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.

Publications

10 25 50
 
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 Academic/University
Country United Kingdom
Start 05/2018 
End 04/2021
 
Description BMC 
Organisation Bugando Medical Centre
PI Contribution We initiated collaboration with Bugando Medical Centre in Mwanza, Tanzania. We visited BMC and met with key administrative contacts. We have since set up an MoU with BMC and involved BMC as a partner on an MRC grant application.
Collaborator Contribution Professor Stephen Mshana from Bugando Medical Centre participated in several workshops on AMR, hosted a visit by delegates from the University of Glasgow, facilitated the signing of an MoU and contributed to the writing of a grant proposal that is under consideration by MRC.
Impact This collaboration is multi-disciplinary and involves one or more representatives of the following disciplines: anthropology, epidemiology, genomics, health economics, human geography, mathematics, medical science, microbiology, pharmacology, sociology, veterinary medicine
Start Year 2017
 
Description Calgary 
Organisation University of Calgary
Country Canada 
Sector Academic/University 
PI Contribution We approached the partner, engaged in discussions, and invited them to contribute to a grant application.
Collaborator Contribution The University of Calgary shared expertise and ideas with us to inform the writing of a grant application, on which a member of their staff is a co-investigator.
Impact Interdisciplinary grant application involving one or more representatives of the following disciplines: anthropology, epidemiology, genomics, health economics, human geography, mathematics, medicine, microbiology, pharmacology, sociology, veterinary medicine
Start Year 2017
 
Description HAZEL-NMAIST 
Organisation Nelson Mandela African Institute for Science and Technology
Country Tanzania, United Republic of 
Sector Academic/University 
PI Contribution I led the write up of the grant proposal HAZEL; submitted under the ZELS call, with contributions from my research team.
Collaborator Contribution Prof. Paul Gwakisa contributed to the writing of the grant proposal HAZEL that was submitted under the ZELS call. NMAIST hosted the launch meeting in Arusha, Tanzania, in December 2014. Professor Joram Buza has since taken over as lead contact for this project. Prof Buza participated in the BBSRC-DfiD ZELS launch meeting in London, 10 November 2014, and in a project specific meeting in London, 11 November 2014. Prof Buza contributes regularly to project discussions and hosted the 2017 Grantholders' Meeting at NM-AIST.
Impact Successful application for the HAZEL project funding. This is a multi-disciplinary collaboration involving medics, veterinarians, quantitative scientists, social scientists, and molecular epidemiologists. Successful application for funding of the Afrique One ASPIRE project Co-supervision of an MSc project: Assessment of risk factors that lead to prevalence of Salmonella and Campylobacter in chicken managed in different production systems Co-supervision of a PhD project: Development of surveillance and typing schemes for anthrax epidemiological studies in endemic areas Conference Presentations: Thomas KM, Crump JA, Benschop J, Buza J, Cleaveland S, French N, Karimuribo E, Kazwala R, Mmbaga B, Mtui N, Prinsen G, Sharp J, Swai E, Zadoks R. 2016. Hazards Associated with Zoonotic enteric pathogens in Emerging Livestock meat pathways (HAZEL) - Understanding meat safety in Tanzania through a One Health approach. Abstract number OR-VF-025. FoodMicro2016. 25th International Committee on Food Microbiology and Hygiene Conference. Dublin, Ireland. 19-22 July 2016. R. Zadoks, K. Thomas, G. Barker, J. Benschop, J. Buza, S. Cleaveland, M. Davis, N. French, E. Karimuribo, R. Kazwala, B. Mmbaga, N. Mtui, G. Prinsen, J. Sharp, E. Swai, L. Waldman, J. Crump. Of Meat and Men, Models and Microbes - Understanding Salmonella risks in Tanzania's Meat Supply Chain. . 34th Tanzania Veterinary Association Conference, 6-8 December 2016, Arusha, Tanzania. Audience: veterinarians, policy makers, PhD students, researchers.
Start Year 2012
 
