Antimicrobial resistance in the Pacific Island countries and territories

Antimicrobial resistance (AMR) is a critical global health threat with a disproportionate impact on low-income and middle-income countries (LMICs) due to their higher burden of infections, reduced laboratory surveillance infrastructure and fewer regulations governing antimicrobial use among humans or animals. While there have been increasing descriptions of AMR within many LMICs in WHO’s Western Pacific and South East Asian regions, there remains a paucity of data from Pacific Island countries and territories (PICTs). The PICTs represent 22 predominantly middle-income countries and territories with a combined population of 12 million people and 20 official languages, spread over hundreds of separate islands spanning an area corresponding to more than 15% of the earth’s surface. Our paper outlines the present state of the evidence regarding AMR in PICTs—discussing the present estimates of AMR and their accompanying limitations, important drivers of AMR, as well as outlining key priorities and potential solutions for tackling AMR in this region. Significant areas for action include developing National Action Plans, strengthening laboratory surveillance systems and educational activities targeted at both healthcare workers and the wider community. Ensuring adequate funding for AMR activities in PICTs is challenging given competing health and environmental priorities, in this context global or regional funding initiatives such as the Fleming Fund can play a key role.

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Supporting surveillance capacity for antimicrobial resistance: Laboratory capacity strengthening for drug resistant infections in low and middle income countries

Wellcome Open Research ◽

10.12688/wellcomeopenres.12523.1 ◽

2017 ◽

Vol 2 ◽

pp. 91 ◽

Cited By ~ 10

Author(s):

Anna C. Seale ◽

Coll Hutchison ◽

Silke Fernandes ◽

Nicole Stoesser ◽

Helen Kelly ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Health Systems ◽

Clinical Laboratory ◽

Surveillance Systems ◽

Middle Income ◽

Middle Income Countries ◽

Laboratory Capacity ◽

Model Combining ◽

Laboratory Surveillance ◽

Low And Middle Income

Development of antimicrobial resistance (AMR) threatens our ability to treat common and life threatening infections. Identifying the emergence of AMR requires strengthening of surveillance for AMR, particularly in low and middle-income countries (LMICs) where the burden of infection is highest and health systems are least able to respond. This work aimed, through a combination of desk-based investigation, discussion with colleagues worldwide, and visits to three contrasting countries (Ethiopia, Malawi and Vietnam), to map and compare existing models and surveillance systems for AMR, to examine what worked and what did not work. Current capacity for AMR surveillance varies in LMICs, but and systems in development are focussed on laboratory surveillance. This approach limits understanding of AMR and the extent to which laboratory results can inform local, national and international public health policy. An integrated model, combining clinical, laboratory and demographic surveillance in sentinel sites is more informative and costs for clinical and demographic surveillance are proportionally much lower. The speed and extent to which AMR surveillance can be strengthened depends on the functioning of the health system, and the resources available. Where there is existing laboratory capacity, it may be possible to develop 5-20 sentinel sites with a long term view of establishing comprehensive surveillance; but where health systems are weaker and laboratory infrastructure less developed, available expertise and resources may limit this to 1-2 sentinel sites. Prioritising core functions, such as automated blood cultures, reduces investment at each site. Expertise to support AMR surveillance in LMICs may come from a variety of international, or national, institutions. It is important that these organisations collaborate to support the health systems on which AMR surveillance is built, as well as improving technical capacity specifically relating to AMR surveillance. Strong collaborations, and leadership, drive successful AMR surveillance systems across countries and contexts.

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Using ‘smart regulation’ to tackle antimicrobial resistance in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-001864 ◽

2020 ◽

Vol 5 (1) ◽

pp. e001864 ◽

Cited By ~ 1

Author(s):

Gerard Porter ◽

Jyoti Joshi ◽

Lovleen Bhullar ◽

Anita Kotwani

Keyword(s):

Antimicrobial Resistance ◽

Low Income ◽

Middle Income ◽

Middle Income Countries ◽

Smart Regulation

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Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis

The Lancet Infectious Diseases ◽

10.1016/s1473-3099(15)00149-8 ◽

2015 ◽

Vol 15 (10) ◽

pp. 1203-1210 ◽

Cited By ~ 61

Author(s):

Marcella Alsan ◽

Lena Schoemaker ◽

Karen Eggleston ◽

Nagamani Kammili ◽

Prasanthi Kolli ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Economic Analysis ◽

Low Income ◽

Health Expenditures ◽

Middle Income ◽

Middle Income Countries

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Tackling antimicrobial resistance in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-002104 ◽

2019 ◽

Vol 4 (6) ◽

pp. e002104 ◽

Cited By ~ 26

Author(s):

Sunil Pokharel ◽

Shristi Raut ◽

Bipin Adhikari

Keyword(s):

Antimicrobial Resistance ◽

Low Income ◽

Middle Income ◽

Middle Income Countries

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Antimicrobial resistance surveillance: can we estimate resistance in bloodstream infections from other types of specimen?

