tackling amr information and networking event: behaviour

Tackling AMR Information and Networking Event: Behaviour within and beyond the healthcare setting

14th June, London [email protected]

mailto:[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Source: WHO, unpublished data.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 Global incidence and prevalence of selected curable sexually transmitted infections – 2012, unpublished data.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



ESRC AMR Research Champion

www.bristol.ac.uk/amr-champ

Network Blog



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



Why Multidisciplinary Research?

AMR is a ‘wicked’ problem

Evidence limited

Different agendas & interest groups

Complex interactions

Multifaceted response



Framing the problem

Consumer / market Human / Animal

Overuse / environmental contamination

Excess / Acess

Biological / technical



‘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



Drivers of antibiotic prescribing / consumption

Perceptions of risk

Interaction between consumer

& provider

Professional norms

Financial incentives

Regulation



International Context

Source: WHO



Local, National, Global

Excess vs. Access

Rising incomes & role biomedicine

Migration

Source: NYT Source: CBC News



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.

• This entailed people listing what skills, knowledge and expertise they could offer a potential research collaboration (under ‘for sale’ heading), and also listing what skills, knowledge and expertise they were looking for from potential partners (under ‘wanted’ heading).

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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

http://www.esrc.ac.uk/files/funding/funding-opportunities/amr/anti-microbial-resistance-setting-the-social-science-agenda/

https://www.mrc.ac.uk/research/initiatives/antimicrobial-resistance/tackling-amr-a-cross-council-initiative/

http://www.esrc.ac.uk/files/funding/funding-opportunities/amr/anti-microbial-resistance-behaviour-within-and-beyond-the-healthcare-setting/

Funders involved

http://www.google.com/url?url=http://www.smf.co.uk/events/chalk-talk-with-edward-fieldhouse-the-fragmentation-of-britains-party-system/&rct=j&frm=1&q=&esrc=s&sa=U&ved=0CB4QwW4wBGoVChMIo93D-7iSxwIVBivbCh3_OQJA&usg=AFQjCNF_syWMG5WREiWyk49J9ts0xwoApg

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/

http://www.jpiamr.eu/activities/jpiamr-3rd-joint-call-jpi-ec-amr-era-net-cofund-call-on-transmission-dynamics/

http://www.jpiamr.eu/activities/4th-joint-call-research-networking-groups/





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

http://www.longitudeprize.org/

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

[email protected]

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.


tackling amr information and networking event: behaviour

Documents