Weekly Digest: CDDEP in Review, 2016

6 Jan 2017
Author: Andrea White

Today’s digest features a roundup of the major work CDDEP has completed in the last year, from the formation of CARA: The Conscience of Antimicrobial Resistance Accountability, to studies published in leading journals, including The Lancet and International Journal of Infectious Diseases.
 
January 22: Can coalitions between neighboring countries increase vaccination coverage by limiting free-riding? CDDEP researchers investigated this question in a study published in the Journal of the Royal Society Interface. Without an international body governing vaccine administration, countries can “free-ride” on their neighbors’ higher vaccination coverage across a porous border, taking advantage of “herd immunity.” Using a model to predict the effects of voluntary coalitions between countries, which include counter-measures to avoid free-riding (e.g., penalties for noncompliance, trade sanctions or links to other agreements), they found that coalitions do lead to higher immunization rates. Coalitions of countries with significant differences in economic and/or epidemiologic status also work surprisingly well in the model, increasing vaccination across countries, leading to consistency in vaccine coverage among the member nations. [Journal of the Royal Society Interface]    
 
February 26: Innovative and cooperative financing mechanisms can help address global health concerns, which are often “commons problems,” writes CDDEP Director Ramanan Laxminarayan in the Oxford Review of Economic Policy. In these trans-boundary commons problems, the actions of one country can have significant implications for countries surrounding it—for instance, if one country under-reports a disease outbreak to protect tourism, other countries may bear an added risk. Laxminarayan writes that such problems require innovative solutions, like large-scale efforts that incentivize countries to report disease outbreaks. They also require coordinated financing mechanisms that go beyond bilateral assistance, such as a subsidy that lowers the cost of quality drugs for all countries in a region, to ensure impacts that don’t disproportionately affect single countries. [Oxford Review of Economic Policy]
 
March 5: CDDEP research published in PLOS Medicine details the state of antibiotic resistance in India, identifying major drivers of resistance and noting opportunities for action. CDDEP Director Ramanan Laxminarayan is a co-author of the paper, which notes that in 2010 India consumed more antibiotics for human health than any other country—including a proliferation of over-the-counter, nonprescription antibiotic sales. The authors also write that the confluence of several other factors—rising incomes, poor public health infrastructure, a high burden of disease—have likely contributed to a rise in antibiotic-resistant infections in India. They recommend improving regulation of drug production and sales, better managing physician compensation, and catalyzing behavior change among physicians and patients. [PLOS Medicine
 
March 12: Does India’s Integrated Child Development Services (ICDS) program improve educational outcomes of children later in life? ICDS, which provides nutritional, educational and healthcare assistance to young children, was evaluated by CDDEP Fellow Arindam Nandi and colleagues. They found that children from villages where ICDS was in place between 1987 and 1990 were more likely to still be in school in 2003-2005, and had completed, on average, 0.84 more grades of school than children from non-ICDS villages. No difference in test scores between the two groups was found, however. The study appeared in The Journal of Nutrition.[The Journal of Nutrition]
 
April 22: Reproductive, Maternal, Newborn and Child Health, volume 2 in the Disease Control Priorities, 3rd edition, was released on April 9 in San Francisco. CDDEP researchers Ashvin Ashok, Arindam Nandi and Ramanan Laxminarayan authored a chapter on “The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis.” The volume provides a basis for low- and middle-income countries (LMICs) to develop national plans based on cost-effective, affordable and scalable interventions. Key messages from the volume were published in The Lancet on April 9. [DCP-3 Volume, Chapter 18, The Lancet]
 
May 27: Can private laboratory networks bridge gaps in antimicrobial resistance (AMR) surveillance for low- and middle-income countries? CDDEP researchers explore the role private laboratory networks—which account for 90 percent or more of nationally and internationally accredited labs in some countries—can play in tracking AMR rates in LMICs, in a paper in Future Microbiology. In many LMICs, public laboratories are accorded low priority for funding, and their overall testing capacity—particularly in bacteriology—suffers from poor infrastructure, consumable stock-outs, and inadequate staff training. CDDEP’s ResistanceMap is one of the first projects to collect AMR data from LMICs, utilizing private laboratory networks in India and South Africa. [CDDEP, Future Microbiology, ResistanceMap]
 
