
d
u
ctio
n
,
wh
ile
E
s
ch
erich
ia
co
li
AT
C
C
2
5
9
2
2
was th
e
n
eg
ativ
e
co
n
tr
o
l.
2
.
7
.
G
eno
m
ic
DNA
ex
t
r
a
ct
io
n a
nd
g
eno
t
y
pic det
ec
t
io
n o
f
ex
t
ended
-
s
pect
rum
bet
a
-
la
ct
a
m
s
e
g
enes
Gen
o
m
ic
DNA
was
ex
tr
ac
ted
f
r
o
m
th
e
is
o
lates
u
s
in
g
th
e
b
o
ilin
g
m
eth
o
d
,
i
n
wh
ich
c
o
lo
n
i
es
wer
e
s
u
s
p
en
d
ed
in
s
ter
ile
wate
r
an
d
h
ea
ted
at
9
5
°C
f
o
r
2
0
m
in
to
ly
s
e
th
e
ce
lls
b
ef
o
r
e
ce
n
tr
if
u
g
atio
n
at
1
2
,
0
0
0
r
p
m
f
o
r
5
m
in
.
T
h
e
DNA
-
r
ich
s
u
p
er
n
atan
t
was
s
to
r
ed
at
−2
0
°C
an
d
u
s
ed
as
a
tem
p
late
f
o
r
s
u
b
s
eq
u
en
t
PC
R
am
p
lific
atio
n
[
1
5
]
.
Po
s
itiv
e
is
o
lates
wer
e
s
cr
ee
n
ed
f
o
r
co
m
m
o
n
E
SB
L
-
en
co
d
i
n
g
g
e
n
es
(
b
la
TEM
,
b
la
SHV
,
an
d
b
la
CTX
-
M
)
u
s
in
g
s
p
ec
if
ic
p
r
im
e
r
s
as
s
h
o
wn
in
T
ab
le
1
.
E
ac
h
2
5
μ
L
PC
R
r
ea
ctio
n
co
n
tain
e
d
3
μ
L
o
f
tem
p
late
DNA,
1
2
.
5
μ
L
o
f
m
aster
m
ix
(
co
m
p
r
is
in
g
4
μ
L
d
NT
P
m
ix
tu
r
e,
5
μ
L
1
0
X
PC
R
b
u
f
f
er
,
0
.
5
μ
L
T
aq
p
o
l
y
m
er
ase,
an
d
0
.
5
μ
L
o
f
ea
c
h
p
r
im
e
r
s
to
ck
s
o
lu
tio
n
)
,
an
d
6
.
5
μ
L
o
f
n
u
clea
s
e
-
f
r
ee
wate
r
,
f
o
llo
win
g
a
s
tan
d
ar
d
p
r
o
to
c
o
l
with
in
itial
d
en
atu
r
atio
n
at
9
4
°C
f
o
r
3
m
in
,
f
o
llo
wed
b
y
3
0
c
y
cles
o
f
d
en
at
u
r
atio
n
at
9
4
°C
f
o
r
3
0
s
,
an
n
ea
lin
g
at
6
0
°C
f
o
r
3
0
s
,
an
d
ex
ten
s
io
n
at
7
2
°C
f
o
r
1
m
i
n
,
with
a
f
in
al
ex
ten
s
io
n
at
7
2
°C
f
o
r
7
m
in
.
T
h
e
PC
R
p
r
o
d
u
cts
wer
e
v
is
u
alize
d
b
y
elec
tr
o
p
h
o
r
esis
o
n
a
1
.
5
%
ag
ar
o
s
e
g
el
in
T
B
E
b
u
f
f
er
at
1
0
0
V
f
o
r
4
5
m
in
.
Gels
wer
e
s
tain
ed
with
et
h
id
i
u
m
b
r
o
m
id
e
f
o
r
1
5
m
in
,
d
estain
ed
f
o
r
3
0
m
in
,
an
d
th
e
n
v
i
s
u
alize
d
u
n
d
er
UV
lig
h
t
u
s
in
g
a
UV
tr
a
n
s
illu
m
in
ato
r
an
d
d
o
cu
m
en
te
d
with
a
ca
m
er
a
[
1
6
]
.
T
h
e
am
p
lifie
d
p
r
o
d
u
cts
wer
e
n
o
t
s
eq
u
en
ce
d
.
T
ab
le
1
.
PC
R
Prim
er
s
f
o
r
Sp
e
cif
ic
E
SB
L
Gen
es
P
r
i
mer
P
r
i
mer se
q
u
e
n
c
e
5
t
o
3
'
Ta
r
g
e
t
g
e
n
e
A
mp
l
i
c
o
n
si
z
e
TEM
F
TTTC
TG
G
TC
G
C
C
C
TTA
T
TC
C
TEM
4
0
3
TEM
R
A
TC
G
TTG
T
C
A
G
A
A
G
TA
A
G
TTG
G
S
H
V
F
C
G
C
C
TG
TG
TA
TTA
T
C
T
C
C
C
T
S
H
V
2
9
3
S
H
V
R
C
G
A
G
TA
G
TC
C
A
C
C
A
G
A
T
C
C
T
C
TX
-
MF
C
G
C
TG
T
TG
TTA
G
G
A
A
G
TG
TG
C
TX
-
M
7
3
4
C
TX
-
MR
G
G
C
TG
G
G
TG
A
A
G
TA
A
G
TG
A
C
2
.
8
.
Da
t
a
a
na
l
y
s
is
Data
wer
e
an
al
y
ze
d
u
s
in
g
Mic
r
o
s
o
f
t
E
x
ce
l
(
2
0
2
1
)
[
1
7
]
an
d
W
I
NPEPI
(
v
e
r
s
io
n
1
1
.
6
5
)
[
1
8
]
.
Un
iv
ar
iate
an
aly
s
is
was
co
n
d
u
cted
to
id
e
n
tify
v
a
r
iab
les
ass
o
ciate
d
with
MD
R
E
.
co
li
ca
r
r
iag
e,
u
tili
zin
g
two
-
tailed
Fis
h
er
's
ex
ac
t
test
s
f
o
r
ca
teg
o
r
ical
v
ar
ia
b
les.
All
v
a
r
i
ab
les
th
at
wer
e
s
ig
n
if
ican
t
in
th
e
in
itial
s
cr
ee
n
in
g
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Mu
ltid
r
u
g
-
r
esis
ta
n
t E
s
ch
erich
ia
co
li c
a
r
r
ia
g
e
a
n
d
r
is
k
fa
cto
r
s
a
mo
n
g
h
ea
lth
y
…
(
Od
eto
yi
n
B
a
b
a
tu
n
d
e
)
1869
wer
e
in
clu
d
e
d
in
a
m
u
ltiv
ar
iat
e
lo
g
is
tic
r
eg
r
ess
io
n
m
o
d
el.
T
h
is
f
in
al
m
o
d
el
was
u
s
ed
to
ca
lcu
late
th
e
ad
j
u
s
ted
o
d
d
s
r
atio
(
OR
)
a
n
d
its
co
r
r
es
p
o
n
d
in
g
9
5
%
c
o
n
f
id
e
n
ce
i
n
ter
v
al
(
C
I
)
,
ass
ess
in
g
th
e
r
elatio
n
s
h
ip
b
etwe
en
MD
R
E
.
co
li
ca
r
r
ia
g
e
an
d
p
r
e
v
io
u
s
l
y
id
en
tifie
d
r
is
k
f
ac
to
r
s
wh
ile
co
n
tr
o
llin
g
f
o
r
co
n
f
o
u
n
d
in
g
v
ar
iab
les.
Statis
tical
s
ig
n
if
ican
ce
was set a
t p
≤
0
.
0
5
.
3.
RE
SU
L
T
S
AND
D
I
SCU
SS
I
O
N
3
.
1
.
Resul
t
s
Sto
o
l
s
am
p
les
f
r
o
m
2
6
9
p
ar
ticip
an
ts
(
1
4
0
m
ales
an
d
1
2
9
f
em
ales)
y
ield
ed
at
least
o
n
e
m
o
r
p
h
o
lo
g
ically
d
is
tin
ct
E
.
co
li
is
o
late
p
er
in
d
iv
id
u
al.
Am
o
n
g
th
em
,
7
9
wer
e
c
h
ild
r
en
a
g
ed
0
–
1
4
y
ea
r
s
,
an
d
7
3
wer
e
y
o
u
n
g
a
d
u
lts
,
lead
in
g
to
a
to
tal
r
ec
o
v
e
r
y
o
f
5
5
5
E
.
co
li
is
o
lates.