10.1101/2020.10.12.20211243 ◽

2020 ◽

Author(s):

Karina-Doris Vihta ◽

Nicola Claire Gordon ◽

Nicole Stoesser ◽

T. Phuong Quan ◽

Carina SB Tyrrell ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Low Income ◽

Bloodstream Infections ◽

Cost Effective ◽

Middle Income ◽

E Coli ◽

Middle Income Countries ◽

Invasive Infections ◽

Tract Infections ◽

Over Time

SynopsisBackgroundAntimicrobial resistance (AMR) surveillance of bloodstream infections is challenging in low- and middle-income countries (LMICs), limited laboratory capacity preventing routine patient-level susceptibility testing. Other specimen types could provide an effective approach to surveillance.ObjectivesOur study aims to systematically evaluate the relationship between resistance prevalence in non-sterile sites and bloodstream infections.MethodsAssociations between resistance rates in Escherichia coli and Staphylococcus aureus isolates from blood and other specimens were estimated in Oxfordshire, UK, 1998-2018, comparing proportions resistant in each calendar year using time series cross-correlations and across drug-years. We repeated analysis across publicly-available data from four high-income and 12 middle-income countries, and in three hospitals/programmes in LMICs.Results8102 E. coli bloodstream infections, 322087 E. coli urinary tract infections, 6952 S. aureus bloodstream infections and 112074 S. aureus non-sterile site cultures were included from Oxfordshire. Resistance trends over time in blood versus other specimens were strongly correlated (maximum cross-correlation 0.51-0.99, strongest associations in the same year for 18/27 pathogen-drug combinations). Resistance prevalence was broadly congruent across drug-years for each species. 276/312 (88%) species-drug-years had resistance prevalence in other specimen types within ±10% of that blood isolates. Results were similar across multiple countries and hospitals/programmes in high/middle/low income-settings.ConclusionsResistance in bloodstream and less invasive infections are strongly related over time, suggesting the latter could be a surveillance tool for AMR in LMICs. These infection sites are easier to sample and cheaper to obtain the necessary numbers of susceptibility tests, providing more cost-effective evidence for decisions including empiric antibiotic recommendations.

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Event-based surveillance at health facility and community level in low-income and middle-income countries: a systematic review

BMJ Global Health ◽

10.1136/bmjgh-2019-001878 ◽

2019 ◽

Vol 4 (6) ◽

pp. e001878 ◽

Cited By ~ 4

Author(s):

Anna Kuehne ◽

Patrick Keating ◽

Jonathan Polonsky ◽

Christopher Haskew ◽

Karl Schenkel ◽

...

Keyword(s):

Public Health ◽

Health Facility ◽

Low Income ◽

Surveillance Systems ◽

Community Based ◽

Middle Income ◽

Middle Income Countries ◽

Routine Surveillance ◽

Set Up ◽

Event Based

BackgroundThe International Health Regulations require member states to establish “capacity to detect, assess, notify and report events”. Event-based surveillance (EBS) can contribute to rapid detection of acute public health events. This is particularly relevant in low-income and middle-income countries (LMICs) which may have poor public health infrastructure. To identify best practices, we reviewed the literature on the implementation of EBS in LMICs to describe EBS structures and to evaluate EBS systems.MethodsWe conducted a systematic literature search of six databases to identify articles that evaluated EBS in LMICs and additionally searched for grey literature. We used a framework approach to facilitate qualitative data synthesis and exploration of patterns across and within articles.ResultsWe identified 778 records, of which we included 15 studies concerning 13 different EBS systems. The 13 EBS systems were set up as community-based surveillance, health facility-based surveillance or open surveillance (ie, notification by non-defined individuals and institutions). Four systems were set up in outbreak settings and nine outside outbreaks. All EBS systems were integrated into existing routine surveillance systems and pre-existing response structures to some extent. EBS was described as useful in detecting a large scope of events, reaching remote areas and guiding outbreak response.ConclusionHealth facility and community-based EBS provide valuable information that can strengthen the early warning function of national surveillance systems. Integration into existing early warning and response systems was described as key to generate data for action and to facilitate rapid verification and response. Priority in its implementation should be given to settings that would particularly benefit from EBS strengths. This includes areas most prone to outbreaks and where traditional ‘routine’ surveillance is suboptimal.

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Waves of attention: patterns and themes of international antimicrobial resistance reports, 1945–2020

BMJ Global Health ◽

10.1136/bmjgh-2021-006909 ◽

2021 ◽

Vol 6 (11) ◽

pp. e006909

Author(s):

Kristen Overton ◽

Nicolas Fortané ◽

Alex Broom ◽

Stephanie Raymond ◽

Christoph Gradmann ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Low Income ◽

International Organisations ◽

International Policy ◽

Middle Income ◽

Middle Income Countries ◽

Biomedical Innovation ◽

Qualitative Approaches ◽

Rational Drug ◽

Global North

This article uses quantitative and qualitative approaches to review 75 years of international policy reports on antimicrobial resistance (AMR). Our review of 248 policy reports and expert consultation revealed waves of political attention and repeated reframings of AMR as a policy object. AMR emerged as an object of international policy-making during the 1990s. Until then, AMR was primarily defined as a challenge of human and agricultural domains within the Global North that could be overcome via ‘rational’ drug use and selective restrictions. While a growing number of reports jointly addressed human and agricultural AMR selection, international organisations (IOs) initially focused on whistleblowing and reviewing data. Since 2000, there has been a marked shift in the ecological and geographic focus of AMR risk scenarios. The Global South and One Health (OH) emerged as foci of AMR reports. Using the deterritorialised language of OH to frame AMR as a Southern risk made global stewardship meaningful to donors and legitimised pressure on low-income and middle-income countries to adopt Northern stewardship and surveillance frameworks. It also enabled IOs to move from whistleblowing to managing governance frameworks for antibiotic stewardship. Although the environmental OH domain remains neglected, realisation of the complexity of necessary interventions has increased the range of topics targeted by international action plans. Investment nonetheless continues to focus on biomedical innovation and tends to leave aside broader socioeconomic issues. Better knowledge of how AMR framings have evolved is key to broadening participation in international stewardship going forward.

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