Unlocking AMR surveillance potential of boarding schools

In Tanzania, availability of community-level AMR data is challenging. The solution hinges on people-centred framework to enhance community engagement and empowering the next generation of scientists and AMR ambassadors. Embedding AMR into existing students' programs can easily increase community-level AMR data accessibility and availability.

Dr Tolbert Sonda (PhD), Head of data management and bioinformatics unit and postdoctoral researcher focusing on strengthening microbial diagnostics and AMR surveillance in Tanzania

AMR is a serious threat to global health; 1.27 million annual deaths being directly caused by bacterial AMR. AMR/AMU in Africa is higher (50.0%) than in other continents (<43%). In LMICs, there is known overuse of antimicrobials in human, plant and veterinary sectors. Except in specialised hospitals, in difficult-to-reach rural communities there is no routine utilisation of antimicrobial susceptibility results prior to treatment initiations, meaning that data generated from specialised hospitals can hardly be used for informed-empirical treatment elsewhere. In Tanzania, there are virtually no ongoing initiatives on community-level AMR data generation and utilisation. Following the WHO's people-centred framework for addressing AMR, we have designed a boarding-schools approach to access and engage rural communities and collecet AMR/AMU data that can be used to optimise AMU and slow down the AMR spread. Improved community engagement, knowledge and compliance to both correct AMU and willingness to provide data will ensure continuous surveillance and availability of OneHealth AMR/AMU data. Thus, there is a major need to 1) collect data from  difficult-to-reach rural communities, 2) create more permanent solutions embedded in local infrastructures for sustainability and 3) provide general rural community acceptance and awareness on AMR.

The proposal aims to establish a sustainable platform for continuous surveillance of OneHealth AMR/AMU data in hard-to-reach rural communities. Overcoming administrative and societal constraints, the solution will leverage on the students involvement as parents and local communities are more likely to assist and collaborate with students than with authorities or researchers. Therefore students will provide much easier and broader community acceptance, engagement, collaboration and local ownership of the proposed solution. 

Additionally students will play a crucial role in addressing local community needs and concerns on AMR/AMU by bridging communication and data gaps between authorities and rural communities. The solution emphasises on the importance of providing AMR/AMU education and awareness, concurrently building a sustainable surveillance capacity at community level. Empowering students through training and active involvement in AMR/AMU within their communities is an indispensable component of this solution.

This solution extends beyond conventional and hospital-based approaches for AMR/AMU data collection. We will use mobile nanopore sequencing platform and real-time data capturing and visualisation dashboards for effective community engagement to foster future engagement in national and international collaborations to collectively address AMR/AMU challenges

This solution will provide a range of “public goods” including:

• More datasets on OneHealth AMR/AMU in difficult-to-monitor community settings in Tanzania and integrate on a free-to-use DHIS2 dashboard

• More available genome sequences shared publicly through the European Nucleotide Archive

• Data and knowledge directly to the engaged local communities thereby influencing the future use of antibiotics

• Education and engagement of the next generation researchers

• The approach and experience is also expected to be described in white paper/peer reviewed publication

• Finally, a possible scalable long-term sustainable solution for improved surveillance of AMR/AMU that can be implemented also across other countries in Africa

The impact of increased general community knowledge and education is difficult to measure especially in the short term. It is well-documented that having available data easily accessible on a dashboard, as well genome sequences deposited in ENA will impact local politics, decisions and public research. 

The main expected impact however, will be the direct engagement with local communities and education of school students, which is much more difficult to quantify. As part of the project we will however, conduct baseline community and student surveys before and after the project to determine the impact of the project on OneHealth AMR/AMU. Apart from develpoing a secondary school AMR/AMU programme, additionally the project is expected to result in a range of scientific reports, publications and policy briefs from the school students involved all of which will be collated and reported.

With the funding from the Trinity challenge it is our plan to pilot this in two regions during the first year, where we will also be setting up the central data sharing and visualisation dashboard. During year 2 and 3 we expect to expand this to an additional at least 8 regions. We will also engage with local communities through events where the students present their individual work and the summary of all combined efforts, thus, bringing information directly to the local communities and simultaneously get experience in research ownership and presentations.

Year 1: minimum of 2 schools, 20 students, 200 households, 6 villages, 20 datasets. 

Year 2 and 3: minimum of 10 schools, 100 students/groups, 2000 households, 30 villages, 100 datasets. 

A comprehensive M&E framework will be developed to include measurable indicators as below: 

WP1 deliverables: curriculum stakeholders identified, Reviewing existing modules/resource, curriculum developed. Indicators: lists of AMR/AMU stakeholders, curriculum review workshops done, review reports, curriculum approved

WP2 deliverables: IT solution for students virtual training installed, Baseline students knowledge assessed, Students taught and AMR/AMU clubs formed. Indicators: eLearning IT solution working, first webinar attendees list, baseline student AMR/AMU scores, students AMR/AMU clubs

WP3 deliverables: CABs formed, training conducted, joint school clubs-CABs meeting conducted, community awareness meeting conducted. Indicators: List of CAB members trained, Number of CAB meetings done

WP4 deliverables: Special students project proposals generated, AMR/AMU data generated, Sociobehavioral AMR/AMU interviews, Samples (bacteria/metagenomes) sequenced, dissemination meetings, reports made. Indicators: number of students/group proposals, sampling protocols and interview guide, data collection tools, number of datasets on DHIS2, number of datasets/audios transcripts, sequence data available, number of students reports generated, number of dissemination meeting done,  data visualisation dashboards

Political will can be a major challenge in Africa, but can be overcome through proper engagement with government officials. Since this is embedded with schools and thus, part of the official education, we do not expect to encounter major problems. However, if issues arise in some districts we will focus on districts where minimum opposition is encountered.

The cultural challenges that often are the main problem in traditional surveillance and research projects are expected to be minimal here, since we are engaging through Tanzania's highly respected educational system (Mwalimu is a very honourable title) and the students that are considered a highly valuable part of the local communities.    

Availability and distribution of equipment and reagents including procurement and importing them into the country can be a major challenge. We have considerable experience with ensuring procurement, including arranging orders and payment though our long-term partner in Europe and importation as well as national distribution. 

The trinity challenge is an excellent opportunity for my solution. I have not come across any other similar funding opportunities. The solution suggested is not a traditional research project and can not apply for funding though such sources; it is not embedded into the classical health system and can not apply for funding through for example National Surveillance grants, WHO, Fleming Fund or BMGF; and it will be considered too advanced for the educational system. Thus, the Trinity challenge is a potential opportunity to combine nodes that do not normally mix and hopefully create something new that can make a difference in Tanzania, across Africa, and even beyond.

I would like to collaborate with research/academic institutions, NGOs, pharmaceutical companies that could be willing to provide support and resources for scaling up the solution.This could be organisations supporting education in African local communities or organisations supporting initiatives aiming at improving AMR/AMUed surveillance in resource limited settings.

 Additionally, partnership with regional bodies like Afro WHO, MSF and African CDC would be very crucial as they have expertise, resources and networks and that they can see the benefits of combining secondary school education with community-level AMR/AMU data generation and visualisation.