R
eg
ar
d
in
g
ed
u
ca
tio
n
al
b
ac
k
g
r
o
u
n
d
,
4
1
p
ar
ti
cip
a
n
ts
r
ep
o
r
ted
n
o
f
o
r
m
al
ed
u
ca
tio
n
,
wh
ile
o
n
ly
n
in
e
h
ad
a
n
ed
u
ca
tio
n
lev
el
u
p
to
th
e
Nig
e
r
ian
C
er
tific
ate
in
E
d
u
ca
tio
n
.
Of
t
h
e
3
4
7
p
a
r
ticip
an
ts
f
o
r
wh
o
m
f
am
ily
s
ize
d
ata
wer
e
av
aila
b
le,
1
1
5
wer
e
f
r
o
m
h
o
u
s
eh
o
ld
s
with
o
n
e
to
f
iv
e
m
em
b
er
s
an
d
5
7
wer
e
f
r
o
m
f
am
ilies
with
n
in
e
o
r
m
o
r
e
m
em
b
e
r
s
.
Hig
h
r
esis
tan
ce
r
ates
wer
e
o
b
s
er
v
ed
ag
ain
s
t
s
u
lf
am
eth
o
x
a
zo
le
(
9
4
.
0
%),
a
m
p
icillin
(
8
5
.
0
%),
an
d
tetr
ac
y
clin
e
(
8
3
.
2
%),
wh
er
ea
s
im
ip
en
em
s
h
o
wed
th
e
lo
west
r
esis
tan
ce
(
6
.
7
%)
,
as
s
h
o
wn
i
n
Fig
u
r
e
1
.
A
s
ig
n
if
ican
t
m
ajo
r
ity
o
f
th
e
i
s
o
lates (
9
3
.
5
%,
5
1
9
)
s
h
o
wed
r
esis
tan
ce
to
at
least two
an
tib
i
o
tics
.
Am
o
n
g
th
ese,
2
7
8
is
o
lates
(
5
0
.
1
%)
wer
e
ca
t
eg
o
r
ized
as
m
u
ltid
r
u
g
-
r
esis
tan
t,
m
ea
n
in
g
th
ey
wer
e
r
esis
tan
t
to
m
o
r
e
th
an
th
r
ee
class
es
o
f
an
tib
io
tics
.
W
h
ile
a
s
m
all
f
r
ac
tio
n
ex
h
i
b
ited
ex
tr
e
m
e
r
esis
tan
ce
,
with
o
n
e
is
o
late
(
0
.
2
%)
r
esis
tan
t
to
all
1
1
test
ed
an
tib
io
tics
an
d
t
wo
is
o
lates
(
0
.
4
%)
r
esis
tan
t
to
all
an
tib
io
tic
class
es,
a
co
n
t
r
asti
n
g
f
in
d
in
g
was
th
at
1
0
is
o
lates (
1
.
8
%)
r
em
ain
ed
s
u
s
ce
p
tib
le
to
all
an
tib
io
tic
s
test
ed
,
as sh
o
wn
in
T
ab
le
2
.
Fig
u
r
e
1
.
An
tib
i
o
tic
r
esis
tan
ce
p
r
o
f
ile
T
ab
le
2
.
Nu
m
b
er
o
f
is
o
lates r
esis
tan
t to
d
if
f
er
en
t c
lass
es o
f
an
tib
io
tics
C
l
a
s
ses
o
f
a
n
t
i
b
i
o
t
i
c
s
N
u
mb
e
r
o
f
i
s
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l
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t
e
s
P
e
r
c
e
n
t
a
g
e
o
f
i
s
o
l
a
t
e
s
C
l
a
s
ses
o
f
a
n
t
i
b
i
o
t
i
c
s
0
10
1
.
8
%
0
1
27
4
.
9
%
1
2
97
1
7
.
5
%
2
3
1
4
3
2
5
.
8
%
3
4
1
3
9
2
5
.
1
%
4
5
90
1
6
.
2
%
5
6
34
6
.
1
%
6
7
13
2
.
3
%
7
8
2
0
.
4
%
8
To
t
a
l
5
5
5
1
0
0
%
To
t
a
l
Of
th
e
2
7
E
SB
L
-
p
r
o
d
u
cin
g
i
s
o
lates
s
cr
ee
n
ed
f
o
r
SHV,
T
E
M,
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d
C
T
X
-
M,
two
is
o
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es
(
7
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%)
h
ar
b
o
u
r
ed
all
th
r
ee
g
e
n
es.
Ad
d
itio
n
ally
,
1
1
.
1
%
o
f
th
e
is
o
lates
p
o
s
s
es
s
ed
at
m
o
s
t
two
g
en
es
(
T
E
M
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d
C
T
X
-
M,
SHV
an
d
T
E
M,
o
r
SHV
a
n
d
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T
X
-
M)
,
wh
ile
4
0
.
7
%
ca
r
r
ied
o
n
ly
o
n
e
g
e
n
e
(
T
E
M
o
r
SHV)
.
T
E
M
em
er
g
ed
as th
e
p
r
ed
o
m
in
an
t g
e
n
e,
p
r
esen
t in
4
4
.
4
% o
f
t
h
e
to
tal
is
o
lates
,
as sh
o
wn
in
Fig
u
r
e
2
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
8
66
-
1
8
75
1870
As
s
h
o
wn
in
T
ab
le
3
,
th
e
r
e
w
as
n
o
s
tatis
tically
s
ig
n
if
ican
t
a
s
s
o
ciatio
n
b
etwe
en
m
u
ltid
r
u
g
r
esis
tan
ce
an
d
g
en
d
e
r
o
r
ag
e
(
p
>
0
.
0
5
)
.
No
s
ig
n
if
ic
an
t
ass
o
ciatio
n
s
w
er
e
f
o
u
n
d
f
o
r
'
No
f
o
r
m
al
ed
u
c
atio
n
'
,
'
Prim
ar
y
s
ix
'
,
'
Seco
n
d
ar
y
s
ch
o
o
l'
lev
el
o
f
ed
u
ca
tio
n
,
o
r
'
B
u
r
y
in
g
u
n
d
er
g
r
o
u
n
d
'
an
d
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B
u
s
h
waste
d
is
p
o
s
al
m
an
ag
em
e
n
t'
p
r
ac
tices
(
p
>0
.
0
5
)
.
Ho
wev
er
,
th
er
e
was
a
h
ig
h
ly
s
ig
n
if
ican
t
ass
o
ciatio
n
b
etwe
en
ter
ti
ar
y
e
d
u
ca
tio
n
a
n
d
MD
R
E
.
co
li
ca
r
r
iag
e
(
p
=
0
.
0
0
2
)
.
Mu
ltid
r
u
g
r
esis
tan
ce
was
o
b
s
er
v
ed
in
o
n
ly
1
.
8
%
o
f
in
d
iv
i
d
u
als
with
ter
tiar
y
ed
u
ca
tio
n
c
o
m
p
a
r
ed
to
1
1
.
1
%
in
th
o
s
e
with
o
u
t
it.
I
n
d
iv
id
u
als
wh
o
d
i
d
n
o
t
s
elf
-
m
ed
icate
h
ad
a
lo
wer
p
er
ce
n
tag
e
o
f
m
u
ltid
r
u
g
r
esis
tan
ce
(
5
7
.
6
%)
th
an
th
o
s
e
wh
o
s
elf
-
m
ed
icate
d
(
4
2
.
4
%).
A
s
ig
n
if
ican
t
ass
o
ciatio
n
(
p
=
0
.
0
4
9
)
was
o
b
s
er
v
ed
b
et
wee
n
s
elf
-
m
ed
icatio
n
an
d
th
e
ca
r
r
iag
e
o
f
m
u
ltid
r
u
g
-
r
esis
tan
t
E
.
c
o
li
.
On
ly
2
.
2
%
o
f
in
d
iv
id
u
als
with
m
u
ltid
r
u
g
r
esis
tan
ce
r
ep
o
r
ted
p
o
o
r
r
e
f
u
s
e
m
an
ag
em
en
t,
co
m
p
ar
ed
with
8
.
9
%
in
th
o
s
e
with
o
u
t
m
u
ltid
r
u
g
r
esis
tan
ce
.
A
s
ig
n
if
ican
t
ass
o
ciatio
n
(
p
=
0
.
0
4
6
)
was
f
o
u
n
d
b
et
wee
n
p
o
o
r
r
ef
u
s
e
m
an
ag
em
en
t a
n
d
th
e
ca
r
r
iag
e
o
f
MD
R
E
.
co
li
as sh
o
wn
in
T
ab
le
3
.
