Tackling community-level AMR transmission by whole of society approach

We propose testing a ‘whole-of-society’ intervention strategy integrated with ‘one-health’ framework to tackle AMR. This multimodal intervention with six panels targets rational antibiotic use and dispensing, community-level surveillance with non-traditional data, and leveraging WGS for action. System dynamic modeling shall test simulation interventions to inform clinical, community, and program/policy action. 

Manoja Kumar Das (Principal Investigator)

Out of the projected 10million deaths attributable to antimicrobial resistance globally in 2050, 2million deaths are anticipated in India. With the highest absolute and per unit population antimicrobial use among humans, India is one of the most vulnerable geographies. Apart from human use, the antimicrobial/antibiotics use in animals/farming and other sectors are of concern. Carbapenem resistance is reported for ~70% gram-negative bacteria (GNB) isolated from hospitalized patients in India. Carbapenem-resistant GNB is isolated from 30% of humans in community settings (without any illness), 12% of animals, 14-18% of fishes and from environmental samples (our ongoing study in India). Combination of poor health systems, irrational prescription and inappropriate use of antimicrobials are key concerns. The AMR/ABR surveillance/research is primarily hospital-based with limited community surveillance for infections, antibiotics/antimicrobial usage and non-health sector data contribution. Lack of public awareness and appropriate practices for antimicrobial/antibiotics use and non-health players (food-chain and environment) further complicate the issue. The use of genomic data for antibiotics/antimicrobial resistance to document community-level transmission is limited. Although advocated, there is limited application of One-health approach for surveillance and action to tackle AMR. We propose to address the super-wicked AMR/ABR problem with a ‘whole-of-society’ approach in community with continuum to hospital. 

The proposed strategy adopts a whole-of-society approach and follows a ‘one-health’ framework. The target audience for the proposed solutions and mechanisms are:

• Public/community at large: improving the knowledge, attitude, practices and behaviour for illness care and antibiotic usage, using the mobile app, which shall be co-designed, and co-developed involving the public from urban and rural areas (with multi-phased formative research). The app and content development/refinement shall adopt user/citizen-centric approach.
• Patients with illnesses: for providing linkage/access to HCPs for care seeking, chemists for drug dispensing and laboratory for testing
• HCPs and chemists: for human HCPs, the access to evidence-based antibiotic selection (as per local antibiogram), drug dispensing and tracking; for animal/livestock/fish-care providers, access to evidence-based antibiotic selection, dispensing and tracking
• Laboratories: for channelizing the sample transfer, testing the samples ad reporting
• Animal farmers: for access to the appropriate information, care providers and medication, peer-network for information
• Policymakers and program managers: for local data/evidence, outbreak and emerging infections or problems for action

For the development of mobile apps, BCM materials contents, platforms and dissemination strategies, formative research (multiple rounds and need-based) shall be done involving a multidisciplinary technical team of investigators, experts, stakeholders and users from different levels. 

The proposed solution shall have a ‘public good’ effect through/at multiple points/audiences.

• The evidence generated on the community-level burden of ABR/AMR, dynamics of inter-host transmission (human-animals/birds-fishes, cohabitating/sharing environment) and environment sectors/reservoirs (household-community-waterbody-farms-agriculture-aerosol) along with the potential influencing factors (structural, behavioural, organisational and others).
• It shall also document changes in burden, transmission pattern and influencing factors with proposed interventions to further inform the stakeholders/actors and potential program and policy actions.
• The interventions are expected to improve the knowledge, attitude, behaviour and practices at the individual/household level, healthcare providers, livestock practitioners, chemists and farmers.
• The SDM modeling shall assist in generating evidence on the potential effects of the interventions at various levels to inform the program managers and policymakers.
• It has the potential to make AMR/ABR a public issue, beyond only clinical and public health issues. 

The proposed solution has the potential to impact on various populations and stakeholders:

• General public- improving knowledge, attitude, behaviour and practices at individual/household level for healthcare seeking, appropriate antibiotic usage, infection prevention and hygiene and WASH practices
• Patients- improving the appropriate care seeking and antibiotic/antimicrobial usage, use of testing
• Healthcare providers- improving the practices as per existing guidelines and evidence-based practices and appropriate antibiotics/antimicrobial prescription practices
• Chemists- appropriate antibiotics/antimicrobial dispensing practices (for human patients, animals)
• Livestock practitioners- improving the practices as per existing guidelines and evidence-based practices and appropriate antibiotics/antimicrobial prescription practices
• Animal/fish farmers- adoption of good practices and reduced use of antimicrobials/antibiotics in farming
• Public health and animal health program- availability of community-level data and insights on the issues and determinants of inappropriate antimicrobial/antibiotic use.

We shall also attempt for further sustenance of the effort through the partnership developed, ongoing and future projects on AMR/ABR and future grants for further expansion.

We hope that the engagement with the hospitals and healthcare providers shall assist in expanding the network and ABR Stewardship program.

