key: cord-0772812-4npyg0cw authors: BIRGAND, Gabriel; CHARANI, Esmita; AHMAD, Raheelah; BONACONSA, Candice; MBAMALU, Oluchi; NAMPOOTHIRI, Vrinda; SURENDRAN, Surya; WEISER, Tom. G.; HOLMES, Alison; MENDELSON, Marc; SINGH, Sanjeev title: Interventional research to tackle antimicrobial resistance in Low Middle Income Countries in the era of the COVID-19 pandemic: lessons in resilience from an international consortium date: 2022-02-09 journal: Int J Infect Dis DOI: 10.1016/j.ijid.2022.02.013 sha: 916c50aaebd1d6031c7f48015adefdb687849fbd doc_id: 772812 cord_uid: 4npyg0cw This article summarizes the consequences of the COVID-19 pandemic, on an international project to tackle the antimicrobial resistance (AMR). The research leadership and process, the access to data and stakeholders were deeply disrupted by the national and international response to the pandemic, including the interruption of healthcare delivery, lockdowns, and quarantines. The key principles to deliver the research through the pandemic were mainly the high degree of interdisciplinary engagement with integrated teams, an equitable partnership across sites with capacity building and leadership training. The level of pre-existing collaboration and partnership were also keys to sustain connections and involvements throughout the pandemic. The pandemic offered opportunities for realigning research priorities. Flexibility in funding timelines and projects inputs are required to accommodate variance introduced by external factors. The current models for research collaboration and funding need to be critically evaluated and redesigned to retain the innovation which has been shown to be successful through this current experience. 1 Highlights:  The COVID-19 pandemic has helped challenge the usual way of doing research  A prolongated on-site presence at the early stage of projects is critical  Research should rely on a capacity-building strategy to provide local skills  Funding should be proportionate to cost of resources and gaps in each LMICs setting The novel coronavirus disease pandemic continues to impose significant health, economic and social impacts. (Douglas et al., 2020) Non-pharmaceutical interventions implemented to prevent the spread of COVID-19, including intermittent lockdowns instituted in many countries, have suspended the lives of citizens, by disrupting their professional and social activities. Academic research was not spared by these restrictions, and while the need for research and real-time evaluation was all the more important, universities and healthcare institutions closed laboratories and sites for all but essential work. (WHO, 2015; WHO; World Health Organization., n.d.) In response to the pandemic, many research activities were put on hold or redirected to investigate the evolving pandemic. (Lv et al., 2020) Global projects in the oft labelled 'continuous pandemic' of antimicrobial resistance (AMR) were amongst those particularly affected due to the reliance on international collaborations and data sharing. (Charani et al., 2017) AMR projects were particularly challenged by reliance on the workforce that is one of the most affected in the pandemic, namely antimicrobial stewardship and infection prevention and control resources. The ASPIRES (Antibiotic use across Surgical Pathways -Investigating, Redesigning and Evaluating Systems) project, led by Imperial College London started in May 2017.(Imperial College London, n.d.) This international research consortium aims to optimise infection management and antibiotic use across the surgical pathway with ambitious field work in England, India, and South Africa. The initial phases of the research, including a macro-level analysis of drivers and constraints in implementing effective policy and strategy for tackling AMR, (Ahmad et al., 2019) and in-depth examination of the local context Singh et al., 2021) were successfully completed in 2018-2019. The COVID-19 pandemic began at the early stage of the critical co-design and implementation phase. In this article, we reflect on the ability to continue delivering non-COVID-19 infectious diseases research through the pandemic, and the effectiveness of contingency plan which was implemented to meet the original research aims. The healthcare and public health context. The interruption to healthcare delivery imposed by the pandemic included disruption to, or modification of, services as well as healthcare workforce capacity. (Table 1) In the ASPIRES study, we had carefully mapped quantitatively and qualitatively, patient pathways, clinical priorities, and the behaviours of stakeholders. These were all changed as primary and secondary consequences of COVID-19. With the mandate of control measures, the dynamic in the hospital ward had shifted to focus on essential activities only. In all study sites, elective surgeries were halted and the surgical teams were deployed to support the clinical response to the pandemic, with intensive care beds prioritised for COVID-19 patients. Clinical research staff was also redeployed to clinical duties. The research priorities evolved as a result of these changes and capacity was generated for the teams to carry out COVID-19 related research. The principal investigators of the ASPIRES project in each participating countries, being senior infectious diseases specialists, were largely drawn to front line strategic and operational tasks to lead/support the pandemic response nationally and internationally. Rawson et al., 2020; Zhou et al., 2020) The research teams in each of the participating countries were variably affected; some diverted to support regional level data collection or to contribute to the local clinical response. Non-clinical researchers were able to proceed with desk research, working from home, requiring self-organization and motivation. Maintaining the schedule of small and whole project meetings to keep the project progress and slippage documented was important. The obvious loss of opportunities for the research team