AMR in urban informal settlements of Fiji: insights for policy action

This project will capture first-of-its-kind evidence of AMR prevalence in urban informal settlements in Suva, Fiji, to (i) fill a key knowledge gap on this potentially significant AMR reservoir and effectiveness of mitigations, (ii) establish a national AMR facility, and (iii) provide evidence-based policy guidance toward Fiji’s National Action Plan.

Professor Karin Leder, Co-Lead Planetary Health Division and Head of Infectious Disease Epidemiology Unit, School of Public Health and Preventive Medicine, Faculty of Medicine, Monash University

Urban informal settlements house >1 billion people globally. These impoverished communities live without formal government services, often in highly degraded and contaminated environments – conditions that create a ‘perfect storm’ for AMR transmission risks. In these settlements, faecal microbes – including the core ESKAPE pathogens (https://doi.org/10.1155/2016/2475067) – are released into the local environment due to poor or absent sanitation services. This daily exposure is compounded by widespread, often unregulated use of pharmaceuticals exacerbated by recurrent infections among community members, creating a cycle of AMR amplification and transmission potential, as well as broader ecological dysbiosis. With their growing population, urban informal settlements could therefore represent a significant global reservoir of AMR, and are a priority concern in the AMR threat to public health.

However, there is a recognised critical knowledge gap in our understanding of the actual prevalence of AMR in these settings and the environmental and community conditions that exacerbate AMR accumulation. Providing this information, combined with estimated use of antibiotics in the community, could provide indisputable evidence of the extent to which these settlements serve as reservoirs of AMR, permitting for the first time an evidence-based approach to mitigating both accumulation and exposure for public health benefit. 

This project serves:

• The participating informal settlement communities by providing knowledge on AMR prevalence and community-specific risk levels, education and risk mitigation strategies. This feedback loop to communities will be managed through our existing RISE fieldworker teams, utilising the close links already established.
• The local public health authorities by linking public health systems to community health/knowledge. This project will provide the first evidence of AMR in informal settlement correlated with community health and estimates of antibiotic use, enabling development of evidence-based, community-centred public health strategies for AMR mitigation.
• The government of Fiji by making significant progress and meaningful action toward the needs identified in the NAP for AMR.
• Fiji by establishing an accredited national AMR research laboratory and trained local teams with the research and analytical skills to address AMR over the long term (https://doi.org/10.1016/j.ijid.2020.08.057).
• The Asia-Pacific region by establishing a regional AMR research hub that addresses a recognised need in the region post pandemic (https://doi.org/10.1080/17565529.2023.2185479) and will draw people to the region for training. Through the association with FNU, the hub will offer a new avenue for undergraduate teaching in the globally important areas of AMR, genomics and bioinformatics. 

The project will provide the first concrete evidence of AMR prevalence in urban informal settlements and the effectiveness of a novel approach to structural (as opposed to only behavioural) mitigation methods. This will provide data on potential AMR-relevant co-benefits from novel solutions addressing chronic exposure to faecally-derived pathogens in contaminated environments with inadequate sanitation management.

While exposure to pathogens associated with faecal contamination is well-known to cause diarrhoeal disease, poor gastrointestinal function and consequent nutritional deficits, AMR exposure and transmission may be another important morbidity outcome. Traditional WaSH approaches have generally neglected to address management of faecal sludge, potentially explaining why more recent evaluations of large WaSH trials in urban settings have shown limited overall health benefits. This problem is most extreme in dense urban locations such as informal settlements, and given increasing urbanisation globally, requires urgent attention. New approaches to combat the linked challenges of poor environmental quality, poor human health and rising levels of AMR are urgently needed. 

 The knowledge gained will enable policy-makers and health authorities develop evidence-based strategies to reduce AMR health risks using rigorous regionally relevant data, resulting in improved public health and a deeper understanding of what communities can do to support mitigation.

In addition to providing novel data, there is also a need to uplift local capacity for AMR investigations and responses, and to trial real-world mitigation strategies as a basis for proposed evidence-based public health mitigation. This AMR project is a unique opportunity to apply a multi-tiered and multi-pronged approach to the AMR problem.

The RISE interventions will create tangible improvement in living conditions for thousands of residents of informal settlements, with an expected significant reduction in their daily exposure to AMR pathogens. This proposed AMR project will evaluate the effectiveness of these interventions as an AMR risk reduction strategy with immediate applicability to informal settlement communities across the Indo-Pacific.

