CitiSafe

CitiSafe empowers sanitation workers to collect swabs from public surfaces for analysis of antimicrobial resistant bacteria, generating real-time community-level surveillance data. By identifying hotspots, CitiSafe aims to reduce transmission risks through targeted policy responses, addressing a critical gap in understanding resistance spread beyond clinical settings.

Nyamizi Maganga, Epidemiologist and Sanitation Worker Trainer

The rise of antimicrobial resistance poses a serious threat in Tanzania and around the world. According to the WHO, antibiotic resistance kills an estimated 700,000 people globally each year, and by 2050 this could rise to 10 million annual deaths. In Tanzania, studies show that over 50% of common bacterial pathogens now demonstrate resistance to medicines like amoxicillin and cotrimoxazole, drugs which are mainstays of treatment for common infections like pneumonia and diarrhea. 

Dar es Salaam, Tanzania's largest city with over 6 million residents, faces particular challenges. As in many crowded urban areas, antimicrobial resistance can spread rapidly through public surfaces that see high human contact. A recent study at Muhimbili National Hospital in Dar es Salaam found that over 60% of sampled patients carried drug-resistant bacteria, with urban residents at significantly higher risk. 

However, Tanzania lacks systematic, community-level surveillance of antimicrobial resistance outside hospitals. As a result, policymakers have an incomplete picture of transmission dynamics and exposure hotspots in urban areas. Without this data, it is difficult to optimize prevention strategies or target resources effectively. Our solution aims to address this gap.

CitiSafe serves several key stakeholder groups in Tanzania:

- 37 Sanitation workers in Dar es Salaam: Through training and resources provided, the solution will upskill our entire municipal sanitation workforce of 37 people who collect waste across the city daily. 

- 5 Municipal managers: Monthly analysis and data presentations will support optimized budget allocation decisions for the 5 districts that oversee sanitation services for 98% of the city's population.

- 15 Ministry of Health officials: Evaluation meetings with clinicians and policymakers from relevant departments like the Antimicrobial Resistance Directorate will ensure data meets the needs of their national action plan to tackle resistance. 

- 6,134,440 citizens of Dar es Salaam: By implementing targeted interventions in the 2 highest risk areas identified, the solution aims to help reduce exposure to drug-resistant infections for over 30% (2 million) of the city's total 6.1 million residents within the first year alone.

We conducted surveys with 30 sanitation workers and interviews with all 5 municipal managers to understand current practices and gather stakeholder insights before developing our sampling methodology and reporting procedures. 

CitiSafe provides several key public goods through its work:

1. Open access resistance mapping data: All anonymized geospatial AMR data generated through surveillance is published through an interactive online dashboard for open access. This real-world knowledge supports global efforts to understand resistance dissemination dynamics. 

2. Policy briefs and recommendations: Regular reports synthesizing analytical findings and lessons learned are broadly distributed to stakeholders including the Ministry of Health and municipal leaders to guide evidence-based policymaking and resource allocation decisions benefitting Tanzanian citizens. 

3. Community engagement resources: Standard operating procedures, training material and educational posters developed by CitiSafe epidemiologists are freely shared to support other groups seeking to establish similar antimicrobial resistance monitoring programs. 

4. Peer-reviewed publications: Analyses of surveillance outcomes and methodological approaches are published in open-access scientific journals to inform the international scientific community and advance global knowledge and strategies in this domain.

5. At-cost sample collection services: Subject to local ethics approvals and import clearances, other researchers can utilize the system and existing sanitation workforce trained by CitiSafe to collect site-specific surface samples for their studies at the cost-recovery rate.

Through its annual surveillance cycle, CitiSafe is expected to have the following impacts:

- Sanitation workers (37): Will be upskilled through training, improving employment opportunities. 

- Citizens of Dar es Salaam: Targeting of handwashing stations and disinfection in high-risk areas identified by analysis will help reduce exposure to drug-resistant infections for 2 million residents within 1 year.

- Ministry of Health: Data will track effectiveness of the National Action Plan on AMR and inform evidence-based adjustments to policies over time, improving nationwide response. 

- Municipalities (5): Optimization of sanitation budgets based on resistance hotspot maps will enhance outcomes of waste management and public health promotion programs benefiting residents.

Evidence from our small pilot showed sampling was logistically feasible for workers and cultures yielded actionable resistance data. Discussions with stakeholders validated the solution meets their needs. 

As CitiSafe scales, we will regularly survey participants and track changing infection indicators to quantify impacts on this vulnerable population over subsequent years of implementation.

