Abstract
Recognized as a threat to the achievement of the Sustainable Development Goals (SDGs), the Quadripartite organizations developed the One Health Priority Research Agenda for antimicrobial resistance (AMR).(1) The Research Agenda emphasizes that addressing the interlinked and multi-faceted challenges posed by AMR necessitates a One Health approach. One Health is defined as "a collaborative, multisectoral, and transdisciplinary approach—working at the local, regional, national, and global levels—with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment”.(2)
The ongoing intensification of the livestock industry to meet growing demands for nutrition has been largely successful in low- and middle-income countries (LMICs).(3) This is facilitated by the routine use of antimicrobials to treat, control, and prevent animal diseases and to increase the productivity of animals. While there is lack of reliable data on antimicrobial use (AMU) in agriculture in LMICs, some recent studies suggest that ~73% of all antimicrobials sold globally are used in food-producing animals.(4) Such over-use and misuse of antibiotics in animals contributes to the emergence and spread of AMR.
For the current project, we will utilize a One Health approach and address AMR in the animal health sector and supplement our ongoing efforts surrounding human health and AMR in Nepal, over the last decade.(5-11) A recent study conducted in Nepal identified a total of 96 trade name registered antimicrobials available for use in animals, comprising 35 different genera of antibiotics, belonging to 10 different classes.(12) While Nepal has a legal ban on the use of antimicrobials as growth promoters, sales of drugs without prescriptions from veterinarians are common practice for prophylactic and therapeutic purposes among paraprofessionals and agrovets.(13, 14) Moreover, a recent study reported that the volume of veterinary antibiotic sales increased over 50% from 2008 to 2012.(15, 16) Such misuse of antimicrobial agents in the livestock sector is one of the main drivers for farm-to-fork transmission and the continued spread of AMR, especially in LMICs where there are poor biosecurity measures in place, looser regulations on veterinary drugs, and frequent human-animal contact. Therefore, there is an urgent need to improve the awareness and understanding of AMR and institute established antimicrobial stewardship (AMS) principles in the animal health sector (veterinary service providers and community members) to optimize the use of antimicrobial agents. For the purposes of this study, veterinary service providers will include veterinarians, veterinary paraprofessionals, animal health technicians, and agrovets. Community members will include dairy and/or poultry farmers and farm workers in traditional smallholder and commercial farming settings. In Nepal, traditional farmers typically own 1-5 dairy animals and 10-50 poultry, while commercial dairy farms raise ~10-150 cows/buffaloes and commercial poultry farms have more than 500 chickens. The primary objectives of the proposed 2-year project include:
1. Conduct a mixed-methods study to assess knowledge and perceptions among veterinary service providers and community members to identify antibiotic dispensing and use practices and key factors which contribute to inappropriate use of antibiotics in livestock and pathogen resistance. The mixed methods will include qualitative interviews, focus groups and surveys with veterinarian service providers, community members, and district and national policy makers. The qualitative data will provide socioeconomic contextual information to support understanding of emergent issues and factors associated with antibiotic dispensing/use patterns. The surveys will provide more generalizable data to assess types of antibiotics dispensed/used for livestock, factors associated with antibiotic dispensing/use, farm hygiene/sanitation and infection prevention and control (IPC) practices, and knowledge and perceptions of antimicrobial resistance and impact on animal and human health. These data will help establish a baseline for a longitudinal outcome evaluation of the intervention (Aims 2 & 3). During this assessment phase, we will also expand our existing AMR Scientific Advisory Board (SAB) and establish a Community Advisory Board (CAB) in order to promote broader engagement in the program and local involvement in program development, implementation, and evaluation. Experts from Nepal Veterinary Association, Nepal Paraveterinary Association, and Nepal Animal Health service technician's association will be included as members of SAB. The CAB will include leaders and members of Nepal Poultry Farmers Association, Nepal Dairy Association, Nepal Egg Producers Association, and District Milk Producers Cooperative Association.
2. Utilize data to develop/adapt AMR education, training, and stewardship to support appropriate antibiotic dispensing and use among veterinary service providers and community members, and promote behavior change and decrease AMR in Nepal. The study team in collaboration with the SAB and CAB will develop context- and country-specific education modules to support One Health stewardship goals. These modules will be implemented with local stakeholders including veterinary service providers, and a comprehensive social mobilization and communication strategy will be developed for community members.
3. Implement a randomized control trial of the veterinarian service provider and community interventions. Districts will be randomized to receive or not receive the interventions. Longitudinal evaluation data will include the above-mentioned baseline surveys (Aim 1) and 6-month post-intervention surveys. The survey will provide data on the impact of the educational modules and communication strategy.
4. Conduct a process evaluation based on the Consolidated Framework for Implementation Research.(17) This approach will provide data at multiple levels (policy, programmatic, health system, and community) which can inform further dissemination of the intervention by the Nepal Ministry of Agriculture and Livestock Development (MoALD) and Nepal Agricultural Research Council (NARC).
5. Engage with policy makers, program managers, veterinary service providers and community members through scientific and community advisory boards (SAB/CABs) and a post-project dissemination workshop. This engagement is designed to support data interpretation, intervention adaptation/development, and future implementation of the interventions at a national level.
Assessment (Aim 1)
Hypothesis 1: Farmers and farm workers reporting greater awareness/knowledge of AMU and AMR are more likely to exhibit animal healthcare seeking behavior which support One Health stewardship goals.
Hypothesis 2: Veterinary service providers reporting greater knowledge of recommended antibiotic prescribing/dispensing guidelines and policies are less likely to prescribe/dispense unjustified use of antibiotics.
Outcome Evaluation (Aim 3)
Hypothesis 1: Farmers and farm workers exposed to the communication strategy, compared to those not exposed, will have increased awareness of appropriate usage of antibiotics and AMR.
Hypothesis 2: Farmers and farm workers exposed to the communication strategy, compared to those not exposed, will have increased intent to visit veterinarians and exhibit animal healthcare seeking behavior which supports AMR stewardship.
Hypothesis 3: Agrovets exposed to the educational intervention will be more likely to require prescriptions before selling antibiotics.
Hypothesis 4: Veterinarians and paraprofessionals exposed to the educational intervention, compared to those not exposed, will be more aware of justified antibiotic use in agriculture which can result in decrease in AMR and risks to human health.
The proposed project is a collaboration between Henry Ford Health Global Health Initiative (HFH-GHI) and Division of Infectious Disease, the Nepal Ministry of Agriculture and Livestock Development (MoALD), and Nepal Agricultural Research Council (NARC), and a local non-profit, GTA Foundation. NARC is a governmental agency that falls within MoALD, has regional offices, and works closely with the provincial and local government to develop/enhance the dissemination of agricultural research. HFH and GTA have partnered on multiple projects related to infectious disease over the past seven years.
The objectives and approach of this proposal meet the Interests of the Merck Investigator Studies Program (MISP) request for proposals for studies evaluating a CDC One Health approach to stewardship. Specifically, the study will identify barriers which contribute to imprudent use of antibiotics in agriculture and utilize a randomized control trial to evaluate interventions to improve knowledge, attitude and practices related to antibiotic use in agriculture in Nepal. The resulting evidence-based AMS program could be scaled up in Nepal and adapted and implemented elsewhere in South Asia and other LMICs.