One Health Drivers of Antibacterial Resistance in Thailand

Lead Research Organisation: University of Bristol
Department Name: Cellular and Molecular Medicine

Abstract

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

Technical Summary

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.

Planned Impact

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.
 
Description FARMS-SAFE: Future-proofing Antibacterial resistance Risk Management Surveillance and Stewardship in the Argentinian Farming Environment
Amount £989,327 (GBP)
Funding ID BB/T004592/1 
Organisation Biotechnology and Biological Sciences Research Council (BBSRC) 
Sector Public
Country United Kingdom
Start 07/2019 
End 05/2022
 
Description One Health Drivers of Antibacterial Resistance in Thailand
Amount £2,919,177 (GBP)
Funding ID MR/S004769/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 05/2018 
End 04/2021
 
Description AMR Force (Reyher) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Exploration of collaboration opportunities with VMD, Langford
Year(s) Of Engagement Activity 2019,2020
 
Description Agriculture and Horticulture Development Board Mastitis Control Plan Management Group meeting (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Mastitis Control Plan Management Group Committee meeting in Wells
Year(s) Of Engagement Activity 2019
 
Description Bristol AMR/Colston Research Symposium. The Antibiotic Age: The End or a New Beginning? 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Gave a speech entitled: 'Antibiotics Anonymous - Antimicrobial stewardship and voluntary reduction across the UK livestock sectors' and networked with conference attendees
Year(s) Of Engagement Activity 2019
URL https://www.bristol.ac.uk/amr/events/2019/colston-research-society-symposium.html
 
Description Bristol, North Somerset, South Gloucestershire CCG, One Health AMR meeting (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Meeting of the Bristol, North Somerset, South Gloucestershire Clincial Commissioning Group One Health AMR meeting at Bristol Royal Infirmary
Year(s) Of Engagement Activity 2019
 
Description CHAWG AMU Steering group (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Cattle Health and Welfare Group, Antimicrobial Use Group steering group committee meeting in London
Year(s) Of Engagement Activity 2019
 
Description Capacity Building Workshop for FARMS-SAFE research group 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Postgraduate students
Results and Impact The Capacity Building Workshop was held at the Faculty of Veterinary Medicine of University of La Plata from 3rd to 7th February 2020. The workshop was facilitated by the UK & Argentine PIs and CoIs to learn more about farm systems and the data that exists in Argentina, especially in La Plata and Cordoba.
By adopting a participatory approach SOPs were designed for data and sample collection for: i) drafting a national survey & tools for WS1 and WS2, ii) AMU and AMR for WS3, iv) AMR and AM/chemical contamination for WS4 and v) developing a risk-based approach to targeting AMR for WS5. National Autorities from SENASA, academics and postgraduate students from UNLP and Rio Cuarto as well as the team from UoB participated in the meeting.
During the workshop farm visits were organised for both the UK and Argentine colleagues to interview and participatorily observe and analyse the different farming practices among dairy and pig farms around La Plata.
Year(s) Of Engagement Activity 2020
 
Description Cattle Health and Welfare AMU Steering Group (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact committee meeting of the steering group on Cattle Health and Welfare at Stoneleigh
Year(s) Of Engagement Activity 2019
 
Description Chulabhorn Royal Academy (CRA) Visit 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Worked with Bristol Veterinary School to welcome and discuss opportunities for training and research alongside the Chulabhorn Royal Academy in Thailand
Year(s) Of Engagement Activity 2019
 
Description Collaborative meeting with Rothamsted Research 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact North Wyke Farm Platform researchers visiting Langford as a collaborative meeting with Rothamsted Research; talked about potential collaborations and updated on work
Year(s) Of Engagement Activity 2019
 
Description Food Industry Initiative on Antimicrobials Research & Development Committee + Data Committee - Quarterly Meeting (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Quarterly committee meeting of the Food Industry Initiative on Antimicrobials Research & Development Committee + Data Committee
Year(s) Of Engagement Activity 2019
 
Description Gloucestershire One Health AMR group (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Prepared communication plan for Gloucestershire on One Health AMR
Year(s) Of Engagement Activity 2019
 
Description Grant Launch Workshop - UK & Argentina AMR in the environment 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact The Grant Launch Workshop was organised by BBSRC & CONICET. Five projects funded through DoHSC/UKAid (along with BBSRC & NERC) in the UK and CONICET in Argentina presented their workpackages in order to create a collective proposal to develop a Pan-Program Intregration Project (PPIP) and policy translation activities within the Argentine context. A draft PPIP document was gathered from the workshop aiming to:

- Aim 1 Combine expertise and data from all five project teams to provide consistency to (i) the co-design of policy with agricultural livestock sectors (ii) the measurement of antimicriobial use (AMU) and resistance (AMR), and (iii) knowledge exchange messages across all the livestock species and production systems encompassed by the program.
- Aim 2 "A whole that is greater than the sum of its parts" - to generate research outcomes at the level of the program that would not be possible for any one project alone through combining effort and new work in specifically defined areas.