Fig
u
r
e
2
.
Dis
tr
ib
u
tio
n
o
f
E
SB
L
g
en
es
T
ab
le
3
.
R
is
k
f
ac
to
r
s
f
o
r
ca
r
r
ia
g
e
o
f
m
u
ltid
r
u
g
-
r
esis
tan
t
E
.
co
li
C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
M
u
l
t
i
d
r
u
g
r
e
s
i
st
a
n
c
e
n
=
2
2
4
(
%)
N
o
t
m
u
l
t
i
d
r
u
g
r
e
si
s
t
a
n
t
N
=
4
5
(
%)
C
r
u
d
e
O
R
9
5
%
C
I
p
-
v
a
l
u
e
†
G
e
n
d
e
r
F
e
mal
e
1
0
2
(
4
5
.
5
)
2
7
(
6
0
.
0
)
0
.
5
6
0
.
2
7
-
1
.
1
2
0
.
1
0
1
M
a
l
e
1
2
2
(
5
4
.
5
)
1
8
(
4
0
.
0
)
A
g
e
C
h
i
l
d
r
e
n
6
5
(
2
9
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0
)
1
4
(
3
1
.
1
)
0
.
8
0
0
.
3
9
-
1
.
7
5
0
.
5
8
6
Y
o
u
n
g
a
d
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l
t
6
5
(
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9
.
0
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8
(
1
7
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8
)
1
.
8
9
0
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8
1
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.
9
5
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4
3
A
d
u
l
t
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4
(
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2
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0
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1
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1
)
0
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6
9
0
.
3
5
-
1
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3
9
0
.
3
2
3
Le
v
e
l
o
f
e
d
u
c
a
t
i
o
n
N
o
f
o
r
m
a
l
e
d
u
c
a
t
i
o
n
3
4
(
1
5
.
2
)
7
(
1
5
.
6
)
0
.
9
7
0
.
3
9
-
2
.
7
9
1
.
0
0
0
P
r
i
mary
si
x
7
1
(
3
1
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7
)
1
5
(
3
3
.
3
)
0
.
9
3
0
.
4
5
-
1
.
9
8
0
.
8
6
2
S
e
c
o
n
d
a
r
y
sc
h
o
o
l
1
1
5
(
5
1
.
3
)
1
8
(
4
0
.
0
)
1
.
5
8
0
.
7
9
-
3
.
2
3
0
.
1
9
2
Te
r
t
i
a
r
y
4
(
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)
5
(
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1
.
1
)
0
.
1
5
0
.
0
3
-
0
.
7
2
0
.
0
0
8
*
D
r
u
g
u
se
N
o
se
l
f
-
me
d
i
c
a
t
i
o
n
1
2
9
(
5
7
.
6
)
3
3
(
7
3
.
3
)
0
.
4
9
0
.
2
2
-
1
.
0
5
0
.
0
4
9
*
S
e
l
f
-
me
d
i
c
a
t
i
o
n
9
5
(
4
2
.
4
)
1
2
(
2
6
.
7
)
W
a
st
e
d
i
s
p
o
s
a
l
p
r
a
c
t
i
c
e
s
B
u
r
y
i
n
g
u
n
d
e
r
g
r
o
u
n
d
1
1
9
(
5
3
.
1
)
1
8
(
4
0
.
0
)
1
.
7
0
0
.
8
5
-
3
.
4
7
0
.
1
4
1
B
u
s
h
w
a
st
e
d
i
s
p
o
s
a
l
ma
n
a
g
e
m
e
n
t
1
0
0
(
4
4
.
6
)
2
3
(
5
1
.
1
)
0
.
7
7
0
.
3
9
-
1
.
5
4
0
.
5
1
2
P
o
o
r
r
e
f
u
s
e
ma
n
a
g
e
me
n
t
5
(
2
.
2
)
4
(
8
.
9
)
0
.
2
3
0
.
0
5
-
1
.
2
4
0
.
0
4
6
*
†
F
i
s
h
e
r
’
s
e
x
a
c
t
t
e
st
f
o
r
d
i
c
h
o
t
o
m
o
u
s
p
r
e
d
i
c
t
o
r
s;
*
st
a
t
i
s
t
i
c
a
l
l
y
si
g
n
i
f
i
c
a
n
t
.
O
R
;
O
d
d
s
r
a
t
i
o
;
C
I
,
C
o
n
f
i
d
e
n
c
e
i
n
t
e
r
v
a
l
T
h
e
ass
o
ciate
d
f
ac
to
r
s
wer
e
f
u
r
th
er
s
u
b
jecte
d
to
m
u
ltiv
ar
ia
te
an
aly
s
is
u
s
in
g
th
e
b
in
o
m
ia
l
lo
g
is
tic
r
eg
r
ess
io
n
m
o
d
el
to
d
eter
m
in
e
th
e
in
d
ep
en
d
e
n
t
p
r
ed
icto
r
s
o
f
MD
R
E
.
co
li
ca
r
r
iag
e.
Ou
t
o
f
th
e
v
ar
iab
les
th
at
wer
e
test
ed
,
ter
tiar
y
ed
u
ca
tio
n
(
OR
=
0
.
1
7
;
9
5
%
C
I
=
0
.
0
4
-
0
.
7
7
;
p
=
0
.
0
2
2
)
,
s
elf
-
m
ed
i
ca
tio
n
(
OR
=
2
.
0
3
;
9
5
%C
I
=
0
.
9
9
-
4
.
1
3
;
p
=
0
.
0
5
)
an
d
p
o
o
r
r
ef
u
s
e
m
an
ag
em
en
t
(
OR
=
0
.
1
9
;
9
5
%C
I
=
0
.
0
5
-
0
.
7
7
;
p
=
0
.
0
2
)
wer
e
f
o
u
n
d
to
b
e
in
d
ep
e
n
d
en
t
p
r
ed
i
cto
r
s
o
f
MD
R
E
.
co
li
ca
r
r
ia
g
e
in
th
is
s
tu
d
y
,
as sh
o
wn
in
T
ab
l
e
4
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Mu
ltid
r
u
g
-
r
esis
ta
n
t E
s
ch
erich
ia
co
li c
a
r
r
ia
g
e
a
n
d
r
is
k
fa
cto
r
s
a
mo
n
g
h
ea
lth
y
…
(
Od
eto
yi
n
B
a
b
a
tu
n
d
e
)
1871
T
a
b
l
e
4
.
I
n
d
e
p
e
n
d
e
n
t
p
r
e
d
i
c
t
o
r
s
o
f
c
a
r
r
i
a
g
e
o
f
m
u
l
ti
d
r
u
g
-
r
e
s
i
s
t
a
n
t
E
.
c
o
l
i
i
n
m
u
l
t
i
v
a
r
i
a
t
e
l
o
g
i
s
ti
c
r
e
g
r
e
s
s
i
o
n
m
o
d
e
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P
r
e
d
i
c
t
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A
d
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u
st
e
d
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R
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p
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t
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r
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)
0
.
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7
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.
0
4
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0
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7
7
0
.
0
2
2
*
D
r
u
g
u
se
(
se
l
f
me
d
i
c
a
t
i
o
n
)
2
.
0
3
0
.
9
9
-
4
.
1
3
0
.
0
5
*
W
a
st
e
d
i
s
p
o
s
a
l
(
p
o
o
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r
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f
u
s
e
ma
n
a
g
e
m
e
n
t
)
0
.
1
9
0
.
0
5
-
0
.
7
7
0
.
0
2
0
*
3
.
2
.
Dis
cus
s
io
n
3
.
2
.
1
.
Ant
ibi
o
t
ic
re
s
is
t
a
nce
p
a
t
t
er
ns
T
h
e
o
b
s
er
v
ed
h
ig
h
lev
els
o
f
a
n
tib
io
tic
r
esis
tan
ce
to
s
u
lf
a
m
e
th
o
x
az
o
le
(
9
4
.
0
%),
a
m
p
icillin
(
8
5
.
0
%),
tetr
ac
y
clin
e
(
8
3
.
2
%),
an
d
tr
i
m
eth
o
p
r
im
(
7
1
.
8
%)
am
o
n
g
a
p
p
ar
en
tly
h
ea
lth
y
co
m
m
u
n
ity
d
weller
s
ar
e
d
ee
p
ly
co
n
ce
r
n
in
g
an
d
m
ir
r
o
r
f
in
d
in
g
s
f
r
o
m
m
an
y
s
tu
d
ies
in
Nig
er
i
a
an
d
g
lo
b
ally
,
r
ein
f
o
r
cin
g
t
h
e
u
n
d
er
s
tan
d
in
g
th
at
AM
R
is
a
p
er
v
asiv
e
ch
allen
g
e
ex
ten
d
in
g
b
ey
o
n
d
h
ea
lth
ca
r
e
s
ettin
g
s
[
1
9
]
,
[
2
0
]
.
