TRICLAP: Tricycle surveillance and a community-led AMR stewardship

Our solution aims to optimize antimicrobial use in humans and livestock through evidence-based community-led AMR stewardship with a special focus on childhood febrile illness (FI). The stewardship program will be guided by the evidence from tricycle-based surveillance, identifying health-system drivers and genomic traits. 

Kshitij Karki, Program Director at GTA Foundation, and associate professor at Purbanchal University of Nepal. He has 17 years of experience in public health, surveillance, research, and AMR stewardship programs. 

The global crisis of Antimicrobial Resistance (AMR) claims approximately 1.27 million lives each year, with one in five deaths occurring among children under the age of 5 (WHO 2019). In Nepal, an estimated 23,200 deaths were attributed to AMR in the same year.

Children under 5 are especially vulnerable to FI. However, in Nepal, the vulnerability to diseases is often underreported and underestimated due to limited diagnostic and surveillance systems at healthcare facilities. This leads to the overprescription of antimicrobial drugs among children. In 2020, out of 42,897 registered cases of childhood illnesses, 9.89% were identified as Possible Severe Bacterial Infections, with antibiotics being the primary treatment administered by paramedics, sometimes lacking proper qualification.

The Nepalese healthcare system is largely driven by private sectors, resulting in a concerning 77.5% of over-the-counter antimicrobial prescriptions for children in Kathmandu, the capital city. The situation is even more critical in rural areas, necessitating urgent attention.

Additionally, the extensive use of antimicrobials in the livestock sector as growth promoters and for disease prevention leads to residues in food and water, contributing to the development of resistant microbes. Inadequate surveillance, over-the-counter sales, and lack of policy oversight exacerbate the issue. We will address these issues.

The solution will engage parents and caregivers, community members, healthcare providers, public health officials, veterinarians and animal health workers, and policymakers.

We seek to support the targeted beneficiaries through awareness among parents and community members, training and development of standard treatment guidelines for health workers, and veterinarians, and policy advocacy. The solution focuses on surveillance to identify the pattern of AMR and AMU. Through community-level surveys, we will assess health system drivers, knowledge, attitudes and practices, related to AMR and AMU and stewardship and identify the gaps. The genomic traits of the pathogens from human, animal and environment samples will be examined to assess AMR risks for childhood FI.

Community-led AMR stewardship programs will be designed by engaging community members through the formation of community stewardship groups (CSG). It will be composed of health workers, farmers, parents, and veterinarians at the community level. The CSG will help ensure that local voices and perspectives are integrated and tailored during both the project planning and implementation phases.

Our solution aims to provide a mobile application for data gathering, integration, interpretation and education. We commit to a peer-reviewed publication disseminating findings and aiding LMICs. It contributes to global knowledge on childhood AMR and AMU. Our tricycle approach includes regular AMR and AMU surveillance, generating open-access data for evidence-based interventions and policy design. We emphasize training programs and public campaigns for responsible AMU.

This process is expected to benefit the target population by providing data-driven insights into antimicrobial use, resistance prevalence, and health system drivers.

Below is the logical links between the activities, outputs and outcomes;

Activities                   

• Collect data regarding AMU and AMR     
• Informed strategies for one health and policies including evidence-based data
• Gather data using mixed methods and analyze community-level health system drivers
• Collect, test and analyze genomic traits from animal, human, and environmental samples
• Develop education and training materials
• Conduct stewardship program that includes training, capacity building, stakeholder engagement
• Evaluate stewardship program

Outputs

• Conducted community-level surveillance for AMU and AMR
• Identified factors influencing AMU and AMR at the municipality level
• Assessed prevalence of AMU and AMR among children under 5 with febrile illness
• Assessed risk factors of AMR through genomic analysis
• Education and training program conducted 
• Community stakeholders engaged through Community Stewardship Group (CSG)

Outcomes

• Optimized AMU and mitigating AMR among children under 5 with febrile illness.
• Evidence-based strategies to mitigate AMR risk  
• Optimized AMU and mitigating AMR across all sectors

In the next year, the focus will be on immediate actions:

We will coordinate with the Ministry of Health and Population (MoHP), Ministry of Agriculture and Livestock Development (MoALD) and selected municipalities for implementing the solution. There will be the formation of CSGs, and designing and implementing surveillance. Protocols will be developed for health-system drivers, and development of Standard Operating Procedures (SOP) for sample collection, storage, testing, and genetic analysis. Health workers and veterinary practitioners will receive training and stakeholders’ meetings will be held to share initial data after surveillance and survey.

