One-Health United

Utilizing a community-centric One-Health approach, our solution includes surveillance, AST, Genome sequencing, GIS tracking, AI, and policy dialogue to combat AMR. It integrates AMS programs across sectors and regions, emphasizing community engagement, socio-behavioral research, and AI-driven diagnostics to promote rational antibiotic use and stewardship.

Dr. Muhammad Imran Khan

Founding & Executive Director PHC Global (Pvt.) Ltd.

In Pakistan, over 280,000 deaths were directly due to or associated with AMR in 2019. Pakistan is the third-highest consumer of antibiotics among LMICs. Antibiotics are classified as prescription-only; however, these regulations are not stringently enforced due in part to shortages of a qualified workforce in retail pharmacies and public-sector hospitals, as well as inadequate licensed healthcare providers in rural areas. National pharmaceutical sales data indicate high antibiotic human consumption of beta-lactams, beta-lactamase-inhibitor combinations including 3rd generation antibiotics, and 2nd line agents that are reserved for Multiple Drug Resistant Organisms.  On average, more than 3 drugs are prescribed to patients per physician consultation, and an estimated 50% of the population takes prescription-only drugs without consultation to offset health costs. The usage of antibiotics in farm animals and poultry is widespread, including antibiotics designed for human use. A study in Pakistan indicated that 22% of farmers do not consult veterinarians regarding antibiotic use, 33% do not follow dosage instructions, and 39% discontinue treatment. AMR transmission to the environment stems from various sources including animal waste, uncontrolled grazing, and pharmaceutical and municipal waste disposal. Poultry waste, often used as fertilizer in Pakistan, contains bioactive antibiotics leading to an increase in AMR.

Our solution, an interconnected One-Health approach with the community at the center of focus, serves stakeholders across human-animal-environmental health sectors, to influence national policymakers. To understand and engage stakeholders, we will establish a Stakeholder Advisory Board with representatives from all groups - public health agencies, healthcare organizations, frontline workers, veterinary services, livestock producers, wastewater facilities, and community residents. The board will foster scientific exchange, co-develop open-source tools, facilitate cross-sector dialogues, adapt educational curricula, and guide strategic direction to ensure relevance to community needs.

Robust communication channels within organizations will be fostered to build coalitions sharing insights. Consistent community engagement will capture local knowledge to reflect needs accurately. Champions will be identified to advocate and guide AMS efforts. Access to continuous learning and expert consultation will maintain engagement and address challenges. Training workshops utilizing creative modalities will encourage deeper emotional connection and openness to changing views, integrating factual knowledge with lived experiences. Post-project guidelines will sustain stakeholder engagement through regular community meetings, AMR monitoring updates, and digital platform access.

Regular community meetings throughout the project will garner contextual insights and feedback. A mixed methods approach, using qualitative and quantitative will be used to document the approach for a larger global audience.

Our multifaceted public goods focus on open knowledge exchange, community empowerment, and One-Health systems integration to accelerate sustainable progress against AMR:

• Open-source AI and GIS tracking tools will provide free access to advanced analytics for localized AMR surveillance, overcoming resource barriers.
• Peer-reviewed publications on implementation science insights will create a knowledge base to inform evidence-based, context-specific application of One Health approaches globally.
•  Responsible open data sharing will advance LMIC-centric research into AMR transmission pathways while protecting participant anonymity through de-identification.
• The public data repository of integrated genomic, geospatial, ecological, and community insights will enable open collaboration between researchers to further innovation.
• Extensive dissemination of pilot results and project updates through reports, presentations, and papers will establish shared lessons and best practices.
• Institutionalizing coordination mechanisms across human, animal, and environmental sectors will break down silos that impede effective AMR surveillance and response.
• Generating evidence on successful interventions will provide a framework to enhance health system resilience to shocks by identifying adaptable and scalable solutions.
• Documenting community voices and narratives will foster local ownership, agency, and engagement in AMR mitigation as active partners and decrease disparities in health outcomes across geographic and social boundaries.

Our solution will create tangible impacts on responsible and appropriate antibiotic use, provider and community empowerment, and public awareness and behavior change in Pakistan:

• The Stakeholder Advisory Board with diverse representation will guide the development of context-specific surveillance and stewardship solutions, fostering adoption and sustainability.
• Through a community engagement approach,  healthcare workers, veterinarians, environmental specialists, and community members will engage in processes to adapt and implement effective stewardship programming and awareness regarding AMR/AMS.   Healthcare workers and veterinarians will have the knowledge and skills for appropriate antibiotic dispensing/prescribing. Community members will have knowledge related to antibiotic use in humans and animals.
• Consistent community participation will capture lived experiences and local insights to inform policy and program adaptation. Training workshops utilizing creative modalities will encourage deeper mindset shifts, ensuring behavioral change rather than just knowledge gains. 
• Faster outbreak detection and response lead to more rapid identification of resistance patterns and targeted use of antibiotics,  better health outcomes, lower mortality, and reduced social and economic burden on households and health systems.
• Post-project guidelines will institutionalize mechanisms for ongoing implementation, monitoring, evaluation, and community engagement for AMR surveillance, antibiotic dispensing practices, and stewardship programming

Over the next year, we will:

• Onboard healthcare facilities, government agencies, and communities as data partners to build a robust integrated AMR surveillance system. Facilitate cross-sector dialogues and co-design workshops to foster buy-in.
• Utilize the CFIR framework to assess resources, gaps, and barriers/facilitators for AMR stewardship across human, animal, and environmental health. This will inform context-specific roadmaps.
•  Initiate development of GIS visualizations and analytics tools leveraging collected data.
• Start building AI-enabled point-of-care diagnostics and clinical decision support systems as data accrues.
•  Consolidate learnings on barriers, best practices, and stakeholder insights to refine approaches.

