Shit happens – feces in infection prevention and everybody´s life
Kelsey Lecture, Birmingham, 7 April 2014
Walter Popp
How important is the topic?
40 % of world population live without adequate sanitary conditions: 2.6 billion people
Resulting in dead of 1.5 million children under 5 years per year, mainly because of diarrhea
Defecation and urination are typical inquiries in any medical assessment – important symptoms.
Most of multiresistant gramnegative bacteria are living in our guts.
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1 Extremely important: Life is starting and ending with problems re defecation
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Avoparcin
Glycopeptide antibiotic, effective against Gram-positive bacteria. Used as an additive to livestock feed to promote growth in chickens, pigs, and cattle since around 1970 in Europe.
Similarity with vancomycin selection of VRE transmission to humans´ gut by food.
Forbidden in EU in 1997.
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3 Avoparcin in Taiwan
Forbidden in 2000.
VRE decreased from 2000 to 2003: E. faecalis: 13,7 % 3.7 % E. faecium: 3.4 % 0 % VRE found in chicken farms: 25 % 8.8 %
Lauderdale, Environ Microbiol 2007, 9, 819
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Multiresistente Erreger
Geffers, Christine; Gastmeier, Petra
Nosokomiale Folie 8 InfektionenTitel und multiresistente Erreger in Deutschland: Epidemiologische Daten aus dem Krankenhaus- Infektions8 -Surveillance09.04.2014 | -AutorSystem Präsentationstitel Dtsch Arztebl Int 2011; 108(6): 87-93; DOI: 10.3238/arztebl.2011.0087
4 FDA approval of new antimicrobial substances
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6 EHEC
Enterohaemorrhagic Escherichia coli
Gramnegative
Production of Shigatoxine – STX (= shiga-like Toxin – SLT = Verotoxin – VT)
Few bacteria needed for infection: < 10² bacteria
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EHEC
2005 in Germany: 1,162 infections, 78 cases of HUS
Incubation time 2-10 days
Symptoms: - Diarrhea - 10 – 20 % haemorrhagic colitis - Complication: HUS (around 7 days after start of diarrhea)
HUS: - Hemolytic anemia - Thrombopenia - Acute renal failure
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HUS cases in Germany
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8 EHEC at University Clinics Essen
Adults Children EHEC 10 4 HUS 8 4 Plasmapherese 6 1 Dialysis 6 1 Eculizumab 3 1
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Number of patients with diarrhea coming daily to our hospital (18/5-29/6/2011)
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9 Measures
Isolation ward (by chance available, renovation just finished)
Gowns, gloves Hand disinfection No cap or mask
Until 3 stool examinations were negative, 1-2 weeks between each
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VRE outbreak at University Clinics Essen
05/2011 until 07/2011
25 patients with VRE VAN B, 21 of them with clonal identity
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12 VRE in patients swab
blood culture
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Week 2011
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Measures
. Outbreak management team . Isolation of patients . Personal protective clothing of staff, also for all contact persons . Isolation of all contact patients . Isolation of all patients who were longer than 2 days on that ward . Screening of all new patients . Isolation of all new patients on that ward until results of screening . Training of all staff, especially in hand hygiene . Additional dispensers for hand disinfectant . Daily observations by hygiene nurses . Final disinfection in 3 steps: cleaning with disinfectant in high concentration, fumigation of hydrogen peroxide, cleaning with disinfectant in usual concentration . Many environmental swabs: 4 out of 100 positive for VRE . Contact plates from staff hands: 1 positive for enterococci . Closing of ward for 3 days in July for basic cleaning and throwing away all single use items
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13 After week 30 no new cases.
But: once found at a bascet for suction catheters.
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Outbreak University Clinics Leipzig
Klebsiella pneumoniae carbapenemase
First case from Greece in 2010. 103 patients, over 40 dying. Ending 2013.
Carpapenemase producing bacteria
University Clinics Leipzig
Since October 2012 (screening)
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Definition: Nonsusceptible to one of the following carbapenems: doripenem, meropenem, or imipenem AND Resistant to all of the following third-generation cephalosporins that were tested: ceftriaxone, cefotaxime, and ceftazidine.
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15 Core measures for acute and long-term care facilities
. Hand hygiene . Contact precautions . Patient and staff cohorting . Minimize use of invasive devices . Promote antimicrobial stewardship . Screening
In case of transmission, additionally: . Conduct active surveillance testing . Chlorhexidine bathing
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16 MRGN
4 MRGN: always isolation
3 MRGN: isolation on „risk“ wards (ICU, hematology- oncology), not on „normal“ wards
But: what about common use of toilets? nasal-pharyngeal carriers? Contact patients with immune deficiancy?
