AMR-Nexus: Integrated community-based AMR and AMU Surveillance System

Lack of AMR data from rural communities hampers control efforts. We aim to improve AMR data visibility from vulnerable communities through citizen-driven initiatives and utilizing digital tools innovatively for data collection, analysis, and dissemination to stakeholders for decision-making. 

Dr. Veronicah Chuchu 

AMR poses a significant public health challenge, necessitating global and nationally tailored interventions. India grapples with a high AMR burden with an estimated 300,000 deaths directly caused by antibiotic-resistant infections in 2019.

An effective AMR response requires visibility into resistance patterns, antibiotic consumption and use in communities as well as an understanding of community practices such as health seeking behavior and socio-cultural practices. Existing information gap continue to hinder the government's efforts towards tackling AMR in India. This   gap is especially acute in rural communities such as the tribal ‘Santhal community’ in West Bengal (WB) who are   co-existing with their livestock in remote areas of the WB province. Critically, in communities such as these, there is also an increased risk of animal to human transmission of resistant bacteria. The first step in tackling AMR in such vulnerable communities is clear identification of the problem- which this proposal seeks to solve through AMR data visibility by leveraging new and existing digital tools for data collection, analysis and dissemination to decision makers. We also seek to address the limited awareness of AMR amongst the   community   through citizen-friendly and driven initiatives such as sensitization and reporting through village youth and elders. 

Our solution serves the Santal tribal community in rural WB, one of the largest tribal communities in India (>6million individuals). It is the largest tribe in WB with most of them inhabiting Purulia district (~300,000). This solution solves the problem of limited awareness on AMR amongst the community, to be disseminated through training of community leadership and youth and promotes judicious use of antibiotics. Insights generated from this surveillance will be leveraged to educate the community on consequences of misuse/overuse of antibiotics. An early detection surveillance system identifying diseases in livestock and communities can ultimately prevent income and health losses.

 

The insights from the dashboard will provide surveillance data on antibiotic use and access for humans and livestock (overlaid with socio-cultural behaviors), disease prevalence/patterns/transmission and possible outbreaks including zoonosis. Insights will inform and drive actions/policy and guidance issuance from key decision makers e.g Government of India, Indian Council of Medical Research, Department of Animal Husbandry, Dairy and Fisheries along with the Indian Council of Agricultural Research, who are the agencies ultimately responsible for antimicrobial stewardship in humans and livestock, with ability and authority to action these data through monitoring outbreaks at source and drive rational use of antibiotics. 

Our solution provides a public good through the creation and dissemination of an open-access, AMR surveillance dashboard that integrates data from community, pharmacy, and health facility records. This dashboard offers comprehensive view of antibiotic usage and access patterns, disease and AMR trends within the Santhal community. By making this tool freely available, we ensure that the data and insights generated are accessible to stakeholders, including public health officials, researchers, and policymakers. As this will be designed in consultation with local public health officials, efforts will be made to integrate the dashboard onto the existing surveillance networks. The dashboard will be designed such that it is Ayushman Bharat Digital Mission (ABDM) Compliant.

We aim to publish our findings in a peer reviewed journal on methodologies and effectiveness of community-based surveillance in managing AMR. This paper will contribute to the global body of knowledge on AMR containment strategies, particularly within rural/tribal populations.

The dashboard and publication serve as public goods by enhancing global understanding on management of AMR, promoting responsible antibiotic use, and supporting the development of targeted interventions based on real-time data and community-led initiatives. These outputs align with the goal of improving public wellbeing by addressing a critical health challenge.

By establishing an AMR surveillance dashboard integrated with community engagement through education and awareness programs, we directly address the critical issue of visibility into antimicrobial resistance (AMR) in Santhal community.  

The logical link between our activities and the expected outcomes is as follows: Enhanced surveillance (activity) through the dashboard will lead to better detection of AMR and bacterial disease patterns and outbreaks (output), coupled with targeted education on antibiotic use (activity), is expected to result in reduced antibiotics misuse and improved infectious diseases management (outcome).

This approach is supported by evidence from similar interventions, where increased AMR awareness and surveillance have led to more judicious use of antibiotics and decreased incidence of drug-resistant infections (WHO, "Global action plan on antimicrobial resistance").

A recently conducted pilot exercise amongst pharmacists in the Santhal community for strengthening AMR stewardship and practices amongst local pharmacists showed 85% compliance rate and about 20% reduction in over-the-counter antibiotic purchases in the targeted community, indicating the strong likelihood of a tangible impact on antibiotic over/misuse. Our solution will not only address a public health issue but also empower the community with knowledge and tools to safeguard their health, showcasing a clear path from activities to impactful outcomes.