T
h
ese
al
ar
m
in
g
ly
h
i
g
h
r
ates,
p
ar
ticu
lar
ly
f
o
r
b
r
o
ad
-
s
p
ec
tr
u
m
an
d
co
m
m
o
n
ly
ac
ce
s
s
ib
le
an
tib
io
tics
,
ar
e
lar
g
ely
attr
ib
u
te
d
to
th
e
wid
esp
r
ea
d
an
d
o
f
ten
u
n
r
eg
u
lated
o
v
e
r
u
s
e
an
d
m
is
u
s
e
o
f
th
ese
d
r
u
g
s
with
in
th
e
co
m
m
u
n
ity
,
i
n
clu
d
in
g
s
elf
-
m
ed
icatio
n
an
d
in
co
m
p
lete
tr
ea
tm
en
t
co
u
r
s
es,
wh
ich
f
ac
ilit
ate
s
elec
tiv
e
p
r
ess
u
r
e
an
d
th
e
t
r
an
s
f
er
o
f
r
e
s
is
tan
ce
g
en
es.
T
h
e
co
m
p
ar
ativ
ely
lo
w
r
esis
tan
ce
to
im
ip
e
n
em
(
6
.
7
%)
is
lik
el
y
a
r
ef
lectio
n
o
f
its
h
ig
h
e
r
co
s
t
an
d
r
estricte
d
clin
ical
u
s
e,
wh
ich
lim
its
b
ac
ter
ial
ex
p
o
s
u
r
e
a
n
d
c
o
n
s
eq
u
e
n
tly
p
r
eser
v
es
its
ef
f
icac
y
,
m
a
k
i
n
g
it
a
cr
u
cial
last
-
r
eso
r
t
o
p
tio
n
.
T
h
e
s
ig
n
if
ican
t
p
r
esen
ce
o
f
r
esis
tan
t
s
tr
ain
s
in
h
ea
lth
y
in
d
iv
id
u
als
u
n
d
er
s
co
r
es
th
eir
r
o
le
as
s
ilen
t
r
eser
v
o
ir
s
o
f
AM
R
,
co
n
tr
ib
u
tin
g
to
th
e
c
o
n
tin
u
e
d
cir
c
u
latio
n
an
d
tr
an
s
m
i
s
s
io
n
o
f
r
e
s
is
tan
ce
with
in
th
e
co
m
m
u
n
ity
,
th
er
eb
y
co
m
p
licatin
g
ef
f
ec
tiv
e
i
n
f
ec
tio
n
c
o
n
tr
o
l
an
d
tr
ea
tm
en
t
o
u
tco
m
es [
2
1
]
.
T
h
e
f
in
d
in
g
th
at
5
0
.
1
%
o
f
E
.
co
li
is
o
lates
f
r
o
m
ap
p
ar
en
tly
h
ea
lth
y
co
m
m
u
n
ity
d
weller
s
ex
h
ib
ited
MD
R
is
h
ig
h
ly
c
o
n
s
is
ten
t
with
r
ec
e
n
t
an
d
o
n
g
o
in
g
s
u
r
v
eill
an
ce
ac
r
o
s
s
Nig
er
ia
an
d
o
th
er
lo
w
-
an
d
m
id
d
le
-
in
co
m
e
co
u
n
tr
ies,
wh
er
e
E
.
co
li
f
r
eq
u
en
tly
s
er
v
es
as
an
in
d
i
ca
to
r
o
f
cir
cu
latin
g
an
tim
icr
o
b
ial
r
esis
tan
ce
[
2
2
]
.
A
r
ec
en
t
s
tu
d
y
f
r
o
m
E
th
i
o
p
ia
f
o
u
n
d
4
3
%
MD
R
in
h
u
m
a
n
-
o
r
ig
in
E
.
co
li
,
with
v
er
y
h
ig
h
r
esis
tan
ce
to
alm
o
s
t
all
th
e
test
ed
d
r
u
g
s
[
2
3
]
.
T
h
e
p
r
ev
alen
ce
in
t
h
is
s
tu
d
y
u
n
d
e
r
s
co
r
es
th
e
s
ig
n
if
ican
t
r
o
le
th
at
h
ea
lth
y
in
d
iv
i
d
u
als
p
lay
as si
len
t r
e
s
er
v
o
ir
s
an
d
d
is
s
em
in
ato
r
s
o
f
AM
R
with
in
th
e
co
m
m
u
n
ity
,
ev
e
n
with
o
u
t a
ctiv
e
in
f
ec
tio
n
[
2
4
]
.
Alth
o
u
g
h
s
o
m
e
o
f
th
e
r
ea
s
o
n
s
f
o
r
th
ese
o
b
s
er
v
ed
h
ig
h
MD
R
r
ates
h
av
e
b
ee
n
p
r
ev
io
u
s
ly
m
en
tio
n
ed
,
th
e
ex
ten
s
iv
e
u
s
e
o
f
a
n
tim
icr
o
b
ia
ls
as
g
r
o
wth
p
r
o
m
o
ter
s
o
r
f
o
r
p
r
o
p
h
y
la
x
is
in
liv
esto
ck
an
d
aq
u
ac
u
ltu
r
e
c
o
u
ld
also
b
e
a
co
n
t
r
ib
u
tin
g
f
ac
to
r
[
2
5
]
.
R
esis
tan
t
s
tr
ain
s
ca
n
th
e
n
s
p
r
ea
d
th
r
o
u
g
h
th
e
f
o
o
d
c
h
ain
,
c
o
n
tam
in
ated
wate
r
,
an
d
d
i
r
ec
t c
o
n
tact,
f
u
r
th
er
ex
ac
er
b
atin
g
th
e
p
r
o
b
le
m
in
co
m
m
u
n
ity
s
ettin
g
s
[
2
6
]
.
T
h
e
f
in
d
in
g
t
h
at
2
7
.
4
%
o
f
f
ae
ca
l
E
.
co
li
is
o
lates
f
r
o
m
h
ea
lth
y
r
u
r
al
co
m
m
u
n
ity
d
weller
s
d
em
o
n
s
tr
ated
r
esis
tan
ce
to
ei
th
er
ce
f
tazid
im
e
o
r
ce
f
o
tax
im
e,
o
r
b
o
t
h
,
is
a
s
ig
n
if
ican
t
co
n
ce
r
n
,
with
wid
er
p
u
b
lic
h
ea
lth
im
p
licatio
n
s
[
2
0
]
.
T
h
is
lev
el
o
f
th
ir
d
-
g
en
e
r
atio
n
ce
p
h
alo
s
p
o
r
in
r
esis
tan
ce
in
co
m
m
en
s
al
E
.
co
li
is
co
n
s
is
ten
t
with
p
r
ev
io
u
s
s
t
u
d
ies
f
r
o
m
d
if
f
e
r
en
t
p
ar
ts
o
f
Nig
er
ia
th
at
h
av
e
r
ep
o
r
ted
v
a
r
y
in
g
b
u
t
o
f
ten
h
ig
h
r
ates
o
f
E
SB
L
p
r
o
d
u
ce
r
s
i
n
b
o
th
clin
ical
an
d
en
v
ir
o
n
m
en
tal
s
am
p
les,
as
well
as
in
th
e
g
u
t
m
icr
o
b
io
ta
o
f
h
ea
lth
y
in
d
i
v
id
u
als [
2
7
]
,
[
2
8
]
.
Oth
er
Af
r
ican
s
tu
d
ies h
av
e
r
ep
o
r
ted
s
im
ilar
r
esu
lts
[
2
3
]
.
3
.
2
.
2
.
Resis
t
a
n
ce
g
enes pre
v
a
lence
T
h
e
an
aly
s
is
o
f
2
7
E
SB
L
-
p
r
o
d
u
cin
g
is
o
lates
r
ev
ea
led
th
at
T
E
M
was
th
e
m
o
s
t
p
r
ev
alen
t
g
en
e,
eith
er
alo
n
e
o
r
i
n
co
m
b
in
atio
n
,
with
two
is
o
lates (
7
.
4
%)
h
ar
b
o
u
r
in
g
all
th
r
ee
s
cr
ee
n
ed
g
en
es (
SH
V,
T
E
M,
an
d
C
T
X
-
M)
.
