The impetus to Africa CDCís mandate in curbing the rising trend of Antimicrobial Resistance (AMR) in Africa: the launch of the Africa CDC AMR surveillance network during the 8th advanced course in diagnostics (ACDx)
Noah Fongwen Takah1,2,&, Priyanka Shrestha1, Rosanna Peeling1
1The International Diagnostics Centre, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom, 2Ministry of Public Health, Cameroon
Noah Fongwen Takah, The International Diagnostics Centre, Clinical Research Department,
London School of Hygiene and Tropical Medicine, Keppel Street, London, United
Kingdom, Ministry of Public Health, Cameroon
The rise of antimicrobial resistance is a global threat and Africa like any other developing setting is heavily affected. As one of its missions, the Africa CDC is poised to ensure this rising trend takes a diminishing route in the few years ahead. Diagnostics obviously play a pivotal role in AMR control and the advanced course in diagnostics (ACDx) has been instrumental in training critical decision makers over the past 7 years. This commentary presents an analysis of discussions and exchanges during the launch of the Africa CDC AMR surveillance network at the ACDX and the way forward for its implementation. The diagnostics priorities are also highlighted.
The emergence of "Superbugs" that are resistant to almost all conventional
antibiotics clearly presents as one of the most daunting global health
challenges in the 21st century . Given the
crucial role of antibiotics in preventing the spread of infectious
diseases and reducing
the rate of mortality among patients in clinics, care homes and intensive
care units, the problem of antimicrobial resistance (AMR) has attracted
global attention from governments and international health agencies
in both developed
and developing settings . Inferring from the Lord Jim
O'Neil report on AMR, as many as 700,000 people die from AMR annually
Worldwide with a projected global annual mortality rate of 10 million
by 2050 if nothing
urgent is done . There are fears of an apocalyptic
picture in a do-nothing scenario in which we might revert to the
pre-antibiotic era .
The international response has been unprecedented
and encouraging. While there are ongoing efforts towards the establishment
of a global fund for AMR, the World Health Assembly (WHA) in May 2015 endorsed
a global action plan to tackle AMR and has called on governments and private
sector commitments towards mitigating the AMR crisis [4
Consequently, the World Health Organization (WHO) in February 2017 has published
a list of bacteria of which urgent antibiotics are needed in a bid to guide
Research and Development (R&D) [5
] and have developed
the GLASS(Global Antimicrobial resistance Surveillance System) to which countries
are expected to report the state of AMR [6
in Africa, the Africa CDC is committed to curb the rising trend of AMR in
the continent through the establishment of a surveillance network in the continent
that can effective respond to the AMR threat [7
International Diagnostics Centre(IDC) of the London School of Hygiene and
Tropical Medicine(LSHTM) and the Fondation Merieux have been pivotal in the
training of policy makers through the Advanced Course in Diagnostics(ACDx),
on critical decision in diagnostics for the past 7 years.
This year's 8th
was unique because it was dedicated to AMR. Taking into account the pervasiveness
of diagnostics in tackling AMR and that the ACDx is a forum where experts
and policy makers from academia, industry, government and other private sector
agencies converge, there was no better opportunity to launch the Africa CDC
AMR Surveillance Network (AMRSNET). This diverse gathering was an essential
starting point in the creation of sustainable public private partnerships
that can drive and support the AMRSNET in fulfilling its goals and challenges.
The objectives of the launch of the Africa CDC Antimicrobial resistance (AMR)
surveillance network was to enable participants to learn about the Africa
CDC AMR Surveillance Network and how the network should function based on
lessons learnt from other global, regional and country AMR strategies and
policies as well as to brainstorm on the way forward for the use of diagnostics
to combat AMR. This commentary presents an analysis of some of the exchanges
that took place during the launch of the Africa CDC AMRSNET and the way forward
for its implementation, taking into the consideration some overarching diagnostic
In a roundtable discussion with AMR experts from five African
countries, immediate actions were obtained which will be very instrumental
in defining specific in-country targets in the national strategic plans. From
this roundtable discussion, it was clear that not all countries are at the
same level in the control of AMR. Africa CDC would need to take this into
consideration when implementing its plan on AMR in the African continent.
The findings from the roundtable and the perceived challenges are shown in Table
Lessons learnt will also be crucial in guiding in-country implementation
of AMR control. Two important lessons would need to be learnt from ongoing
experiences in public health implementation in Africa. Firstly, there would
be need for an economic case to be made to ensure governments can adopt the
AMR strategy. With funding from the UNITAID, the London School of Hygiene
and Tropical Medicine carried out an economic evaluation to show the cost
effectiveness of introducing and adopting quality assured diagnostics. The
final costs on the health system and the government if there is no quality
assured testing was shown to be huge [8
This economic case was instrumental in convincing the government of Zimbabwe in engaging in the implementation and scale up of quality assured diagnostics. A similar economic case would be needed alongside a business model to ensure the adoption of the surveillance network by the government. Such a business model will be crucial for the sustainability of the AMR surveillance network in the country. Secondly, there is need to conduct a survey on the current state of antibiotics consumption in the continent. The Global Point Prevalence survey would be a good starting point. Global Point Prevalence Survey is the initiative of Professor Herman Goossens of the Institute of Tropical Medicine, Antwerp, Belgium. This survey, with funding from the European Council, is an innovative strategy to assess global antimicrobial consumption and resistance in hospital settings. It utilizes a simple and sustainable Web-based point system for instant report of hospital data on antimicrobial consumption [9
]. Data are collected using two forms: a ward form and a patient form which provide information of the kind of antibiotics used, dose, reason for prescription and if they were in compliance with the guidelines, the use of antibiotics for empirical or targeted therapy and use of biomarkers such as C-reactive protein or pro-Calcitonin. These data are then fed into the web based system for local analysis of findings to inform appropriate clinical practice. This system has the following benefits for AMR surveillance: increase awareness among health personelle on use of antibiotics, building a team where all health personelle work together in achieving a common goal, and providing a quantifiable quality target for improved antimicrobial prescribing [9
]. One key limitation of the system is that it considers only clinical antimicrobial resistance control and does not include veterinary and agriculture sectors. In addition, there are challenges on how to standardize human and animal data.
