Antibacterial Resistance Drivers in Ugandan Agro-Pastoral Communities

We aim to identify drivers of antibacterial resistance linked to community level practices, the environment, and domestic animals in Uganda. We will utilize a snowball approach where individuals with suspected infection at the health facility are evaluated for antibiotic resistance, and followed up in the community to determine predisposing factors. 

Dr. Fred C. Semitala MB.Ch.B, M.Med, MPH-Epi: Executive Director for Makerere University Joint AIDS Program-MJAP. He has led several consortia on community-based projects, published over 100 papers in infectious diseases. 

Globally ABR is projected to cause 10 million deaths by 2050, with Africa being particularly vulnerable due to a high infectious disease burden, underdeveloped laboratory infrastructure to detect ABR and limited regulation of human-animal interactions.

The Uganda National Action Plan on Antimicrobial resistance showed a high burden of bacterial diseases among domestic animals which are resistant to many of the available antibacterial molecules. A broad range of bacteria isolated from animal products showed high resistance (over 50 percent in many cases) to commonly used antimicrobials. https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-spc-npm/nap-library/uganda-nap-amr.pdf?sfvrsn=6ea2650d_5&download=true

 A study conducted in Nakasongola district, an agro-pastoral community in Uganda indicated that raw milk was contaminated with antibacterial resistant pathogens with an overall antibiotic resistance of 45%. https://link.springer.com/article/10.1186/s13570-020-0158-4

Misuse and overuse of antibiotics have been identified as the major causes of ABR in cattle corridors. https://nru.uncst.go.ug/handle/123456789/5370.  However, majority of the studies on the drivers of ABR have been health facility based with limited community level data.  

This study will establish an integrated community level approach using human, animal and environmental data to inform the design of tailored interventions that address antibacterial resistance in Uganda.

Individual; establishing community ABR data sources will help develop interventions that target prevention, treatment and follow-up of patients with antibacterial resistance.  Dissemination of findings will enable participants to modify their practices to prevent ABR at household and community level.

Agro pastoral communities; we will inform the community about how their culture, norms and practices influence development of ABR, they will also understand best practices to reduce the spread of ABR. This will bridge the existing knowledge gaps about antibacterial resistance in the communities

Human and veterinary care providers; we will inform them about the patterns and distribution of ABR in the communities they serve and how their practices contribute to the development of ABR.

Policy makers; District local government, Ministry of Health (MoH) and National Drug Authority (NDA), Ministry of Agriculture, Animal Industry and Fisheries (MAAIF), cultural and opinion leaders. Data will be provided to inform policy and design interventions to combat ABR.

Community engagements through technical oversight, support supervision and dissemination of findings.

Since 2021, MJAP has been doing surveillance of ABR in a tertiary hospital in Kampala Uganda which serves patients across the country. However, there is limited community level data to address ABR hence the proposed solution. 

1. Insights into antibiotic resistance dynamics: The study aims to comprehensively investigate antibiotic resistance within communities aiming to uncover its underlying drivers. The findings from this research will provide valuable insights into the dynamics of antibiotic resistance which is crucial information for public health officials, policymakers and healthcare providers in developing effective strategies to mitigate its impact.
2. Standardized Data Collection Tools and Protocols: Standardized data tools ensure reliable, consistent collection enhancing data quality and comparability for researchers and organizations in similar fields.
3. Community engagements: Engaging workshops, surveys and discussions involving stakeholders foster transparency, trust and collaboration which is vital for effective public health interventions.
4. Data analysis: The synthesis of data across different workstreams and the use of advanced analytical techniques such as Bayesian network analysis and multilevel regression provide valuable insights into the drivers of antibiotic resistance at various levels. This analysis generates hypotheses and identifies key factors influencing antibiotic resistance outcomes contributing to the collective knowledge base on this public health issue.
5. Development of appropriate interventions: The study's interdisciplinary approach facilitates targeted interventions against antibiotic resistance while safeguarding public health. By identifying resistance drivers and understanding behaviors, it informs tailored interventions benefiting community health outcomes.

1. Improved antibiotic practices: By examining antibiotic sources and factors influencing provider and patient decisions, the study aims to enhance prescribing practices, reduce unnecessary use and promote adherence aiding antibiotic stewardship and resistance reduction.
2. Targeted interventions: Insights from community visits, surveys, interviews and mapping inform tailored initiatives including educational campaigns, provider training, and healthcare access improvements in agro-pastoral communities.
3. Community engagements and empowerment: Community workshops, focus group discussions and dialogues provide opportunities for community members to actively engage in discussions about illness experiences, healthcare access and perceptions of antibiotic resistance. By involving communities in the research process and fostering dialogue, the study will empower community members to become advocates for change and active participants in efforts to address antibiotic resistance in their communities.
4. Enhanced surveillance and monitoring: The laboratory analysis including Whole Genome Sequencing of pathogens and data linkage enables the identification of drivers of resistance at various levels including patient, hospital and household. This enhanced surveillance and monitoring capacity will provide valuable insights into the dynamics of antibiotic resistance and help identify emerging trends or hotspots of resistance guiding targeted interventions and resource allocation efforts.

