One Health Drivers of Antibacterial Resistance in Thailand

Like many Overseas Development Assistance (ODA) countries, and particularly those in South and South East Asia, Health and well-being in Thailand is significantly undermined by the high prevalence of antibacterial drug resistance (ABR) in disease-causing bacteria found in humans, animals and the environment. ABR reduces the ability of doctors to treat infections with antibiotics and other antibacterial drugs, with an estimated impact on Thailand in 2010 of
38,000 deaths and an economic loss of 1.2 billion US$. ABR rates continue to rise and its impact is rising in parallel.

Because of the threat of ABR, the Thai National Strategic Plan on Antimicrobial Resistance (2017-2022) has been instigated. This will involve improved national surveillance for ABR bacteria to quantify the problem, initiatives to reduce the rates of infections and those to reduce the usage of antibiotics and other antibacterial drugs, which are known to select for ABR bacteria. However, even when this strategic plan starts to pay dividends, there will be much still to learn about ABR in Thailand, and in other ODA countries, as is also true for developed countries where ABR reduction strategies have been in place for some time.

In this development project, we will build on partnerships we have already initiated between UK and Thai clinicians and academics. We will develop a consortium grant application to address knowledge gaps about ABR in Thailand, which we have identified through discussions between UK and Thai partners. The consortium will consider whether chemicals in the environment - present naturally or as a result of agricultural pollution (e.g. herbicide use) - can select for ABR bacteria. This would render strategies to reduce antibiotic use less effective in reducing ABR in a community where chemical pollution of the environment is common. We will also consider whether ABR bacteria circulate within local environments in rural Thailand, and will measure how this changes over time as the Thai National Strategic Plan on Antimicrobial Resistance progresses. We will perform research aimed at understanding key behaviours around antibiotic use by farmers, farm management practices, and how people make decisions around healthcare. We will use the information that we generate from the microbiology, genomic and chemical screens and the anthropological research to produce mathematical models that can be used to predict useful changes that can be made to reduce ABR in Thailand and other ODA countries. We will also help Thai policymakers evaluate the effectiveness of changes initiated through the Thai National Strategic Plan. Finally, we will develop technologies that will be used to streamline our research; technologies that may also be useful to help local communities tackle the problem of ABR.

During the development project we will run a series of workshops in Thailand, which will be used to develop the details of our proposed research project and to identify the study sites we will use. These workshops will also give us the opportunity to share knowledge amongst Thai and UK ABR experts, and bring together a group of early career academics, to raise the knowledge base around ABR in Thailand. We will also discuss postgraduate education strategies, and public engagement events in Thailand. The development phase will also involve a comprehensive investigation of policymaking around ABR in Thailand, enabling us to tailor our consortium research project to the needs and knowledge gaps of these groups and individuals

In the development phase we will use a series of workshops and an initial stakeholder assessment to define the research questions for our consortium project application, and identify key users for our research in Thailand.

In the consortium phase we will study, in detail, a selection of defined study sites representative of different agricultural systems and environmental locations in Rural Thailand. The research areas that we are focusing on during the project are:

1: Environmental influences on antibacterial drug resistance selection - pollutants including heavy metals, antibacterials and pesticides/herbicides etc; also the influence of flooding/rainfall runoff etc.

2: Drivers (social, cultural, economic) for the use of antibacterials, and other polluting chemicals that select ABR in agriculture and aquaculture, coupled with a survey of actual usage.

3: The prevalence of bacterial pathogens, and ABR bacteria in different compartments: agriculture, indoor, environmental, human and animal skin and faecal flora and, using genomics, an investigation of the transmission of ABR bacteria and genes between compartments, and the influence of this on ABR in serious infections in hospitalised patients at various geographical distances.

4: Anthropological investigation of culturally rooted attitudes to infection, antimicrobial use, ABR and the environmental cycling of ABR, and an investigation of the efficacy of education and other antimicrobial usage reduction strategies.

5: Intervention modelling of the impact of these various factors to identify best value intervention points for future trials.

6: Technology development, focusing on diagnostic and monitoring technologies that are field deployable in a resource-poor setting in order to monitor ABR and pathogen levels; social/economical evaluation of their prospective use by farmers and in primary healthcare.

Our ultimate aim is to develop a fundable consortium project application. Should such a consortium be funded, the following general impacts might be envisaged:

Health and Welfare of the Thai people, and those from other countries.
There is a significant burden of disease and economic cost of antibacterial drug resistance (ABR) in Thailand; estimated as 38,000 extra deaths and 1.2 billion US dollars of economic cost in 2010. Since ABR has risen world-wide since that time, inevitably the health and well-being cost of ABR in Thailand will also have risen and is set to rise further in future. Rates of carriage of resistance to last resort antibacterial drugs has risen and are some of the highest in the world, rendering some key first-line drugs essentially useless. Our aim is to understand the drivers of ABR selection and spread in a One Health context, and uncover interventions designed to reduce ABR, and/or the incidence of infection. This would have a potentially transformative effect on healthcare in Thailand. It is likely that what we learn will be transferable to other countries, particularly neighbouring countries where ABR is also a significant burden, but where a response to the threat of ABR is less developed.

The Thai and UK Economies.
Over-use of antibacterial drugs and other polluting chemical in Thai agriculture may reduce its economic efficiency. Better farm management practices would not only reduce the reliance on chemicals, but they would improve agricultural yields and so economic growth. Our anthropological work will uncover farm management practices, and potential leverage points that might be used to encourage more efficient practice, whether this is to reduce ABR or not.
Our work developing better, field deployable technologies has the potential to improve economic activity in Thailand and the UK as these devices are pushed into mass production and sale.

Education and Knowledge Transfer
Our Thai/UK partnership will open up the possibility of collaboration in educational initiatives, such as, for example postgraduate student training and research exchange, and professional education - e.g. of vets, clinicans etc. Improved public understanding of the science around ABR, and the implications and potential solutions to the problem will be important when implementing change, but also to raise the profile of research in this area.