Tackling AMR Information and Networking Event: Behaviour within and beyond the healthcare setting
14th June, London [email protected]
Agenda: • The day started with an introduction from the chair, Prof Dame Sally Macintyre
and presentations from: Tariq Saddiq, St George’s University of London – A Clinician’s perspective Elizabeth Marier, Veterinary Medicines Directorate - AMR in animals –
behaviour and economics Christie Cabral, University of Bristol – Social Science Research on AMR Slides from each of the above follow this slide.
• Those present then separated in to groups and discussed the following questions:
1. “How can we, as researchers and other stakeholders, make sure that research undertaken through this call makes a difference?”
2. “What evidence needs could research funded through this call on ‘behaviour within and beyond the healthcare setting’ address?”
Antimicrobial resistance: behaviour within and beyond the healthcare setting
A Clinician’s Perspective
Dr Tariq Sadiq
Tuesday 14 June 2016
Source: WHO, unpublished data.
64 million
Preliminary WHO estimates: 357 million new cases of curable STIs in 2012
31 million
63 million
18 million
142 million
39 million
Curable STIs: chlamydia, gonorrhea, syphilis, trichomoniasis
Source: WHO. Global incidence and prevalence of selected curable sexually transmitted infections – 2012, unpublished data.
Estimated Prevalence of Mycoplasma genitalium in genital discharge patients
18%
6%
50%
17%
17%
5-38% 7-42%
Sethi et al 2012 IJMR 2012
26%
7.6%
Emergence of MDR and XDR N. gonorrhoeae Priorities for DH, EU and WHO
Ceftriaxone (XDR) Resistance strains: H041 / F89 – From Japan and France (2012); Now spreading across Europe
Gonorrhoea: Global: 109 Million EU/EEA: 52,995 (2013) England: 34,958 (2014) (⬆19%, 2013)
Detection of decreased susceptibility to ESCs (≥ 0.125 mg/L) in N. gonorrhoeae and treatment failure up to 2010
H041, CSW; Kyoto; Japan; 2009
F89 2012
Ohnishiet al; Unemo et al. Antimicrob Agents Chemother. 2011; 2012
Lis, Rowhani-Rabar, Manhart CID 2015
Mycoplasma genitalium is a cause of serious reproductive health sequelae
Pelvic Inflammatory Disease Pre-term Birth
Spontaneous Abortion Female Infertility
Diagnose Disease at PoC
Treat empirically
Health Promotion
Partner notification
Pool of STI Pathogens Reduced Pool of Pathogens
Rapid STI Detection in Clinical and Public Health Medicine
R = b x c x D
A Double Personalised Medicine Challenge for Sexual Health
• 1. Treating Genital Discharge Syndrome – Chlamydia trachomatis – Neiserria gonorrhoeae – Trichomonas vaginalis – Mycoplasma genitalium
Doxycycline Ceftriaxone & Azithromycin Metronidazole Azithromycin or Moxifloxacin or Pristinamycin?
• 2. Antibiotic Resistance – Neiserria gonorrhoeae
– Mycoplasma genitalium
Ciprofloxacin/ Penicillin – 30% Resistance Azithromycin 40-50% Resistance Moxifloxacin 30-50% resistance
Genital Discharge and Antibiotic Resistance
Current Standard of Care for patients with genital discharge: a complex care pathway, multiple attendances, missed diagnoses and inappropriate antibiotics
prescribed for different or absent pathogens.
Visit 1
Visit 2
Visit 3
Weeks
Episode type Sensitivity Specificity PPV NPV
Urogenital infection (n=164) 95.8%
(90.4-98.6%)
100%
(92.3-100%)
100%
(96.8-100%)
90.2%
(78.6-96.7%)
Extra-genital infection (R&P) (n=70) 95.8%
(85.8-99.5%)
100%
(84.6-100%)
100%
(92.3-100%)
91.7%
(73.0-99.0%)
Resistance Marker
All M. gen cases N=22
% (95%CI)
Wild-Type 55% (35-74)
All 23s RNA 41% (23-61)
A2058G 5
A2059C 1
A2059G 3
QRDR: parC S83R
5% (1-22)
No
Urethritis
NGU P
Chlamydia
trachomatis
2/107
2% (0-5)
15/102
15% (8-22)
<0·001
Mycoplasma
genitalium
5/107
4·7% (1-9)
17/102
17% (10-24)
0·005
One Clinical Visit Solution to Personalised Medicine Challenge
Patient with Genital
Discharge
First void urine sample (men) or self-collected vaginal swab (women)
Multiplex STI & Antibiotic
Resistance Rapid Test
Negative Test
Clinical review
Chlamydia Positive
Trichomonas Positive
Mycoplasma Positive
Gonorrhoea Positive
Doxycycline
Metronidazole
Az Resistant? No: Give Azithromycin
Yes: Moxi Resistant?