However, the developers have confirmed that the system can be adapted with ease to capture the use of antibiotics in the veterinary, environmental and agricultural sectors. From conception, the developers were keen to ensure that the system should not be costly and should be done once to reduce the human resource constraints peculiar in low resource settings. In terms of the cost, it is estimated to cost about 120,000 Euros to run the system annually, taking into consideration the cost for the soft-ware and cost of payment of salaries of part-time staff. This system will likely be affordable and sustainable if implemented in Africa. The Africa CDC can emulate from the Global PSS example as follows: adapting the same system by recruiting more hospitals in Africa in order to have a more comprehensive picture of antimicrobial consumption in the continent. This should also involve adapting the use of the web based system to capture the veterinary and agricultural sectors in a One Health approach; review the costing to include human resource and logistics specificities in African health systems. It is estimated that for a 500 bed hospital, it would take just 2 weeks to capture all the surveillance data needed. This means even if veterinary and agricultural sectors are included, it would still be a cost effective and sustainable strategy for the AMRSNET to implement; with the availability of online E-modules for training on AMR, there will not be need to spend in organizing costly workshops on AMR.
A major challenge for the AMRSNET is how to implement and monitor the progress in a phase based approach. From the deliberations by participants, it was suggested that lessons could be learnt from well-structured approaches such as SLIPTA (Stepwise Laboratory Quality Improvement Towards Accreditation). Based on the ISO 15189:2012(E) standard, the SLIPTA approach uses a checklist that outlines requirements for quality and competency aimed to develop and improve laboratory services towards accreditation [10
Laboratory mentors who have been trained in the implementation of the checklist are deployed and stationed in laboratories to provide technical support for the laboratories as well as to participate in the training of trainers. This approach has been scaled up in Africa with the support of the US CDC and the Africa Society for Laboratory Medicine (ASLM). A similar system could be adapted for the AMRSNET with the training of AMR mentors who can further train other AMR mentors in clinical, veterinary and agricultural sectors towards the step wise phase based approach. A scorecard that details targets to be met by the different sectors could be adapted for use in monitoring the implementation of this approach. Diagnostics play a crucial role in the control of infectious diseases and in the control of antimicrobial resistance. Researchers, policy makers and implementers really need to be clear on the priority diagnostic needs for antimicrobial resistance surveillance. From our consultations, the following could be considered as diagnostic priorities: the availability of a rapid test to distinguish bacterial and viral infection. The need to ensure the uptake of any of such diagnostics if available in future should be high among clinicians and health personnel.
There are some ongoing efforts. For example, in Tanzania there is the use the
e-POCT phone system with biomarkers such as CRP and pro-Calcitonin in reducing
inappropriate antibiotic prescription in children. The results of this technology
have been encouraging and should be encouraged in other African countries; there
is need to select the diagnostic technologies that would be needed for surveillance.
For example in Africa, if gram negative bacteria surveillance is chosen, major
hospitals could be selected and affordable technologies that detect gram negative
bacteria should be considered. If this is implemented, it would be easier to
evaluate stewardship programmes aimed at reducing antimicrobial resistance; connectivity
with current diagnostics used for AMR. This would help networking and real time
implementation of action. Senegal declared a Dengue epidemic on October 24, 2017
and a lot can be learnt and leveraged from their current connectivity capabilities.
Using a web based system, notifications about the epidemic can be obtained from
cell phones, says Dr Amadou Sall of the Pasteur Institute in Dakar during an
informal consultation at the ACDx. The Africa CDC can utilize the same connected
system in its AMR network which will be able to be adapted to provide real time
information of the strains of bacteria circulating in the network; continuous
capacity building in diagnostics to support the AMRSNET. In conclusion, the launch
of the Africa CDC AMRSNET is a very important step towards the implementation
of its strategic plan on reducing the rate of antimicrobial resistance in Africa.
However, lessons must be learnt from ongoing efforts so that we don't re-invent
the wheel. Diagnostics certainly play a crucial role in the control of AMR, hence
more attention should be given the urgent diagnostic priorities in the continent.
The authors declare no competing interests.
All the authors have read and agreed to the final manuscript.
1: immediate actions and perceived challenges from the African country
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