Supporting the National Action Plan for Antimicrobial Resistance (SNAP-AMR) in Tanzania

Lead Research Organisation: University of Glasgow
Department Name: College of Medical, Veterinary &Life Sci

Abstract

Antimicrobial resistance (AMR), the ability of bacteria to resist the effect of drugs, is a threat to human and animal health in resource rich nations like the UK and low and middle income countries like the United Republic of Tanzania. In Tanzania, as in many low and middle income countries, the AMR problem is compounded by the fact that people and livestock often live close together and widespread use of antimicrobials in both. In response to a global call to action from the World Health Organisation, Tanzania has created an ambitious National Action Plan to combat AMR, including improving awareness and understanding of the AMR problem among policy makers, professionals and the public and enhancing surveillance, research, infection prevention and antimicrobial stewardship in people and livestock. Successful implementation of the NAP is challenged by lack of human and financial resources, making prioritisation of activities and interventions an essential component of an effective and efficient campaign to control AMR.

Our research will provide new evidence to support this prioritisation and targeting, taking an approach that recognises that individuals are part of a larger system and that behaviour of professionals and the public may depend on policy, regulations or knowledge, but also on cultural background, social norms and access to medical, veterinary or diagnostic infrastructure and drugs. Our team of UK and Tanzania-based researchers and policy experts will take an interdisciplinary approach, working with a wide range of biological and social scientists as well as health professionals and community members, to provide novel insights into cultural, socio-economic and biological drivers of antimicrobial use (AMU) in hospitals and the community and in contextually appropriate methods of communication around those issues.

The origin of AMR problems can be described as hospital-, community- or livestock-associated so we will work with doctors and nurses, householders and patients, and veterinarians and livestock keepers as well as (in)formal drug providers and other stakeholders to investigate knowledges, beliefs, attitudes and practices around health and AMU/AMR. We will compare health care settings (health centres, district, regional and referral hospitals) and livestock keeping communities (Chagga, Masaai and Sukuma) to reflect a range of professional and cultural contexts. Using focus group discussions, questionnaires and interviews, we will examine factors that influence prescribing and use of antimicrobials and through choice experiments we will examine how changes in e.g. knowledges, social norms or access might change such behaviour. To complement the socio-economic investigations, we will use DNA-sequencing of hospital -, community - or livestock-associate bacteria in combination with mathematical modelling approaches to establish the relative contribution of different sources and transmission routes to the clinical and economic burden of AMR. The combination of insight into the drivers and relative importance of behaviours that may contribute to the AMR problem provides a unique opportunity to identify and prioritise levers of behavioural change to reduce AMU and limit the risk and impact of AMR.

Finally but importantly, we will work with policy makers, professionals and the public to design context-specific messages and methods to communicate AMR awareness and infection prevention and control messages in hospitals and community settings, and evaluate the impact of those communication campaigns using a combination of the social and biological sciences methods described above. The combined outcomes of our research will help priority setting in AMR control by identifying the settings where change is practicable and cost-effective. It will inform implementation of the National Action Plan in Tanzania and serve as a generalisable transdisciplinary model of AMR control in low and middle income country settings.

Technical Summary

We aim to provide novel insights into biological, social and cultural drivers of AMR within and out with hospitals at individual (inherent), micro- (community), meso- (institutional) and macro- (policy) level to prioritise use of limited human and financial resources in targeting evidence-based levers of behavioural change that will reduce the risk and burden of AMR.

Socio-anthropological methods to elicit information on knowledge, attitudes, practices and access to antimicrobials across tiers of the hospital system and distinct livestock keeping communities include focus group discussions, surveys, questionnaires, in depth interviews and observations to foster stakeholder discussion, elicit community views, provide quantitative data, seek detailed information on key knowledges, and cross check responses. This will provide a rich baseline understanding to inform the design of stated choice experiments, which will complement a micro-costings approach to generate evidence on (non-)pecuniary incentives to motivate intentions for behaviour change in antimicrobial use.