No: Give Moxifloxacin Yes: Give Pristinamycin
Ciprofloxacin Susceptible? Yes: Give Ciprofloxacin
No: Penicillin Susceptible?
Yes: Give Penicillin No: Give Ceftriaxone &
Azithromycin 45 – 90 Minutes
Tier 1
Tier 2
Social Science Perspective’s on AMR and PoC testing for STIs
• Patients with symptoms felt more willing to spend more time in clinic for diagnosis and treatment (if needed).
“…if there was something going on that was causing me discomfort, then I imagine I’d probably be more keen to get it sorted faster, really. … Because you’d be aware that
there was a problem….that needed fixing….you’d probably be worried that it might be getting worse before you had the opportunity to get it treated.”
Heterosexual man, age 26, London
• Many patients wanted clear information on the expected time in clinic, when results would be available, allowing them to manage expectations
“…I think it would be all about how it was explained to me, that if someone explained how that was going to happen, then I think I would be okay about that.
- Heterosexual woman, age 41, Devon
Fuller et al 2016
Electrochemical multiplex capability
Curr
ent
Voltage
Targets 1-6
Targets 7-12
Targets 13-18
Targets 19-24
4 detection chambers x 6 Labels = 24 Targets on 1 sample 30 Minutes
PCR 1-12
PCR 13-24
Det 1
Det 2
Det 3
Det 4 Sample preparation PCR amplification Detection
Diagnose Disease at PoC
Determine Drug Susceptibility at PoC
Treat patient empirically with ABx that work
Re-use old discarded Abx
?reduced selection pressure on 1st line Abx
Pool of AMR pathogens Reduced Pool
of AMR Pathogens
Rapid AMR Detection in Clinical and Public Health Medicine
R0res = bres x cres x Dres
Technology
development
Micro-engineering SGUL/Brunel
Assay
development
Micro-biology SGUL
Industry: Partner/FfS; Academic; DoH
STBRU / NICE / NOCRI / Academic collaborators / CROMSOURCE
Diagnostic evaluation SGUL/PHE/NHS-GUM/NCSP
Early POCT evaluations
Late POCT evaluations
and regulatory trials
Clinical and public health impacts
SGUL/PHE/Brunel/PHE
Epidemiological and public
health benefit
Assessment of clinical & cost effectiveness
Development Pipeline, Progress to NHS Adoption
Applied Diagnostic Research & Evaluation Unit
Funding
MRC/NIHR/Wellcome
Research Councils
Research Charities
DoH/Innovate
Industry
ADREU Capacity
Trial Coordinators
Research Scientists
Clinicians
Public Health Scientists
Sexual Health, HIV and ID Clinics
Overarching Regulatory and Ethical Approval
Tissue Bank Facility
Tariq Sadiq Marcus Pond Emma Harding Esch Catherine Hall Achyuta Nori Mark Harrison Claire Broad Sebastian Fuller Christine Chow Laura Phillips/ Emma Cousins Philip Butcher Jason Hinds Adam Witney Tim Planche Ken Laing Wamadeva Balachandran Ruth Makay Pascal Craw Manoharanehru Branavan Angel Naveenathayalan Raj Patel - Solent NHS Trust
Kathy Lowndes Kevin Dunbar Stephanie Chisholm - Gwenda Hughes Emma Harding Esch Michelle Cole Cathy Ison David Livermore John Clarkson Daniel Adlerstein Marc Green Anna Dixon Jorgen Jensen SSI Denmark
The Applied Diagnostic Research and Evaluation Unit
Antimicrobial Resistance in animals: Behaviour & Economics Elizabeth Marier 14 June 2016
Defra at a glance
Defra at a glance 21
Defra Executive Agency
Executive non-dept
public body
Advisory non-dept
public body Non-
ministerial dept
Tribunal non-dept
public body
Others • APHA • VMD • CEFAS • RPA
• AHDB • Environment Agency • National Forest Company • Botanic Kew Gardens • Nature Conservation • Natural England • Council for water • Marine Management • Fish Industry Authority
• Environment and Rural • Strategy, International,
food and Farming
• Forestry commission • Water service regulation authority
• Drinking water Inspectorate • National Park authority
What the AMR team at VMD does
AMR work at the VMD 22
Surveillance
Antibiotic usage
Sales
Consumption
Resistance
Veterinary pathogens
Zoonotic pathogens
Engagement
Policy
Communication
One health strategy
One health strategy 23
Theme 4: what was discussed
Theme 4 24
- Presentation from Ruth Little (U of Sheffield): meta review of the literature available on behavioural research around animal health
- Presentation from Kristen Rehyer (U of Bristol): REA on social science in AMR in animal sector + work a U of Bristol
Theme 4: what was discussed
Theme 4 25
- Nine clusters of ideas of which a few were discussed - Engagement - Farm design and biosecurity - Regulations and guidelines - Knowledge, expertise and trust - Diagnostics - Prophylactic or in-feed use and economics - Perception and risk - Environment and sustainable practices - Public and consumers
Theme 4: Ideas generated by attendees
Theme 4 26
- Diagnostics - Need for a tool which will provide a more accurate diagnosis
BUT - Need to understand barriers to adoption when designing tools
- Behaviour & perception - Engaging farmers and vets on a one health agenda - Risk perception - Dealing with uncertainty - Sustainable change in behaviour and perception = how? - What is the best way to disseminate message out
Theme 4: ideas generated by attendees
Theme 4 27
- Knowledge, expertise and trust - Need to understand habits and how to break them - How do vets and farmers update their knowledge - How do we segment farmers / early adopters
- Sustainable farming - Understand farmers/vets perception: what is
biosecurity? What is sustainable farming? What does responsible use mean?