Description KCMC 
Organisation Kilimanjaro Christian Medical Centre (KCMS)
Country Tanzania, United Republic of 
Sector Hospitals 
PI Contribution I led the write up of the grant proposal HAZEL; submitted under the ZELS call, with contributions from my research team. I also led the writing of the SNAP-AMR consortium building grant and the full SNAP-AMR grant with KCMC as partner.
Collaborator Contribution Prof. Moshi Ntabaye contributed to the writing of the grant proposal HAZEL; that was submitted under the ZELS call. Prof. Gibson Kibiki initially took over as the main collaborator and he helped our team to implement a BSL2 laboratory for testing of samples of animal origin at the Kilimanjaro Clinical Research Institute where the laboratory component of our project will be based. Gibson Kibiki was replaced by Prof Blandina Mmbaga in mid-2015, and has contributed intellectually to the ongoing research. Prof Mmbaga attends monthly skype calls and attended two ZELS grantholders' workshop' in 2015 (Cambridge) and 2017 (Arusha). Prof Mmbaga contributed to writing of the SNAP-AMR consortium building and full grant proposals.
Impact Successful funding application for the HAZEL project Operationalization of a new Zoonoses Laboratory at the Kilimanjaro Clinical Research Institute Successful application for Afrique One ASPIRE project funding Successful application for Marie Curie Fellowship (MEBA - DLV-659223): Molecular epidemiology of Bacillus anthracis: novel data and techniques for local surveillance in Tanzania. Fellow: Taya Forde (UoG). Lab work is being conducted at the Zoonoses Laboratory UoG undergraduate veterinary student Milou Nijenhuis conducted a placement in the Zoonoses Lab in Moshi. Co-Supervision of PhD Student: Development of surveillance and typing schemes for anthrax epidemiological studies in endemic areas Conference Presentations: Thomas KM, Crump JA, Benschop J, Buza J, Cleaveland S, French N, Karimuribo E, Kazwala R, Mmbaga B, Mtui N, Prinsen G, Sharp J, Swai E, Zadoks R. 2016. Hazards Associated with Zoonotic enteric pathogens in Emerging Livestock meat pathways (HAZEL) - Understanding meat safety in Tanzania through a One Health approach. Abstract number OR-VF-025. FoodMicro2016. 25th International Committee on Food Microbiology and Hygiene Conference. Dublin, Ireland. 19-22 July 2016. R. Zadoks, K. Thomas, G. Barker, J. Benschop, J. Buza, S. Cleaveland, M. Davis, N. French, E. Karimuribo, R. Kazwala, B. Mmbaga, N. Mtui, G. Prinsen, J. Sharp, E. Swai, L. Waldman, J. Crump. Of Meat and Men, Models and Microbes - Understanding Salmonella risks in Tanzania's Meat Supply Chain. . 34th Tanzania Veterinary Association Conference, 6-8 December 2016, Arusha, Tanzania. Audience: veterinarians, policy makers, PhD students, researchers.
Start Year 2012
 
Description WSU 
Organisation Washington State University
Country United States 
Sector Academic/University 
PI Contribution I led the write up of the grant proposal HAZEL; submitted under the ZELS call, with contributions from my research team.
Collaborator Contribution Dr. Margaret Davis contributed to the writing of the grant proposal HAZEL; that was submitted under the ZELS call. Dr Davis contributes intellectual input into project activities and attends annual in-person meetings and monthly skype calls. Conference Presentations: G. Prinsen, J. Benschop, N. French, E. Swai, R. Zadoks, J. Sharp, L. Waldman. Food Safety Awareness and Practices in Urban and Rural Butcheries and Eateries in Northern Tanzania. 34th Tanzania Veterinary Association Conference, 6-8 December 2016, Arusha, Tanzania. Audience: veterinarians, policy makers, PhD students, researchers. G. Prinsen, J. Benschop, N. French, E. Swai, R. Zadoks, J. Sharp, L. Waldman. Food Safety Awareness and Practices in Urban and Rural Butcheries and Eateries in Northern Tanzania. 9th Biennial Conference New Zealand International Development Studies Network, 5-7 December 2016, Wellington, New Zealand. Audience: researchers, development experts. R. Zadoks, K. Thomas, G. Barker, J. Benschop, J. Buza, S. Cleaveland, M. Davis, N. French, E. Karimuribo, R. Kazwala, B. Mmbaga, N. Mtui, G. Prinsen, J. Sharp, E. Swai, L. Waldman, J. Crump. Of Meat and Men, Models and Microbes - Understanding Salmonella risks in Tanzania's Meat Supply Chain. . 34th Tanzania Veterinary Association Conference, 6-8 December 2016, Arusha, Tanzania. Audience: veterinarians, policy makers, PhD students, researchers. Since then, the collaboration has been extended to include Professor Douglas Call, who has shared a collection of ~600 AMR resistant E. coli isolates with us to inform writing of a follow-on grant proposal.
Impact (1) Successful application for funding of the HAZEL project. This is a multi-disciplinary collaboration involving medics, veterinarians, quantitative scientists, social scientists, and molecular epidemiologists. (2) Submission of a grant application to MRC. This is a multi-disciplinary collaboration involving representatives of the following disciplines: anthropology, bioinformatics, health economics, epidemiology, human geography, mathematics, medicine, microbiology, pharmacology, sociology, veterinary medicine
Start Year 2012
 
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 Invited presentation at Infection Biology symposium, Calgary 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Invited presentation at Infection Biology symposium, University of Calgary, 6-7 September 2018.
Year(s) Of Engagement Activity 2018
 
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 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