• Partnerships and Collaborations: MJAP will collaborate with local healthcare facilities, government agencies, NGOs and international partners to expand intervention reach integrating findings into existing structures.
•  Capacity Building: MJAP will develop training programs for healthcare providers and community workers enhancing knowledge on antibiotic use and infection control. 
• Community Empowerment: Establishing health committees sustains engagement.
•   Policy Advocacy: Advocating policy changes supports stewardship and surveillance efforts at various governmental levels.
• Technology Adoption: MJAP will use GIS which it has used before to facilitate surveillance and8 monitoring. These technologies will improve data collection, analysis and dissemination of findings leading to more targeted interventions and resource allocation.
• Long-Term Sustainability: MJAP will develop plans to ensure intervention impact endures, training local healthcare personnel as trainers, establishing community-led surveillance and integrating stewardship into healthcare practices and policies.
• The inclusion of an analysis of human-animal interaction will provide valuable information about possible cross infection between human beings and their domestic animals. This information will be used to inform policies and guidelines regarding human-animal interactions.

1. Baseline Assessment: MJAP suggests to conduct a baseline assessment of antibiotic usage practices, knowledge, attitudes and behavior related to antibiotic resistance in the study areas before the implementation of interventions. This will provide a benchmark against which progress can be measured.

2. Measurable Indicators:

a. Quantitative Data: The following indicators using quantitative data collected through surveys, interviews and environmental sampling can be measured;

• Percentage of healthcare providers adhering to prescribing guidelines.
• Changes in antibiotic usage patterns (e.g types of antibiotics prescribed, frequency of prescriptions).
• Percentage of community members with increased knowledge about appropriate antibiotic use and antibiotic resistance.

3. Regular Monitoring: MJAP will monitor progress, identify barriers and adjust interventions. This involves reviewing data collection processes, quality checks and stakeholder feedback sessions.

4. Data Synthesis and Analysis: We will analyze data across workstreams using advanced techniques to identify trends and key factors in antibiotic resistance.

5. Stakeholder Engagement: Continuous engagement with stakeholders will solicit feedback, disseminate findings and collaborate on action plans.

6. Endline Assessment:  will evaluate intervention effectiveness and impact on combating resistance in agro-pastoral communities.

• Logistical Barriers:
  • Limited Resources: Conducting a comprehensive study in diverse settings like remote villages requires substantial financial and human resources. MJAP will seek funding from governmental bodies, international organizations or private donors and collaborate with local institutions to leverage existing resources.
  • Infrastructure Challenges: Remote areas lack infrastructure for data collection. MJAP will use offline methods or mobile data tools like EpiCollect 5.
• Contextual Barriers:
  • Cultural and Language Differences: Cultural beliefs and language barriers may impact participant understanding and engagement with the study especially in diverse communities like pastoralist areas.
    • Overcoming the Challenge: MJAP will employ multilingual field staff who are familiar with local cultures and languages. We will adapt data collection tools and communication materials to resonate with the cultural norms and preferences of each study area.
• Methodological Barriers:
• Ethical Considerations: Research in vulnerable communities demands attention to informed consent, privacy and confidentiality. MJAP will secure ethical approval, comply with guidelines and obtain culturally appropriate informed consent.

• Data Quality: Collecting standardized data may vary in quality. MJAP will develop rigorous protocols and pilot testing for consistency.
•  Participant Recruitment: Recruiting from diverse backgrounds may face resistance. MJAP will engage stakeholders, conduct workshops and collaborate for cultural sensitivity.

The Trinity Challenge can significantly aid in identifying key barriers of antibacterial resistance in Uganda. This includes providing crucial funding for data collection, laboratory testing and community engagement efforts. Moreover, it facilitates data integration and collaboration among stakeholders to gain a comprehensive understanding of resistance drivers. The initiative also supports capacity building among local researchers and healthcare professionals through training and mentorship programs. Additionally, The Trinity Challenge offers guidance on ethical considerations, ensuring adherence to research standards. By addressing these challenges, the initiative enhances research capacity and enables the development of effective interventions to combat antibacterial resistance in Uganda, contributing to global health efforts.

1. Uganda Virus Research Institute (UVRI): UVRI, based in Entebbe, Uganda, is a government research institute that conducts research on various infectious diseases, including those caused by antimicrobial-resistant pathogens.
2. Infectious Diseases Institute (IDI): IDI, affiliated with Makerere University, focuses on research, training, and service delivery in infectious diseases, including antimicrobial resistance.
3. Uganda Medical Association (UMA): UMA represents medical professionals in Uganda and is involved in advocacy and research related to antimicrobial resistance.