August 20: Cost, benefits and obstacles to antimicrobial resistance surveillance in low- and middle-income countries assessed in CDDEP-led World Bank case study. Antimicrobial resistance (AMR) surveillance is key to understanding patterns and trends in AMR, but few low-resource countries have begun surveillance programs. CDDEP Associate Director for Policy Hellen Gelband and colleagues from Nigeria and Kenya assessed the East Africa Public Health Laboratory Networking Project (EAPHLN) experience for a World Bank case study on Strengthening the Role of Laboratories in Tracking Antimicrobial Drug Resistance in East Africa, released this week. Despite significant World Bank support and upgraded facilities, bacteriology lags behind other functions in EAPHLN labs, which conduct few of the antibiotic susceptibility tests that form the basis of AMR surveillance. The case study identifies obstacles to better performance and issues a series of recommendations, which have wide applicability in low- and middle-income countries around the world. It also reviews AMR surveillance programs around the world, their organization, costs and benefits. [CDDEP]
 
September 3: The first long-term, national-scale study of antibiotic resistance in India indicates an urgent need for stewardship programs and new antibiotics. In the International Journal of Infectious Diseases, CDDEP researchers report an analysis of more than 18,000 isolates collected from a large private diagnostic laboratory network from 2008 through 2014, finding high and increasing antibiotic resistance rates among Gram-negative and Gram-positive organisms. Resistance rates were high to both first-line and last-resort antibiotics, especially for Gram-negative isolates. More than 40 percent of Staphylococcus aureus isolates were multi-drug resistant (MRSA) over the period, and nearly all Salmonella Typhi isolates were resistant to nalidixic acid. Resistance to last-resort antibiotics—the carbapenems and colistin—were high in some cases and increasing for a number of serious infections. According to lead author Dr. Sumanth Gandra, in India “antibiotics have for too long substituted for general hospital infection control and lagging vaccination rates.” [International Journal of Infectious Diseases]
 
September 18: Antimicrobial resistance in India is threatening the survival of newborns. In a large multi-center study of neonatal sepsis in tertiary care hospitals in India, sepsis incidence and mortality was high and antimicrobial resistance increased the case fatality rates. CDDEP Director Ramanan Laxminarayan, in a Lancet comment, highlights the importance of sepsis prevention in newborns, as births in India and other low- and middle-income countries take place increasingly in health facilities, where the infection risk is high. The results of the Delhi Neonatal Infection Study (DeNIS) indicate the need to understand the pathogenesis of sepsis in newborns and infants, as well as the need to implement proven infection control interventions to prevent the illness in low-income and middle-income countries. [Lancet Global Health Study, Comment]
 
September 25: Nine founding organizations launch CARA, the Conscience of Antimicrobial Resistance Accountability, in support of the United Nations Resolution on Antimicrobial Resistance. CARA members will work to hold the United Nations and other international bodies, national governments, the private sector, and civil society to the commitments they have made to ensure sustainable access to effective antimicrobials. The goals of the alliance include improving the surveillance of antibiotic use and resistance; preserving the effectiveness of antibiotics through conservation; ensuring universal access to antibiotics, particularly in lower-income countries, where access is currently inadequate; supporting innovation to encourage the development of new antimicrobials, compounds to boost their effectiveness, diagnostics to better diagnose infections, and vaccines to prevent infections from occurring; and accountability to hold the relevant agencies to their goals. [CARA]
 
September 25: World leaders met for the United Nations General Assembly and the UN High-Level Meeting on Antimicrobial Resistance on September 21, to ratify a political declaration that calls for a global, multisectoral effort to address antimicrobial resistance. Secretary-General Ban Ki-moon called antimicrobial resistance “a fundamental, long-term threat to human health, sustainable food production and development…These trends are undermining hard-won achievements under the Millennium Development Goals, including against HIV/AIDS, TB, malaria and the survival of mothers and children. If we fail to address this problem quickly and comprehensively, antimicrobial resistance will make providing high quality universal health coverage more difficult, if not impossible.” H.E. Peter Thomson, President of the 71st session of the UN General Assembly, added, “Member States have today agreed upon a strong political declaration that provides a good basis for the international community to move forward. No one country, sector or organization can address this issue alone.” [WHO, Political Declaration]
 
September 25: Experts call for Global Antimicrobial Conservation Fund. CDDEP Director Ramanan Laxminarayan and other experts in antimicrobial resistance make the case for a Global Antimicrobial Conservation Fund, in an International Journal of Infectious Diseases editorial. The developing world is where 90 percent of the estimated 10 million deaths related to antimicrobial resistance per year will occur by 2050. These are also the countries most in need of improved access to antimicrobials and the least able to finance conservation efforts because of limited resources and weak health systems. Without external financial aid, many LMICs are unlikely to put in place public health interventions on par with high-income countries to control antimicrobial resistance. The fund would support antimicrobial stewardship programs in low- and middle-income countries, which include the BRICS nations (Brazil, Russia, India, China and South Africa), currently driving consumption in both animal and human sectors. [International Journal of Infectious Diseases]
 