T
h
is
m
u
ltid
r
u
g
r
esis
tan
ce
m
ec
h
an
is
m
p
r
esen
ts
a
s
ig
n
if
i
ca
n
t
ch
allen
g
e
f
o
r
an
tib
io
tic
t
r
ea
tm
en
t,
alig
n
in
g
with
th
e
d
o
c
u
m
en
ted
tr
en
d
s
o
f
in
cr
ea
s
in
g
co
-
o
cc
u
r
r
en
ce
o
f
E
SB
L
g
en
es
[
2
9
]
.
Fu
r
th
e
r
m
o
r
e,
1
1
.
1
%
o
f
t
h
e
is
o
lates
p
o
s
s
e
s
s
ed
co
m
b
in
atio
n
s
o
f
two
g
en
es
(
T
E
M
a
n
d
C
T
X
-
M,
SHV
an
d
T
E
M,
o
r
SHV
an
d
C
T
X
-
M)
,
h
ig
h
lig
h
tin
g
th
e
d
iv
e
r
s
e
g
en
et
ic
p
r
o
f
iles
co
n
tr
ib
u
tin
g
t
o
E
S
B
L
p
r
o
d
u
ctio
n
,
o
f
ten
d
r
i
v
en
b
y
h
o
r
izo
n
tal
g
en
e
tr
an
s
f
er
an
d
clo
n
al
ex
p
an
s
io
n
[
3
0
]
.
T
h
e
lar
g
est
g
r
o
u
p
,
ac
c
o
u
n
tin
g
f
o
r
4
0
.
7
%
o
f
th
e
is
o
l
ates,
ca
r
r
ied
o
n
ly
a
s
in
g
le
g
en
e
(
T
E
M
o
r
SHV)
,
u
n
d
er
s
co
r
in
g
th
ei
r
in
d
iv
id
u
al
co
n
t
r
ib
u
tio
n
to
th
e
E
SB
L
p
h
e
n
o
ty
p
e.
T
h
e
p
r
ed
o
m
i
n
an
ce
o
f
T
E
M,
f
o
u
n
d
in
4
4
.
4
%
o
f
th
e
is
o
lates,
is
co
n
s
is
ten
t
with
m
an
y
p
r
e
v
io
u
s
s
tu
d
ies
th
at
id
en
tifie
d
T
E
M
an
d
SHV
as
h
is
to
r
ically
co
m
m
o
n
E
SB
L
ty
p
es
[
3
1
]
,
alth
o
u
g
h
C
T
X
-
M
ty
p
es
h
av
e
b
ec
o
m
e
in
cr
ea
s
in
g
ly
p
r
ev
ale
n
t
wo
r
ld
wid
e
s
in
ce
th
e
ea
r
ly
2
0
0
0
s
[
3
2
]
.
Alth
o
u
g
h
th
is
s
tu
d
y
f
o
cu
s
ed
o
n
E
SB
L
-
p
r
o
d
u
cin
g
is
o
lates,
th
e
p
r
es
en
ce
o
f
th
ese
r
esis
tan
ce
g
e
n
es
h
as
im
p
licatio
n
s
f
o
r
h
ea
lth
y
in
d
iv
i
d
u
als.
Asy
m
p
to
m
atic
ca
r
r
ier
s
ca
n
h
ar
b
o
u
r
E
SB
L
-
p
r
o
d
u
ci
n
g
b
ac
t
e
r
ia
in
th
eir
g
u
t
f
lo
r
a,
s
er
v
in
g
as
r
eser
v
o
ir
s
f
o
r
co
m
m
u
n
ity
-
ac
q
u
ir
e
d
in
f
ec
tio
n
s
an
d
f
ac
ilit
atin
g
th
e
s
p
r
ea
d
o
f
r
esis
tan
ce
,
a
m
ajo
r
p
u
b
lic
h
ea
lth
co
n
ce
r
n
[
2
4
]
.
Stu
d
ies
co
n
d
u
cte
d
in
Osu
n
S
tate,
Nig
er
ia,
th
at
r
ep
o
r
ted
t
h
e
p
r
ev
ale
n
ce
o
f
E
SB
L
-
p
r
o
d
u
cin
g
b
ac
ter
ia
o
f
te
n
id
en
tifie
d
T
E
M
an
d
C
T
X
-
M
as
co
m
m
o
n
g
en
o
t
y
p
es
in
b
o
t
h
clin
ical
an
d
co
m
m
u
n
ity
s
et
tin
g
s
[
2
6
]
,
f
u
r
th
er
v
alid
atin
g
th
e
f
in
d
in
g
s
o
f
th
i
s
s
tu
d
y
with
in
th
e
lo
ca
l
c
o
n
t
ex
t.
T
h
is
h
i
g
h
lig
h
ts
th
e
o
n
g
o
in
g
n
ee
d
f
o
r
r
o
b
u
s
t
s
u
r
v
eillan
ce
an
d
e
v
id
en
ce
-
b
ased
p
o
licies t
o
g
u
i
d
e
in
f
ec
tio
n
co
n
tr
o
l m
ea
s
u
r
es in
th
e
r
eg
i
o
n
[
2
0
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
8
66
-
1
8
75
1872
3
.
2
.
3
.
Ris
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o
f
f
er
s
ig
n
i
f
ican
t
in
s
i
g
h
ts
in
to
th
e
f
ac
to
r
s
in
f
lu
en
ci
n
g
th
e
ca
r
r
iag
e
o
f
MD
R
E
.
co
li
with
in
a
co
m
m
u
n
ity
,
p
r
esen
tin
g
f
in
d
in
g
s
th
at
lar
g
ely
r
eso
n
ate
with
th
e
b
r
o
a
d
er
s
cien
tific
u
n
d
er
s
tan
d
in
g
wh
ile
also
in
tr
o
d
u
cin
g
a
n
in
tr
ig
u
in
g
an
o
m
aly
.
T
h
e
in
v
e
r
s
e
r
elatio
n
s
h
i
p
b
etwe
en
te
r
tiar
y
e
d
u
ca
tio
n
an
d
MD
R
E
.
c
o
li
ca
r
r
iag
e
is
a
s
tr
ik
in
g
r
ev
elati
o
n
(
p
=
0
.
0
2
2
)
,
with
o
n
l
y
1
.
8
%
o
f
h
ig
h
ly
e
d
u
ca
ted
i
n
d
iv
id
u
als
ca
r
r
y
in
g
MD
R
s
tr
ain
s
co
m
p
ar
ed
to
1
1
.
1
%
in
th
e
n
o
n
-
MD
R
g
r
o
u
p
.
T
h
is
f
in
d
in
g
s
u
g
g
ests
th
at
h
ig
h
er
ed
u
ca
tio
n
al
attain
m
en
t
m
ay
ac
t
as
a
p
r
o
tectiv
e
f
ac
to
r
ag
ain
s
t
MD
R
E
.
co
li
co
lo
n
is
atio
n
.
T
h
is
alig
n
s
with
ex
is
tin
g
r
esear
ch
in
d
icatin
g
th
at
h
ea
lth
liter
ac
y
im
p
r
o
v
es
with
ed
u
ca
tio
n
,
lead
in
g
t
o
b
etter
h
y
g
ie
n
e
p
r
ac
tices,
g
r
e
ater
awa
r
en
ess
o
f
an
tib
io
tic
s
tewa
r
d
s
h
ip
p
r
i
n
cip
les,
an
d
p
o
ten
tially
d
if
f
er
en
t
h
ea
lth
ca
r
e
-
s
ee
k
in
g
b
eh
a
v
io
u
r
s
[
3
3
]
.
Fo
r
in
s
tan
ce
,
m
o
r
e
ed
u
ca
te
d
in
d
iv
i
d
u
als
m
ig
h
t
b
e
less
p
r
o
n
e
to
s
elf
-
m
e
d
icatio
n
o
r
m
o
r
e
lik
ely
t
o
ad
h
er
e
to
p
r
escr
ib
ed
an
tib
io
tic
r
eg
im
en
s
,
th
er
eb
y
r
ed
u
cin
g
s
elec
tiv
e
p
r
ess
u
r
e
f
o
r
r
esis
tan
ce
.
T
h
ey
m
ig
h
t
also
h
av
e
b
etter
ac
ce
s
s
to
clea
n
wate
r
an
d
s
an
itatio
n
f
ac
i
liti
es,
f
u
r
th
er
m
in
im
i
s
in
g
e
x
p
o
s
u
r
e
to
en
v
ir
o
n
m
e
n
tally
r
esis
tan
t b
ac
ter
ia
[
3
4
]
.
