IARIS (Interdisciplinary AMR Response Initiative Sri Lanka)

In this project a real time dashboard with antimicrobial consumption and susceptibility data will be created to get comprehensive information on the AMR threat. A comprehensive Guideline for the WWTP operations will be formulated based on the Antimicrobial concentrations and Prevalence of AMR genes will be checked in environmental samples.

The primary Investigator is Dr. P.W.Vidanage from The Department of Chemical and Process Engineering, University of Moratuwa, (Sri Lanka) experienced in Environmental Engineering and Biotechnology research. 

Anti-microbial resistance (AMR) poses significant threats to public health and various sectors in Sri Lanka. The country has reported 2300 deaths attributed to AMR, with an additional 8800 deaths associated with this phenomenon, highlighting the urgent need for a real-time surveillance system. Sri Lanka ranks as the 58th highest in age-standardized mortality rates related to AMR globally, emphasizing the severity of the issue. Failure to intervene promptly and effectively may exacerbate the mortality. Among numerous underlined causes following key challenges have been identified to be addressed in this project.

1. The underutilization of data from antimicrobial consumption surveillance has resulted in poor awareness and inadequate antibiotic stewardship practices. Regulatory measures governing antibiotic usage in human and animal health are insufficient.
2. The release of antibiotics into water sources through inadequately managed wastewater treatment systems (WWTPs) poses a significant threat, fostering the development of antibiotic-resistant bacteria and contaminating natural water sources and drinking water treatment systems. This scenario undermines efforts to maintain community health.
3. Environmental engineers and policymakers who set the discharge limits do not give their attention to the broad level impact caused by antimicrobial agents released by WWTPs, the “Last line of defense” against AMR. 

   

An interactive web-based AMR dashboard linked to the Database will encourage the general public to refrain from self-prescribing medications, pressuring physicians for unnecessary prescriptions, purchasing antibiotics over the counter, and using antibiotics in suboptimal doses or discontinuing treatment prematurely. Additionally, it will aim to dispel misconceptions regarding the efficacy of antibiotics, thereby reducing the tendency to judge clinicians based on the strength of the antimicrobial agents prescribed.

Clinicians and Veterinarians will benefit from updated information on antimicrobial susceptibility patterns, regional hotspots, and emerging trends in antimicrobial resistance. Armed with this knowledge, clinicians can exercise greater caution in prescribing antibiotics. Furthermore, efforts will be made to limit the irrational use of antibiotics in livestock farming practices.

Environmental engineering professionals will be integrated into a collaborative platform with medical professionals and researchers focused on AMR. This interdisciplinary approach will facilitate a more comprehensive understanding of AMR and its implications for wastewater treatment systems.

To ensure the database meets the diverse needs of stakeholders, qualitative interviews will be conducted to gather multiple perspectives. These insights will be triangulated to inform the planning and design of the database, ensuring it is user-friendly, easily accessible, and effectively addresses the varied interests and concerns of stakeholders.

Our effort will result in a robust database containing island wide data on antimicrobial consumption, susceptibility patterns pertaining to time, location, person and the disease.   This will provide a snapshot of the AMR challenge in the country which will be updated to identify the AMR hotspots, trends and emerging and reemerging species which will be further beneficial for stewardship initiatives. 

The analysis of environmental samples to identify the antimicrobial profile in wastewater i.e. the concentration of antimicrobial agents and the prevalence of AMR genes within microbial communities across various systems will be an eye opener to all stakeholders to identify the current and future risk of emerging AMR patterns.

Defining the discharge limits and standard to be implemented at WWTPs will provide recommendations for optimizing existing systems, implementing upgrades, and ensuring compliance with stringent removal efficiency standards safeguarding environmental integrity and public health. 

Additionally, the data pool will give rise to numerous innovations and novel research topics in the field, filling a long-lasting gap in the local evidence.  The knowledge generated and disseminated will be of use to the public from multiple channels of health system, economy, food and animal husbandry and environmental safety.