The engagement with public health and animal health programs and policymakers is expected to trigger the expansion of the non-conventional and community-level data sources utilization for infectious diseases and AMR/ABR surveillance using a one-health framework.

We plan to scale the efforts to other districts in the state and other states through advocacy and engagement with the stakeholders at government, and non-government levels including the philanthropies, and industries through the corporate social responsibilities (CSR) efforts.

The penetration and success of the proposed solution shall be measured using the following indicators.

• Knowledge, attitude, practices and behaviour on rational antibiotics/antimicrobial use (periodic surveys)
  • General public for illness care and antibiotic usage- by household surveys
  • Animal/fish farmers
  • Community-level healthcare providers and livestock practitioners
• General public mobile app usage
  • Mobile app downloaded and installed
  • Mobile app used for care seeking and/or access to healthcare providers
  • Peer group communications
• Healthcare provider mobile app usage
  • Mobile app downloaded and installed
  • Mobile app used for healthcare advice and prescription
• Chemist mobile app usage
  • Mobile app downloaded and installed
  • Mobile app used for drug dispensing
• Community-level data capture
  • Human illness, care seeking and medication/antibiotics use, hospitalisations, deaths
  • Animals illness, care seeking and medication/antibiotics use, deaths
  • Antibiotic/antimicrobial usage for farm animals
  • Community-level bacteria, antibiogram, ARG/MGE and WGS 
• Processes and awareness generation efforts 
  • Number of households approached for orientation 
  • Number of community meetings held 
  • Number of professional seminars and CMEs conducted 
  • Number of TV and radio shows and radio jingles disseminated  
• System dynamic modeling outputs
  • Development/refinement of the causal loop diagrams (CLDs) for AMR/ABR transmission models at community level
  • Testing the SDM using the CLDs and data from the study and available literature 

• Financial: Implementing proposed solutions at scale, technological developments and stakeholder engagement need financial investment. We have been working on research projects to generate evidence in this domain. If we succeed in the current call, it shall catapult our efforts to the next orbit and assist in further fundraising.
• Technical: To expand the participation of additional stakeholders and experts, there is a need to expand the horizon of solution implementation. If we are successful in the current call, it shall enable attracting technical partnerships and mentorship from global leaders in AMR and public campaigns.
• Technological: The proposed mobile app development and linking with the social marketing effort needs funding, partnership and advisory support from experts.
• Socio-cultural: Health is a personal and private issue in many societies across India. Willingness for data sharing and acceptance of community-based integrated solutions may experience challenges from various stakeholders.
• Acceptance and transparency: Acceptance of the solution and data sharing by the animal farmers may be a challenge. The involvement of the technical stakeholders and community influencers shall be of help.
• Program and policy integration: Adoption of the evidence into program and policy shall need advocacy and engagement at various levels.

We are applying to gain access to the larger funding environment from the various grants, donations and endowments at global, regional and national levels. We hope that the Trinity Challenge, Solve team, facilitators, collaborators and mentors shall be able to guide the team to develop and refine the social innovation and business model along with the fund raising options to target tackling AMR/ABR. The Solve stage is expected to give visibility and also credibility for the team to approach various funding sources.

Funding: We hope that the funding shall accelerate the efforts to tackle at community-level AMR/ABR in India, which is expected to face the biggest clinical and public health challenge globally. The community-level intervention and implementation model shall inform the government, industry and other stakeholders for appropriate adaptation for implementation within the program framework.

Global access: The access to the global network of Solvers, researchers and technical experts shall further the network. The networking shall enable refinement and improvement in the efforts and cross-learning for possible replication/scaling up of the efforts in other countries.

Technical support: We are keen that the technical experts globally leveraged by The SOLVE and Trinity Challenge team shall be critical to refine/improve the solutions. 

We are keen to collaborate with organizations/experts in:

• Antimicrobial resistance and genomics: To gain insight on diversity and genomic basis for AMR/ABR emergence and transmission, outbreaks, and potential mechanisms of reversal. The institute/laboratory shall assist in undertaking advanced analysis for AMR/ABR. The global network insights shall assist in better understanding the issues and unravel the local factors influencing the emergence/persistence/reversal of the AMR/ABR. These data shall be critical to designing appropriate hospital, community and/or integrated interventions to tackle AMR/ABR.
• Technology developers: Assistance/guidance/mentoring from the technology experts (mobile app development, adoption of new platforms/technologies) shall be crucial to adopt the right technology for intervention development and scale-up.
• Policy advocacy and communication: The mentoring and support shall assist in the possible translation of the findings and conducting the right activities for policy advocacy and translation. The communication expert advised/mentoring shall assist in developing the right content and adopting channels/strategies for dissemination of the messages.
• Social marketing, behaviour change management and community processes: This shall assist in using the right content, adopting the right strategies/methods/channels for community engagement and implementation of complex community processes.
• Crowdfunding and philanthropy fund mobilizers to assist in generating funding.