T
h
e
s
ig
n
if
ican
t
ass
o
ciatio
n
b
et
wee
n
s
elf
-
m
ed
icatio
n
an
d
MD
R
E
.
co
li
ca
r
r
iag
e
(
p
=
0
.
0
5
)
is
a
cr
u
cial
f
in
d
in
g
th
at
s
tr
o
n
g
ly
co
r
r
o
b
o
r
ates
g
lo
b
al
co
n
ce
r
n
s
r
eg
a
r
d
in
g
an
tib
io
tic
r
esis
tan
ce
.
Ou
r
d
a
ta
s
h
o
w
th
at
4
2
.
4
%
o
f
MD
R
E
.
co
li
ca
r
r
ier
s
en
g
ag
ed
in
s
elf
-
m
ed
icatio
n
,
a
co
n
s
id
er
ab
ly
h
ig
h
er
p
r
o
p
o
r
tio
n
th
a
n
th
e
2
6
.
7
%
in
th
e
non
-
MD
R
g
r
o
u
p
.
T
h
is
d
ir
e
ct
lin
k
r
ein
f
o
r
ce
s
th
e
estab
l
is
h
ed
u
n
d
e
r
s
tan
d
in
g
t
h
at
in
ap
p
r
o
p
r
iate
u
s
e
o
f
an
tib
io
tics
,
co
m
m
o
n
in
s
elf
-
m
ed
icatio
n
s
ce
n
ar
io
s
in
v
o
lv
i
n
g
in
co
r
r
ec
t
d
o
s
ag
es,
d
u
r
atio
n
s
,
o
r
s
elec
tio
n
o
f
an
tib
io
tics
f
o
r
v
ir
al
in
f
ec
tio
n
s
,
cr
ea
tes
a
s
tr
o
n
g
s
elec
tiv
e
p
r
ess
u
r
e.
T
h
is
p
r
ess
u
r
e
f
av
o
u
r
s
th
e
s
u
r
v
iv
al
a
n
d
p
r
o
life
r
atio
n
o
f
r
esis
tan
t
b
ac
ter
ial
s
tr
ain
s
,
u
ltima
tely
co
n
t
r
ib
u
tin
g
to
th
e
r
is
e
o
f
MD
R
p
ath
o
g
en
s
in
th
e
co
m
m
u
n
ity
[
3
5
]
.
Ma
n
y
s
tu
d
ie
s
wo
r
ld
wid
e
h
av
e
id
en
tifie
d
ir
r
atio
n
al
an
tib
io
tic
u
s
e
as
th
e
p
r
im
ar
y
ca
taly
s
t
f
o
r
th
e
escalatin
g
an
tim
icr
o
b
ial
r
e
s
is
tan
ce
cr
is
is
[
2
0
]
,
[
3
6
]
.
T
h
is
is
p
ar
ticu
lar
ly
p
e
r
tin
en
t
i
n
r
e
g
io
n
s
s
u
ch
as
Osu
n
State
,
Nig
er
ia,
wh
er
e
ac
ce
s
s
to
p
r
escr
ip
tio
n
-
o
n
ly
an
tib
io
tic
s
m
ay
b
e
less
r
eg
u
lated
,
co
n
t
r
ib
u
tin
g
t
o
h
ig
h
er
r
ates o
f
s
elf
-
m
ed
icatio
n
a
n
d
s
u
b
s
eq
u
en
t r
esis
tan
ce
d
ev
elo
p
m
en
t.
Per
h
ap
s
th
e
m
o
s
t
p
er
p
le
x
in
g
f
in
d
in
g
was
th
e
in
v
er
s
e
ass
o
ciatio
n
b
etwe
en
p
o
o
r
r
e
f
u
s
e
m
an
ag
em
en
t
an
d
MD
R
E
.
co
li
ca
r
r
ia
g
e
(
p
=
0
.
0
4
6
)
.
C
o
u
n
ter
to
in
tu
it
iv
e
ex
p
ec
tatio
n
s
,
o
n
ly
2
.
2
%
o
f
th
e
MD
R
g
r
o
u
p
r
ep
o
r
ted
p
o
o
r
r
e
f
u
s
e
m
an
ag
e
m
en
t,
co
m
p
ar
e
d
with
8
.
9
%
in
th
e
n
o
n
-
MD
R
g
r
o
u
p
.
Gen
er
a
lly
,
p
o
o
r
s
an
itatio
n
an
d
in
ad
eq
u
ate
waste
d
is
p
o
s
al
ar
e
s
ig
n
if
ican
t
co
n
tr
ib
u
t
o
r
s
to
th
e
en
v
ir
o
n
m
en
tal
s
p
r
ea
d
o
f
p
ath
o
g
en
s
,
in
clu
d
in
g
a
n
tib
io
tic
-
r
esis
tan
t
b
ac
ter
ia
[
3
7
]
.
T
h
is
u
n
ex
p
ec
t
ed
r
esu
lt
p
r
o
m
p
ts
s
ev
er
al
co
n
s
id
er
atio
n
s
.
I
t
is
p
lau
s
ib
le
th
at
th
e
d
ef
in
itio
n
o
r
ass
ess
m
en
t
o
f
"p
o
o
r
r
e
f
u
s
e
m
an
ag
em
en
t"
with
in
t
h
is
s
tu
d
y
m
ig
h
t
n
o
t
f
u
lly
ca
p
tu
r
e
th
e
s
p
ec
if
ic
p
ath
way
s
th
r
o
u
g
h
wh
ich
r
esis
tan
t
b
a
cter
ia
ar
e
tr
an
s
m
itted
,
o
r
it
m
ig
h
t
r
elate
to
a
p
er
ce
iv
ed
p
r
ac
tice
r
ath
e
r
th
an
an
o
b
jectiv
e
o
n
e.
Fo
r
ex
am
p
le,
th
e
o
p
en
d
u
m
p
i
n
g
o
f
waste,
wh
ile
s
ee
m
in
g
ly
"p
o
o
r
,
"
m
i
g
h
t
n
o
t
lead
to
d
i
r
ec
t
h
u
m
an
ex
p
o
s
u
r
e
if
it
o
cc
u
r
s
in
r
em
o
te
ar
ea
s
.
Alter
n
ativ
ely
,
th
er
e
m
ay
b
e
u
n
m
ea
s
u
r
ed
co
n
f
o
u
n
d
in
g
f
ac
to
r
s
.
Fo
r
ex
am
p
le,
if
in
d
i
v
id
u
als
with
b
etter
r
ef
u
s
e
m
an
ag
e
m
en
t
p
r
ac
tices
also
h
av
e
g
r
ea
ter
ac
ce
s
s
to
h
ea
lth
ca
r
e
an
d
th
u
s
h
ig
h
er
ex
p
o
s
u
r
e
to
an
tib
io
tics
,
it
co
u
ld
o
b
s
cu
r
e
th
e
ex
p
ec
ted
p
o
s
itiv
e
co
r
r
elatio
n
[
3
8
]
.
Fu
r
th
er
m
o
r
e,
co
m
m
u
n
ities
with
o
v
er
all
lo
wer
p
o
p
u
latio
n
d
en
s
ities
o
r
d
if
f
er
en
t
ag
r
icu
ltu
r
al
p
r
ac
tices,
wh
ich
m
ig
h
t
in
cid
en
tally
co
r
r
elate
with
ce
r
tain
r
ef
u
s
e
m
an
a
g
e
m
en
t
s
ty
les,
co
u
l
d
in
f
lu
en
ce
th
e
p
r
ev
ale
n
ce
o
f
r
esis
tan
t
s
tr
ain
s
d
if
f
er
en
tly
[
3
9
]
.
Fu
r
th
er
in
-
d
e
p
th
q
u
alitativ
e
an
d
q
u
an
titativ
e
r
esear
ch
f
o
cu
s
in
g
o
n
s
p
ec
if
ic
waste
d
is
p
o
s
al
b
eh
av
io
u
r
s
,
en
v
ir
o
n
m
e
n
tal
s
am
p
lin
g
f
o
r
r
esi
s
tan
t
b
ac
ter
ia,
an
d
co
m
p
r
eh
e
n
s
iv
e
s
o
cio
ec
o
n
o
m
i
c
f
ac
to
r
s
is
n
ec
ess
ar
y
to
f
u
lly
d
ec
ip
h
er
th
is
u
n
ex
p
ec
te
d
co
r
r
e
latio
n
.