ESBL not longer looked for
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ESBL in nursing homes in Frankfurt
880 residents, 8 nursing homes, Frankfurt/Main
9 % MRSA
27 % ESBL enterobacteriaceae
3 % VRE
Heudorf, Bundesgesundheitsbl 2014, 57, 414
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17 1014 = 100,000,000,000,000
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Enterococci in food production
Ripening of cheese, probably through proteolysis, lipolysis and citrate breakdown. Contributing to typical taste and flavour. Also in other fermented foods, like sausages and olives. Used as probiotics.
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18 Mongolia 36 Mio livestock Folie 37 Titel 37 09.04.2014 | Autor Präsentationstitel 3 mio people
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Feces used as fertilizer
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20 Guano
Ecrement of seabirds or birds, generally.
Highly effective fertilizer with high content of nitrogen, phosphate and potassium, but few nitrates.
Boom in 19th century with imports from Peru, Caribbean islands, Namibia, Oman, Patagonia.
Boom ending after 1909 when Fritz Haber developed Haber-Bosch process of industrial nitrogen fixation.
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Uguisu no fun („Geisha facial“)
Uguisu no fun = nightingale feces Produced by a particular nightingale called the Japanese bush warbler.
Used in facials since ancient Japanese times – around 800-1,100.
The facial is said to whiten the skin and balance skin tone.
High concentration of urea and guanine.
Victoria Beckham is proven used, David has been said to be…
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21 Kopi Luwak (civet coffee)
Beans of coffee berries once they have been eaten and excreted by the Asian palm civet. Indonesia and Philippines.
Prices around 550 € per kilogramme.
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Stool transplantation
Faecal transplantation in patients with fulminant or refractory Clostricium difficile infections.
Review of 22 studies, 239 patients: effective in 87 % (Landy, Aliment Pharmacol Ther 2011, 34, 409)
Review of 27 case series and reports, 317 patients: higly effecitve, disease resolution in 92 % (Gough, CID 2011, 53, 994)
Review of 7 studies, 124 patients: safe and effective procedure, symptoms improved immediately in 83 %, some stayed diarrhoea free for months or years (Guo, Aliment Pharmacol Ther 2012, 35, 865)
Review of 36 reports, 583 patients: overall success rate 80 – 98 % (Dodin, Int J Clin Pract 2013)
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22 Diseases by gut bacteria
… diarrhoea
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Obstipation
In medieval times, obstipation was seen as biggest threat for health: intoxication from inside. In old sight, body fluids can intoxicate the person.
Spitting may clean the body. Also flatulating.
Medicine: Bloodletting, purging, clysterizing. One hour tobacco clyster.
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23 Typhoid Mary
„The most harmless and most dangerous woman of America“ (title of a newspaper in US, 1909)
New York, 1906: Banker family Warren 6 cases of typhus. Until then young Irish cook Mary Mallon.
Medical authorities: Very good cook, But always connection with typhus outbreaks.
Feces full of typhus bacteria. 3 years in quarantine in New York East River Hospital. Demission in 1910 with sanction: eliminate gall bladder or working as a cook is forbidden – she disappeared.
1915 Typhus outbreak in a hospital in Manhattan – again Typhoid Mary. Isolation until death in 1938.
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Mandatory reporting of infectious diseases in Germany 2012 (over 1.000) Disease Numbers Campylobacter enteritis 71,000 EHEC 4,900 other E. coli 8,300 Salmonellosis 25,000 Yersiniosis 3,400 Norovirus 112,000 Rotavirus 39,000 Giardiasis 4,300 Cryptosporidiosis 1,400 Hepatitis C 4,900 Tuberculosis 4,200
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24 Bacterium persistence on dry surfaces Bacterium Duration of persistence Campylobacter jejuni Up to 6 days Clostridium difficile (spores) 5 months Escherichia coli 1,5 hours – 16 months Enterococcus spp. including 5 days – 4 months VRE Klebsiella spp. 2 hours – 30 months Salmonelly typhi 6 hours – 4 weeks
Kramer, BMC Infect Dis 2006, 6, 130
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Ankylostomiasis in mining industry
Hookworm. First described in Italy in 1836, coming from tropic countries. First diseases during building of St. Gotthard tunnel, way to Germany by tunnel. 1885 first diseases in German mining industry.
25.000 sick miners in 1903.
Regulations: 20 % have to be seen by doctor each year. Calcimined commode rooms in the mines. Steam disinfection of commode.
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25 Bristol stool scale
Developed 1997.