The aims will be addressed through four work packages. UoB through the FARMS-SAFE project leads Work Package 1 (WP1) - Harmonising antimicrobial use and data collection.
Year(s) Of Engagement Activity 2019
URL https://bbsrc.ukri.org/news/events/2018/1806-argentina-antimicrobial-resistance/
 
Description Host Head of Population Health and Head of Research, Ontario Veterinary College, Guelph University, Ontario, Canada 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Discuss AMR research and possible overlaps in collaborations
Year(s) Of Engagement Activity 2019
 
Description International Antibiotic Usage Forum (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Collaborative catch-up with AMR groups around the world - collaborations and contributions to practice
Year(s) Of Engagement Activity 2019
 
Description Interview for BBC Points West 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Discussed AMR research at the Bristol Veterinary School on 14th November 2019.
Year(s) Of Engagement Activity 2019
 
Description Involvement in AMR in a Global Context Meeting, Bangkok. 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Avison chaired and spoke at a two-day workshop about AMR in Thailand, involving representatives from academia, medicine, agriculture and government ministries. This led to the establishment of a research collaboration and successful GCRF project grant
Year(s) Of Engagement Activity 2017
 
Description Lecture to vet students - Bristol University 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Undergraduate students
Results and Impact Training of practitioners and professionals: Lecture on "Big ideas in veterinary medicine: AMR" to veterinary students
Year(s) Of Engagement Activity 2019
 
Description MOOC, Creating course on antimicrobial stewardship for vets (Reyher) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Discussion about AMR Massive Open Online Course phone meeting re training of practitioners and professionals
Year(s) Of Engagement Activity 2019
 
Description MRC Blog Antimicrobial resistance in Thailand: taking a holistic approach 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Following the launch of the project, Matthew Avison was interviewed by MRC comms and the information used to develop this blog post, which was used in part to advertise MRC investment into the global challenge of AMR, but also to give insight into interdisciplinary working. The release generated considerable social media engagement, and has subsequently been used by MRC in promotional material concerning AMR investment.
Year(s) Of Engagement Activity 2018
URL https://mrc.ukri.org/news/blog/antimicrobial-resistance-in-thailand-taking-a-holistic-approach/?redi...
 
Description Medical Research Foundation AMR PhD student cohort meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Gave a talk at the training day for PhD students - discussed my background and journey in research and AMR research at Bristol - 15th November 2020.
Year(s) Of Engagement Activity 2019
 
Description Meeting with representatives of the Welsh Government 
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 Phone meeting with Welsh Government to discuss about AMR
Year(s) Of Engagement Activity 2019
 
Description Project presentation to the research community at University of La Plata 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Organised by the Faculty of Veterinary Medicine of the University of La Plata, up to 60 Postgraduate students and Senior Researchers attended this talk on:

1.Selection and transmission of AMR in a One Health context, Matthew Avison.
2.Investigating prescription, usage and control of veterinary medicines: methods and insights from a social science approach, Maria Paula Escobar.
3.Strategies to optimize antimicrobial efficacy in veterinary medicine in the context of One Health, Nora Mestorino
4.FARMS-SAFE, an overview of the project, Kristen Reyher
Year(s) Of Engagement Activity 2019
 
Description RUMA Independent Scientific Group committee meeting (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Responsible Use of medicines in Agriculture Alliance (RUMA) scientific group meeting in London
Year(s) Of Engagement Activity 2019
 
Description Research meeting with representative from Boehringer Ingelheim 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Research meeting with representative from Boehringer Ingelheim to discuss AMR topics
Year(s) Of Engagement Activity 2019
 
Description Responsible use of medicines in Agriculture Alliance (RUMA) Targets Task Force 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Gave an invited talk to challenge livestock industries in AM stewardship targets in Stoneleigh on 10th September 2019
Year(s) Of Engagement Activity 2019
 
Description Royal Society of Biology meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Invited by the Royal Society of Biology to talk about AMR research, specifically transmission of AMR - overview of talk will be loaded on their blog
Year(s) Of Engagement Activity 2019
 
Description Speak with BBC Radio4 Costing the Earth 
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 Media (as a channel to the public)
Results and Impact Phone interview with the BBC Radio4 to discuss AMR research - background information to be used in radio presentation
Year(s) Of Engagement Activity 2020
 
Description Speak with Channel 4 Dispatches 
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 Media (as a channel to the public)
Results and Impact Phone interview with Channel 4 Dispatches to inform a documentary about food safety
Year(s) Of Engagement Activity 2020
 
Description Veterinary Schools Council AMR (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact phone meeting
Year(s) Of Engagement Activity 2019
 
Description Veterinary Schools Council, AMR (Reyher) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Phone meeting with committee
Year(s) Of Engagement Activity 2019