TRACE AMR: Advancing AMR Surveillance by Community Based Monitoring

TRACE AMR integrates AI/ML algorithms, visualization tools, innovative data sources and community engagement for AMR mitigation in rural Andhra Pradesh, India under One-Health approach. The objective is to enhance AMR surveillance at community level in order to improve antibiotic stewardship, expedite case management and improve treatment outcomes.

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Dr. Bulagonda Eswarappa Pradeep, 

Principal Investigator, 

Associate professor, Department of Biosciences, 

Sri Sathya Sai Institute of Higher Learning, 

Prasanthi Nilayam, Puttaparthi, India

Knowledge report for containment of AMR in AP

Between 2000 and 2018, India’s human antibiotic consumption rose from 48% to 67% along with significant Antimicrobial Resistance (AMR) in animals. Andhra Pradesh (AP), a state in India with nearly 50 million people, mostly residing in rural areas across 13,324 villages, faces numerous obstacles in attaining quality healthcare and veterinary services. Despite advancements in healthcare management and AMR containment plans, antimicrobial usage (AMU) remains largely unregulated, with antibiotics often available over the counter.

At the community level, AMR surveillance is hindered by poor-quality data, hampering informed policy-making and effective containment measures. Limited access to microbiology services, coupled with the absence of quality data from the veterinary and aquaculture sectors and lack of integration with Whole Genome Sequencing (WGS) data, exacerbates the issue. Unwarranted empirical antibiotic prescriptions further contribute to AMR.

To address these challenges, we propose leveraging AI/ML tools to enhance integrated-intersectoral surveillance efforts, incorporating WGS data and develop community-level programs. Given the prevalence of handwritten data and language barriers, digital tools for efficient data capture and analysis are proposed. Further, Introduction of culture-free predictive analytics tools using available clinical data will reduce unwarranted empirical antibiotic prescriptions and expedite case management.

TRACE AMR aims to serve three similar populations of ~50,000 in rural Andhra Pradesh, south India. The target audience includes frontline healthcare providers, veterinarians, policymakers, and community members. 

We will conduct landscape analyses and laboratory assessments by reviewing available information and structured surveys to identify human/animal health needs and data gaps in the context of AMR and AMU. Cloud-based, digital technologies will be employed for seamless collection and integration of existing and novel datasets, data pre-processing for analyses and data visualization.

We will gather diverse data from community records, public health centers, animal husbandry facilities, and microbiology labs, along with novel datasets on microfinance records, mobility data, socioeconomic indicators and WGS data generated from bacterial pathogens. After preprocessing the data, we will employ ML techniques for predictive modeling to forecast bacterial infections, identify pathogens, predict patterns of antibiotic resistance and expedite case management. TRACE AMR will empower healthcare providers with advanced tools, aiding efficient decision-making, while policy makers benefit from comprehensive, evidence-based data.

Through workshops and participatory action research, we will actively involve communities in decision-making to enhance AMR surveillance, IPC, and customize TRACE AMR to their needs. This fosters sustainable community participation and ownership.

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TRACE AMR will provide several public goods as direct outputs of its work:

Comprehensive Data Insights: TRACE AMR will integrate diverse datasets from healthcare, veterinary, and community sources, providing comprehensive insights into AMR patterns at the grassroots level. These insights, from WGS of select isolates will include strain type, MLST, clonality, resistome, virulence profiles, etc. This data, constituting a public good, will contribute to global understanding of AMR transmission dynamics, informing evidence-based interventions worldwide.

Real-Time Surveillance Dashboards: Harnessing AI/ML algorithms and integrated WGS data, TRACE AMR's real-time surveillance dashboards offer actionable insights for frontline healthcare and veterinary workers. Actuaries will augment dashboard capabilities with predictive models, enhancing credibility and facilitating improved treatment outcomes, antimicrobial stewardship practices, IPC, and reducing AMR spread and AMU.

Policy Recommendations: TRACE AMR will transform data-driven insights into actionable policy recommendations, empowering policymakers to effectively monitor AMR trends, implement interventions, and ensure access to safe antimicrobial treatments. These evidence-based recommendations will be pivotal in combating AMR

TRACE AMR is poised to create tangible impacts by providing actionable insights for various stakeholders. Through real-time surveillance dashboards empowered by AI/ML algorithms, improved antimicrobial stewardship practices will be achieved. This will directly benefit the identified catchment areas, encompassing ~50,000 individuals each, by enhancing access to effective human and animal health care and reduction in AMU,  safeguarding against the emergence and spread of AMR.

Furthermore, TRACE AMR's emphasis on community engagement and stakeholder collaboration will ensure that solutions are tailored to the specific needs of underserved populations in these selected catchment areas. By empowering frontline healthcare providers and veterinarians at the trial sites, we aim to address the distinct challenges they face in accessing healthcare and managing animal husbandry practices. Integrating diverse datasets and translating data-driven insights into policy recommendations will contribute to improving public health outcomes locally, setting a precedent for replication and expansion to all regions of the state and beyond in the future.

To assess the impact of TRACE AMR over the next one and three years, a comprehensive evaluation framework will be employed, encompassing quantitative, qualitative, and epidemiological metrics.

Quantitative metrics encompass reductions in AMU, changes in AMR patterns, and treatment outcome enhancements for bacterial infections. Expansion of data coverage, tracked by participation of healthcare facilities and labs, will be monitored.

