Anti-Microbials In Society (AMIS): a Global Interdisciplinary Research Hub

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Public Health and Policy

Abstract

Our use of antibiotics has escalated. We are often most aware of antibiotic use when we treat infections - for people, and animals. However, their use is more widespread. We use them routinely to reduce risks of infection amongst people with vulnerable immune systems, in farming livestock, to manage infection and to promote growth and even in crop farming. This widespread use is linked to a rise in antibiotic resistance (AMR). The amount of antibiotic chemicals in circulation is held responsible for driving selection pressure amongst bacteria such that some infections become untreatable with previously effective drugs. This can have dramatic consequences for both health and economics. And yet, scientists have emphasised the lack of evidence for using antibiotics in many scenarios. For example, it is estimated that at least 50% of human antibiotic usage has no clinical benefit.

Policy makers are agreed that we must reduce our reliance on these medicines. But how? Efforts to change end user behaviour are often called for but thus far have not had the widespread impacts required to curb the emergence and spread of resistance. In this research, we propose that antibiotics are embedded within our socioeconomic infrastructure in such a deep way that attempts simply to change behaviour of patients, physicians of farmers are peripheral to our underlying dependency on their use. We suggest that by understanding the ways in which antibiotics are intertwined with our lives, institutions and infrastructures today we may identify ways to replace their use while minimising unintended consequences. For example, attempts to reduce use of one antibiotic often increases the use of another. Removing antibiotics all together may require a more systemic intervention such as the promotion of recovery time. In so-doing, however, other consequences could occur for the workforce and for economies tied up with pharmaceutical production and sales. We need to look closely at measures that have already been taken to reduce antibiotic use and understand what their consequences have been, as well as play out potential new interventions in different settings. If we are able to identify effective measures to reduce reliance on antibiotics in different scenarios, this will be more cost effective and timely than one-size-fits-all efforts to change end user behaviour.

The issue of AMR is global, and is expected to have most severe consequences for low and middle income countries (LMICs). The need to reduce use of antibiotics in these settings presents a particular challenge, where markets fill the gaps of fractured health systems. An access-excess balance is described whereby many in need of antimicrobials remain untreated while these medicines are commonly used unnecessarily. This scenario persists despite decades of research and programmes into the rational use of medicines in LMICs. New approaches are needed to uncover the significance of antibiotics in our societies, to understand why the imperative to target their use so difficult to enact.

This project presents a fresh approach beyond the traditionally delineated domains of social, biological or clinical sciences. The project aims to launch the AMIS Hub, an internationally recognised centre of excellence for developing, implementing and disseminating high quality research on antimicrobials in society, and two initial studies in Thailand and Uganda with the following objectives:

1. To understand the roles of antibiotics in every-day life and infrastructure
2. To evaluate the impact on care of imperatives to restrict antibiotics
3. To identify and rehearse counterfactuals to antibiotic use

This project will generate a critical mass of researchers undertaking high quality research into AMR, high quality comparative evidence indicating the nature of our reliance on antibiotics and recommendations for alternatives to antibiotics that will minimise unintended consequences.

Planned Impact

Societal benefit
This project intends to deliver societal level benefits of curbing the spread of AMR. The paradox of our reliance on antimicrobials, the common of which use renders them less reliable, is a concern for all those reliant on these medicines. At present, we remain unaware of many of the ways in which antimicrobials are interwoven with our social, physical, biological and economic structures. This prevents us from being able to effectively reduce use of these medicines. It also means interventions to reduce antimicrobial use can have unintended consequences. By examining the interrelationships between antimicrobials and different forms of life and infrastructures, this project will enable more informed measures to be taken to reduce our reliance on these medicines. By evaluating the impacts of different interventions already undertaken, we will also identify consequences of such efforts that may be unanticipated. These can then be taken into account in (re)designing such interventions. By identifying counterfactuals to antimicrobial use, we will be able to explore alternative ways to arrange our infrastructures and cross-species relations.

Policy impact
To enable this societal benefit, the research will need to impact policy. We will ensure that our results enable policy makers to be equipped with possibilities for reducing our reliance on antibiotics whilst understanding the potential consequences of doing so in different scenarios. Our comparison across study sites - different income level countries, over time after different interventions, and in farming and industrial settings - means the findings will be tailored to different scenarios. Furthermore, through the AMIS Hub's network of other research, we will be able to identify commonalities more broadly in possible options to reduce or replace antimicrobial use, as well as in consequences of doing so. These recommendations and considerations can be taken into account in the development of national action plans on AMR.

