The Open University is working with Mott MacDonald funded by The Fleming Fund, a UK Government Aid programme to help low and middle-income countries (LMICs) address global challenges such as Antimicrobial Resistance (AMR). AMR threatens the prevention and treatment of an ever-increasing range of infections and poses a serious threat to public health worldwide. We are helping the UK Government Department of Health & Social Care (DHSC) to identify needs and to design, implement and test a series of learning events to support capacity building. This work takes place over the period 2018-2022 and the first year (2018-19) is structured around the following research questions:
RQ1. What are the areas of change needed to improve antimicrobial surveillance and which of these can be improved through learning? (Phase 1: Interviews with 32 AMR experts worldwide)
RQ2. What are the ways of working and learning of professionals within AMR surveillance systems in LMICs? (Phase 2: Site visits to animal and human health labs in 3 low -to-medium income countries)
RQ3: How do outcomes from Phase 1 Phase 2 inform the design of learning events supported by technology that strengthen AMR surveillance? (Phase 3: Co-design of learning events with stakeholders from different countries)
RQ4a: To what extent do learning events from Phase 3 improve professional practice in AMR Surveillance in LMICs?RQ4b: Do the learning events engender or reinforce positive organisational culture to strengthen AMR surveillance? (Phase 4: Design, facilitation and evaluation of learning events across low-to-medium income countries).
This blogpost outlines the reasons why we are carrying out this research and the progress to date.
In recent years global attention has been drawn to the problem of Anti Microbial Resistance (AMR). This problem is associated with the ability of microbes to find ways to reduce the effectiveness of antibiotics.A special meeting of UN General Assembly was held in 2016 to discuss the “fundamental, long-term threat of [AMR] to human health, sustainable food production and development” (see https://news.un.org/en/story/2016/09/539912-un-global-leaders-commit-act-antimicrobial-resistance).
The first true antibiotic, penicillin, was discovered by Alexander Fleming in September 1928 at Saint Mary’s hospital in London. It was used experimentally over the following decade to treat patients with infectious diseases. During this time antibiotics could only be produced at a slow rate in the laboratory. Only a small amount was available to treat patients, which limited practical use as a drug treatment. Developing a process for mass production of antibiotics proved challenging and it took another 14 years for the first penicillin drug to be available commercially available by Merck & Co.
Since then antibiotics have transformed the lives of those who have access to them. In the UK alone the number of people who die from infection diseases has reduced from 40% to 7% over the past century due to a combination of factors including improved public health and sanitation as well as antibiotic treatments. It has contributed to forms of medicine including some cancer cures and transplants which require antibiotic treatment. At the same time, the misuse or overuse of antibiotics has led to increased resistance of the bacteria to drugs, which presents new medical challenges.
Bacteria have proved highly adaptable and resistant and, as new forms of antibiotics are developed, microbes are responding through a broad range of resistance strategies. From the time antibiotics began to be administered, the bacteria started to adapt and survive. The strategies bacteria use range from the evolution of membranes that stop antibiotics breaking them down, to the development of pumps to remove antibiotics from the bacteria (Hall et al (2018) Superbugs: An arms race against bacteria, Chapter 2 – see also https://panopto.lshtm.ac.uk/Panopto/Pages/Embed.aspx?id=d95fd0e0-dca6-4225-b0ff-12eac2a11242).
As bacteria become more resistant to treatments, more people are at risk. 1.5 million people worldwide die each year from forms of infection that are resistant to antibiotic treatments. This problem is getting worse at an alarming rate People who are gravely ill, receiving cancer care or are having invasive surgery may no longer have the option of continual antibiotic treatment since they are at risk of infection from these anti-microbial resistant infections. Therefore immediate global action is needed to minimise the impact of AMR.
With this in mind, the UK Government, in partnership with the Wellcome Trust, commissioned a review on AMR in July 2014 (https://amr-review.org). The aim of the review was to analyse the global problem of rising drug resistance and propose concrete actions and solutions to tackle it internationally. The review considered the problem from a scientific, economic and social perspective and produced a report in 2016 (https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf) Recommendations expand beyond the need for the development of new forms of antibiotics and restricting the use of drugs to developing better detection methods that can instantly diagnose and recommend treatments and encouraging behavioural changes that will reduce instances of infection.
Reducing instances of infection is better than having to treat infections because, aside from the fact that people do not have to be cured from infection, reduced use of antibiotics gives microbes fewer opportunities to develop resistance. Prevention can be improved through simple behavioural changes. For most people this means better hand washing, proper cleaning and vaccination; for doctors, limiting how they prescribe antibiotics to focus on only essential cases; for farmers, stopping the use of antibiotics to prepare livestock for market more rapidly; for scientists and technicians in laboratories it means following the right protocols, gathering high quality data and ensuing reports are available to and used by clinicians; for doctors it means making sure the right patient is prescribed the right drug as appropriate with the right frequency for the right duration.
The relationship between humans and bio technologies is perhaps most complex in low to medium income countries (LMICs), where hospital systems, processes and equipment may be limited. In some countries antibiotic use may not be regulated through prescription and drugs may be available over-the-cuter for anyone who wants to buy and use it without a proper understanding of the impact of their actions, not only for themselves, but for the rest of the world. Behaviour can be influenced through education. When people have a clear understanding of the implications of their actions, they are able to make informed decisions. However, little is known about how to offer education on AMR to different groups of people – farmers, doctors, scientists or the general public – in ways that will trigger effective change.
Our research contributes to supporting this global challenge through building capacity in AMR surveillance. We specifically focus on clinicians, lab technicians and microbiologists in laboratories in LMICs. The research is funded by the UK Government Department for Health and Social Care, through the Fleming Fund and is carried out in partnership with Mott MacDonald over a four year period from April 2018.
In the first year (April 2018 – March 2019) we are investigating who capacity building should be aimed towards, what knowledge, skills and attitudes they need and how they best learn about AMR surveillance through training as well as learning on-the-job. We are talking with 23 renowned experts in AMR to surface a range of issues related to AMR surveillance. In parallel we are identifying the learning needs of laboratory professionals working at specific sites in three focus countries: Bhutan, Tanzania and Ghana. In November 2018 we will submit a report with recommendations for the design, facilitation and evaluation of four learning events across LMICs to build AMR surveillance capacity. These learning events are already being co-designed in partnership with Fleming Fund country and regional representatives as well as country-based Fellows funded through the Fleming Fund. Through country-wide visits to sites we have identified a range of capacity needs and knowledge gaps. From these visits we know, for example, that there is still a general lack of awareness of the problem of AMR and that there are a number of critical topic areas we need to focus on. Topics are likely to range from AMR awareness and basic microbiology to AMR data interpretation and AMR management and leadership. From the country visits we know that, for maximum impact, capacity building should take the form of improvement in awareness, values, beliefs and practices (skills, behaviour, technology use for communication and learning) about AMR engendering or reinforcing positive organisational culture.
More information is at: https://iet.open.ac.uk/projects/fleming-fund-tackling-antimicrobial-resistance.