UK - Department for Business, Energy and Industrial Strategy
One Health Drivers of Antibacterial Resistance in Thailand
Project Data Last Updated: 27/08/2020
IATI Identifier: GB-GOV-13-FUND--GCRF-MR_S004769_1
Antibacterial Resistance (ABR) is a significant source of excess mortality in Overseas Development Assistance (ODA) countries and constitutes a major, increasing threat to wellbeing and economic development. Antimicrobial Resistance (AMR), predominantly ABR, is estimated to have caused 38,000 deaths and an economic loss of 1.2 billion US$ in Thailand in 2010. Because of good record keeping and surveillance, Thailand has been used as an exemplar for characteristics of ABR in ODA countries. ABR is common in human, environmental and animal bacterial isolates. However, ABR has mostly been studied separately in discrete sectors (e.g. hospital patients or poultry). The key drivers of ABR relevant to human health cannot be pinpointed in this way because the selection and transmission of ABR results from interactions between humans, animals, and the environment. A "One Health" approach to the problem is required. During this consortium project, we will study the Enterobacteriaceae family bacteria Klebsiella pneumoniae (Kp) and Escherichia coli (Ec), which reside in the human and animal gut, are common in environments contaminated with faeces, are are considered a significant threat to human health in Thailand. They are commonly carbapenem- and/or 3rd-generation cephalosporin-resistant (3GCR), which are drugs commonly used for serious infections. Carbapenem-resistant Enterobacteriaceae (CRE) are also recognised by WHO as one of the highest priority pathogens globally for which new ABs are urgently needed. Ec and Kp cause a range of infections in hospitalized patients (e.g. surgical site, intra-abdominal, pneumonia, sepsis) and serious community-acquired infections (e.g. complicated urinary tract infection, pyogenic liver abscess, meningitis). The prevalence of 3GCR Kp and Ec in human infections in Thailand has been increasing from less than 10% in 1999 to 50% in 2016, and of carbapenem-resistant Kp from none prior to 2010 to 10%-20% in 2016. Our consortium's vision is to build a holistic picture of the drivers of ABR in Thailand and to use this information to benefit the Thai people, and as an exemplar for other ODA countries. The term "driver" may refer to: 1) a material condition or substance, such as a chemical (e.g. an Antibiotic), which, at a particular concentration, selects for the increased prevalence of ABR bacteria; 2) an action, such as exposing bacteria to that chemical by taking an antibiotic; or 3) a socioeconomic condition or circumstance which accounts for that action (e.g. the economic necessity to keep working in the face of illness). A full understanding of ABR drivers at every level is important for the design of effective and appropriate interventions to limit ABR. Hence, this interdisciplinary consortium will investigate them all. Our study area will be the Mae Klong-Ta Chin Basin, which covers an area of 80x80 km in the central and western part of Thailand. This is the area where the Mae Klong and Ta Chin rivers run from their mountain sources along the Thai-Myanmar border (Mae Klong river) and upper central Thailand (Ta Chin river) down to the Gulf of Thailand. The study area includes districts spread over five provinces (Karnchanaburi, Ratchaburi, Samut Songkram, Samut Sakorn and Nakornprathom). Both rivers enter the study site and run through areas where there are numerous factories, animal farms, rice fields, fruit orchards and communities, allowing multiple possible drivers to be considered in our work. Our work will run alongside Thailand's National Strategic Plan on AMR, giving us a perfect opportunity to embed our findings in annual reviews of the Strategic Plan, influencing policy and having a relatively short term and direct impact on human health in Thailand. Our engagement and stakeholder activities will also facilitate dissemination of our findings into other countries within the same global region, and comparisons with other projects across the globe will yield added value.Objectives
Our first challenge is to address these unknowns and rank the importance of different substances, conditions and actions that drive selection/transmission of 3GCR Ec and Kp and CRE in Thailand. We will: Quantify the contamination of food and key environmental sites with ABs, herbicides, and metals. Quantify the levels of enteric carriage of 3GCR Ec and Kp and CRE in humans and (domestic and farmed) animals in food and in key environmental sites. Quantify AB usage in humans and (domestic and farmed) animals. Use risk factor analysis to identify behaviours/management practices that impact on the level of enteric carriage of 3GCR Ec and Kp and CRE in humans and farm animals. Use bacterial isolates and data collected in these studies to address nine hypotheses: 1. The clinical burden of ABR caused by 3GCR Ec and Kp and CRE is underpinned by a high frequency of asymptomatic enteric carriage in the community. This hypothesis may stand for some types of infection but not for others; each will be tested separately. 2. The clinical burden of ABR caused by 3GCR Ec and Kp and CRE derives primarily from bacteria and ABR mechanisms of human rather than animal origin. 3. The carriage of 3GCR Ec and Kp and CRE in the human or (domestic or farmed) animal gut originates from the environment via ingestion of contaminated food and water. 4. The community carriage of 3GCR Ec and Kp and CRE in the human or (domestic or farmed) animal gut is driven by prior AB therapy. 5. Carriage of 3GCR Ec and Kp and CRE in the human gut is driven by the ingestion of water and food contaminated with ABs, herbicides and/or metals. 6. 3GCR Ec and Kp and CRE can be selected for with sub-lethal concentrations of ABs or through co-selection by herbicides and metals. 7. Commonly encountered 3GCR Ec and Kp and CRE isolates outcompete less commonly encountered isolates or strains in the absence and/or presence of selection and or their resistance plasmids are more transmissible. 8. Contamination of human or animal food with 3GCR Ec and Kp and CRE is derived from both human and animal faecal carriage. Such contamination is less clinically significant for food produced by industrial versus smallholder farming. 9. 3GCR Ec and Kp and CRE in water ingested by humans and animals derive from both human and animal faecal contamination. Where animal faecal contamination is found, contamination is more likely to be caused by smallholder farms than industrial farms. Our second challenge is to investigate the specific sociocultural, organizational and economic formations (concepts, arrangements and practices) associated with the anthropogenic drivers of ABR identified as key during completion of challenge 1. Resources will be flexibly deployed once we have a preliminary understanding of the key drivers, but lines of enquiry that are certainly under consideration are: We will study AB usage practices and healthcare seeking behaviour for humans and animals, including direct (over the counter) purchasing of ABs from retail outlets and animal food suppliers, professional practices around AB use at all levels of human and animal healthcare, and local rationales for these practices. We will consider behaviours and practices relating to food procurement, slaughter, domestic preparation and consumption, and water use in study communities. Our third challenge is to develop a model incorporating all the identified drivers in order to identify interventions for reducing the impact of 3GCR Ec and Kp and CRE on human health. This holistic approach will inform interventions that are underpinned by a full understanding of the social and policy contexts at provincial and national levels.
|Extending:||UK Research & Innovation|
|Funding:||UK - Department for Business, Energy and Industrial Strategy|
|Implementing:||University of Bristol|
Sectors groups as a percentage of country budgets according to the Development Assistance Committee's classifications.
A comparison across six financial years of forecast spend and the total amount of money spent on the project to date.