Abstract
Antimicrobial resistance (AMR) is a growing public health challenge that is expected to disproportionately burden lower- and middle-income countries (LMICs) in the coming decades. Although the contributions of human and veterinary antibiotic misuse to this crisis are well-recognized, environmental transmission (via water, soil or food contaminated with human and animal faeces) has been given less attention as a global driver of AMR, especially in urban informal settlements in LMICs—commonly known as ‘shanty towns’ or ‘slums’. These settlements may be unique hotspots for environmental AMR transmission given: (1) the high density of humans, livestock and vermin living in close proximity; (2) frequent antibiotic misuse; and (3) insufficient drinking water, drainage and sanitation infrastructure. Here, we highlight the need for strategies to disrupt environmental AMR transmission in urban informal settlements. We propose that water and waste infrastructure improvements tailored to these settings should be evaluated for their effectiveness in limiting environmental AMR dissemination, lowering the community-level burden of antimicrobial-resistant infections and preventing antibiotic misuse. We also suggest that additional research is directed towards developing economic and legal incentives for evaluating and implementing water and waste infrastructure in these settings. Given that almost 90% of urban population growth will occur in regions predicted to be most burdened by the AMR crisis, there is an urgent need to build effective, evidence-based policies that could influence massive investments in the built urban environment in LMICs over the next few decades.
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Data availability
The Demographic Health Survey (DHS) datasets that support the findings of Table 1 are available from the DHS Program (https://dhsprogram.com/data/available-datasets.cfm).
Code availability
The code used to generate the country-level antibiotic consumption estimates presented in Table 1 is publicly available on Github via Zenodo (https://doi.org/10.5281/zenodo.3802123).
References
Population Living in Slums (% of Urban Population) (World Bank, 2014); https://data.worldbank.org/indicator/en.pop.slum.ur.zs
World Cities Report 2016: Urbanization and Development – Emerging Futures. (UN-Habitat, 2016).
Riley, L. W., Ko, A. I., Unger, A. & Reis, M. G. Slum health: diseases of neglected populations. BMC Int. Health Hum. Rights 7, 2 (2007).
Kit, O., Lüdeke, M. & Reckien, D. Defining the bull’s eye: satellite imagery-assisted slum population assessment in Hyderabad, India. Urban Geogr. 34, 413–424 (2013).
Dyson, P. Slum tourism: Representing and interpreting ‘reality’ in Dharavi, Mumbai. Tour. Geogr. 14, 254–274 (2012).
Veljanovski, T., Kanjir, U., Pehani, P., Otir, K. & Kovai, P. in Remote Sensing – Applications (ed. Escalante, B.) Ch. 18, 407–434 (InTech, 2012).
Angeles, G. et al. The 2005 census and mapping of slums in Bangladesh: design, select results and application. Int. J. Health Geogr. 8, 32 (2009).
2010 Demographic Profile Data: New York County (Manhattan Borough), New York (United States Census Bureau, 2010); https://www.census.gov/quickfacts/newyorkcountymanhattanboroughnewyork
State of World Population 2007: Unleashing the Potential of Urban Growth (United Nations Population Fund, 2007).
Prasad, A., Gray, C. B., Ross, A. & Kano, M. Metrics in urban health: current developments and future prospects. Annu. Rev. Public Health 37, 113–133 (2016).
O’Neill, J. (ed.) Tackling Drug-Resistant Infections Globally: Final Report and Recommendations (United Kingdom Review on Antimicrobial Resistance, 2016).
Woerther, P.-L., Andremont, A. & Kantele, A. Travel-acquired ESBL-producing Enterobacteriaceae: impact of colonization at individual and community level. J. Travel Med. 24, S29–S34 (2017).
Wilson, M. E. & Chen, L. H. NDM-1 and the role of travel in its dissemination. Curr. Infect. Dis. Rep. 14, 213–226 (2012).
Ruppé, E., Andremont, A. & Armand-Lefèvre, L. Digestive tract colonization by multidrug-resistant Enterobacteriaceae in travellers: an update. Travel Med. Infect. Dis. 21, 28–35 (2018).
Das, J. & Hammer, J. Location, location, location: residence, wealth, and the quality of medical care in Delhi, India. Health Aff. 26, w338–w351 (2007).