Assumption that the form of stool may be a useful surrogate measure of colon transit time – today seen with limited validity
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Test of banknotes
Contact plates – number of cfu
Skin flora and Staphylococcus aureus, no enterobacteriaceae
Purse and register Cash machine Value n cfu cfu n n cfu cfu n sign. in € mean range with mean range with Staph Staph au au All 139 19 0-50 28 79 8 0-100 0 5 31 23 1-30 12 16 15 1-100 0 + 10 38 23 0-150 5 19 7 1-45 0 20 36 16 1-120 5 36 6 0-35 0 ++ 50 29 15 1-49 5 8 8 2-21 0 100 5 13 0-31 1 Folie 52 Titel 52 09.04.2014 | Autor Präsentationstitel
26 Test of banknotes
„Pecunia non olet“ - „Money does not stink“ Emperor Vespasian (ruling 69-79 CE) introducing a urine tax on public toilets. The urine was sold and used for tanning and as a source of ammonia for cleaning clothes. The buyers of the urine had to pay the tax.
The results show: He was right.
Left: „Vespasienne“ in Montreal, Canada
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28 Folie 57 Titel Does57 quality09.04.2014 of | Autor currency Präsentationstitel influence contamination risk with feces bacteria???
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29 Toilet in a district hospital (secondary level) (left) and with a family doctor (primary level) (right), Ulaanbaatar, Mongolia, 2010 Folie 59 Titel 59 09.04.2014 | Autor Präsentationstitel
Benares - Hindu pilgrims taking a bath in the Ganges river
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30 Benares – Bestattung von Toten mit vorherige Verbrennung (oft unvollständig)
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MRGN and toilets
Prof. Engelhard, Bonn:
Outbreak of 4MRGN Pseudomonas aeruginosa in hematology- oncology ward
50 % in rim of toilets
Change to rimfree toilets – end of outbreak
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31 Fifth book of Moses, chapter 23
Thou shalt have a place without the host whither thou shalt resort to and thou shalt have a sharp point at the end of thy weapon: and when thou wilt ease thyself, dig therewith and turn and cover that which is departed from thee.
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Roman public toilets, Ostia Antica
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32 Cloacina
Cloacina, goddess of the Romans in whom they placed their faith and trust for the wellbeing of Rome's sewers. In particular she was the patron goddess over the Cloaca Maxima, the main sewer of the city.
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History
Garderobes on castles in medieval times.
Garderobes in houses of higher classes from 13th century on (1. floor).
Beginning of 19th century: Installation of water closetts in London
1837 first water cloiset in hospital in Zürich (Kantonsspital).
1860 first water closet in Germany – visit of Queen Victoria in Castle Ehrenburg.
1865 some thousand water closets in Berlin
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33 History
Toilets moving near to houses, then staircase, then inside flat.
In parallel municipalization of waste and sewage management.
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Garderobe at Campen castle and Hradschin, Prague
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34 Toilets
1596 first water closett by Sir John Harrington, installed in Richmond Palace (forgotten, because seen as a joke by public)
1775 patent for „water closed“ by Alexander Cummings (water closed means odour-proof)
From 1800 on: pot cupboards, eg. from furniture manufacturer Heppelwhite, spreading all over Europe
1851 first public toilets on World Exhibition
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35 Flying toilets
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Toilets in space
Working by vaccuum. Feces is pressed in flat slices and brought back to earth.
ISS: Converting urine to drinking water – 170 mio €
Photo: Spaceshuttle
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36 Flying toilets
Called aviazinhos in favelas, Rio de Janeiro
Defecation in plastic bags and throw away
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Portable toilets invented end of 1940ies in US
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37 Mobile toilets
Paper mobile toilet with bag – 20-50 €
Left: Bumper Dumper Right: shit box
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Words ….
Toilet: French „toile“ (= cloth – used as visual cover)
Lokus, locus: latin: locus (locus necessitatis)
Privet: private (French)
Klo, Klosette: German (to close)
Restroom (American English)
Cabinet de toilette (French): powder-room
Lavatory: latin: lavare (to wash), lavatorium (common in airlines)
Water closed (WC): not used in English-speaking countries
00: room number in old hotels with toilets at the beginning of the hall
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38 Canalisation and typhus mortality in Berlin 1870-1920
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1892 Cholera epidemia in Hamburg
16,000 people sick, 8,000 died
R. Koch: „Meine Herren, ich vergesse, daß ich in Europa bin.“ „… I forget that I am in Europe.“
Folie 78 Titel 78 09.04.2014 | Autor PräsentationstitelHygiene und Medizin 78 - 4/2010
39 Cholera epidemia in Hamburg 1892
Morbidity and mortality in Altona and Hamburg.
Altona: Water filtration since 1859, Hamburg not.
