Harmonized One Health Trans-Species and Community Surveillance for Tackling Antibacterial Resistance in India: Protocol for a Mixed Methods Study

Background: India has the largest burden of drug-resistant organisms compared with other countries around the world, including multiresistant and extremely drug-resistant tuberculosis and resistant Gram-negative and Gram-positive bacteria. Antibiotic resistant bacteria are found in all living hosts and in the environment and move between hosts and ecosystems. An intricate interplay of infections, exposure to antibiotics, and disinfectants at individual and community levels among humans, animals, birds, and fishes triggers evolution and spread of resistance. The One Health framework proposes addressing antibiotic resistance as a complex multidisciplinary problem. However, the evidence base in the Indian context is limited. Objective: This multisectoral, trans-species surveillance project aims to document the infection and resistance patterns of 7 resistant-priority bacteria and the risk factors for resistance following the One Health framework and geospatial epidemiology. Methods: This hospital- and community-based surveillance adopts a cross-sectional design with mixed methodology (quantitative, qualitative, and spatial) data collection. This study is being conducted at 6 microbiology laboratories and communities in Khurda district, Odisha, India. The laboratory surveillance collects data on bacteria isolates from different hosts and their resistance patterns. The hosts for infection surveillance include humans, animals (livestock, food chain, and pet animals), birds (poultry), and freshwater fishes (not crustaceans). For eligible patients, animals, birds and fishes, detailed data from their households or farms on health care seeking (for animals, birds and fishes, the illness, and care seeking of the caretakers), antibiotic use, disinfection practices, and neighborhood exposure to infection risks will be collected. Antibiotic prescription and use patterns at hospitals and clinics, and therapeutic and nontherapeutic antibiotic and disinfectant use in farms will also be collected. Interviews with key informants from animal breeding, agriculture, and food processing will explore the perceptions, attitudes, and practices related to antibiotic use. The data analysis will follow quantitative (descriptive and analytical), qualitative, and geospatial epidemiology principles. Results: The study was funded in May 2019 and approved by Institute Ethics Committees in March 2019. The data collection started in September 2019 and shall continue till March 2021. As of Ju