Surveillance for Antimicrobial Drug Resistance in Under-Resourced Countries

Guy Vernet

, Catherine Mary, Dany M. Altmann, Ogobara Doumbo, Susan Morpeth, Zulfiqar A. Bhutta, and Keith P. Klugman

Author affiliations: Fondation Mérieux, Lyon, France (G. Vernet);Avicenne, Lyon (C. Mary); The Wellcome Trust and Imperial College, London, UK (D.M. Altmann); Malaria Research and Training Center, Bamako, Mali (O. Doumbo); Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya (S. Morpeth); University of Oxford, Oxford, UK (S. Morpeth); The Aga Khan University, Karachi, Pakistan (Z.A. Bhutta); Emory University, Atlanta, Georgia, USA (K.P. Klugman);University of the Witwatersrand, Johannesburg, South Africa (K.P. Klugman)

Abstract

Antimicrobial drug resistance is usually not monitored in under-resourced countries because they lack surveillance networks, laboratory capacity, and appropriate diagnostics. This accelerating problem accounts for substantial number of excess deaths, especially among infants. Infections particularly affected by antimicrobial drug resistance include tuberculosis, malaria, severe acute respiratory infections, and sepsis caused by gram-negative bacteria. Nonetheless, mapping antimicrobial drug resistance is feasible in under-resourced countries, and lessons can be learned from previous successful efforts. Specimen shipping conditions, data standardization, absence of contamination, and adequate diagnostics must be ensured. As a first step toward solving this problem, we propose that a road map be created at the international level to strengthen antimicrobial resistance surveillance in under-resourced countries. This effort should include a research agenda; a map of existing networks and recommendations to unite them; and a communication plan for national, regional, and international organizations and funding agencies.

Antimicrobial drug resistance has become such a global concern that it was the focus of the 2011 World Health Day sponsored by the World Health Organization (WHO). Although antimicrobial drug resistance is well mapped and tightly monitored in some well-resourced countries, such processes do not exist in under-resourced countries. An increasing body of evidence reveals accelerating rates of antimicrobial drug resistance in these countries. Resistance may arise in the absence of any surveillance and threatens the achievement of the Millenium Goals for Development in terms of reduction of maternal and infant deaths (www.un.org/millenniumgoals/). The problem is even more pressing because, in a globalized world, microorganisms and their resistance genes travel faster and farther than ever before, and the pipeline of new drugs is faltering.

Mapping antimicrobial drug resistance in under-resourced countries is urgently needed so that measures can be set up to curb it. Such mapping must rely on efficient surveillance networks, endowed with adequate laboratory capacity, and take into account up-to-date diagnostic techniques. The way forward is to assess the effects of resistance, its clinical effects, and increase in deaths, with the ultimate objective of providing achievable guidelines for surveillance and control.

In this article, we report examples of successful surveillance networks in under-resourced countries and address the framework upon which to deploy reliable and sustainable networks on antimicrobial drug resistance surveillance. This initiative was begun during the Expert Meeting on Diagnosis and Detection of Antimicrobial Resistance in Developing Countries, convened at the Fondation Mérieux Conference Centre “les Pensières,” Veyrier-du-Lac, France, October 26–28, 2011.

What Are the Main Threats?

Tuberculosis

Figure

Figure. . Proportion of multidrug resistance among strains causing new tuberculosis cases from latest available world data, 1994–2010. Dotted lines on maps represent approximate borders for which there...

Resistance of Mycobacterium tuberculosis to antimycobacterial drugs is a global concern (Figure). In 2010, an estimated 650,000 cases of multidrug-resistant tuberculosis (MDR TB) (i.e., infections with strains resistant to, at minimum, rifampin and isoniazid) occurred worldwide, (1). An estimated 10% of cases were extensively drug resistant (XDR) (i.e., MDR strains that are also resistant to second-line drugs). Almost no surveillance system is in place and no data exist on TB resistance in sub-Saharan Africa (apart from South Africa) and Asia.

Malaria

Plasmodium falciparum strains resistant to chloroquine, fansidar, and mefloquine are widespread. Interventions using artemisinin and insecticide-treated bed nets have led to a drop of 40% of malaria cases since 2004 according to WHO. An estimated 750,000 lives were saved in Africa alone (2). Those efforts are potentially hindered by the emergence of resistance to artemisinin, which was first reported in 2008 at the Thailand–Cambodia border and subsequently reported in neighboring countries, although not in Africa so far (3,4). Resistance mechanisms to artemisinin are poorly understood, although mutations in some parasite genes have been partially correlated with resistance (5,6).