aslm

Guide for establishing laboratory-based
surveillance for antimicrobial resistance
Dr Jean Bosco NDIHOKUBWAYO, MD
Regional Adviser, Laboratories &Clinical Technologies
ndihokubwayoj@who.int
ASLM and WHO‐AFRO Joint meeting on Global Health Security Agenda, Freetown, Sierra Leone, 15‐16 October 2015
Presentation Outline
Background/introduction
Current situation of AMR in the WHO‐AFR
Guide for establishing laboratory‐based surveillance for antimicrobial resistance Take away messages
Conclusion 2
Background
Critical role of antimicrobials in reducing the burden of communicable diseases all over the world. The curative power of infectious diseases by drugs or drug efficacy is not infinite.
AMR threatens the effectiveness of successful treatment of infections and is a public health issue with national and global dimensions. In low‐income countries, AMR frequently occurs in microorganisms that are likely to be transmitted in the community: organisms causing pneumonia, diarrheal diseases, TB, STDs and malaria. Drug resistance has dramatically increased the costs of fighting TB and malaria, and slowed gains against childhood dysentery and pneumonia.
AMR also threatens the push to treat people living with HIV/AIDS effectively.
Political momentum to tackle AMR
 Since 2011, WHO increased efforts across the Organization to scale up the fight against AMR
http://www.who.int/drugresistance/activities/en/
 Resolution WHA67.25 on AMR on the 24th of May 2014
 Global Health Security Agenda
4
Current situation of AMR in the WHO African Region Inadequate data as surveillance of drug resistance is limited to a few countries resulting in complete data of the true extent and magnitude of this problem
Despite limited laboratory capacity to monitor AMR, available data suggest that the African Region shares the worldwide trend of increasing drug resistance.
Significant resistance has, for example, been reported for diseases such as cholera, dysentery, typhoid, meningitis, gonorrhea, TB, malaria and AIDS.
Current situation of AMR in the WHO African Region‐TB Since 2006, the AFR has witnessed the increasing emergence of MDR/XDR‐TB 2004‐2011, a total of 3 231 XDR‐TB cases were reported from eight countries.
Most African countries lack the laboratory capacity to confirm drug‐resistant TB and so the true burden is not well known
Reported cases of RR‐/MDR‐TB in 2013‐ WHO AFRO region
Cases tested for RR‐/MDR‐TB
•
•
•
New
Retreatm
ent Total
5083 (<1%)§
9925 (7.1%)§
292,797
Lab confirmed RR‐/MDR‐TB cases
34480
Patients started on MDR‐TB treatment
14418 (41.8%) §§
DST capacity in the region is a limiting factor in achieving UNIVERSAL ACCESS ǂ for testing
XDR is reported in all WHO‐Regions. Globally, the average proportion of MDR‐TB cases with XDR‐
TB** was 9.0% (95% CI: 6.5–11.5%), in 2013.
All countries, in the region, need capacity to
• Scale up rapid testing and detection of all MDR‐TB cases
• Strengthen the Lab and Referral Networks for MDR‐TB/ XDR‐TB detection/confirmation
• Initiate continuous surveillance of DR‐TB
§
Among total notified cases in the region; §§ among lab confirmed + empiric treatment
**XDR‐TB is defined as MDR‐TB plus resistance to at least one fluoroquinolone and a second‐
line injectable
ǂ The World Health Assembly (WHA) resolution on M/XDR‐TB in 2009; ‐Post 2015 STOP TB strategy
*Global TB report, 2014, WHO‐Regional profiles
Current situation of AMR in the WHO‐AFR‐Enterics
Percentage of resistance among Shigella
2008 to 2011
Trimethoprim-sulfamethoxazole
• 82% resistant to primary drug (SXT)
191
8
954
S
I
R
82%
• AMR data disseminated to improve treatment protocols
 Introduction of other drugs
(e.g CIP) with increased
effectiveness
Source: Member States
Ciprofloxacin
14
15
1330
98%
Disk diffusion testing
S
I
R
Current situation of AMR in the AFR-meningitis
Meningitis: 500 million people at risk in 21 countries
Pathogens identified by labs in the meningitis belt countries Week 01‐35, 2015
Country
Number Contam. CSF In process
CSF
Benin
19
Burkina Faso 1 419
Cameroun
62
Centrafrique
283
Côte d'Ivoire
126
Ethiopia
‐
Ghana
160
Guinea
93
Gambia
17
Kenya
‐
Mali
254
Mauritania
1
Niger
4 079
Nigeria
32
RD Congo
161
Senegal
375
South Sudan
‐
Sudan
‐
Tchad
69
Togo
152
Uganda
‐
Total
7 302
0
0
0
0
2
‐
0
0
0
‐
0
0
0
0
3
0
‐
‐
6
0
‐
11
0
0
0
0
0
‐
0
0
0
‐
0
0
40
3
0
0
‐
‐
1
0
‐
44
CSF negative
NmA
17 0
783 3
48 0
269 0
107 0
‐ ‐
108 0
13 74
16 0
‐ ‐
200 0
0 0
2 583 0
9 0
127 0
362 0
‐ ‐
‐ ‐
51 0
125 0
‐ ‐
4 818 77
NmB
NmC
NmX
0
0 0
0
6 4
0
0 0
0
0 0
0
1 1
‐
‐ ‐
1
0 0
0
0 0
0
0 0
‐
‐ ‐
0
7 13
0
0 0
01 087 1
0 20 0
0
0 0
0
0 0
‐
‐ ‐
‐
‐ ‐
0
0 0
0
0 0
‐
‐ ‐
11 121 19
NmY Nm W135
0
0
0
0
0
‐
0
0
0
‐
0
0
0
0
0
0
‐
‐
0
0
‐
0
1
217
6
0
0
‐
27
0
1
‐
3
1
196
0
0
5
‐
‐
1
8
‐
466
Other Nm ind.