The database developed will provide the knowledge on AMR country profile which will encourage both AMR stewardship and infection control and hygiene practices.

Improved knowledge on rational use of antimicrobials was effective in developing the stewardship behaviors among the general public. Exploring the cascade of AM use and release to the environment in each step will be an eye opener to all levels from the general public to policy level. It will highlight the importance of avoiding misuse, monitoring the discharge to the environment and being vigilant on environmental transfer and evolution of antimicrobial resistance. The link generated between antibiotic consumption, discharge to the environment, availability in water sources used for human consumption and the emerging resistance patterns will depict the severity of the challenge and also will reveal the lines of defense. 

The wastewater facilitates gene transfer and antimicrobial resistance, and wastewater treatment has been proven to reduce the rapid spread of AMR.

Monitoring the WWTPs and regulating the discharge of antimicrobials to the environment will be beneficial to the marginal populations who use natural open water sources for drinking, who are vulnerable to develop infections and underprivileged to use state of the art healthcare. 

Over the first year of the project, the acquisition, familiarization and utilization of existing modes of data collection will be done. The system will be integrated with the national antimicrobial consumption and susceptibility database. The project will conduct multiple stakeholder meetings and partner education workshops to streamline the data entry to the system from both public and private health care delivery units. The efficiency and timeliness of the data will be improved with a continuous monitoring system. The project will be continued to the second year to build and fine tune the web-based dashboard and dissemination of summarized data among the public. 

Simultaneously, the experiments on environmental antimicrobial existence, the concentration of antimicrobial agents and the prevalence of AMR genes within microbial communities across various systems   will be conducted from the beginning of the second year. The cascade of AMR will be deeply studied which will lead to identifying the discharge limits of antimicrobials in the WWTPS in the third year of the project by a series of scientific experiments. 

The knowledge sharing and dissemination of findings will be done throughout the project at each milestone including public awareness, peer reviewed publications and scientific forums.

The project will be monitored as process, output and outcome indicators and finally the evaluation will be done to measure the impact.

Process 

• Project Proposal Development- submitted to the deadline on 07th March 2024
• Number of stakeholder meetings conducted per quarter.
• Number  of review meetings conducted per year.
• Percentage increase of the data entering health care delivery institutions per quarter
• Development of the web-based dashboard 
• Development of the website
• Number  of site visits conducted per quarter.
• Number of samples collected and processed per month.

Output

• Development of the web-based dashboard 
• Development of the website

Outcome

• Number of personnels accessing the database per month 
• Qualitative assessment of the perception of stakeholders on the project and how it improved the quality of care in medical and veterinary fields.
• A guideline with discharge limits of antimicrobials in WWTPs is developed at the end of three years.

Impact

• The percentage reduction of antimicrobials (AM) consumption in the country compared to initial data and the incidence of infections (In DDDs)
• Improved awareness among the general public and the medical, veterinary and  environmental engineering professionals on AMR.
• Monitoring mechanisms of AM at WWTPs and using discharge limits as a guideline is available.

Infrastructure and accessibility barriers.

In Sri Lanka, out of the total of nearly 1500 health care institutions in both free public and private sectors consisting of 588 hospitals and 517 primary care institutions. The data collection on antibiotic consumption and AMR will obviously be a huge challenge. We will collaborate with the health information section of the management development and planning unit of the Ministry of Health Sri Lanka to identify the available data sources and train the field staff in data entering and data management. The available sources will be piled up as the initial step and others will be linked in the future. 

Barriers in integration and cooperation

The four fields involved never have been performed in one platform and a huge resistance will be generated in getting all to work towards one goal. Multiple stakeholder meetings, advocacy meetings and facilitating the knowledge sharing and networking events will be done to increase the intersectoral collaboration and coordination.

Technical barriers

There will be obvious technical barriers in all steps from database management to environmental sample collection processing and analysis. A through training on the subject will be given to field staff and research assistants.