We will examine genomic data from hospital, community and livestock associated Escherichia coli using phylogenetic and diversity analysis and source attribution methods to explore the contribution of within- and between hospital transmission and human or animal associated AMR in the community to clinical burden. This evidence will enable us to prioritise levers of change in hospitals and livestock-keeping communities based on predicted impact and cost-benefit.

Using a bespoke theoretically informed approach we will co-construct, design, deliver and evaluate an AMR awareness campaign at hospital and community level to learn how best to communicate in a culturally appropriate context and manner. By involving professionals, the public and policy makers these campaigns will also contribute to capacity strengthening across all layers of society in Tanzania.

Planned Impact

Context: Antimicrobial resistance (AMR) is a major threat to humanity. Most of the direct and indirect impacts of AMR are felt in low- and middle-income countries (LMIC), where basic sanitation and medical provisions are often limited, and treatment of common conditions such as diarrhoea, respiratory disease or urinary tract infection relies on antimicrobials. On the DAC list of ODA recipients, the United Republic of Tanzania is classed among the least developed LMIC, and over 30% of its population lives under the national poverty line. To combat AMR and its impacts on people's lives, livelihoods and food security, the World Health Organization adopted a Global Action Plan for AMR, urging all member countries to develop National Action Plans (NAPs). The government of Tanzania heeded this call and presented its NAP in early 2017. Our transdisciplinary research into the drivers and burden of AMR in Tanzania will support the NAP's objectives of strengthening the knowledge and evidence base on AMR and improving awareness and understanding of AMR across policy, professional and public stakeholders.

Policy makers: The NAP includes an analysis of strengths, weaknesses, opportunities and threats. Lack of resources is cited as a major threat to successful implementation of the NAP, whilst inadequate public awareness and communication programmes are recognised as major weaknesses.
Implementation of the NAP is coordinated by the AMR Focal point, a unit within the Ministry of Health, Community Development, Gender, Elderly and Children, in collaboration with the Ministry of Livestock and Fisheries and the One Health Coordination Unit under the Prime Minister's Office. Policy makers across those units will benefit from our research on culturally relevant communication methods and messages for professional and public audiences, and from capacity strengthening in media campaign design and impact evaluation. In addition, our research will support prioritisation of audiences and messages to allow for optimal use of limited government resources for AMR control.

Professionals: As prescribers and sellers of antimicrobials for use by people and livestock, the medical, veterinary and pharmaceutical professions play a key role in responsible use of medicines and AMR control. We will work with members of those professions to understand their role in antimicrobial use and drivers of their prescribing behaviour. This provides them with a chance to discuss the pressures and constraints they face in their professional roles as well as their needs, e.g. in development of AMR policy and legislation, communication campaigns for prescribers and users of antimicrobials, or other types of research and capacity strengthening. Although our focus is on health care professionals, we will also provide capacity building in other disciplines, e.g. health economics, to support development of a whole system thinking to AMR control.

Public: The health of all people and animals, in Tanzania and globally, would benefit from improved control of AMR. However, the need to limit AMR must not be misconstrued as an obstacle to access to antimicrobials as life-saving drugs. We will investigate how people understand and access health care for themselves and their animals, and how this access might be improved to obtain a better balance between underuse and overuse of antimicrobials. Our project, particularly the co-design and implementation of awareness campaigns, will help the public and us understand the threat that AMR poses to their lives, livestock and livelihoods as well as their contribution to the risk of AMR and what they can do to reduce that risk. With no major new developments in drug discovery, reduced use and reduced production of antimicrobials are major tools in protecting the public from AMR and safeguarding the efficacy of our existing drugs for future generations.
 