October 2: The next steps after UNGA in the fight against antimicrobial resistance: On the CDDEP Blog, Associate Director for Policy Hellen Gelband discusses the next steps in the fight against antimicrobial resistance after the United Nations General Assembly High-Level Meeting on Antimicrobial Resistance. Gelband also discusses the role of the recently-formed alliance, CARA: The Conscience of Antimicrobial Accountability, in holding global organizations to goals established in the UN’s recent declaration on antimicrobial resistance. The Center for Infectious Disease Research and Policy (CIDRAP) also discussed the next steps in the fight against antimicrobial resistance following the UN declaration, with comments from AMR experts, including CDDEP Director Ramanan Laxminarayan. [CDDEP, CIDRAP]
 
October 9: Resource-poor countries experience higher levels of antimicrobial resistance. The first study to examine the association between national income status and antimicrobial resistance (AMR) prevalence, conducted by CDDEP researchers and colleagues, found that AMR prevalence increases as national income decreases, and is highest among the poorest countries. These findings underscore the urgent need for new policies to address AMR in resource-poor settings. In their analysis, researchers used ResistanceMap, a web-based collection of data visualization tools developed by CDDEP, featuring antibiotic consumption data from 75 countries and antibiotic resistance data from 49 countries. [IJID, ResistanceMap]
 
October 21: Quality standards in development for treating respiratory infections in Vietnam would avoid antibiotic overprescribing. The Oxford University Clinical Research Unit (including Global Antibiotic Resistance Partnership collaborators) and the Vietnamese MOH convened a working group to recommend evidence-informed guidelines for treating community-acquired pneumonia and acute exacerbations of chronic obstructive pulmonary disease. The group began with international guidelines and adapted them to the local context, reporting to an MoH committee in June 2016. That committee identified some additional steps needed before the guidelines can be finalized, but agreed on most of the recommendations. The ongoing development is reported in The Lancet as an example of a national process to develop the best possible guidelines under challenging conditions, where patients have access to antibiotics without medical advice, and where surveillance is less than adequate to define the local epidemiology of infections and antibiotic resistance. [The Lancet]
 
October 30: Only half of U.S. patients received the recommended first-line antibiotic for three common infections. New research from the Centers for Disease Control and Prevention (CDC) and the Pew Charitable Trusts finds that 52 percent of patients prescribed outpatient antibiotics for sinus infections, middle-ear infections, and pharyngitis, get the first-line antibiotics. Instead of narrow-spectrum penicillin or amoxicillin, nearly half of patients were prescribed a broad-spectrum antibiotic such as azithromycin or another macrolide, which can increase the risk of adverse effects, including antibiotic resistance in a serious infection in the future and Clostridium difficile infection. According to co-author and a senior officer for Pew's antibiotic resistance project, David Hyun, "This tells us that there's a lot of room for improvement. When you don't use a first-line agent, the benefit-to-risk ratio changes.” [CIDRAP, JAMA Internal Medicine]
 
November 18: Antimicrobial-resistant healthcare-associated infection, Pseudomonas aeruginosa, increased steadily among U.S. children over the last decade. In a study published in The Journal of the Pediatric Infectious Diseases Society, CDDEP researchers and collaborators report increases in multidrug-resistance (MDR) and carbapenem-resistance (CR) in Pseudomonas aeruginosa between 1999 and 2012. The prevalence of MDR P. aeruginosa increased from 15.4 percent in 1999 to 26 percent in 2012, and of CR, from 9.4 percent 20 percent. The proportion of both MDR and CR P. aeruginosa increased each year by 4 percent. The study underscores the need for aggressive prevention strategies, including bacterial surveillance and antimicrobial stewardship programs in pediatric settings. [Journal of PIDS]
 
December 10: First large-scale study of recurrent emergency department visits for skin and soft tissue infections. A study from CDDEP researchers and collaborators, published in Epidemiology & Infection, examined factors associated with recurrent emergency department (ED) visits for skin and soft tissue infections (SSTIs), using California emergency department discharge data from 2005 to 2011. More than 16 percent of the nearly 200,000 SSTI records represented repeat visits within six months of the initial encounters. Drug or alcohol abuse and liver disease [odds ratio (OR) 1·4, 95% confidence interval (CI)] and obesity (OR 1·3, 95% CI) are associated with the likelihood of recurrent SSTI visits. Patients whose infections had been subject to incision and draining or aspiration also had a slightly higher risk of a repeat ED visit (OR 1·10, 95% CI). [Epidemiology & Infection]

The Digest will be back to reporting current events next week. 

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