- What would motivate farmers/vets to adopt and sustain new practices?
28
In short
A better understanding on how to: • Get people on board • Send the message out • Change the perception on the risk of AMR • Understand the economic impact of such changes
Research is unusable if we can’t change behaviour
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Social Science Research on Antimicrobial
Resistance
Dr Christie Cabral
#amrchamp
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
ESRC AMR Research Champion
www.bristol.ac.uk/amr-champ
Network Blog
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Social Science Research & AMR
Social norms Moral dimensions Professional roles Economic incentives Sociology of technology use Health inequalities History of drug resistant infection Behaviour change interventions Design to reduce transmission
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Why Multidisciplinary Research?
AMR is a ‘wicked’ problem
Evidence limited
Different agendas & interest groups
Complex interactions
Multifaceted response
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Framing the problem
Consumer / market Human / Animal
Overuse / environmental contamination
Excess / Acess
Biological / technical
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
‘Othering’: “It’s not us it’s them”
Health professionals blame
farming industry
Farmers blame doctors
Doctors blame patients
GPs blame hospitals &
visa versa
Everyone blames migrants
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Drivers of antibiotic prescribing / consumption
Perceptions of risk
Interaction between consumer
& provider
Professional norms
Financial incentives
Regulation
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
International Context
Source: WHO
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Local, National, Global
Excess vs. Access
Rising incomes & role biomedicine
Migration
Source: NYT Source: CBC News
School of SOCIAL AND COMMUNITY MEDICINE
University of BRISTOL
Key challenges
Complexity of prescribing and consumption contexts –
antibiotic use as social interaction e.g.
Professional hierarchies in health care settings
Producer and supplier relations in agricultural settings
Stewardship vs safety of individual patients
Equitable access vs essential use
FOR SALE/ WANTED BOARDS explained
• Those present at the event were given the opportunity to fill in a ‘for sale/ wanted’ card.
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Tackling AMR: Advice for applicants
Naomi Beaumont, ESRC
Presentation covers:
▶ Broader context ▶ Outline of research areas in call
specification ▶ Types of proposal that are possible ▶ Example queries to date
How we got here….. ▶ Working group to scope social science: report ▶ Funders Forum and Cross council agreement on a
themed initiative: 1) Understanding Resistant Bacteria 2) Accelerating therapeutic and diagnostic development 3) Understanding the real world interactions 4) Behaviour Within and beyond the health care setting* *this is the first major activity under theme 4
▶ Workshop to scope theme 4 in more depth: report ▶ Consultation with stakeholders
What this call is seeking: cross cutting objectives
Behaviour relevant research underpinning: ▶ Identify strategies for action ▶ Needs of practitioners/ others to influence behaviour ▶ Preserve efficacy of antibiotics ▶ Inform and evaluate interventions Impact on antibiotic use or AMR
What this call is seeking: sub themes
▶ Awareness and engagement ▶ Public health as an opportunity to reduce use of
antibiotics: preventing infection & transmission ▶ Informal markets and access to antibiotics ▶ Stewardship and appropriate use of antibiotics ▶ Behaviour as it relates to animals and AMR Proposals crossing the above sub themes welcome
What this call is seeking: things to note
▶ Research that makes a difference: recommend10% to
impact activities, think about all communications at all stages
▶ Cross disciplinary research and collaborations ▶ Analyses existing sources welcome eg:
– Wellcome Trust Monitor – European Social Survey – Public Health England resources – eg fingertips
Eligible funding types: Pump Priming ▶ Up to £250k, up to 24 months ▶ Primarily Low and Middle Income Country focussed ▶ Element of networking permissible, as long as
substantive output ▶ Early Career Researchers welcome ▶ Closing date 20th July; start January 2017
Eligible funding types: Collaborative grants ▶ Up to £2m, up to 48 months ▶ UK or LMIC ▶ National/ international focus point ▶ Cross disciplinary teams ▶ Partnerships with non academics ▶ Closing date 8 September; Expression of Interest due
27 July
ODA relevance: what it all means
▶ £1.5bn ‘Global Challenges Research Fund’ partly funding this AMR call
▶ GCRF = Research to benefit countries on DAC list
▶ In this call, proposals ‘self identify’ as ODA relevant through fill in one page attachment: – Which country/ countries on the DAC list will directly benefit? – How is your proposal relevant to development challenges of these countries? – How will the outcome of your proposed activities promote the economic
development and welfare of a country or countries on the DAC list?