Target audience
To achieve this policy impact, our target audience will include: (1) political and public health officials in Thailand and Uganda; (2) policy makers and public health practitioners working within and across other LMICs; (3) local officials and members of the public in the study countries and beyond.

Outputs of the research
The two country studies will provide detailed information and examples on: perceptions about antibiotics and AMR; why and how we rely on antibiotics; what are the consequences when antibiotics are not provided; and what alternatives to antibiotics are possible and already in place. The interdisciplinary approach of the project will provide alternative ways of viewing AMR as societal problem, which could contribute to novel configurations of non-academic collaborations and solutions.

Communication strategy
The AMIS Hub will develop a central communications operation which will support each country's engagements with target audiences as well as reaching out to international audiences. In each country, inception meetings with each target group will be held to refine the project plans to meet specific concerns. This will facilitate buy-in and increase the potential for findings to have lasting and meaningful impact. Subsequent meetings will be held in the course of the research and at the end, to discuss progress and findings, and identify possibilities of translating them into meaningful outputs. Specific meeting plans differ between countries due to different political contexts: eg. in Thailand we will visit specific stakeholders and carry out site visits in other regions of this larger country; in Uganda we will utilise established community advisory board methods and will host centralised meetings. Policy briefs will be prepared and translated for each country and a third for cross-study findings, to be distributed at dissemination events in country, in London and at conferences.
 
Description The AMIS programme of work includes an online Hub. We launched this website in November 2017 at www.antimicrobialsinsociety.org as a way to connect users with social researchers and social research projects relating to antimicrobial resistance. By February 2018 we had 36 researchers actively working on AMR from a social science perspective listed on the website, as well as 10 research projects. The AMIS Hub also promotes relevant social science research and theory materials that can be useful for AMR, and so far we have uploaded our own summaries of these 'Essential Readings' for 34 articles and books. We have also published three commentaries and four thematic reviews on the website. The impact of the website has been to connect social researchers with each other, as well as to connect users from other academic disciplines with social researchers, and to inform policy makers about issues relating to AMR from a social perspective.
First Year Of Impact 2017
Sector Healthcare
Impact Types Policy & public services

 
Description PI Clare Chandler invited to provide inputs into Wellcome Trust strategies on behaviour change for AMR on 21 Feb 2018, based on her participation in the WHO Behaviour Change Group
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a advisory committee
 
Description PI Clare Chandler member of WHO AMR Secretariat Behaviour Change Consultation on 6 Nov 2017 to define priorities and strategies for Pillar 1 of the Global Action Plan on AMR
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a advisory committee
 
Description Bloomsbury Colleges PhD Studentships 2017
Amount £77,109 (GBP)
Organisation Bloomsbury Colleges 
Sector Academic/University
Country United Kingdom
Start 09/2017 
End 08/2020
 
Description Fogarty International Centre PhD Studenship
Amount $20,469 (USD)
Funding ID D43TW010526 
Organisation Fogarty International Centre 
Sector Public
Country United States
Start 09/2017 
End 08/2020
 
Description Invited proposal from the WHO - Antibiotic Prescribing and Resistance: Views from LMIC Prescribing and Dispensing Professionals
Amount £96,600 (GBP)
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 06/2017 
End 03/2018
 
Description Medical Research Foundation National Training Programme in AMR
Amount £123,800 (GBP)
Funding ID MRF-145-0004-TPG-AVISO 
Organisation Medical Research Council (MRC) 
Department Medical Research Foundation
Sector Charity/Non Profit
Country United Kingdom
Start 09/2017 
End 12/2022
 
Title Awareness of AMR Survey for Human and Animal Health Professionals 
Description Our group has developed a tool for capturing levels of awareness amongst human and animal health care professionals. We developed it based on our initial qualitative research and are piloting the tool in 2018. The tool is particularly designed to gauge awareness of AMR amongst trained professionals in low and middle income country settings, and the initial piloting was done with the AMIS Hub's Uganda site. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2018 
Provided To Others? No  
Impact At this point we are still validating the tool and testing relevance across countries. 
 
Title Medicines use pile sorting survey 
Description Our group has developed a method for assessing familiarity with different types of antibiotics, interpretations of efficacy and resistance, and access to antibiotics. The method involves visiting residents of a particular study area and asking them to sort piles of medicines that have been acquired locally. We use the Open Data Kit software to record responses and are able then to assess responses against the World Health Organisation's 'Access, Watch and Reserve' list of antibiotics. We are testing this methodology in multiple countries within and beyond the AMIS Hub. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2018 
Provided To Others? No  
Impact At this point the method is still being tested, and once we have assessed its utility across settings we will publish it and make the survey tool and protocol available to others. 
 
Description AMIS Hub launch mentioned in the WHO Global Action Plan on AMR Newsletter No. 32 sent on 20 Nov 2017 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Mention of the AMIS Hub in the WHO AMR newsletter helps raise the profile of the Hub, which hopefully will lead to increased participation and engagement from stakeholders in future. "This new online hub and resource from the London School of Hygiene & Tropical Medicine, U.K., brings together research relevant to AMR from across different social science disciplines. Aimed at those designing and implementing AMR policy, as well as researchers from the life sciences, the AMIS Hub introduces readers to relevant social research on AMR. The AMIS research team will explore four key thematic strands across two countries - Thailand and Uganda."
Year(s) Of Engagement Activity 2017
 
Description AMIS Thai team first consultative meeting with their advisory board 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact AMIS Thai team held a consultative meeting with their advisory board on 7/11/17 consisting of senior members of the Thai AMR research, public communication and policy communities - engaging with the advisory board helps shape the Thai team's research and engagement activities, as well as keeps these leaders informed of the study's progress and findings. Attendees:
1. Prof. Visanu Thamlikitkul (Faculty of Medicine Siriraj Hospital)
2. Asst. Prof. Niyada Kiatyingangsulee (Center for Drug Development and Monitor)
3. Vanchai Tantivitayapitak (Director of News, PPTV channel)
4. Prof. Pattarachai Kiratisin (Faculty of Medicine, Siriraj Hospital)
5. Prof. Leuchai Sringernyuang (Mahidol University)
6. Dr. Komatra Cheungsatiansap (Ministry of Public Health)
7. Dr. Panoopat Poompreuk (Silpakorn University)
8. Dr. Uravadee Chanchamsaeng (Ministry of Public Health)
9. Mr. Sittichoke Chawraingern (Ministry of Public Health)
10. Miss Pakha Whanpuch (Mahidol University)
11. Miss Suchira Rompanatham (Ministry of Public Health)
Year(s) Of Engagement Activity 2017
 
Description AMIS featured in Winter 2018 issue of ESRC magazine Society Now 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact AMIS is featured on page 10 of the ESRC Society Now article on tackling AMR by focusing on social and behavioral issues.
Year(s) Of Engagement Activity 2018
URL http://www.esrc.ac.uk/files/news-events-and-publications/publications/magazines/society-now/society-...
 
Description Film screening and panel discussion for AMIS launch 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Following the screening of the classic 1940's British film "The Third Man" (which has a counterfeit antibiotics subplot), a panel, together with audience participation, discussed (a) how the film depicts the roles of antimicrobials in society after they had so recently been mass-produced; (b) how this has changed today; and (c) how the roles of antimicrobials has spread and gained traction across the world. There was positive feedback from members of the audience (approximately 150 in attendance) both during the event, and via email following the event.

Chair: Ms. Madlen Davies, health and science reporter at the Bureau of Investigative Journalism
1) Dr. Clare Chandler, Medical Anthropologist, co-Director of the Antimicrobial Resistance Centre & Principal Investigator of the AMIS Hub, LSHTM
2) Dr. Laura Shallcross, NIHR Clinician Scientist & Honorary Consultant in Public Health, UCL
3) Mr. Ross Macfarlane, Research Development Lead, Wellcome Collection
Year(s) Of Engagement Activity 2017
URL https://www.thebureauinvestigates.com/blog/2017-11-21/the-third-man-and-the-changing-role-of-antibio...
 