to meet, train and learn in physical proximity has been detrimental to progress against milestones but also in terms of momentum and motivation. Access to data and stakeholders was compromised. The project relied on clinicians' willingness and motivation, especially surgeons, as well as infection prevention and control (IPC) and antimicrobial stewardship (AMS) teams. The non-availability of IPC and infectious disease specialists was one of the key challenges as they were fully dedicated to the COVID-19 response. The pandemic response left few opportunities for their contribution to their routine work and to the project. While interruption of the surgical program delayed the co-design and implementation of interventions, the cancellation of elective surgical procedures meant that surgeons were more available with extended possibilities to engage via remote meetings. Online workshops for the co-design of interventions were progressed, with uncertainty as to when interventions could be implemented. The person power and scientific effort on AMR were diverted to COVID-19 management. At the same time, progressing AMR research had to be maintained to mitigate the longer term public health threat of drug resistant bacterial infections. (Knight et al., 2021) The changes in antimicrobial use in some pandemic settings highlighted the need for continued AMS. (Townsend et al., 2020) The strong focus of the clinical and scientific world on COVID-19 continues alongside the response to the emergence of mutant variants of the SARS-CoV-2. There is a risk however, that this divergence of resource may de-prioritize and potentially un-do progress in other research topics, including AMR. It is not yet clear how AMR research programs can recover and accomplish their original goals. The success and fate of funded research projects already underway when the restrictions were imposed will depend on the resilience of the teams, strength of the partnerships developed and the multidisciplinary nature of the research approach. We propose four key mostly affected areas for large scale global research (Table 1) . As our research project aimed to investigate the complex issue of organizational and individual behaviours in surgical care to improve infection related outcomes, the design of the methods was highly interdisciplinary. The research methods included ethnographic qualitative, epidemiological quantitative, strategic social-political and operations research modelling. The experience of the research team and organization of project work packages strategically enabled the integration of all these research disciplines experts in a cohesive way. An overarching work package led by experienced international senior researchers was dedicated to ensuring the output of the work was not a collection from each of the disciplines but an integrated understanding of the problem and derived and tested solutions. The leadership of this overarching work package with monthly meeting organised throughout the pandemic has made it possible to avoid the "silo effect", adopting a research approach integrated across tasks and disciplines. Finally, the indisposition of some researchers for COVID-19 related issues was cross-cover by available colleagues from other disciplines. Building on-site capacities and equitable partnerships. Secondly, research projects should rely on a capacity-building strategy to provide skills to the local stakeholders for a better sustainability of interventions and outcomes. (Veepanattu et al., 2020) Capacity-building is defined as the "process of developing and strengthening the skills, instincts, abilities, processes and resources that organizations and communities need to survive, adapt, and thrive in a fast-changing world." (Dako-Gyeke et al., 2020) In the ASPIRES project, researchers were recruited early during the project, with an equitable distribution representing each of the disciplines to ensure that methodological skills were locally situated. Two researchers, one in India and one in South Africa started PhD studies based on emergent themes from the research. Both are co-supervised by senior investigators from across the sites (South Africa, India and UK). These initiatives strengthened the collaboration between the senior investigator(s) and the researchers on site. Instituting a publications policy, all coinvestigators and researchers were encouraged to contribute to the publications plan from the outset. Mid-way through the project, outputs from all international researchers, early and senior, have been published in international journals and presented at international conferences demonstrating sustained development beyond the life of the project. Finally, leadership training for early career researchers, regular mentoring, and encouraging them to learn from and support each other, succeeded in maintaining the connection and relation across researchers and teams. We developed a network of research management which connects junior staff to each other in different sites, has research leads that work with junior staff, but also liaise closely with principal investigators. Staff and meetings were shared across the two LMICs sites. Having contextual insight by matching staff with previous field experience to manage junior researchers remotely was perceived as a positive factor for resilience. The relationship between the principal investigator(s), their collaborators and the coinvestigators on site and their profiles are critical to stability in the project during erratic interruptions such as that posed by COVID-19. The challenge faced during the pandemic period may be overcome by the motivation and the pre-existing degree of collaboration and partnership. There must be a degree of willingness to be flexible, adaptable and have a measure of good will to work through the difficulties facing the research team members in each setting. Working with, and getting to know local stakeholders, will improve the sustainability of dawning collaborations. A