Institute of Medicine (US) Committee on Health Literacy in Health Literacy: A Prescription to End Confusion (eds. Nielsen-Bohlman, L., Panzer, A. et al.) Ch. 2 (National Academies Press, 2004).
Kehinde, O. O. & Ogunnowo, B. E. The pattern of antibiotic use in an urban slum in Lagos State, Nigeria. West Afr. J. Pharm. 24, 49–57 (2013).
Kenya Demographic and Health Survey 2015 (Dataset). KEKR72FL.DTA (General Directorate of Statistics (Kenya), Ministry of Finance (Kenya) and ICF, 2015); https://dhsprogram.com/Data/
Lipsitch, M. & Samore, M. H. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg. Infect. Dis. 8, 347–354 (2002).
Morgan, D. J., Okeke, I. N., Laxminarayan, R., Perencevich, E. N. & Weisenberg, S. Non-prescription antimicrobial use worldwide: a systematic review. Lancet Infect. Dis. 11, 692–701 (2011).
Shehadeh, M. et al. Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study. Saudi Pharm. J. 20, 125–133 (2012).
Nepal, A., Hendrie, D., Robinson, S. & Selvey, L. A. Knowledge, attitudes and practices relating to antibiotic use among community members of the Rupandehi District in Nepal. BMC Public Health 19, 1558 (2019).
Miller, R. & Goodman, C. Performance of retail pharmacies in low- and middle-income Asian settings: a systematic review. Health Policy Plan. 31, 940–953 (2016).
Nair, M. et al. “Without antibiotics, I cannot treat”: a qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India. PLoS ONE 14, e0219002 (2019).
Ozawa, S. et al. Prevalence and estimated economic burden of substandard and falsified medicines in low- and middle-income countries: a systematic review and meta-analysis. JAMA Netw. Open 1, e181662 (2018).
Lawley, T. D. & Walker, A. W. Intestinal colonization resistance. Immunology 138, 1–11 (2013).
Chandel, D. S. et al. Extended-spectrum beta-lactamase-producing Gram-negative bacteria causing neonatal sepsis in India in rural and urban settings. J. Med. Microbiol. 60, 500–507 (2011).
Breiman, R. F. et al. Population-based incidence of typhoid fever in an urban informal settlement and a rural area in Kenya: implications for typhoid vaccine use in Africa. PLoS ONE 7, e29119 (2012).
Souza, T. B. et al. High prevalence of antimicrobial drug-resistant diarrheagenic Escherichia coli in asymptomatic children living in an urban slum. J. Infect. 59, 247–251 (2009).
Ferraro, C. F. et al. Household crowding, social mixing patterns and respiratory symptoms in seven countries of the African meningitis belt. PLoS ONE 9, e101129 (2014).
Akinwale, O. P. et al. Living conditions and public health status in three urban slums of Lagos, Nigeria. South East Asia J. Public Health 3, 36–41 (2014).
Bird, J., Montebruno, P. & Regan, T. Life in a slum: understanding living conditions in Nairobi’s slums across time and space. Oxf. Rev. Econ. Policy 33, 496–520 (2017).
Mitlin, D., Beard, V. A., Satterthwaite, D. & Du, J. (eds) Unaffordable and Undrinkable: Rethinking Urban Water Access in the Global South (World Resources Institute, 2019).
Katukiza, A. Y. et al. Sustainable sanitation technology options for urban slums. Biotechnol. Adv. 30, 964–978 (2012).
Kumpel, E. & Nelson, K. L. Intermittent water supply: prevalence, practice, and microbial water quality. Environ. Sci. Technol. 50, 542–553 (2016).
Kumpel, E. & Nelson, K. L. Comparing microbial water quality in an intermittent and continuous piped water supply. Water Res. 47, 5176–5188 (2013).
Howard, G. & Bartram, J. (eds) Domestic Water Quantity, Service Level and Health (World Health Organization, 2003).
Unger, A. & Riley, L. W. Slum health: from understanding to action. PLoS Med. 4, 1561–1566 (2007).
Ross, A. G. P., Zaman, K. & Clemens, J. D. Health concerns in urban slums: a glimpse of things to come? JAMA 321, 1973–1974 (2019).
Longini, I. M. Jr. et al. Epidemic and endemic cholera trends over a 33-year period in Bangladesh. J. Infect. Dis. 186, 246–251 (2002).
