Sonia Lewycka: One Health interventions to combat antimicrobial resistance

I'm Sonia Lewycka. I'm a senior epidemiologist at OUCRU in Hanoi, and I'm interested in antimicrobial resistance. My work particularly takes a macroscale focus. I'm using a One Health approach to look at antibiotic use and antibiotic resistance in humans, animals and the environment and the intersections between those, trying to understand the pathways of transmission between the different sectors, and develop interventions to tackle the overuse of antibiotics, and also the resistance that gets transmitted between those different areas.

We recently completed and published a trial in The Lancet which was one of the largest trials, I think, done by the unit, including 40,000 patients in primary care centres. We had 48 primary care centres in a northern province of Vietnam. We were trying to test in a pragmatic trial, in a real-world setting, what happens when you introduce a point-of-care test for primary care doctors, to help them guide their antibiotic prescribing and hopefully reduce the amount of antibiotics that are prescribed unnecessarily. We found that there was a significant reduction in prescribing of antibiotics by primary care doctors, but it wasn't as large as we'd hoped. So, now we want to do further research based on interviews that we did during the intervention, to understand barriers to using the test so not all of the patients who are eligible to have the test received the test. We want to understand the patient factors and the doctor factors that made the decision about whether or not the test could be used for them to guide this antibiotic prescribing.

Then we've got plans to do further research. We've just done a feasibility study about using point-of-care tests outside of formal healthcare settings, using them in pharmacies which are actually a more popular point-of-care for mild infections in the community. Most people would go to a pharmacy first when they have symptoms of a respiratory infection, and we wanted to see if we introduced tests in that setting, whether or not we could have an impact on the drugs that are given and sold over-the-counter without a prescription, by replacing the sale of an antibiotic with the sale of a point-of-care test.

The Just Transition initiative is a group of 20 social science and humanities researchers. It's very interdisciplinary and very global as well, the programme members are from many different countries across the world and come together to explore policies to address and mitigate antimicrobial resistance, thinking about the justice concerns that arise, thinking about equity and fairness in terms of policies, but also possible unintended consequences. For example, if we restrict antibiotic use in farming, those farmers and particularly the ones whose incomes are very tentative may be most impacted by measures to remove antimicrobials from their use, so it may impact on their livelihoods. And similarly, in communities where these drug sellers or pharmacies are one of the most important sources of essential medicines for people, and the health care infrastructure to deliver primary care and important health services in the community is limited or lacking completely, if we remove over-the-counter access to antibiotics and other medicines, then that might have implications for health. So, it's just really trying to make those tensions visible, not to say that we shouldn't introduce those measures, but just to make the tensions visible so that policies and strategies that are developed are appropriate and fair.

Over the next two years of the programme, we plan to further the work in understanding and looking at contextual ways in which the Just Transitions can be applied for AMR, and also looking at what we can learn from Just Transitions for climate change. We want to have conversations with people who are already thinking about Just Transitions for climate change and thinking about strategies to help accelerate progress towards climate change targets, and really identify whether there are synergistic actions that would have co- benefits for mitigating climate change and also AMR. Particularly, in the space of intensive livestock production which is driving a lot of methane emissions and contributing to global warming, it's also really a kind of a hotspot area for AMR activity. If we can develop forms of livestock production that are more sustainable and have less impact on both climate and AMR then that would be a win-win for both situations.

There's growing understanding about the connections between climate change and AMR's problems. They're both collective action problems that require coordination across multiple sectors, and they're termed as super wicked problems because of the kind of complexity of dealing with them. But there are also biological connections between the two problems and networks of activities, human activities particularly that connect them. For example, I've mentioned already that livestock production is something that contributes to both greenhouse gas emissions and also the development and dissemination of antimicrobial resistance, but there's feedback there, so increasing temperatures may also accelerate the development of resistance by increasing bacterial populations in the environment, but also potentially accelerating the process of transfer of resistance between bacteria. That's something that really needs further investigation, something that our group would like to learn more about in future.

This interview was recorded in January 2024.