Description Launch of antimicrobialsinsociety.org, the AMIS Hub website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact The AMIS Hub (antimicrobialsinsociety.org) is an online resource that brings together research relevant to AMR from across social science disciplines. Aimed at those designing and implementing AMR policy, as well as researchers from the life sciences, the AMIS Hub introduces readers to a wealth of relevant social research on AMR. The AMIS Hub materials include research summaries, blogs 'from the field', and reviews of existing and ongoing research and theory. We envision the Hub as a mechanism for policy-makers and life scientists to engage with social science research on AMR, to forge future collaborations and to inspire new ways to address AMR. The Hub launched in late November 2017, and was officially announced to current and potential partners in our first e-newsletter which was sent out in December 2017 to 150 stakeholders. Feedback has been positive, site visits are routinely monitored, although impact is yet to be measured given the idea is to build the website over time, engaging with partners to provide and promote content.
Year(s) Of Engagement Activity 2017
URL http://www.antimicrobialsinsociety.org/
 
Description PI Clare Chandler featured in an LIDC podcast on 4 Dec 2017 on the global threat of AMR 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact This episode of "Development Matters" broadcast on SOAS Radio as part of the LIDC explores what exactly we mean by antibiotic resistance, the use of antibiotics in food production, the potentially devastating effects of not addressing antibiotic resistance and solutions to this frightening problem. The speakers were Dr Clare Chandler (Associate Professor in Medical Anthropology at the London School of Hygiene and Tropical Medicine) and Dr. Lucy Brunton (Lecturer in Molecular Epidemiology at the Royal Veterinary College).
Year(s) Of Engagement Activity 2017
URL https://soundcloud.com/soasradio/lidc-antibiotics
 
Description PI Clare Chandler profiled in the 13 Nov 2017 RCUK AMR Newsletter, in a feature titled Applying Social Science Theory to the Problem of AMR 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact Clare's work on applying social science theory was featured prominently in the RCUK AMR Newsletter, with a link to a detailed interview blog post, that emphasized the fresh perspectives approach the AMIS project brings to the field of AMR research.
Year(s) Of Engagement Activity 2017
URL https://blogs.rcuk.ac.uk/2017/11/09/applying-social-science-theory-to-the-problem-of-amr/
 
Description PI Clare Chandler quoted in Science Magazine on 7 March 2018 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Clare is quoted in Science Magazine talking about the unintended consequences of malaria RDT testing - such as increases in antibiotics use, changes in treatment seeking behaviour, in addition to strains on already weak health systems. Although it is hard to measure immediate impact, such engagement with scientific media helps contribute to the public discourse on AMR and ways to prevent it.
Year(s) Of Engagement Activity 2018
URL http://www.sciencemag.org/news/2018/03/malaria-free-still-sick-whats-giving-millions-kids-fevers
 
Description PI Clare Chandler quoted in the Guardian on 7 Nov 2017 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We hope Clare's expert quote in the Guardian on antibiotic use in farming will help shape the public discourse on AMR, although immediate public impact is hard to gauge or measure. One form of impact is that based on this and the Telegraph article, she was invited by the BMJ to provide an opinion piece for them, which was submitted and accepted in Feb 2018, and will be published shortly.
Year(s) Of Engagement Activity 2017
URL https://www.theguardian.com/environment/2017/nov/07/farmers-must-stop-antibiotics-use-in-animals-due...
 
Description PI Clare Chandler quoted in the Telegraph on 13 Nov 2017 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We hope Clare's quote in the Telegraph on three quarters of GPs incorrectly prescribing antibiotics will help shape the public discourse on AMR, although immediate public impact is hard to gauge or measure. One form of impact is that based on this and the Guardian article, she was invited by the BMJ to provide an opinion piece for them, which was submitted and accepted in Feb 2018, and will be published shortly.
Year(s) Of Engagement Activity 2017
URL http://www.telegraph.co.uk/science/2017/11/13/three-quarters-gps-still-wrongly-prescribing-antibioti...
 
Description PI Clare Chandler responded to several interview requests following contribution to UK Parliament event on Global Superbug Crisis on 31 Jan 2018 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Clare's contributions at the UK parliament event on the Global Superbug Crisis on 31/1/18 was followed up by interviews with journalists from Science magazine, Bureau of Investigative Journalism and the Independent, as well as by film makers preparing the 2019 Superbugs film
Year(s) Of Engagement Activity 2018