Graham, J. P., Eisenberg, J. N. S., Trueba, G., Zhang, L. & Johnson, T. J. Small-scale food animal production and antimicrobial resistance: mountain, molehill, or something in-between? Environ. Health Persp. 125, (2017).
Muloi, D. et al. A cross-sectional survey of practices and knowledge among antibiotic retailers in Nairobi, Kenya. J. Glob. Health 9, 010412 (2019).
Wall, B. A. et al. (eds) Drivers, Dynamics, and Epidemiology of Antimicrobial Resistance in Animal Production (Food and Agriculture Organization of the United Nations, 2016).
Nisha, A. Antibiotic residues – a global health hazard. Vet. World 2, 375–377 (2008).
Van Boeckel, T. P. et al. Global trends in antimicrobial resistance in animals in low- and middle-income countries. Science 365, eaaw1944 (2019).
Okeke, I. N. et al. Antimicrobial resistance in developing countries. Part I: recent trends and current status. Lancet Infect. Dis. 5, 481–493 (2005).
Kimani-Murage, E. W. & Ngindu, A. M. Quality of water the slum dwellers use: the case of a Kenyan slum. J. Urban Health 84, 829–838 (2007).
O’Neill, J. (ed.) Antimicrobials in Agriculture and the Environment: Reducing Unnecessary Use and Waste. (United Kingdom Review on Antimicrobial Resistance, 2015).
Pruden, A. et al. Management options for reducing the release of antibiotics and antibiotic resistance genes to the environment. Environ. Health Perspect. 121, 878–885 (2013).
Larsson, D. G. J. Pollution from drug manufacturing: review and perspectives. Philos. Trans. R. Soc. Lond. B 369, 20130571 (2014).
Bengtsson-Palme, J., Kristiansson, E. & Larsson, D. G. J. Environmental factors influencing the development and spread of antibiotic resistance. FEMS Microbiol. Rev. 42, fux053 (2018).
Pehrsson, E. C. et al. Interconnected microbiomes and resistomes in low-income human habitats. Nature 533, 212–216 (2016).
Lundborg, C. S. & Tamhankar, A. J. Antibiotic residues in the environment of South East Asia. BMJ 358, j2440 (2017).
Ishii, S. et al. Factors controlling long-term survival and growth of naturalized Escherichia coli populations in temperate field soils. Microbes Environ. 25, 8–14 (2010).
Naganandhini, S., Kennedy, Z. J., Uyttendaele, M. & Balachandar, D. Persistence of pathogenic and non-pathogenic Escherichia coli strains in various tropical agricultural soils of India. PLoS ONE 10, e0130038 (2015).
Montealegre, M. C. et al. Risk factors for detection, survival, and growth of antibiotic-resistant and pathogenic Escherichia coli in household soils in rural Bangladesh. Appl. Environ. Microbiol. 84, e01978-18 (2018).
Penakalapati, G. et al. Exposure to animal feces and human health: a systematic review and proposed research priorities. Environ. Sci. Technol. 51, 11537–11552 (2017).
Barreiro, C., Albano, H., Silva, J. & Teixeira, P. Role of flies as vectors of foodborne pathogens in rural areas. ISRN Microbiol. 2013, 718780 (2013).
Lindeberg, Y. L. et al. Can Escherichia coli fly? The role of flies as transmitters of E. coli to food in an urban slum in Bangladesh. Trop. Med. Int. Health 23, 2–9 (2018).
Fuhrimann, S. et al. Disease burden due to gastrointestinal pathogens in a wastewater system in Kampala, Uganda. Microb. Risk Anal. 4, 16–28 (2016).
Mberu, B. U., Haregu, T. N., Kyobutungi, C. & Ezeh, A. C. Health and health-related indicators in slum, rural, and urban communities: a comparative analysis. Glob. Health Action 9, 33163 (2016).
Fink, G., Günther, I. & Hill, K. Slum residence and child health in developing countries. Demography 51, 1175–1197 (2014).
Rashid, H., Hunt, L. M. & Haider, W. Urban flood problems in Dhaka, Bangladesh: slum residents’ choices for relocation to flood-free areas. Environ. Manage. 40, 95–104 (2007).
Cissé, A. & Mendy, P. Spatial relationship between floods and poverty: the case of region of Dakar. Theor. Econ. Lett. 8, 256–281 (2018).
Bangalore, M., Smith, A. & Veldkamp, T. Exposure to floods, climate change, and poverty in Vietnam. EconDisCliCha. 3, 79–99 (2019).