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40 Luis Bunuel: Le fantome de la liberte Folie 81 Titel 81 09.04.2014 | Autor Präsentationstitel 1974
Piero Manzoni: Project Merda d´artistica 1961, 60 g, 90 tins
2008: 132.000 € Folie 82 Titel 82 09.04.2014 | Autor Präsentationstitel
41 Rocko Schamoni, Germany Scheisse by Schamoni
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Lucas Cranach, 1545: Birth and origin of the pope
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Rolling Stones: Beggars Banquet, 1968
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44 The legendary “Petomane” Joseph Pujol
Born in Marseille, he was able to breathe with the butt like with the mouth. Soon he was called only "Petomane" (le pet French: the fart). His gut bacteria were not involved, the emissions were odorless. He could, for example, blow out the candles. From 1892 on, he entered the stage for 22 years in the Parisian vaudeville "Moulin Rouge".
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Siegmund Freud: Anal stage
Second stage in Freud´s theory of psychosexual development.
Lasting from age of 18 months to three years.
Anus is the primary erogenous zone and pleasure is derived from controlling bladder and bowel movement.
The major conflict issue during this stage is toilet training.
A fixation at this stage might result in a personality that is too rigid or one that is too disordered.
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45 Coprophilia (scatophilia)
Sexual pleasure from feces.
Diagnostic and Statistical Manual of Mental Disorders (DSM): 302.89 – Paraphilia, not otherwise specified „The diagnosis is made if the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning“
Coprophagia – consumption of feces.
Dirty Sanchez – smearing feces under the nose of partner in the form of a moustache.
Hot Karl (slang): defecating on one´s sexual partner or someone who is asleep.
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Defecation of animals: typical postures
Wild hog with special tail posture
Brown bear contorting
Sheep spradd
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46 Defecation of animals: typical postures
Fox stretching
Lion pawing with hind feets
Flying fox reverse hanging
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Toilet paper
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47 How to clean
Toilet paper – not really clean
Moistured/wet toilet paper – may be irritative or allergenic
Left hand method – not really clean
Washlet – Japan – takes time Loudspeaker producing sound of water flushing
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Toilet paper
2nd century BC: documented in China
8th century AC: Chuugi used in Japan, wooden stick to be used for cleaning inside and outside
Greek-Roman times: sponge on a stick to clean anal area, after that put in salted water or vinegar water
Middle ages: clothes used which were washed after that
16th century: first mentioned in western world
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50 IFIC survey on worldwide practice
Survey from July 2012 – April 2013 (SurveyMonkey).
1,440 answers.
93 countries.
Few answers from South America (only Uruguay) and African countries (but South Africa).
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Who is caring if defecation is done in bed . Patient himself 6 % . Relatives or friends or caregivers 24 % . Nurses 76 % . Other hospital staff 41 %
If bedpans are used Multiple use 76 % Nearly 100 % Norway, Denmark, Netherlands, Germany, France, Hong Kong, Uruguay, Thailand, Tunisia, Mongolia,Indonesia Made from plastics 49 % Made from steel 51 % Single use 24 % Nearly 100 % Australia, UK; above 50 % Canada, US, China Macerator in 38 % (especially Australia, UK)
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51 If bedpans are cleaned manually, it is done . in dirty utility room 61 % . in patient´s bathroom 44 % . other rooms 10 %
. Many comments from Belgium, Canada, US that the advice from IPC is to clean and disinfect bedpans after each use, but nurses do it only with water in the bathroom because of workload, sometimes followed by wiping or spraying with disinfectant.
. Different comments from Canada and US that single use bags/liners are used inside the bedpan which are given to waste. (reason for cleaning in bathroom?)
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Typical hand shower used when people clean by hand in countries with no toilet paper (Oman, 2013).
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52 Typical ground toilet and water supply in a small hospital (left) and toilet in a big hospital (right) (Damaskus, Syria, 2010)
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Typical “LOTA” used for cleaning after defecation in case no shower is available (Pakistan, 2013)
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53 For India, it was commented that “ward boys” are caring for cleanliness on wards, but their education is very bad and cleaning and disposing feces is seen as a dirty job.
For Pakistan, it was commented that usually non-muslim staff is responsible for cleaning toilets. This is the reason why cleaning is breaking down during Christmas time.
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Conclusions
Shit happens – that´s true! And even daily.
Tremendous number of gut bacteria – with positive effects – but also negative ones.
Growing problem of multiresistant gut bacteria.
Face the problem or resign?
Antibiotic stewardship – and fight against transmission.
Handling of feces worldwide challenge.
Big influences of religion and culture.
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54 Start with simple philosophies
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55