RADARS: Rural Antimicrobial resistance Data And Response System

Our solution is an innovative data system that pairs real-time community-level AMR surveillance data from a novel source in rural India with individual-level antibiotic consumption data. We will integrate these data onto an online dashboard, which can then be used by collaborators to design, implement, and evaluate AMR mitigation interventions.

This team is led by Dr. Anoop Jain (SHRI), Dr. Maya Nadimpalli (Emory University), and Dr. Helen Pitchik (SHRI).

Hundreds of millions of people in India live in antimicrobial resistance (AMR) surveillance deserts. AMR is a major public health issue in India. Estimates show that almost 25% of all global deaths attributable to AMR in 2019 were in India alone. This has prompted India’s government to invest heavily in bolstering surveillance capacity. However, the country’s testing capacity is mostly limited to individual-level AMR testing at medical colleges in large cities. Thus, the burden of AMR in poorer communities is not well-known. This means there is limited impetus to innovate, develop, and test strategies to combat AMR in settings that are least equipped to deal with AMR. For example, two of India’s states Bihar and Jharkhand, are home to 170 million people, of which approximately 147 million (86%) live in rural communities. These states only have one AMR testing facility in their respective capital cities. Thus, the a) true burden of AMR in India is unknown, and b) poor rural communities are being left behind from prevention and treatment strategies. Therefore, while low-and-middle-income countries lag in AMR testing, poor regions within these countries are even more vulnerable to the AMR pandemic.

Our solution serves India’s rural poor to address their urgent need for AMR surveillance and mitigation. A 2018 study in The Lancet Planetary Health highlights socioeconomic status as a key determinant of AMR. Thus India’s 900 million rural poor could be at a greater risk of AMR infection than urban residents because of their lower socioeconomic status. Furthermore, approximately 63% of India’s rural households own food animals that often require antibiotics. India is among the nations with the highest global antibiotic consumption in food animal production. Of SHRI’s 67 full-time employees, 65 are from the communities we serve in Bihar and Jharkhand. This includes members of our senior management team. Thus, our team members represent the communities we work in and will play an integral role in deploying our solution. They understand antibiotic use among humans and food animals and common diseases affecting the local population. These insights will help us design our individual-level data collection module and any future interventions aimed at curbing unnecessary antibiotic use and community-level AMR. Their involvement will be critical as we seek to serve them and their communities.

This solution will produce several public goods. First, all the community-level data that we collect will be made publicly available via our freely accessible online dashboard. This will allow policy makers, researchers, and scientists both in India and around the world to gain real-time insights into the burden of AMR in communities where this has never been evaluated before. Furthermore, this will allow us to forge partnerships and collaborations that will improve and strengthen our surveillance efforts. Second, we will use community-and individual-level data to publish reports, policy briefs, and peer-reviewed publications. We will work with open-access publishers and journals to ensure that these materials are freely available to the public and will disseminate our solution widely through national and international conferences. These outputs will elucidate how antibiotic consumption patterns shape the community-level burden of AMR in rural India. Third, our protocols for data collection, analysis, and uploading to the dashboard (including code) will be made freely available so that people in non-sewered contexts who have access to wastewater and testing equipment can upload AMR data to our dashboard. This will lower the barrier to entry for AMR surveillance in low resource and last-mile communities.

Our mission is to ensure that India’s rural poor are not left out of AMR surveillance and mitigation efforts. We believe that this can, in the long-term, prevent AMR-associated morbidity and mortality. We will create this impact by first testing wastewater to track AMR burden over time in rural communities that until now, have had no AMR surveillance. In year one this testing will be done at an outside lab before we build our own capacity to conduct the tests in years two and three. Second, we will pair these data with individual-level data on antibiotic consumption in these communities. Third, we will integrate these multiple levels of data onto our data dashboard and conduct data analyses to examine prevalence and trends over time both within and across communities. Fourth, we will use this platform to advocate for interventions aimed at preventing AMR in last-mile communities. Fifth, partners can design, implement, and evaluate contextually appropriate AMR prevention interventions.  Thus, our solution, which covers steps one through four, will create a data system that can then be leveraged to advocate for and rigorously test solutions aimed at reducing population-level rates of AMR.

SHRI is partnering with the government in Jharkhand to bring another 50 sanitation facilities online in the next three years. Each of these facilities, along with the 14 SHRI currently operates, is in a unique community.