Douglas, I. et al. Unjust waters: climate change, flooding and the urban poor in Africa. Environ. Urban. 20, 187–205 (2008).
Yu, P. et al. Elevated levels of pathogenic indicator bacteria and antibiotic resistance genes after Hurricane Harvey’s flooding in Houston. Environ. Sci. Technol. Lett. 5, 481–486 (2018).
Kapoor, V., Gupta, I., Pasha, A. B. M. T. & Phan, D. Real-time quantitative PCR measurements of fecal indicator bacteria and human-associated source tracking markers in a Texas river following Hurricane Harvey. Environ. Sci. Technol. Lett. 5, 322–328 (2018).
Presley, S. M. et al. Assessment of pathogens and toxicants in New Orleans, LA following Hurricane Katrina. Environ. Sci. Technol. 40, 468–474 (2006).
Berendes, D. M. et al. Associations between open drain flooding and pediatric enteric infections in the MAL-ED cohort in a low-income, urban neighborhood in Vellore, India. BMC Public Health 19, 926 (2019).
Fowler, A. M. & Hennessy, K. J. Potential impacts of global warming on the frequency and magnitude of heavy precipitation. Nat. Hazards 11, 283–303 (1995).
Saleem, A. F., Qamar, F. N., Shahzad, H., Qadir, M. & Zaidi, A. K. M. Trends in antibiotic susceptibility and incidence of late-onset Klebsiella pneumoniae neonatal sepsis over a six-year period in a neonatal intensive care unit in Karachi, Pakistan. Int. J. Infect. Dis. 17, e961–e965 (2013).
Musicha, P. et al. Trends in antimicrobial resistance in bloodstream infection isolates at a large urban hospital in Malawi (1998–2016): a surveillance study. Lancet Infect. Dis. 17, 1042–1052 (2017).
Roy, M. P. et al. Changing trend in bacterial etiology and antibiotic resistance in sepsis of intramural neonates at a tertiary care hospital. J. Postgrad. Med. 63, 162–168 (2017).
Luby, S. P. Urban slums: a supportive ecosystem for typhoidal Salmonellae. J. Infect. Dis. 218, S250–S254 (2018).
Eliopoulos, G. M., Cosgrove, S. E. & Carmeli, Y. The impact of antimicrobial resistance on health and economic outcomes. Clin. Infect. Dis 36, 1433–1437 (2003).
Alsan, M. et al. Poverty and community-acquired antimicrobial resistance with extended-spectrum β-lactamase-producing organisms, Hyderabad, India. Emerg. Infect. Dis. 24, 1490–1496 (2018).
Gelband, H. & Delahoy, M. (eds) Policies to Address Antibiotic Resistance in Low- and Middle-Income Countries (Center for Disease Dynamics, Economics & Policy, 2014).
Transforming our World: the 2030 Agenda for Sustainable Development. (United Nations General Assembly, 2015).
Subbaraman, R. et al. The social ecology of water in a Mumbai slum: failures in water quality, quantity, and reliability. BMC Public Health 13, 173 (2013).
Desai, R., McFarlane, C. & Graham, S. The politics of open defecation: informality, body, and infrastructure in Mumbai. Antipode 47, 98–120 (2015).
Araya, P., Hug, J., Joy, G., Oschmann, F. & Rubinstein, S. (eds) The Impact of Water and Sanitation on Diarrhoeal Disease Burden and Over-Consumption of Antibiotics (United Kingdom Review on Antimicrobial Resistance, 2016).
Levels & Trends in Child Mortality Report 2018 (United Nations Inter-agency Group for Child Mortality Estimation, 2018).
Pickering, A. J. et al. Effect of in-line drinking water chlorination at the point of collection on child diarrhoea in urban Bangladesh: a double-blind, cluster-randomised controlled trial. Lancet Glob. Health 7, e1247–e1256 (2019).
Manohar, P. et al. The distribution of carbapenem-and colistin-resistance in Gram-negative bacteria from the Tamil Nadu region in India. J. Med. Microbiol. 66, 874–883 (2017).
2017 UN World Water Development Report, Wastewater: The Untapped Resource (United Nations World Water Assessment Programme, 2017).