Queries to date ▶ Do all applications need to be ODA relevant? No ▶ Are interventions permissible? The research part of
interventions (develop, inform and evaluate), yes, with caution! Must be realistic, affordable, needed etc
▶ Can I cost those not at eligible UK institutions in to bids? Yes, in various ways
▶ Will there be future AMR calls? Probably, tbc ADVICE: Read the call again before finalising bids
Reminder of key dates
▶ Pump Priming: – closing date 20 July – Decisions Oct – Start dates 1 Jan 2017 (up to 2 yr)
▶ Collaborative grants: – Expressions of Interest 27 July – closing date 8 Sept – Decisions January 2017 – Start dates from March 2017 (up to 4 yr)
Thank you
▶ To contact ESRC about this call for
proposals email: [email protected] ▶ Today’s presentations and a list of
attendees (including contact details) will be placed on the ESRC website in the coming week.
Other funders and stakeholders then quickly presented information about existing and future opportunities, as well as available data resources. These slides follow.
Tackling AMR – new ways of working Ghada Zoubiane Medical Research Council [email protected]
Current AMR activities
Cross council initiative phase 1: • Theme 4 call • Theme 3 Indoor environment call • Medical Research Foundation funding – PhD progamme
across all 4 themes
Joint Programming initiative AMR: • Transmission call - closed • Network working groups call – closed
http://www.mrc.ac.uk/research/initiatives/antimicrobial-resistance/
Future AMR activities
Cross council initiative phase 2 and beyond: • Phase 2 - Challenge-led antibacterial resistance call:
interdisciplinary, LMIC, collaborations call (autumn 2016) • GCRF pot – cross council common pot bidding (in ~2
years)
Joint Programming initiative AMR • Call topics underway for 2017/18 with intervention
research identified as a priority
Newton Fund • Potential calls in 2017 that are infection/AMR relevant
AHRC AMR Theme 3 – The indoor environment contact: [email protected]
• To follow on from NERC led Theme 3 (outdoor environment) • Launching Autumn 2016 (October/November)
• Scoping workshop held Likely direction (all subject to further discussion and confirmation)- • ‘Indoors’ likely to include the whole urban/built environment (city parks, transport hubs,
homes, veterinary surgeries).
• Anticipate that it will be design-led – design in a very broad sense – inc. designing ‘things that are not things’
• Potential for a wide range of specialisms across the RCUK remit
• Likely themes involve physical interactions within and with the indoor environment and data / monitoring.
• Funding model likely to be smaller scale innovation style grants
Arts & Humanities Research Council
A global challenge with a 300 year history and a £10m prize fund. This 5 year competition opened in November 2014
• UK’s biggest science prize • Following a UK vote, the Longitude Prize will reward the
development of a transformative point–of–care diagnostic test. It must significantly reduce the overuse or misuse of antibiotics around the world
• Discovery Awards, seed funding of up to £25k, are available now. Applications can be made until 26th August on the website
@longitude_prize www.longitudeprize.org
Funded by
Wellcome Trust Monitor • Explores knowledge & attitudes toward science &
medical research – (understanding & behaviour around antibiotic resistance – Wave 3)
• Triennial random sample survey of UK population • Wave 3 (2015) 45 min face to face interviews 1524
adults only, young people separately in 2016
• www.wellcome.ac.uk/monitor
Tackling antimicrobial resistance: Behaviour within and beyond the healthcare setting ▶ To contact ESRC about this call for
proposals email: [email protected] ▶ Today’s presentations and a list of
attendees (including contact details) will be placed on the ESRC website in the coming week.