WHO local pilot projects to contain AMR

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WHO local pilot projects to contain AMR

• ICIUM 2004
• K.A.Holloway and T.L.Sorensen
• Essential Drugs and Medicines Policy
• WHO Geneva

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Why local pilot projects?

• WHO global strategy published 2001 recommends 67
  interventions but no country is implementing them
  all and few countries could do so
• Very little evidence to use in prioritising
  interventions
• Very little epidemiological AMR or use
  surveillance
• Governments will need evidence before they act
• Local surveillance may provide the evidence for
  local communities to act and later for government
  to act
• Urgent need to develop a methodology suitable for
  local routine use

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Objectives

• develop, implement evaluate interventions to
  contain AMR using surveillance data
• develop a new methodology for the integrated
  surveillance of antimicrobial use and resistance
  - that can be used in many different countries
• to build local capacity in developing a
  multidisciplinary approach to the containment of
  antimicrobial resistance

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Method for integrated surveillance (1)

• Resistance to antimicrobials of 1-2 selected
  organisms in patients with pre-defined clinical
  condition in hospital OPD PHC facilities on
  presentation before treatment
• Strep.pnuemoniae in throat swabs in ARI cases,
  E.Coli in MSUs in UTI cases, Shigella in faeces
  in dysentery cases, gonococcus in urethral swabs
• Resistance rate in terms of cases, not isolates
• Data collected monthly

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Method for integrated surveillance (2)

• Antimicrobial use at all health care levels in
  the same locations as the specimens for AMR
  testing are taken
• Hospital OPD patients with pre-defined clinical
  condition
• Antimicrobial use for all clinical conditions in
  shops, PHC facilities (public and private) and
  hospital OPD
• Data collected monthly
• Analysis of baseline time series data
• What are the trends in resistance and use?
• Are resistance patterns in community-acquired
  infections similar in hospital PHC outpatients?
• What proportion of patients have resistant
  infections?
• What is the impact of a local intervention on
  local antimicrobial use and resistance?

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Choosing sites

• Multi-disciplinary capacity within single
  institution
• pharmacology and expertise in drug use studies
• microbiology and infectious diseases
• public health and primary health care
• social sciences for behaviour interventions
• Contacts in-country for coordination
  supervision
• pharmaceutical support programmes in India and
  S.Africa
• communication problems common without local
  contact
• Site visit following letter of intent from
  institution
• expressions of interest from Vietnam, Sri Lanka,
  Iran, Kenya
• Lab. inspection - only S.African labs had true
  external QA
• meeting with all concerned specialists
• proposal writing and revision - usually takes gt
  1year
• drop-out rate after visit of 50

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Current Projects

• BYL Nair Medical College, Mumbai, India - started
  09/02
• Commensal E.Coli resistance in patients faeces
  and antimicrobial use in shops, dispensaries,
  private practitioners and hospital OPD
• CMC Vellore, Tamil Nadu, India started 08/03
• Commensal pathogenic E.Coli resistance in urine
  of pregnant women and antimicrobial use in rural
  and urban areas
• Gangaram private hospital, Delhi, India started
  11/03
• Pathogenic E.Coli resistance in urine of women
  with suspected uncomplicated UTI and
  antimicrobial use in hosp OPD and local shops
• Durban Westville, S.Africa - started 07/02
• Commensal and pathogenic S.Pneumoniae and
  H.Influenzae in sputum patients with a productive
  cough public/private antimicrobial PHC use
• MEDUNSA, S.Africa - started 07/03
• Pathogenic E.Coli resistance in urine of women
  with suspected uncomplicated UTI and
  public/private antimicrobial PHC use

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Looking at trends in cotrimoxazole resistance and
use in Mumbai, India, 2002
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Establishing differences in E.Coli resistance
levels in rural urban areas in Vellore, 2002
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(No Transcript)
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Problems encountered

• Poor coordination sometimes between team
  conducting microbiology and team undertaking drug
  use surveillance
• Insufficient sample size to adequately detect
  monthly trends in resistance
• number of patients
• number of isolates
• Patients giving specimens have already taken
  antibiotics
• Specimens not always taken adequately so
  resulting in non-growth
• Access to private sector difficult
• Difficulty to analyse use in association with
  resistance

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Conclusions

• Five projects started and resulting in
• Multidisciplinary teams
• Experience in surveillance
• Development of a basic local surveillance tool to
  use in evaluating the impact of local
  interventions
• Effort to use routine methodologies so as to
  facilitate later sustainability
• Need multidisciplinary expertise in one site
• Advisory committee in India coordinated by
  DSPRUD/WHO pharmaceutical support

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Key lessons, policy implications and future
research

• Key lessons
• It is feasible and useful to undertake
  surveillance of resistance and use in communities
  in developing countries
• Such surveillance has provided local data and
  stimulated the formation of locally-based
  multi-disciplinary teams better able to address
  AMR
• Policy implications
• Local community surveillance to provide local
  data and build understanding may better aid the
  development and implementation of the
  multi-sectoral strategies needed to contain AMR,
  than national meetings
• Future research
• Further community-based surveillance of
  resistance and use in order to evaluate the
  impact of interventions and identify the most
  effective ones