Fuhrmeister, E. R., Schwab, K. J. & Julian, T. R. Estimates of nitrogen, phosphorus, biochemical oxygen demand, and fecal coliforms entering the environment due to inadequate sanitation treatment technologies in 108 low and middle income countries. Environ. Sci. Technol. 49, 11604–11611 (2015).
Karkman, A., Pärnänen, K. & Larsson, D. G. J. Fecal pollution can explain antibiotic resistance gene abundances in anthropogenically impacted environments. Nat. Commun. 10, 80 (2019).
Newton, R. J. et al. Sewage reflects the microbiomes of human populations. mBio 6, e02574-14 (2015).
Hendriksen, R. S. et al. Global monitoring of antimicrobial resistance based on metagenomics analyses of urban sewage. Nat. Commun. 10, 1124 (2019).
De Boeck, H. et al. ESBL-positive Enterobacteria isolates in drinking water. Emerg. Infect. Dis. 18, 1019–20 (2012).
Muhonja, C., Christabel, M., Budambula, N., Kiiru, J. & Kariuki, S. Characterization of antibiotic resistance in environmental enteric pathogens from Kibera slum in Nairobi-Kenya. J. Bacteriol. Res. 4, 46–54 (2012).
Talukdar, P. K. et al. Antimicrobial resistance, virulence factors and genetic diversity of Escherichia coli isolates from household water supply in Dhaka, Bangladesh. PLoS ONE 8, e61090 (2013).
Ercumen, A. et al. Upgrading a piped water supply from intermittent to continuous delivery and association with waterborne illness: a matched cohort study in urban India. PLoS Med. 12, e1001892 (2015).
Adane, M., Mengistie, B., Medhin, G., Kloos, H. & Mulat, W. Piped water supply interruptions and acute diarrhea among under-five children in Addis Ababa slums, Ehtiopia: a matched case-control study. PLoS ONE 12, e0181516 (2017).
Pulling Together to Beat Superbugs: Knowledge and Implementation Gaps in Addressing Antimicrobial Resistance (World Bank Group, 2019).
Citywide Inclusive Sanitation: A Call to Action (World Bank Group et al., 2016).
Sanganyado, E. & Gwenzi, W. Antibiotic resistance in drinking water systems: occurrence, removal, and human health risks. Sci. Total Environ. 669, 785–797 (2019).
Manaia, C. M. et al. Antibiotic resistance in wastewater treatment plants: tackling the black box. Environ. Int. 115, 312–324 (2018).
Ashbolt, N., Pruden, A., Miller, J., Riquelme, M. V. & Maile-Moskowitz, A. in Global Water Pathogen Project (eds. Pruden, A., Ashbolt, N. & Miller, J.) Part 3 (Michigan State University, 2019).
Bürgmann, H. et al. Water and sanitation: an essential battlefront in the war on antimicrobial resistance. FEMS Microbiol. Ecol. 94, fiy101 (2018).
Clasen, T. & Edmondson, P. Sodium dichloroisocyanurate (NaDCC) tablets as an alternative to sodium hypochlorite for the routine treatment of drinking water at the household level. Int. J. Hyg. Environ. Health 209, 173–181 (2006).
He, H. et al. Degradation and deactivation of bacterial antibiotic resistance genes during exposure to free chlorine, monochloramine, chlorine dioxide, ozone, ultraviolet light, and hydroxyl radical. Environ. Sci. Technol. 53, 2013–2026 (2019).
Pickering, A. J. et al. Differences in field effectiveness and adoption between a novel automated chlorination system and household manual chlorination of drinking water in Dhaka, Bangladesh: a randomized control trial. PLoS ONE 10, e0118397 (2015).
Graham, J. P. & Polizzotto, M. L. Pit latrines and their impacts on groundwater quality: a systematic review. Environ. Health Perspect. 121, 521–530 (2013).
Evaluating the Potential of Container-Based Sanitation (World Bank Water Global Practice, 2019).
Tilmans, S. et al. Container-based sanitation: assessing costs and effectiveness of excreta management in Cap Haitien, Haiti. Environ. Urban. 27, 89–104 (2015).
Auerbach, D. in Broken Pumps and Promises: Incentivizing Impact in Environmental Health (ed. Thomas, E. A.) 211–216 (Springer, 2016).
Hennigs, J. et al. Field testing of a prototype mechanical dry toilet flush. Sci. Total Environ. 668, 419–431 (2019).
Kotloff, K. L. et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet 382, 209–222 (2013).