Over the next three years, efforts will be shifted towards sustainable strategies.

The integration of data and mobile technology will facilitate surveys on health-system drivers of AMU and sample collection from laboratories for genomic analysis. Stewardship programs will include training for health workers and veterinarians, awareness campaigns for caregivers and parents, and advocacy for policymakers. Data dissemination to stakeholders and development of treatment guidelines, along with dispensing antimicrobials with prescriptions, will be emphasized. Integration of surveillance into the local governmental system of selected municipalities is planned, with monitoring and evaluation of stewardship programs.

To monitor and evaluate the impact against our objectives, we employ a multifaceted approach incorporating the tricycle method. Our surveillance system for AMU and AMR prevalence, established through the tricycle approach, provides real-time data to inform one-health strategies and policies. By implementing mixed methods analysis, we identify key health system drivers, and veterinary practices, and environmental factors influencing AMU and AMR at the municipality level, enhancing our understanding of targeted interventions. Additionally, through genomic analysis of samples, we comprehensively assess the risk of AMR development, enabling evidence-based strategies to mitigate this risk during childhood FI.

Specific measurable indicators include:

• Antimicrobial usage by type, class, and administration route.
• Pattern of AMR in human (children with FI), animal and environment using tricycle approach.
• Percentage of healthcare facilities/pharmacies/agrovet participating in surveillance activities.
• Timeliness of data reporting and analysis to inform timely interventions.
• Diversity of AMR genetic traits observed across animal, human, and environmental samples.
• Effectiveness AMR stewardship program

These indicators allow us to track progress and measure the effectiveness of interventions. 

For the next year, the barriers for implementing the solution will be:

• Lack of awareness related to AMR and AMU among local stakeholders
• Lack of coordination among stakeholders
• Cultural and social barriers among the local people to participate in the survey
• Unavailability of lab facilities at communities and limited access to healthcare facilities
• Hesitancy among parents related to child illness data and providing test samples
• Hesitancy to download the mobile application by stakeholders

Next three years;

• Lack of political commitment
• Lack of technical resources
• Regular data reporting from healthcare facilities
• Timely sample transportation and maintaining the quality

To address these barriers within the next year and three years, leveraging local leaders' support during surveys can enhance community engagement. Involving experienced facilitators to ensure equal participation from all stakeholders fosters inclusivity in decision-making. Utilizing validated tools and thorough staff training minimizes bias and improves data reliability.

Key resources include community leaders for support, experienced facilitators for guidance. These resources will be deployed strategically to enhance community engagement and ensure the effectiveness of quality improvement initiatives in AMU and health system policies.

This challenge provides opportunities to address real-time issues and foster collaboration between stakeholders from health, veterinary and environmental sectors. In addition, we will get a chance to scale up our solution and collaborate with the leading experts. Also, the challenge encourages to produce evidence on generating AMR data and promote more effective policy and  action. There will be an opportunity for organizational growth, foster partnership and strengthen the capacity to collectively deal with AMR at the local, regional and global levels. 

The organizations we would like to collaborate are:

1. Nepal Agricultural Research Council (NARC): Collaboration for technical support and expertise in agricultural practices related to AMR and AMU. Also, advocacy among policymakers to promote responsible AMU in agriculture.
2. Wellcome Trust: The collaboration is for further research project scale-up and grants as the AMR is one of the urgent issues in Nepal.
3. Liverpool School of Tropical Medicine (LSTM): Collaboration for technical support for AMR research project.
4. World Health Organization (WHO): A close collaboration is required for knowledge exchange and advocacy for mitigating AMR and optimizing AMU for human health particularly focusing on childhood FI.  
5. Food and Agriculture Organization (FAO): A close collaboration is required for knowledge exchange and advocacy for mitigating AMR and optimizing AMU for livestock and veterinary practitioners.  
6. Nepal Applied Mathematics and Informatics Institute for Research (NAAMII): Collaborating for data analytics techniques for optimizing AMU and mitigating AMR. Also, sharing of informatics tools to analyze AMR data and predict trends.