Qualitative assessments will gauge healthcare provider satisfaction, stakeholder engagement, and policy adoption based on TRACE AMR data. Stakeholder feedback from surveys, interviews, and workshops will inform the usability and impact of TRACE AMR.

Epidemiological surveillance entails continuous monitoring of disease trends and identifying AMR hotspots. Real-time surveillance dashboards integrated with predictive models will facilitate disease surveillance and targeted interventions.

Long-term impacts will be evaluated in terms of reductions in healthcare costs associated with inappropriate AMU and the sustainability of TRACE AMR interventions. This assessment will gauge the continued engagement of stakeholders and the integration of TRACE AMR into existing healthcare systems, ensuring long-term antimicrobial stewardship practices and IPC.

Through this multifaceted evaluation approach, TRACE AMR will provide valuable insights into the effectiveness of its interventions and guide future efforts to combat AMR.

To measure the success of TRACE AMR, we will employ a comprehensive monitoring and evaluation plan, tracking specific, measurable indicators:

Reduction in antibiotic prescriptions: We will monitor the decrease in unnecessary antibiotic prescriptions at selected sites, aiming for a 20% reduction in inappropriate antibiotic prescription and AMU through comparative analysis of pre- and post-implementation data.

Improvement in antibiotic stewardship practices: Assessing adherence to evidence-based prescribing guidelines, we target a 30% enhancement in adherence rates among frontline healthcare providers and veterinarians, contributing to expedited case management and better antimicrobial stewardship.

Decrease in AMR prevalence: Through real-time surveillance dashboards empowered by AI/ML algorithms, we anticipate a minimum 15% decline in antibiotic-resistant pathogens within clinical and veterinary settings, indicating the effectiveness of intervention strategies.

Community engagement and empowerment: Evaluating community awareness and participation levels through surveys and discussions, we aim for a 25% increase in engagement, fostering sustainable ownership of AMR initiatives.

Whole genome sequencing (WGS) integration: Integrating WGS into surveillance efforts will offer valuable insights into AMR transmission dynamics and genetic markers. 

Regular monitoring and analysis of these indicators will enable us to assess TRACE AMR's impact effectively and refine strategies to combat AMR.

Potential Barriers in the Next Year: Engaging and convincing the local community, particularly healthcare providers and veterinarians, poses a significant challenge in the short and long term. Obtaining timely approvals from Institutional Review Boards within the first six months is crucial. Additionally, integrating Whole Genome Sequencing data presents a technical challenge that must be addressed within the first 1 to 1.5 years to enhance AMR surveillance capabilities.

Overcoming Barriers (First Year): Implementing targeted communication strategies, leveraging local networks, and involving community leaders through workshops and training sessions will build awareness, trust, and ownership among frontline stakeholders. Continuous refinement of technology, collaboration with stakeholders, and investment in workforce capacity building will address technical constraints.

Potential Barriers in the Next Three Years: Sustaining scalability and impact may require overcoming technical constraints such as interoperability issues and adapting our technology to diverse community contexts.

Overcoming Barriers (Over Three Years): Engaging healthcare providers and veterinarians through workshops, training sessions, and participatory decision-making processes will be essential. Actively involving them in the design, implementation, and evaluation of TRACE AMR aims to ensure sustained engagement for long-term success. Adequate workforce training and adapting to evolving market dynamics will be critical for sustained operations and relevance.

We are applying to The Trinity Challenge because it offers a unique opportunity to leverage our innovative solution, TRACE AMR, in combating antimicrobial resistance (AMR) effectively. One of the key barriers we face is scaling our solution to cover a larger proportion of rural communities in Andhra Pradesh over the next three years. 

The challenge of scalability encompasses infrastructure limitations, workforce capacity constraints, and the need for sustained funding. The Trinity Challenge can help us overcome these barriers by providing access to resources, expertise, and networks that can support our scaling efforts. 

Specifically, we can benefit from The Trinity Challenge's network of collaborators and partners, who can provide guidance on expanding infrastructure, enhancing workforce capacity, and securing funding. Additionally, The Trinity Challenge's platform can help us showcase the impact and effectiveness of TRACE AMR, attracting further support and investment for its expansion. Overall, The Trinity Challenge aligns with our mission to address AMR at the grassroots level, and its resources and networks can significantly contribute to the success and scalability of TRACE AMR in rural Andhra Pradesh.

We seek collaboration with organizations specializing in healthcare, veterinary sciences, data science, genomics, public health, and international collaboration to initiate, accelerate, and scale our solution, TRACE AMR.

Key organizations for collaboration include:

1. International Vaccine Institute (IVI): Their expertise in infectious diseases and vaccine development can provide insights and support for our AMR surveillance efforts, aiding in data integration and intervention strategies.

2. World Health Organization (WHO): Partnering with WHO can offer credibility to our solution, access to global networks, and alignment with global standards for AMR surveillance.

3. Indian Council of Medical Research (ICMR): Collaboration with ICMR ensures alignment with national initiatives, access to relevant data, expertise, and assistance in navigating regulatory requirements.

4. National Centre for Disease Control (NCDC): NCDC's proficiency in disease surveillance can complement our efforts in analyzing surveillance data and informing public health interventions.

5. Wellcome Trust: Their funding opportunities and technical expertise in global health challenges, including AMR, can support the scaling of TRACE AMR and widen its reach beyond rural Andhra Pradesh.

6. NITI Aayog: Collaboration with NITI Aayog of India can provide strategic guidance, policy insights, and support in integrating TRACE AMR into national health agendas and initiatives.