The national AMR and genomic sequencing facility to be established at FNU will also provide immediate and long-term impact for FNU and Fijian health authorities by creating capacity for AMR investigations and research to inform evidence-based policy development. This project will bring community and health authorities together to co-design community-centred approaches to mitigating AMR risk, which will result in more practical strategies and effective policies to address the needs outlined in Fiji’s One Health NAP for AMR.

This project will generate new knowledge that will enable novel pathways for governments and health authorities to mitigate AMR risk in informal communities (1) through the uptake of policy recommendations locally, nationally and regionally across the Indo-Pacific, (2) through the expanded implementation of RISE-style settlement upgrades, and (3) by establishing local capacity for AMR research, recognising the significant need in the Pacific for trained personal on molecular and genomic technologies.

Year 1: Recruitment, training and analysis. We will determine the AMR risk posed by informal settlements (before intervention) using our biobank of existing samples, and start conversations with local health authorities of the implications and drivers of that risk.

Year 2: Analysis and model development, including comparative analysis of intervention and control settlements. Year 3: (1) Complete evaluation of intervention effectiveness for AMR risk mitigation, (2) establish self-sustaining accredited AMR research laboratories and a cohort of trained experts and practitioners, (3) co-design with community and health authorities practical mitigation approaches, and support government to take the next steps in implementing mitigation strategies through policy change and inclusion of settlement upgrades in government budgets and planning.

• Output 1: Reporting on AMR risks in informal settlements through academic publications and government communications, recommendations and workshops.
• Output 2: Reporting on the effectiveness of settlement upgrades in mitigating AMR risk through academic publications and whitepapers for government.
• Output 3: Providing a comprehensive suite of evidence-based knowledge products in collaboration with local partners and authorities.
• Output 4: Workshops and engagement with health authorities and communities to educate on AMR risks and develop community-centred mitigation strategies.
• Measure 1: Briefings and workshops with relevant government, health, institutional and non-government stakeholders completed to present the findings and workshop policy settings.
• Measure 2: Assessment of post-intervention AMR risk completed as evidence of mitigation effectiveness.
• Measure 3: Results to be shared and workshopped with regional authorities in other Pacific Island Nations to provide guidance on pathways for reducing AMR risks.
• Measure 4: Established AMR research facility and cohort of trained practitioners.

• We do not expect any significant barriers to completion of the AMR study or policy recommendations within the 3-year project timeframe. The project platform is already well established with all partnerships, resources and facilities in place, with local leadership through FNU.
• Accreditation of the local laboratory and integration within FNU as an ongoing national AMR research facility are dependent on the capacity and administrative requirements of FNU. FNU already hosts the dedicated laboratory that will be used for this project, which has been equipped as part of the investment made by the RISE program in institution capacity. We intend to work closely with FNU to support accreditation and establish sustainable research and commercial income streams as a national AMR facility. With strong local leadership from the FNU leads on this project, we are confident of achieving this by the end of the project.
• The RISE interventions are fully funded with completion expected by end 2024. We do not expect any barriers to completion. RISE has strong support and cooperation from government including the Ministry of Health (https://www.facebook.com/share/p/wXDztXejDoCzCdM9/?mibextid=xfxF2i), which will be essential to developing policy guidance that can be implemented in the short term.

Due to the poor sanitation and degraded conditions typical of urban informal settlements in LMICs and the increasing access these communities have to antibiotics (including over-the-counter), combined with low levels of pharmaceutical literacy, such settlements are potential global hotspots for AMR as high-risk reservoirs and incubators of AMR organisms. They are also a potential significant source of new, highly virulent and AMR-resistant pathogens. Our preliminary investigations have confirmed this potential.

This risk has been recognised theoretically (see https://doi.org/10.1038/s41564-020-0722-0 and https://doi.org/10.1016/S0140-6736(22)02351-0), but on-the-ground-evidence and comprehensive data on AMR in informal settlements (a conspicuous knowledge gap) are needed to drive evidence-based policy change and strategic mitigations.

The AMR risk in informal settlements should be concerning to everyone as a largely overlooked reservoir. We therefore believe it is imperative that AMR in informal settlements be investigated rigorously and, more than that, that we take the opportunity to create local lab and research capacity to allow local institutions and health authorities to continue these investigations into the future. At the same time, with settlement interventions being constructed, we have the opportunity to evaluate real-world mitigation measures with communities as active participants. The Trinity Challenge is an ideal vehicle for this multi-pronged initiative.

WHO Western Pacific

Indo-Pacific Alliance Against AMR