Title Dala Dala Song 
Description Song written and CD produced. 
Type Of Art Composition/Score 
Year Produced 2021 
Impact Now being played in Dala Dalas (Taxis) 
 
Description We now started to publish findings
Exploitation Route too early to say
Sectors Healthcare

 
Description An integrated approach to tackling drug resistance in livestock trypanosomes.
Amount £343,273 (GBP)
Funding ID BB/S000143/1 
Organisation Biotechnology and Biological Sciences Research Council (BBSRC) 
Sector Public
Country United Kingdom
Start 01/2019 
End 12/2021
 
Description Supporting the National Action Plan for Antimicrobial Resistance (SNAP-AMR) in Tanzania
Amount £3,089,371 (GBP)
Funding ID MR/S004815/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 04/2018 
End 04/2021
 
Description SNAP-AMR Annual Science Days 
Organisation Catholic University of Health and Allied Sciences
Country Tanzania, United Republic of 
Sector Academic/University 
PI Contribution SNAP-AMR Annual Science Days
Collaborator Contribution Fieldwork
Impact Developing Essential Information Pack
Start Year 2019
 
Description SNAP-AMR Annual Science Days 
Organisation Kilimanjaro Clinical Research Institute
Country Tanzania, United Republic of 
Sector Academic/University 
PI Contribution SNAP-AMR Annual Science Days
Collaborator Contribution Fieldwork
Impact Developing Essential Information Pack
Start Year 2019
 
Description Antimicrobial Resistance - Genomes, Big Data and Emerging Technologies, Wellcome Genome - Poster 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Event: Antimicrobial Resistance - Genomes, Big Data and Emerging Technologies, 27-29 November 2018, Hinxton
Authors: Mshana S1, Laurie E2, McIntosh E2, Shirima G3, Davis A2, Lembo T2, Hanley N2, Mmbaga BT4, Matthews L2, Oravcova K2, Mapunjo S5, Hilton S2, Van der Meer F6, Call DR7, Zadoks RN2
Title: Supporting the National Action Plan on AMR in Tanzania - SNAP-AMR
Year(s) Of Engagement Activity 2018
 
Description Dala Dala Workshops 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Dala Dala Workshops
Year(s) Of Engagement Activity 2021
 
Description Essential Information Pack on Antimicrobial Resistance Workshops 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Essential Information Pack on Antimicrobial Resistance
Year(s) Of Engagement Activity 2021
 
Description IMMEM, Dubrovnik, Sep 2019 - Poster presentation 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Event: 12th International Meeting on Microbial Epidemiological Markers (IMMEM XII) "Moving towards genome-based pathogen surveillance - lessons learnt and challenges ahead", an ESCMID - ESGEM Conference, 18-21 September 2019, Dubrovnik, Croatia
Authors: Jeremiah Seni, Nyambura Moremi, Vitus Silago, Stephen E. Mshana, Dorottya Kovacs, Louise Matthews, Ruth N. Zadoks, Katarina Oravcova
Title: ESBL Escherichia coli diversity amongst meat and meat sellers in North-Western Tanzania
Year(s) Of Engagement Activity 2019
URL https://www.escmid.org/research_projects/escmid_conferences/immemxii/
 
Description IVVN presentation on AMR and vaccination 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Invited presentation "Could and Should Vaccination be Used to Control Antimicrobial Use or Antimicrobial Resistance in Animal Populations?" at the UK & International Veterinary Vaccinology Network Conference, London, January 2019
Year(s) Of Engagement Activity 2019
 
Description Instagram Post [Bugando Medical Centre] 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Instagram Post [Bugando Medical Centre]
Year(s) Of Engagement Activity 2021
URL https://www.instagram.com/p/CQ_S815HfDm/
 
Description Participatory workshops with key stakeholders and clinicians 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Study participants or study members
Results and Impact A series of participatory workshops with key stakeholders and clinicians were held to iteratively develop campaign messaging and ensure it was grounded in context as well as data. One such workshop was held during the annual meeting and the others in the target hospitals. A bespoke participatory 'game' was created to help direct discussions in a constructive way.
Year(s) Of Engagement Activity 2019,2020
 
Description Reaction to member of parliament tweet and retweets [Dr Norman Jonas] 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Reaction to member of parliament tweet and retweets "Great Initiative... Community engagement for health promotion. [Dr Norman Jonas]
Year(s) Of Engagement Activity 2022
URL https://twitter.com/NormanJonasMD/status/1500154976173436928
 