Over the next year, we plan to scale our impact by expanding the real-time AMR surveillance dashboard's reach to tribal communities within WB and neighboring states with similar populations. We will leverage existing networks and partnerships and collaborate with local health authorities to adapt and implement our solution in new contexts. Building on the pilot's success, we aim to integrate feedback mechanisms and tailor educational programs to fit diverse community needs, facilitating broader adoption and impact.

In the next three years, our goal is to support the development of a national framework for community-led AMR surveillance and management, through partnerships with governmental and non-governmental organizations across India. To enhance scalability, we will enhance the dashboard's capabilities to include AI-driven predictive analytics for identifying potential AMR hotspots and outbreaks. Additionally, we plan to advocate for policy changes based on our findings, promoting the adoption of responsible antibiotic use practices in livestock and human healthcare at a policy level.

By systematically expanding our reach and continuously improving our solution, we aim to transform how AMR is monitored and managed in India, significantly reducing the prevalence of antibiotic-resistant infections and improving public health outcomes across vulnerable populations.

Key indicators for measuring success of this solution include: 1) Number of available data sources related to AMR or potential AMR risk; 2) the coverage of these data sources (% of subdivisions of Purulia District covered); 3) geographic coverage of dissemination activities (% of subdivisions covered); 4) change in community awareness of AMR; 5) change in antibiotic dispensing rate (for humans and animals where available).

(1-3) will be collected through routine project implementation data; (4) will be collected through pre/post surveys at the community level; data to assess (5; collected via 1-3) include dispensing rates, pre/post implementation of the surveillance solution and dissemination of results. The geospatial granularity of the data will allow for a robust impact evaluation to guide future scale-up.

To date, we have engaged with the Santhal community in 200 villages through our partner, MANT. Preliminary results indicate a notable increase in awareness of proper antibiotic use among community members, with a 20% reduction in the purchase of over-the-counter antibiotics reported by local pharmacies. 

Financial Constraints: Securing funding for scaling operations and maintaining the data collection, analysis, and feedback cycle at community level poses a significant challenge. 

solution: We plan to pursue grants from public health-focused organizations and partnerships with private entities interested in CSR initiatives targeting AMR reduction.

Cultural and Educational Gaps: Resistance to changing traditional practices and low awareness about AMR in rural communities could hinder our education and awareness programs.

Solution: Develop culturally sensitive educational materials and engage community leaders to foster trust and acceptance.

Policy and Regulatory Hurdles: Navigating legal frameworks and obtaining approvals for data sharing and public health interventions can be time-consuming. 

Solution: Work closely with local/national health authorities and legal advisors to ensure compliance and advocate for supportive policies on AMR surveillance.

Market Dynamics: The reliance on over-the-counter antibiotics and unregulated livestock medications may limit the effectiveness of our interventions.

Solution: Engage with pharmacies/agrovets to promote responsible selling practices and monitor compliance through the surveillance dashboard

Linkage to impact: In many interventions, the linkage of activities to impact is oftentimes unclear. We shall mitigate this by including FIND’s Impact team in identifying the impact indicators and their measurement. 

FIND seeks to halt and prevent AMR development and mortality through diagnostics. The overarching objectives for the programme are to (1) preserve new and existing antibiotics by strengthening stewardship programmes, (2) support development and early implementation of innovative AMR solutions (diagnostics, digital and AMR data) to reduce mortality (3) empower on-the-ground AMR surveillance efforts to strengthen use of local data and improve the One-Health approach.

This challenge will help us understand antibiotic access/use patterns at community level and thus inform our strategies on strengthening stewardship programmes aimed at optimizing antibiotic use. Availability of estimates of AMR/disease burden at the community-level will help in better articulation of the need for affordable diagnostics solutions as close as possible to the community including the point-of-care-test to enhance appropriate access and use of antibiotics at pharmacies. By leveraging existing and developing open-source or free-to-use digital tools, this challenge will help us empower communities through creation of awareness to seek care (including diagnosis) earlier and make informed health choices through improved knowledge and care-seeking guidance. Additionally, community-based-surveillance will help inform public health response through improved collection, interoperability and use of data for disease surveillance, policy, and resource optimization

Access to affordable diagnostics for AMR is very central to FIND mission. Consequently, we would seek collaboration in resource mobilization to help scale the capability of existing laboratories to test AMR, strengthen antimicrobial stewardships at pharmacy level through point of care test and improve AMR surveillance to increase the availability of data on AMR - access, use, consumption, and resistance. To ensure sustainability of the approach, we would like to collaborate and consult with state and national-level stakeholders in AMR (e.g Indian Council of Medical Research, Indian Council of Agricultural Research, National Center for Disease Control) to understand information needs and create channels where this intervention can be integrated at the national level.

Realizing the central role digital technology plays in scaling health intervention, empowering both the patients and health care providers, and informing policy. We seek collaboration on accelerating adoption of these digital tools for health, technology innovation (AI, Interoperability) and translating results into policy articulation in other LMICs beyond India.