senior researcher from Imperial College London, spent three consecutive months on each research site at the early stage of the international consortium to work in partnership and mentoring roles, assess the cultural norms, established hierarchies, team roles and methods of communication around AMS and IPC and in the research institute. (Singh et al., 2021) This on-site work has led to strong collaboration with the local researchers recruited for the project, hospital leaders and stakeholders. (Veepanattu et al., 2020) These visits were reciprocated with two-week long visits to the UK site from researchers in India and South Africa and a week-long visit from the India team to South Africa. The reciprocal visit from South African researchers to India was halted due to the travel restrictions during the pandemic. This level of onsite visits not only facilitates familiarisation of researchers with all the different contexts, but also created opportunities for the PhD students to gather field data relevant to their studies. The partnership underpinning this research is sustained by being agile to working off site and remaining remotely connected with regular and iterative meetings. These meetings were not only between senior and junior researchers, but also through day-to-day dialogue and meetings between the junior researchers in each site. Staff were monitored and mentored through different media. Resilience in partnerships and communication was built through 39 meetings with local researchers and 7 workshops with clinicians to co-design and implement the intervention organised online in 2020. Capitalizing on the movement to investigate the impact of COVID-19 on AMR and AMS is critical. The COVID-19 pandemic offered opportunities for realigning research priorities of the ASPIRES project. First, the PESTELI (Political factors, Economic influences, Sociological trends, Technological innovations, Ecological factors, Legislative requirements, Industry analysis) framework employed to assess the macro-level factors of IPC and AMS at each point of the surgical pathway, was adapted for the analysis of the COVID-19 pandemic. (Ahmad et al., 2021) Moreover, a survey was developed to assess the perception of changes in IPC and AMS practices during the pandemic by stakeholders from the two LMICs countries. Second, a large amount of qualitative data has been collected on site through ethnographic research to describe the role and context of IPC and AMS across the surgical pathway. We may assume that the pandemic largely changed pre-existing organizations in the roles of stakeholders including patients, and also in terms of outcomes. We plan to reexamine the organization and the resilience of IPC and AMS after the pandemic in the ASPIRES project sites in India and SA. The cumulated knowledge in such context will build memory for how to respond to emerging issues through contingency planning and forecasting. Finally, the COVID-19 pandemic generated research questions such as modifications of practices and the role played by the surgical ecosystem in emerging infectious diseases. A worldwide event such as the COVID-19 pandemic has helped challenge the usual way of doing research. To develop resilience and sustainability in global partnerships, the current models for research collaboration and funding need to be critically evaluated and redesigned. In these ways, being more efficient, and responsible in the use of publicly funded research, and enhancement of capacity building of local actors appear as best solutions for the future of global health research. Ethics approval: Not applicable. Competing interests: None to declare from all authors. Availability of data and material: Not applicable. Research project reorientations to reconcile the project aim with the local priorities. Global/whole project Flexibility in funding timelines and project outputs. Macro level influences on strategic responses to the COVID-19 pandemic -an international survey and tool for national assessments Strengthening strategic management approaches to address antimicrobial resistance in global human health: a scoping review Visual mapping of team dynamics and communication patterns on surgical ward rounds: an ethnographic study Opportunities for system level improvement in antibiotic use across the surgical pathway Capacity building for implementation research: a methodology for advancing health research and practice Mitigating the wider health effects of covid-19 pandemic response ASPIRES: Antibiotic use across Surgical Pathways -Investigating, Redesigning and Evaluating Systems n Antimicrobial resistance and COVID-19: Intersections and implications Coronavirus disease (COVID-19): a scoping review Healthcare workers experiences of infection prevention and control practices in South Africa and India during the SARS-CoV-2 pandemic Long-COVID: An evolving problem with an extensive impact COVID-19 and the potential long-term impact on antimicrobial resistance Investigating infection management and antimicrobial stewardship in surgery: a qualitative study from India and South Africa Bacterial pneumonia coinfection and antimicrobial therapy duration in SARS-CoV-2 (COVID-19) infection Building resilient and responsive research collaborations to tackle antimicrobial resistance-Lessons learnt from India, South Africa, and UK WHO; World Health Organization. Country progress in the implementation of the global action plan on antimicrobial resistance: who, FAO and OIE global tripartite database Investigating SARS-CoV-2 surface and air contamination in an acute healthcare setting during the peak of the COVID-19 pandemic in London Acknowledgements: We would like to acknowledge the support of clinicians from Amrita, India and the Groote Schuur Hospital, South Africa, for their engagement in the project. Authors' contributions: EC and GB developed the study design. The first draft of the manuscript was written by GB, EC and RA. Subsequent versions had input from all co-authors.