1. WHO local pilot projects to contain AMR ICIUM 2004 K.A.Holloway and T.L.Sorensen Essential Drugs and Medicines Policy WHO Geneva

2. 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

3. 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

4. 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

5. 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?

6. 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 > 1year –drop-out rate after visit of 50%

7. 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

8. Looking at trends in cotrimoxazole resistance and use in Mumbai, India, 2002

9. Establishing differences in E.Coli resistance levels in rural & urban areas in Vellore, 2002

11. 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

12. 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

13. 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