Development of a protocol for assessing the role of WASH in AMR distribution in the environment

Tracy Morse, Kondwani Chidziwisano, David Musoke, Derek Cocker, Nicholas Feasey

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Resistance in Malawi and Uganda (DRUM) consortium to measure the role of WASH in the transmission and control of AMR Abstract In Low and Middle Income countries (LMICs), there is a high incidence of severe bacterial infection, a critically inadequate health system infrastructure to diagnose and treat bacterial infections and widespread and uncontrolled availability of antimicrobials. This situation causes both a huge burden of morbidity and mortality, and is increasing selective pressure for the emergence of antimicrobial resistance (AMR) in pathogens. As LMICs will be the last to benefit from new classes of antimicrobials it is therefore urgent to undertake research addressing AMR in LMICs that aims to identify drivers and interrupt transmission of AMR determinants responsible. Exposures associated with WASH are integral to enteric bacteria and AMR transmission. AMR elements have been found in water, faeces and wastewater in LMICs, and this is compounded by a lack of faecal management (e.g. open defaecation, lack of access to faecal sludge management) and multiple uses of water (e.g. washing, irrigation, animal management and drinking). These factors contribute to community borne AMR transmission, and must be considered across multiple exposure pathways within the community. Focused in urban, peri-urban and rural settings in Malawi and Uganda, the Drivers of Antimicrobial Resistance in Uganda and Malawi (DRUM) consortium is an interdisciplinary programme funded by the Medical Research Council (2018 – 2021). The study aims to address three key questions (1) What are the drivers of ESBL E. coli and ESBL Klebsiella pneumoniae transmission in Uganda and Malawi?; (2) What are the critical points at which efforts to interrupt human AMR acquisition are likely to have the greatest impact?; and (3) Which strategies are likely to be most affordable and feasible to societies and how far is this specific to context? The research will develop agent-based models to enable us to predict how these transmission pathways can be interrupted. Data will be collated on a range of issues including: antibiotic use; antibiotic availability; illness; household demographics; and environmental contamination using both qualitative and quantitative methods. Key to this model will be the under researched area of AMR and WASH. This will develop a clear understanding of water, sanitation and hygiene (WASH) infrastructure and practices both domestically and institutionally [transect walks n=8; observations and checklists at household n=255; institutions n=50], identify the underlying influences on current practices [in depth interviews n=75; key informant interviews n=50; behavioral determinant questionnaires n=500; focus group discussions n=25] and identify drivers which may be amenable to change. These methods will be described in detail. Data will be collected with extensive environmental sampling to identify the transmission routes, support the design of the model and inform interventions. Existing national and international policies in the WASH sector do not currently consider AMR, and the production of evidence in this area is key to supporting and driving policy integration and uptake.
Original languageEnglish
Number of pages1
Publication statusPublished - 7 Oct 2019
EventWater and Health: Where Science Meets Policy - University of North Carolina, Raleigh, United States
Duration: 7 Oct 201911 Oct 2019


ConferenceWater and Health: Where Science Meets Policy
Country/TerritoryUnited States


  • antimicrobial resistance (AMR)
  • Uganda
  • Malawi
  • E. coli
  • antibiotics
  • Klebsiella Pneumoniae


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