Barreto, M. L. et al. Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies. Lancet 370, 1622–1628 (2007).
Pickering, A. J. et al. Effects of single and integrated water, sanitation, handwashing, and nutrition interventions on child soil-transmitted helminth and Giardia infections: a cluster-randomized controlled trial in rural Kenya. PLoS Med. 16, e1002841 (2019).
Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team et al. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial: rationale, design, and methods. Clin. Infect. Dis. 61, S685–S702 (2015).
Luby, S. P. et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. Lancet Glob. Health 6, e302–e315 (2018).
Matheu, J., Aidara-Kane, A. & Andremont, A. The ESBL tricycle AMR surveillance project: a simple, one health approach to global surveillance. AMR Control: Overcoming Global Antimicrobial Resistance http://resistancecontrol.info/2017/the-esbl-tricycle-amr-surveillance-project-a-simple-one-health-approach-to-global-surveillance/ (2017).
Huijbers, P. M. C., Flach, C. F. & Larsson, D. G. J. A conceptual framework for the environmental surveillance of antibiotics and antibiotic resistance. Environ. Int. 130, 104880 (2019).
Integrated Surveillance of Antimicrobial Resistance in Foodborne Bacteria: Application of a One Health Approach (World Health Organization, 2017).
Omulo, S. et al. Evidence of superficial knowledge regarding antibiotics and their use: Results of two cross-sectional surveys in an urban informal settlement in Kenya. PLoS ONE 12, e0185827 (2017).
Wang, H. et al. Predictors of urinary antibiotics in children of Shanghai and health risk assessment. Environ. Int. 121, 507–514 (2018).
Larsson, D. G. J. et al. Critical knowledge gaps and research needs related to the environmental dimensions of antibiotic resistance. Environ. Int. 117, 132–138 (2018).
Bangladesh Demographic and Health Survey 2011 (National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International, 2013); http://dhsprogram.com/pubs/pdf/FR265/FR265.pdf
India National Family Health Survey NFHS-4 2015-16, India [Dataset] IAKR74FL.DTA (International Institute for Population Sciences - IIPS/India and ICF, 2017); https://dhsprogram.com/pubs/pdf/FR339/FR339.pdf
Kenya Demographic and Health Survey 2014 [Dataset] KEKR72FL.DTA (Kenya National Bureau of Statistics; Ministry of Health, Kenya; National AIDS Control Council, Kenya; Kenya Medical Research Institute; National Council for Population and Development, Kenya; and the DHS Program, ICF International (2015); http://dhsprogram.com/pubs/pdf/FR308/FR308.pdf
Perú Encuesta Demográfica y de Salud Familiar - ENDES 2012 [Dataset] PEKR6IFL.DTA (Instituto Nacional de Estadística e Informática, 2012); http://dhsprogram.com/pubs/pdf/FR284/FR284.pdf
Rogawski, E. T. et al. Use of antibiotics in children younger than two years in eight countries: a prospective cohort study. Bull. World Health Organ. 95, 49–61 (2017).
Acknowledgements
M.L.N. and M.C.M. were supported by the Thrasher Research Foundation during the writing of this manuscript. Unpublished survey data from Nairobi presented in Table 1 was collected by a project funded by the Bill and Melinda Gates Foundation (no. OPP1200651). Unpublished survey data from Peru was collected by a project funded by the National Institutes of Health (R01 AI108695-01A1). We thank the study respondents for their participation.
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A.J.P., S.J.M., T.R.J. and M.L.N. developed the concept. R.H.G., M.J.P., M.S., S.M.N., J.S. and A.J.P. collected the data. A.J.P., S.J.M., T.R.J. and M.L.N. wrote the first draft. A.J.P., T.R.J., J.S. and M.L.N. designed the figures. M.L.N., S.J.M., M.C.M., R.H.G., M.J.P., M.S., P.T., S.M.N., J.K., J.S., M.A.I., T.R.J. and A.J.P. contributed to the literature search and reviewed the manuscript at all stages.
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Nadimpalli, M.L., Marks, S.J., Montealegre, M.C. et al. Urban informal settlements as hotspots of antimicrobial resistance and the need to curb environmental transmission. Nat Microbiol 5, 787–795 (2020). https://doi.org/10.1038/s41564-020-0722-0
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DOI: https://doi.org/10.1038/s41564-020-0722-0
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