Year 1: We will test the wastewater at five of SHRI’s current 14 facilities, which are all near a local testing lab, twice per month. These five facilities are used by almost 2,000 people per day, a subsample of whom will be surveyed for antibiotic use.

Year 2: We will test wastewater from an additional 15 community facilities. These facilities will also be near a testing lab and serve about 6,000 users, a subsample of whom will be surveyed for antibiotic use.

Year 3: We will test the wastewater from an additional 25 community facilities that will serve approximately 10,000 users, a subsample of whom will be surveyed for antibiotic use. We will start building our internal testing capacity in years two and three so that we can start testing wastewater in communities without testing labs. Overall, we will scale to 45 communities in the next three years and will have individual-level data from approximately 200 individuals from each community (9,000 total people).

We will use the following metrics to measure success against our impact goals:

Impact goal 1 – Wastewater testing: We will track the number of facilities from which we are testing wastewater per year, and the number of IDEXX Quanti-Tray assays that pass QA/QC completed per facility per month. This will help us ensure that we are expanding our data collection efforts while assessing community-level AMR burden over time.

Impact goal 2 – Individual surveys: We will track the number of individual-level antibiotic use surveys we are conducting per year as well as the number of surveys relative to the number of facilities that are being surveilled for community-level AMR. This will help ensure we are tracking antibiotic use consistently over time among a representative population.

Impact goal 3 – Surveillance network integration: We will track how many and which surveillance networks our data is being integrated into. This will help us advocate for resources for AMR prevention where we work.

Impact goal 4 – Intervention implementation: We will track how many interventions are being designed, implemented, and evaluated by new partner organizations. These interventions will help alleviate the deleterious consequences of AMR infections among India’s most vulnerable.

We might encounter several barriers over the next three years. First, the most socially undesirable jobs are often relegated to the lowest castes in India. Thus, the social undesirability of working with wastewater could be a barrier to us building our own internal capacity of wastewater testing. SHRI’s team has the experience of working closely with local communities to raise the prestige of these kinds of fair-wage jobs so that those hired are seen as critical frontline workers in the fight against AMR. Second, establishing wastewater sampling and testing protocols in field labs in years two and three could take longer than expected, which would delay the integration of our data onto national surveillance networks. Third, our platform will allow other partners to implement interventions aimed at reducing community-level AMR. However, finding the right partner that understands the myriad complexities associated with designing such studies in low-resource settings could be a barrier. Fourth, some of the testing materials that we will use are not produced in India which could pose a potential supply chain issue. We do not anticipate this being a major barrier given that IDEXX Quanti-Tray technology has been regularly deployed in India for years.

We understand the devastating effects of AMR. In 2019, Dr. Jain’s aunt in India was recovering from a heart attack in the hospital when she developed a hospital-associated AMR infection that led to her death. Four years later, her husband suffered the same fate while recovering from COVID-19. Support from the Trinity Challenge will help us meaningfully contribute to the fight against the AMR pandemic. First, the Trinity Challenge network will provide us with the logistical and technical support we need to build our own capacity to test wastewater for AMR in years two and three. This will be critical as we scale our solution to communities without local testing labs. Second, support from the Trinity Challenge will help us establish protocols to ensure our data are high quality and rigorously collected so that our surveillance data can be integrated with other national surveillance networks. Third, support from the Trinity Challenge will help us identify the best partners and collaborators who can leverage our data system to design and implement interventions aimed curbing community-level AMR. The Trinity Challenge can then help us use this evidence to advocate for population-level strategies aimed at fighting the AMR pandemic.

Several Challenge collaborators could catalyze our work. First, implementation experts at McKinsey & Company can help us build our internal wastewater testing systems and protocols so that we can scale to communities without local labs. Second, we rely on Google technology for our dashboard, and they can help us improve our use of these tools as we scale. Third, the Institute for Health Metrics and Evaluation can incorporate our community and individual-level data as a part of their local and small area evaluation program thus helping us highlight the burden of AMR in last-mile Indian communities. Fourth, the Institute for Disease Modeling at the Bill & Melinda Gates Foundation can help us analyze our data to better understand what kinds of AMR prevention strategies might be most effective. Fifth, we can then work with university partners such as the London School of Economics or the Imperial College London to design and implement a study aimed at alleviating the burden of AMR where we work. Sixth, the Clinton Health Access Initiative can highlight our work as a critical effort in the mission to ensure that everyone, regardless of where they live, is able to live a healthy and fulfilling life.