S.Pneum
0
3
0
1
3
‐
1
0
0
‐
0
0
65
0
0
0
‐
‐
0
7
‐
80
1
390
8
5
7
‐
23
5
0
‐
23
0
101
0
6
6
‐
‐
6
12
‐
593
Hib
0
11
0
0
4
‐
0
1
0
‐
3
0
5
0
1
2
‐
‐
1
0
‐
28
Other Pathogens
0
2
0
8
1
‐
0
0
0
‐
5
0
1
0
24
0
‐
‐
3
0
‐
44
Meningitis in Africa: Map of meningitis ppathogens identified in the meningitis belt, Week 01‐35, 2015
Current situation of AMR in the WHO‐AFR‐meningitis
Resistance rates to oxacillin among Neisseria meningitidis
using the disc diffusion testing in 2008-2009
78
35%
146
65%
S
R
AMR rates suggest that ATCC strains is not
regularly used for quality control and MIC
is not performed in most Member states
Disc diffusion tests are unreliable
11 countries
•
In 2008‐2009, MIC were determined for 83 isolates from 6 countries using Etest on MH + 5% sheep blood (EMGM) •
Only eight isolates (10%) were less susceptible to penicillin (0.094≤MIC≤0.25) Source: WHO CC on Meningococci in Marseille [7th Meningitis annual revue and planning meeting 2009]
Guide for establishing laboratory‐based surveillance for antimicrobial resistance
http://apps.who.int/medicinedocs/documents/s20135en/s201
5en.pdf
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Main objectives of the guide 1/2 To provide background information and define the key steps for the countries to conduct AMR surveillance for meningitis, bacteraemia and common enteric epidemic‐prone diseases in a national bacteriology reference laboratory
To support IDSR implementation and global health security agenda as envisaged by IHR (2005) through strengthening laboratory services and sharing information on AMR
To promote discussion on a step‐by‐step approach for involving multidisciplinary teams from hospitals, laboratories, universities, national surveillance units and veterinary sector in containment of AMR.
To contribute to the improvement of surveillance of antimicrobial resistance at the country level 14
Main objectives of the guide 2/2
To facilitate establishing of laboratory‐based surveillance for priority bacterial diseases in the WHO African Region.
To promote the development of a plan for implementing and strengthening laboratory‐based AMR surveillance and strengthening the capacity of laboratories responsible for isolation and identification of selected bacterial diseases.
To improve the standardization process used by bacteriology reference laboratories to confirm the bacterial causative agents of severe diseases such as bacteraemias, enteritis and meningitis
To strengthen the capacity of bacteriology reference laboratories to monitor AMR; improve the quality of AMR data by harmonizing laboratory techniques; and enhance the regional database on AMR.
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Regional antimicrobial resistance network Goals
To Build national laboratory capacity in African countries to conduct AST
Provide access to standardized practices for conducting laboratory‐based surveillance of AMR Promote advanced and specialized testing on selected pathogens by regional reference laboratories or collaborating centres Build the foundation for future studies on the containment of AMR.
Key steps and activities in implementing the Guidance (1/2)
Step
Key point to consider
Roles of WHO and partners
Adoption of the generic laboratory‐based surveillance guide on AMR
•
Technical meeting for adoption of the key elements
of the guide. This will allow staff involved in AMR
surveillance to learn and comply with its objectives
and content even though CLSI or CA-SFM
guidelines are subject to change annually
Technical support in adaptation or adoption of the guide
•
Dissemination of the guide as appropriate
Designation of the national reference laboratory for AMR
Selection of one national reference bacteriology
laboratory with capacity for AST for meningitis and
enteric and other pathogens
Define or update the terms of reference of the national
reference laboratory related to AMR surveillance (see
Section VII)
Assessment of the capacity for
Self-assessment of laboratory capacity using existing
AMR surveillance, identification
WHO standardized tools and proposed key activities
of the gaps and development on a need to be supported based on findings of the
national plan
assessment and the requirements of the national
guidelines on AMR
Advocacy
To help develop an appropriate plan
Key steps and activities in implementing the Guidance (2/2)
Step
Key point to consider
Roles of WHO and partners
Implementation
of laboratorybased
surveillance of
AMR
 Key actions may include but are not limited to:
Technical support to Member States through the AMR laboratory network activities •
Updating or creating new SOPs
•
Procuring essential reagents and supplies for the national
reference laboratory
•
Ensuring the laboratory has adequate personnel and
ongoing training of staff
•
Active participation in EQA Programs on AMR testing and
reporting
•
Collection and sharing of data on AMR for MoH and WHO
•
Providing regular annual reports on AMR
•
Monitoring, evaluating and improving the implementation
process
Take away messages
Develop comprehensive national policies and plans to prevent and combat AMR
Establish national policy platform for management of antibiotic resistance
Build clinical and public health laboratory capacity
Improve antimicrobial surveillance systems by collecting and sharing information on AMR across national/regional networks of laboratories
Establish Regional framework for collaborative surveillance of antibiotic resistance
Strengthen national medicines regulatory capacities in the African Region
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Conclusion
 Left unchecked, the uncontrolled rise in resistant germs threatens lives and wastes limited resources.  Urgent and coordinated action is required at all levels to ensure the preservation of these life‐saving drugs for future generations.  Laboratory capacity for AMR testing and reporting should be strengthened as key element of AMR surveillance for action to limit the evolution and possible spread of resistant germs.
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Mahatma Gandhi and a lab tool in 1946
Thank you
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