Innovate4Health Community Pillar: Building resilience to emerging infectious diseases and the threat of drug-resistance

Between the healthcare delivery and the food system, the community is key to building resilience to emerging infectious diseases and the threat of drug-resistant infections. Up to 80 percent of antimicrobials consumed by humans or by food animals ends up in the waste stream in the environment. Antibiotic pollution flows into the environment from pharmaceutical manufacturing plants, as agricultural run-off from intensive farming operations, from hospitals where patients are treated with the latest antibiotics, and in municipal sewerage where expired antibiotics might be disposed. The borders of urban development spill into once rural areas, and this shifting boundary also introduces greater risk of zoonotic disease transmission. Wet markets, particularly where exotic animals may be sold or where just sanitary or cold chain conditions may be lacking, also increase the risk of foodborne infections.

Different actors and forces are at work when public health challenges converge in the community. Public attitudes and cultural issues come into play. In a survey in 2015, the World Health Organization found that antibiotic use reported over the prior six months was 65% across 12 countries, higher in lower income countries and among the young over the past month. Public understanding of optimal use of antibiotics showed ample room for improvement. Nearly a third thought they should stop taking antibiotics if they did not feel better rather than taking the full course as directed, and a majority (64%) wrongly believed antibiotics could treat viruses such as colds and flu. Of course, public perceptions are not the same as evidence of health-seeking behaviors. To translate awareness into action, a deeper understanding of what motivates behavior change at the individual or collective level might be important.

Community is often where several product value chains that contribute to the flow of antimicrobials and their byproducts into the environment or the commons intersect. Taking a systems thinking approach, one can trace where and how the healthcare delivery system controls antimicrobial use and the effluent from hospitals and clinics. However, when antibiotics are dispensed from the pharmacy, where do patients dispose of unused or expired supplies of these drugs? With seasonal spikes in vaccine-preventable diseases like influenza or COVID-19, who mobilizes the community to become vaccinated so that fewer patients present to clinics where they might be prescribed antibiotics unnecessarily? And what are the behavior change strategies for making change and measuring impact in tackling emerging infectious diseases and antimicrobial resistance (AMR)? How can journalists, social media, mobile phone apps, or biometric monitoring devices carry the messaging to the public? What opportunities are there to find teachable moments, from waiting rooms to markets, to bring public health messages to the community? Evaluation of the impact of community-based efforts are important to consider. While storytelling can sometimes document impact, quantitative indicators can powerfully make the case for adopting or reshaping a mass media or outreach approach to a target community. Using a behavioral economics strategy, the Chief Medical Officer of Australia mailed high-prescribing general practitioners in the community, and those alerted to how they fared compared to their peers responded by decreasing their antibiotic prescribing. Rigorous evaluation of a comprehensive, mass radio campaign in Burkina Faso targeted how family behaviors might change to improve under-5 child survival. The randomized controlled trial failed to detect any lowering of child mortality, but both intervention and control arms registered significant declines in child mortality. Modeling this intervention’s potential effects on child survival through increased care-giving across five sub-Saharan countries with different media markets, however, suggested that it could potentially become a very cost-effective approach in improving child survival where media penetration was high.

Looking at the intersection with the food system, intensive agriculture can result in greater use of antimicrobials, sometimes applied to offset shortfalls in hygiene and other conditions in raising the livestock. The agricultural run-off from farming operations can also contaminate local water sources, and manure and water reclaimed for irrigating vegetable crops may also carry antimicrobial residues, antibiotic resistance genes and drug-resistant bacteria. Food production workers can also carry the bacteria back to the community. In crop production and aquaculture, the antimicrobials used may enter directly into the environment. Importantly, the food produced moves to markets, where they are purchased for consumption. While food producers and buyers can manage some of the AMR risks, a systems approach must still include the community. How can the risk of agricultural run-off be managed if it affects local water sources? How can one identify potential environmental hotspots of AMR, where microplastics or herbicides might mix and amplify AMR risk? Microplastics provide surfaces conducive to more rapid transfer and exchange of genetic determinants of drug resistance. Herbicides have been found, both in vitro and in vivo, to change the antibiotic susceptibility of key enteric bacteria as well. While the clinical significance of these findings requires further research, there may be co-benefits from tackling these sources of environmental pollution.

As the system diagram reveals, there are not only community connections to various product value chains (pharmaceutical manufacturing, healthcare delivery and food production), but also in many parts of the world, there are several convergent factors that make urban areas potential AMR hotspots. In particular, the high density of humans and animals, the misuse of antibiotics, and the inadequate infrastructure for sanitation, sewerage and drinking water all contribute to urban informal settlements where AMR risk is greater. Explore different targets, as well as resources for Innovate4Health teams, using the drop-down menus below: