Antibiotic stewardship in agricultural communities in Africa and Asia: A unified One Health strategy to optimise antibiotic use in animals and humans

Antibiotic medicines are a vital resource for treating bacterial infections both in humans and in animals. Unfortunately, all around the world, some infections are becoming resistant to the antibiotics used to treat them. This could lead to a future scenario in which illnesses last longer, deaths increase, and the cost of treatment rises. Resistance additionally threatens livelihoods due to farmers' reliance on antimicrobials in livestock production to meet growing demand. Under this scenario, the greatest impact will be felt in low-income countries, where infectious diseases are common and many families lack financial security. Antibiotic resistance is now considered to be one of the biggest threats to global health. The UN General Assembly has called for concerted action by every national government to limit the development and spread of drug resistance. The World Health Organization advocates urgent action, research and investment, through both the development of new antimicrobials and more responsible use of existing drugs.

Poor prescription practices such as overuse of antibiotics, partial doses, or non-adherence to the full treatment course, all create situations which are conducive to the selection and spread of resistant mutations. Health workers, pharmacists, farmers, caregivers and patients can all help tackle resistance by only dispensing antibiotics when they are truly needed, and by using the right drug in the right quantities. Improving the use of antibiotics thus ultimately involves developing effective interventions to guide the treatment decisions made by health workers, patients and farmers to discourage indiscriminate use.

The private sector plays an important role in provision of health care in many low-income countries, with a majority of patients and farmers depending on drug shops and informal providers for medicines - and cannot be overlooked in strategies to control misuse of antibiotics. Neither can antibiotic resistance be addressed by focusing on one sector in isolation - a holistic approach is needed for the effective control of antibiotics in animals and humans. Yet regulation of the private sector is an acknowledged weakness of the health system in many low-middle income countries.

The proposed cluster aims to address this challenge. We shall pool the knowledge and insights that have been generated in six projects previously funded by GCRF, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a range of countries in Africa and Asia - to identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus will be on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. We shall use this collective evidence to design an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops and improving rural treatment services for humans and animals. This strategy will be tested in future studies.

Ultimately, the intervention strategies we develop are intended be of value to national governments, Ministries of Health and Ministries of Agriculture, in low-middle income countries in the formulation and enactment of national plans to counter the threat of antibiotic resistance. Our findings can also be used to strengthen health services in rural areas.

As antibiotic resistance is recognized as one of the greatest threats facing global public health, research on how to contain the emergence and spread of antimicrobial resistance is urgently needed by policy makers and national health authorities. Attempts that seek to change practice at the national level without taking into account what is happening in communities is likely to fail as it is at the frontline of medicine use that the most dramatic changes need to take place.

The proposed will provide policy-relevant data on antibiotic quality in primary health care settings and animal production in India, Uganda and other LMICs and the results will provide an essential component in the construction of workable solutions to support the prudent use of antibiotics in both settings. For example, in Uganda, the results will add to the current sustained investments in surveillance and control implemented by the Fleming fund and others in Uganda. It will provide evidence for the committee charged with implementing Uganda's first Antimicrobial Resistance (AMR) National Action Plan (NAP). The Ugandan co-investigators on this application are all members of this Taskforce. Beyond Uganda, results from this research and subsequent interventions will provide a valuable case study for work in other countries with similar health care systems and challenges. In India, the research will be disseminated to the Ministry of Health, health and animal husbandry departments and members of the AMR Coordination Committee and Task Force, the Indian Pharmaceutical Association, medical associations of Indian doctors and infectious disease physicians, and informal providers and rural communities.

Similarly, other Co-Is have developed relationships with key stakeholders in Pakistan, Cambodia, Tanzania, Kenya so that our findings will extend beyond these two countries of focus. We also have a Latin American Co-I from Colombia so our stakeholder impact will extend to that region as well. These engagements will be strengthened over the duration of this project through the interactive workshops and also through the rapid feasibility/intervention readiness research that will be conducted in India and Uganda.

When we disseminate our findings, we will conduct a stakeholder analysis to identify key individuals who are likely to work as policy champions and who will identify policy windows and opportunities for policy implementation at global and national levels. We anticipate that these champions will be critical to our research being taken into policy.

Finally, we will communicate with the scientific community by publishing in international peer-reviewed journals with high impact factors. To reach the broad multidisciplinary audience to whom this research will be of interest, including those in LMICs, we shall publish in open-access journals. Results will also be actively disseminated through our professional contacts in international and regional organisations, and academic networks and invited talks. Research briefs that summarize the key findings and are designed for a policy audience will also be disseminated through the websites, newsletters and press offices of our host institutions.