Description Reaction to member of parliament tweet and retweets [Pharmacist Cliff Dotto] 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Reaction to member of parliament tweet and retweets "We need to continue to provide education as professionals everywhere because we still have a lot of challenges on issues of proper use of drugs for many Tanzanians when they recover they know they have recovered without completing the dose @ wizara_afyatz @Pharm_Council @tmda_tanzania @ummymwalimu" [Pharmacist Cliff Dotto]
Year(s) Of Engagement Activity 2022
URL https://twitter.com/Chriphorddotto6/status/1500487087535046657
 
Description Reaction to member of parliament tweet and retweets [TAPSA-cuhas] 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Reaction to member of parliament tweet and retweets "Spreading the knowledge" [TAPSA-cuhas]
Year(s) Of Engagement Activity 2022
URL https://twitter.com/tapsacuhas/status/1500486052825419782
 
Description Reaction to member of parliament tweet and retweets [Tumaini Makole] 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Reaction to member of parliament tweet and retweets "Communicating a message in a simple way to the community about #AntimicrobialResistance" [Tumaini Makole]
Year(s) Of Engagement Activity 2022
URL https://twitter.com/neemalugangira/status/1500154277792260100/retweets/with_comments
 
Description Reaction to member of parliament tweet and retweets [Udom Health Club] 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Reaction to member of parliament tweet and retweets "As each ambassador together we can put an end to parasitic resistance. #antibioticresistance" [Udom Health Club]
Year(s) Of Engagement Activity 2022
URL https://twitter.com/udomhealthclub/status/1500171770913071105
 
Description SEFARI AMR presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Invited presentation "Introducing AMR" by grant holder Prof. R Zadoks at Scottish Government supported SEFARI event "Antimicrobials and Food production:
Should we be worried?" held on 25 September 2018 in Edinburgh
Year(s) Of Engagement Activity 2018
 
Description SNAP_AMR launch and symposium 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Official launch SNAP_AMR project by Chief Pharmaceutical Officer of Tanzania at Graduation Symposium of Catholic University of Health and Allied Sciences, Mwanza, Tanzania. Presentations by SNAP_AMR team members Prof. S. Mhana, Prof R. Zadoks, Dr. J. Seni, Prof. L. Matthews, and press interviews by Prof. S. Mshana.
Year(s) Of Engagement Activity 2018
 
Description SNAP_AMR presentation RZ at HATUA launch 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Presentation on SNAP_AMR and MRC funded activity in East-Africa by grant holder Prof. R. Zadoks at HATUA launch event in Tanzania.
Year(s) Of Engagement Activity 2018
 
Description Social media reaction to campaign material, individual unknown. 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Social media reaction to campaign material, individual unknown.
Year(s) Of Engagement Activity 2022
 
Description Social science training workshop Arusha 2019 
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 Training workshop in qualitative social science by SNAP_AMR team members Dr A. Davis and Dr. T. Lembo, targeting SNAP_AMR co-investigators and field team members as well as postgraduate students in AfriqueOne training programme.
Year(s) Of Engagement Activity 2019
 
Description The post-antibiotic apocalypse?, E Laurie - Royal Geographical Society, August 2019 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Presentation by Dr Emma Laurie titled 'The post-antibiotic apocalypse?' at the Royal Geographical Society - Institute of British Geographers International Annual Conference, London, UK, August 2019
Year(s) Of Engagement Activity 2019
 
Description Tweet by a Member of Parliament 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Tweet by a Member of Parliament "I hailed a taxi here #Mwanza and came across these messages about the importance of completing doses of antibiotics and side effects. What I was happy about was when I asked him if these advertisements had been paid, he said no he went @BugandoC and found them providing Education, he saw others educated through his car [inc. pictures of signage]"
Year(s) Of Engagement Activity 2022
URL https://twitter.com/neemalugangira/status/1500154277792260100
 
Description [YouTube Video] SNAP-AMR: Supporting the Tanzanian National Action Plan for Antimicrobial Resistance 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact [YouTube Video] SNAP-AMR: Supporting the Tanzanian National Action Plan for Antimicrobial Resistance
Year(s) Of Engagement Activity 2022
URL https://www.youtube.com/watch?v=Hnqsngi1t6M