T
h
e
ab
s
en
ce
o
f
a
s
tatis
tically
s
ig
n
if
ican
t
ass
o
ciatio
n
b
etwe
e
n
MD
R
E
.
c
o
li
ca
r
r
iag
e
a
n
d
s
ex
o
r
ag
e
(
p
>0
.
0
5
)
s
u
g
g
ests
th
at,
with
i
n
th
is
p
ar
tic
u
lar
co
m
m
u
n
ity
,
th
ese
d
em
o
g
r
ap
h
ic
v
ar
iab
les
ar
e
n
o
t
th
e
p
r
im
ar
y
d
r
iv
er
s
o
f
r
esis
t
an
ce
ac
q
u
is
itio
n
.
T
h
is
i
n
d
icate
s
th
at
b
e
h
av
io
u
r
al
an
d
s
o
cio
ec
o
n
o
m
i
c
f
ac
to
r
s
,
s
u
ch
as
ed
u
ca
tio
n
an
d
s
elf
-
m
ed
icatio
n
p
r
ac
tices,
m
ay
p
lay
a
m
o
r
e
d
o
m
in
an
t
r
o
le
in
s
h
ap
in
g
th
e
lan
d
s
ca
p
e
o
f
an
tim
icr
o
b
ial
r
esis
tan
ce
in
th
is
s
p
ec
if
ic
co
n
tex
t.
T
h
is
alig
n
s
with
r
ese
ar
ch
s
u
g
g
esti
n
g
t
h
at
wh
ile
ag
e
an
d
g
en
d
er
ca
n
s
o
m
etim
es
b
e
f
a
cto
r
s
,
b
eh
a
v
io
u
r
al
r
is
k
f
ac
t
o
r
s
o
f
ten
h
o
ld
m
o
r
e
weig
h
t
i
n
co
m
m
u
n
ity
-
lev
el
r
esis
tan
ce
[
4
0
]
.
T
h
e
f
in
d
i
n
g
s
co
llectiv
ely
em
p
h
asis
e
th
e
m
u
ltifa
ce
ted
n
at
u
r
e
o
f
a
n
tim
icr
o
b
ial
r
esis
tan
ce
,
u
n
d
er
s
co
r
i
n
g
th
e
c
r
itical
n
ee
d
f
o
r
c
o
n
tex
t
-
s
p
ec
if
ic
in
te
r
v
en
tio
n
s
th
at
g
o
b
ey
o
n
d
g
e
n
er
al
d
em
o
g
r
ap
h
ic
co
n
s
id
er
atio
n
s
to
tar
g
et
m
o
d
if
i
ab
le
r
is
k
b
eh
a
v
io
u
r
s
an
d
im
p
r
o
v
e
p
u
b
lic
h
ea
lth
in
f
r
astru
ctu
r
e.
4.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
r
e
v
ea
led
t
h
e
p
r
ess
in
g
is
s
u
e
o
f
wid
esp
r
ea
d
a
n
tib
io
tic
r
esis
tan
ce
in
r
u
r
al
c
o
m
m
u
n
ity
s
ettin
g
s
in
Nig
er
ia,
d
r
iv
en
b
y
s
o
cio
ec
o
n
o
m
ic
a
n
d
b
e
h
av
io
u
r
al
f
ac
to
r
s
.
T
h
e
h
i
g
h
p
r
e
v
alen
ce
o
f
MD
R
E
.
co
li
an
d
E
SB
L
-
p
r
o
d
u
cin
g
s
tr
ain
s
am
o
n
g
h
ea
lth
y
in
d
iv
id
u
als
u
n
d
er
s
co
r
es
th
ei
r
cr
itical
r
o
le
as
s
ilen
t
r
eser
v
o
ir
s
,
co
n
tin
u
ally
f
u
ellin
g
th
e
s
p
r
ea
d
o
f
AM
R
.
Alth
o
u
g
h
h
ig
h
er
ed
u
ca
tio
n
s
ee
m
s
to
c
o
n
f
er
a
p
r
o
t
ec
tiv
e
ef
f
ec
t,
lik
ely
d
u
e
to
en
h
a
n
ce
d
h
ea
lth
liter
a
cy
,
th
e
s
tr
o
n
g
ass
o
ciatio
n
b
et
wee
n
s
elf
-
m
ed
icatio
n
an
d
M
DR
E
.
co
li
ca
r
r
iag
e
r
em
ain
s
a
s
ig
n
if
ican
t
c
o
n
ce
r
n
.
Ultim
ately
,
co
m
b
atin
g
t
h
is
escalatin
g
p
u
b
lic
h
ea
lth
th
r
ea
t
n
ec
ess
itates
co
m
p
r
eh
e
n
s
iv
e
in
ter
v
e
n
tio
n
s
,
in
clu
d
in
g
r
o
b
u
s
t
s
u
r
v
eillan
ce
,
tar
g
eted
p
u
b
lic
e
d
u
ca
tio
n
ca
m
p
aig
n
s
,
an
d
s
tr
in
g
en
t
r
eg
u
lato
r
y
m
ea
s
u
r
es
to
p
r
o
m
o
te
ju
d
icio
u
s
an
tib
io
tic
u
s
e
an
d
lim
it
th
e
s
p
r
ea
d
o
f
r
esis
tan
ce
wi
th
i
n
th
e
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Mu
ltid
r
u
g
-
r
esis
ta
n
t E
s
ch
erich
ia
co
li c
a
r
r
ia
g
e
a
n
d
r
is
k
fa
cto
r
s
a
mo
n
g
h
ea
lth
y
…
(
Od
eto
yi
n
B
a
b
a
tu
n
d
e
)
1873
co
m
m
u
n
ity
.
A
s
p
ec
if
ic
r
ec
o
m
m
en
d
atio
n
wo
u
ld
b
e
to
o
r
g
an
ize
co
m
m
u
n
ity
-
wid
e
f
o
r
u
m
s
to
ed
u
ca
te
th
e
p
o
p
u
latio
n
o
n
wh
at
MD
R
is
an
d
h
o
w
to
g
u
id
e
a
g
ain
s
t
it.
W
id
er
s
tu
d
ies
ex
am
in
in
g
MD
R
E
.
co
li
in
d
if
f
er
e
n
t
r
u
r
al
co
m
m
u
n
ities
ac
r
o
s
s
Os
u
n
State
an
d
Nig
er
ia
ar
e
n
ee
d
ed
to
b
etter
u
n
d
e
r
s
tan
d
th
e
p
r
esen
t
r
ea
liti
es
an
d
g
u
id
e
p
u
b
lic
h
ea
lth
p
o
licies
r
eg
ar
d
in
g
an
tib
io
tic
r
esis
tan
ce
in
Nig
er
ia.
A
lim
itatio
n
o
f
t
h
is
s
tu
d
y
is
th
at
n
o
en
v
ir
o
n
m
en
tal
s
am
p
lin
g
was
p
er
f
o
r
m
e
d
f
o
r
co
m
p
ar
ativ
e
an
aly
s
is
.
I
t
m
u
s
t
al
s
o
b
e
n
o
ted
th
at
th
er
e
is
a
lik
elih
o
o
d
o
f
r
e
p
o
r
ted
b
ias in
s
elf
-
r
ep
o
r
ted
d
ata
ca
p
tu
r
ed
b
y
t
h
e
q
u
esti
o
n
n
ai
r
e.
ACK
NO
WL
E
DG
M
E
N
T
S
T
h
e
au
th
o
r
ex
p
r
ess
es
g
r
atitu
d
e
to
th
e
co
m
m
u
n
ity
'
s
tr
ad
itio
n
al
lead
er
s
an
d
r
esid
en
ts
f
o
r
th
eir
s
u
p
p
o
r
t
an
d
co
llab
o
r
atio
n
.
F
UNDING
I
NF
O
R
M
A
T
I
O
N
T
h
e
au
th
o
r
s
s
tate
th
at
n
o
f
u
n
d
i
n
g
was in
v
o
lv
e
d
in
th
is
s
tu
d
y
.
AUTHO
R
CO
NT
RI
B
UT
I
O
NS ST
A
T
E
M
E
N
T
T
h
is
jo
u
r
n
al
u
s
es
th
e
C
o
n
t
r
ib
u
to
r
R
o
les
T
a
x
o
n
o
m
y
(
C
R
ed
iT)
to
r
ec
o
g
n
ize
in
d
iv
i
d
u
al
au
th
o
r
co
n
tr
ib
u
tio
n
s
,
r
ed
u
ce
au
th
o
r
s
h
ip
d
is
p
u
tes,
an
d
f
ac
ilit
ate
co
llab
o
r
atio
n
.