Over the next 3 years, we will:

• Complete platform development and launch multi-site pilots to evaluate real-world effectiveness and sustainability as per CFIR indicators.
• Build partnerships with educational institutes to sustain and scale context-specific AMS programs.
• Expand data integration from 5-10 additional regional sources to enrich surveillance insights. Continuously improve algorithms.
• Develop a comprehensive sustainability plan including handover to local partners, ongoing monitoring, and knowledge dissemination.
• Share evidence, best practices, and implementation learnings through global networks to inform the replication of successful community-centric One Health models worldwide.

This phased approach will help drive broad adoption and ultimately transform antibiotic stewardship across Pakistan's socio-ecological landscape.

1. Reduction in Antibiotic Consumption

Hospital records will be utilized to track changes in in-patient antibiotic prescribing practices based on established guidelines and protocols. These data will include diagnosis (empirical and definitive), antibiotics prescribed, route (IV, OP), dosage, and duration. The analysis will be based on antibiotic days per 1000 patient days.  Data will be collected at baseline and post-intervention. Clinic records (as available) will be tracked for the same information. 

2. Increase awareness and knowledge regarding AMR and stewardship among CHWs and veterinarians.

Baseline, immediate post-intervention, and 6-month post-intervention data will be collected to assess the impact of educational and training modules.  Data analysis will include standard descriptive, bilateral, and multilateral approaches to determine significant increases between time points and intervening moderating and mediating variables.  Outcomes will include increased knowledge, self-reported prescribing practices,  and accessibility to AMR/AMS resources.  Additional outcomes will vary by group and type of intervention.

 3. Process evaluation related to community engagement and implementation.  Qualitative and quantitative data will be collected from advisory board members, during community meetings, and as part of longitudinal outcome evaluations to assess the feasibility of the interventions from an implementation perspective and perceptions of project ownership and engagement among stakeholders.    

Key barriers include:

• Data accessibility - Government entities reluctant to share siloed data due to proprietary concerns. We will leverage the networks and trust of partners like Henry Ford Health and Aga Khan University to secure buy-in for data sharing.
• Community reluctance - Logistical and cultural challenges for participatory engagement. Securing government endorsement as a stakeholder will facilitate community participation through official communication channels.
• Sustainability beyond project duration - We will institutionalize mechanisms for continued funding, monitoring, and governance. The CFIR implementation framework will guide transition planning and capacity building from the outset.
• Suboptimal volume/quality of microbiology, genomic sequencing, and antibiotic prescribing data to develop robust AI diagnostic and predictive models. We will employ techniques like data augmentation, increased feature extraction, and transfer learning to overcome risks of data limitations.
• Infrastructure limitations at clinical and veterinary facilities. We will implement a progressive modular approach to distribute costs over phases. Public-private partnerships will be leveraged to secure resources.
• Difficulty coordinating diverse human, animal, and environmental stakeholders. Our One Health integration mechanisms like the Stakeholder Advisory Board will align priorities across siloes.
• Funding: Having the required capital to launch and sustain the project. This project will fill that gap. 

We are applying to The Trinity Challenge because our solution objective aligns with its core principles of inclusivity, collaboration, and innovation in tackling global health emergencies. Our project aims to harness data-driven solutions to combat antibiotic resistance, a growing threat to global health. However, we face several barriers that The Trinity Challenge is uniquely positioned to help us overcome. Data accessibility, suboptimal data quality for AI models, and funding is where Trinity Challenge can help us. The Trinity Challenge, with its global network across public health and data science, can aid us in overcoming these hurdles. Specifically, it can help us secure data-sharing agreements through its partnerships, leveraging its platform for official endorsements, guiding sustainable project planning, and offering resources to improve our data analysis capabilities. Moreover, the Challenge's emphasis on innovative solutions and its support for projects tackling antibiotic resistance can help us navigate infrastructure and funding challenges, ensuring our project's success and impact.

Collaborating with prestigious organizations such as the British Society of Antimicrobial Chemotherapy (BSAC), Ineos Oxford Institute for Antimicrobial Research, and the Institute for Health Metrics and Evaluation (IHME) is essential to effectively tackle antimicrobial resistance. The expertise and network of the aforementioned organizations will facilitate refining our understanding of resistance mechanisms and ensure alignment with best practices. IHME's data analytics will guide us for robust evaluations across diverse populations, informing advocacy efforts and integration into health agendas. Together, these collaborations enhance our capacity to combat antimicrobial resistance