Over the next year, CitiSafe aims to scale our impact in Tanzania as follows:

1 year:
- Consolidate our methodology by piloting surveillance across 3 districts, collecting 500 samples per month
- Refine analytical approaches and mapping with a larger dataset  
- Engage 10 additional sanitation workers to scale sample collection
- Publish first results and coordinate 2 intervention rollouts based on findings
- Present outcomes at national AMR conference to expand reach

Over 3 years:  
- Continue monthly district-level surveillance, analyzing 1500+ samples annually
- Expand solution coverage to 5 districts, involving 30 sanitation workers  
- Roll out targeted public health interventions in 5 high-risk areas identified
- Publish longitudinal analyses and hold regular roundtables to guide policy  
- Build national capacity by training 10 people from other municipalities on our model
- Submit global journal articles to shape international understanding of AMR dynamics
- Negotiate cost-recovery collection service agreements with 3 external researchers
- Pursue longer-term funding to transition CitiSafe into an independent social enterprise

By methodically expanding our scope and refining analyses over time, we believe CitiSafe can transform AMR surveillance nationally and establish Tanzania as a leader depicting community-based solutions to a global crisis.

We are measuring CitiSafe's success using several key performance indicators:

1. Samples collected monthly - Targeting 500 samples/month within 1 year. Pilot achieved 60 samples in 1 month.

2. Actionable results generated - Monthly reports identify 2 or more localized resistance hotspots to guide interventions. Pilot identified 3 priority areas.  

3. Interventions rolled out - Within 1 year we aim to roll out targeted actions in 2 hotspot communities based on results. 

4. Knowledge products developed - By year 1, we will publish 1 peer-reviewed paper on methodology and present findings at 1 national conference. 

5. Stakeholder engagement - Track meetings/workshops held with policymakers and municipalities annually to ensure solution meets their needs. Pilot secured support from 5 municipal leaders.

6. Population coverage - Increase sample collection sites to 3 districts within 1 year covering 20% of Dar es Salaam.

We also survey sanitation workers and municipalities annually to measure training effectiveness and solution uptake. Comparing outcomes to targets allows us to evaluate progress, identify challenges, and refine our approach to maximize impacts on AMR transmission in Tanzania.

Over the next 1-3 years, some key barriers CitiSafe may face and plans to overcome them are:

Financial: Limited funds, especially to expand. We will apply to NGO and foundation grants, pursue social enterprise partnerships, and seek municipal/ministry cost-sharing over time. 

Technical: Maintaining laboratory quality as volume increases. CitiSafe will train additional micro lab technicians, introduce quality checks, procure backup equipment and pursue accreditation within 3 years.

Policy: Navigating different district-level regulations. We will engage early with municipal health officials and respective ministries to streamline necessary approvals and ensure policies support rather than hinder scale-up. 

Cultural: Gaining trust in new communities. CitiSafe will hold sensitization sessions facilitated by existing program volunteers and community leaders to explain goals and approach prior to starting new sites in a culturally sensitive manner.

Capacity: Training additional participants. We have developed standalone training modules and will pursue external partnerships to build capacity through satellite labs and field placements.

CitiSafe aims to strategically mitigate barriers proactively through stakeholder buy-in, participant engagement, diversified funding, and a scalable operating model designed for the Tanzanian environment and priorities.

The Trinity Challenge is an ideal fit for scaling up CitiSafe's work due to its focus on improving public health through partnerships and community-driven solutions.

The scale of funding available from The Challenge, up to £1 million over 3 years, will allow us to tackle the foremost financial and capacity limitations currently restricting our impact. This level of support is precisely what is needed to expand sample collection sites, engage additional municipalities, hire more staff, and perform targeted public health interventions across Tanzania. 

Through The Challenge network, we also foresee opportunities to strengthen strategic and operational partnerships that can help address policy and technical barriers. Policy guidance from collaborators like WHO could streamline future scale-up activities. Expert evaluations provided may aid technical improvements like laboratory certification.

By measuring outcomes against their stated goals and indicators, The Challenge framework will greatly improve our accountability and ability to refine approaches. Its global visibility and knowledge-sharing platforms are ideal for amplifying learnings from Tanzania internationally. 

Wellcome and Imperial College London are two organizations that could help accelerate and scale my solution. 

As a founding partner of the Trinity Challenge, Wellcome has provided crucial anchor funding to support challenges related to antimicrobial resistance. As the largest medical charity in Europe, their extensive expertise in areas like global health research, policy engagement, and advocating for open data would be extremely valuable to help expand real-world testing of my solution. Wellcome has a vast network of research institutions around the world, which could provide opportunities to pilot my solution in diverse locations and healthcare systems, demonstrating its impact on a larger scale. 

Imperial College London is another organization that could aid in scaling my solution. As a world-leading university for engineering, life sciences and medicine, Imperial brings together multidisciplinary experts who are working on various fronts to address AMR. Their Ineos Oxford Institute for Antimicrobial Research is at the forefront of developing new antibiotic treatments. Partnering with Imperial would allow me to incorporate scientific and clinical guidance from their network of researchers and practitioners. This would help ensure my solution is addressing real needs identified from 'the frontlines' of healthcare.