Na
m
e
o
f
Aut
ho
r
C
M
So
Va
Fo
I
R
D
O
E
Vi
Su
P
Fu
Od
eto
y
in
B
ab
atu
n
d
e
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Ak
in
d
e
Olu
wato
y
in
✓
✓
✓
✓
✓
✓
C
:
C
o
n
c
e
p
t
u
a
l
i
z
a
t
i
o
n
M
:
M
e
t
h
o
d
o
l
o
g
y
So
:
So
f
t
w
a
r
e
Va
:
Va
l
i
d
a
t
i
o
n
Fo
:
Fo
r
mal
a
n
a
l
y
s
i
s
I
:
I
n
v
e
s
t
i
g
a
t
i
o
n
R
:
R
e
so
u
r
c
e
s
D
:
D
a
t
a
C
u
r
a
t
i
o
n
O
:
W
r
i
t
i
n
g
-
O
r
i
g
i
n
a
l
D
r
a
f
t
E
:
W
r
i
t
i
n
g
-
R
e
v
i
e
w
&
E
d
i
t
i
n
g
Vi
:
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su
a
l
i
z
a
t
i
o
n
Su
:
Su
p
e
r
v
i
s
i
o
n
P
:
P
r
o
j
e
c
t
a
d
mi
n
i
st
r
a
t
i
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n
Fu
:
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n
d
i
n
g
a
c
q
u
i
si
t
i
o
n
CO
NF
L
I
C
T
O
F
I
N
T
E
R
E
S
T
ST
A
T
E
M
E
NT
T
h
e
au
th
o
r
s
d
ec
lar
e
n
o
co
n
f
licts
o
f
in
ter
est.
I
NF
O
RM
E
D
CO
NS
E
N
T
I
n
f
o
r
m
ed
co
n
s
en
t w
as o
b
tain
e
d
f
r
o
m
all
in
d
iv
id
u
als in
clu
d
e
d
in
th
is
s
tu
d
y
.
E
T
H
I
CAL AP
P
RO
V
AL
E
th
ical
ap
p
r
o
v
al
f
o
r
th
is
s
tu
d
y
was
o
b
tain
ed
f
r
o
m
th
e
R
esear
ch
E
th
ics
C
o
m
m
ittee
o
f
th
e
I
n
s
titu
te
o
f
Pu
b
lic
Hea
lth
,
Ob
af
em
i
Awo
lo
wo
Un
iv
er
s
ity
,
I
le
-
I
f
e,
Nig
er
ia.
B
ef
o
r
e
co
m
m
en
ce
m
e
n
t,
p
e
r
m
is
s
io
n
was
also
s
ec
u
r
ed
f
r
o
m
th
e
tr
ad
itio
n
al
r
u
ler
o
f
th
e
c
o
m
m
u
n
ity
,
wh
o
o
v
er
s
ee
s
s
ev
er
al
n
eig
h
b
o
u
r
in
g
v
illag
es
with
in
th
e
s
tu
d
y
ar
ea
.
All
p
ar
ticip
an
ts
p
r
o
v
id
ed
v
e
r
b
al
in
f
o
r
m
ed
c
o
n
s
en
t
p
r
io
r
to
r
ec
r
u
itm
en
t.
T
o
e
n
s
u
r
e
co
n
f
i
d
en
tiality
,
n
o
p
er
s
o
n
ally
id
e
n
tifia
b
le
in
f
o
r
m
atio
n
,
s
u
ch
as
n
am
es
o
r
tr
ac
ea
b
le
co
d
es,
was
r
ec
o
r
d
ed
o
r
u
s
ed
d
u
r
i
n
g
d
ata
co
llectio
n
an
d
a
n
aly
s
is
.
DATA
AV
AI
L
AB
I
L
I
T
Y
T
h
e
d
ata
s
u
p
p
o
r
tin
g
th
e
f
i
n
d
i
n
g
s
o
f
th
is
s
tu
d
y
ar
e
a
v
ailab
l
e
u
p
o
n
r
eq
u
est
f
r
o
m
th
e
c
o
r
r
esp
o
n
d
in
g
au
th
o
r
[
OB
]
.
T
h
e
d
ata,
wh
ich
co
n
tain
in
f
o
r
m
atio
n
th
at
co
u
ld
co
m
p
r
o
m
is
e
th
e
p
r
iv
ac
y
o
f
r
e
s
ea
r
ch
p
ar
ticip
an
ts
,
ar
e
n
o
t p
u
b
licly
av
aila
b
le
d
u
e
to
ce
r
tain
r
estrictio
n
s
.
RE
F
E
R
E
NC
E
S
[
1
]
C
.
J.
M
u
r
r
a
y
e
t
a
l
.
,
“
G
l
o
b
a
l
b
u
r
d
e
n
o
f
b
a
c
t
e
r
i
a
l
a
n
t
i
m
i
c
r
o
b
i
a
l
r
e
si
s
t
a
n
c
e
i
n
2
0
1
9
:
a
s
y
s
t
e
m
a
t
i
c
a
n
a
l
y
si
s,
”
T
h
e
L
a
n
c
e
t
,
v
o
l
.
3
9
9
,
n
o
.
1
0
3
2
5
,
p
p
.
6
2
9
–
6
5
5
,
2
0
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2
,
d
o
i
:
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0
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1
0
1
6
/
S
0
1
4
0
-
6
7
3
6
(
2
1
)
0
2
7
2
4
-
0.
[
2
]
M
.
N
a
g
h
a
v
i
e
t
a
l
.
,
“
G
l
o
b
a
l
b
u
r
d
e
n
o
f
b
a
c
t
e
r
i
a
l
a
n
t
i
mi
c
r
o
b
i
a
l
r
e
si
s
t
a
n
c
e
1
9
9
0
–
2
0
2
1
:
a
s
y
s
t
e
m
a
t
i
c
a
n
a
l
y
si
s
w
i
t
h
f
o
r
e
c
a
s
t
s
t
o
2
0
5
0
,
”
T
h
e
L
a
n
c
e
t
,
v
o
l
.
4
0
4
,
n
o
.
1
0
4
5
9
,
p
p
.
1
1
9
9
–
1
2
2
6
,
2
0
2
4
,
d
o
i
:
1
0
.
1
0
1
6
/
S
0
1
4
0
-
6
7
3
6
(
2
4
)
0
1
8
6
7
-
1.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
8
66
-
1
8
75
1874
[
3
]
J.
A
c
h
a
r
y
a
e
t
a
l
.
,
“
E
x
t
e
n
d
e
d
s
p
e
c
t
r
u
m
b
e
t
a
-
l
a
c
t
a
m
a
s
e
p
r
o
d
u
c
i
n
g
Esc
h
e
r
i
c
h
i
a
c
o
l
i
a
n
d
a
n
t
i
m
i
c
r
o
b
i
a
l
r
e
si
s
t
a
n
c
e
g
e
n
e
s
h
a
r
i
n
g
a
t
t
h
e
i
n
t
e
r
f
a
c
e
o
f
h
u
ma
n
,
p
o
u
l
t
r
y
a
n
d
e
n
v
i
r
o
n
m
e
n
t
:
r
e
s
u
l
t
s
o
f
e
s
b
l
t
r
i
c
y
c
l
e
s
u
r
v
e
i
l
l
a
n
c
e
i
n
K
a
t
h
m
a
n
d
u
,
N
e
p
a
l
,”
O
n
e
H
e
a
l
t
h
O
u
t
l
o
o
k
,
v
o
l
.
7
,
n
o
.
1
,
2
0
2
5
,
d
o
i
:
1
0
.
1
1
8
6
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s
4
2
5
2
2
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0
2
5
-
0
0
1
4
5
-
9.
[
4
]
R
.
W
.
Y
.
N
g
,
L.
Y
a
n
g
,
S
.
H
.
La
u
,
P
.
H
a
w
k
e
y
,
a
n
d
M
.
I
p
,
“
G
l
o
b
a
l
p
r
e
v
a
l
e
n
c
e
o
f
h
u
ma
n
i
n
t
e
s
t
i
n
a
l
c
a
r
r
i
a
g
e
o
f
e
sb
l
-
p
r
o
d
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c
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n
g
E
.
c
o
l
i
d
u
r
i
n
g
a
n
d
a
f
t
e
r
t
h
e
C
O
V
I
D
-
19
p
a
n
d
e
m
i
c
,
”
J
AC
-
A
n
t
i
m
i
c
r
o
b
i
a
l
Re
s
i
st
a
n
c
e
,
v
o
l
.
7
,
n
o
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[
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[
31
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