Global challenges and opportunities for tackling antimicrobial resistance

This post was written by Sophie Allcock andoriginally posted on the Global Health, Epidemiology and Genomics blog – view more at:

Antimicrobial resistance (AMR) is a global public health concern. In 2014, an estimated 700,000 deaths were attributed to AMR globally and it is predicted that by 2050 this number could reach 10 million.[1] Antibiotics have been the cornerstone of many medical interventions, for example surgical interventions, transplants and the treatment of common bacterial infections, for decades. Without effective antibiotics, many medical practices that we now consider to be routine will be jeopardised.

Although there is much global attention to AMR, there is a need to better understand the burden, distribution and determinants of AMR at the population level. Antimicrobial use, appropriate or inappropriate, is a driver of AMR yet there is a lack of specific advice as to which interventions are likely to have the greatest impact on reducing the emergence and spread of AMR in both hospital and community settings.

In our paper “Antimicrobial resistance in human populations: challenges and opportunities”, we argue for the integration of a range of epidemiological approaches, which could help to improve our understanding of the population level factors that may influence the development and spread of AMR. This is important for informing interventions to reducing excess use of antimicrobials, whilst also ensuring that those in need of these treatments have access to them.

One such approach is to use routine clinical data and electronic health records (EHRs) in combination with pathogen surveillance, using techniques such as whole-genome sequencing. This could help to improve our understanding of drug resistance, how it emerges and how it spreads. EHRs could also provide an insight into prescribing practices in general practices and hospitals, and how this could be related to the emergence of drug-resistant infections. Using prospective (or longitudinal) study designs, researchers could explore the real-time development of resistant strains in a given population as well as the factors that may drive resistance.

Other preventative strategies to reduce the burden of AMR include basic hygiene and sanitation practices, waste management and safe food preparation. However, in some low- and middle-income countries (LMICs), conducting these basic practices can be challenging due to human resource constrains and weaker civil and health infrastructures. Furthermore, it is often the case in these countries that more people suffer due to a lack of access to drugs than drug resistance itself.

The suggested research initiatives may help to better understand the burden, distribution and determinants of AMR. These approaches should be combined with improved preventative measures, including vaccinations and good hygiene and sanitation practices to reduce the need for therapy in the first instance, and strategies to reduce excess use of antimicrobials to slow the development of resistance. Furthermore, although AMR is a global problem, we need to consider that the issue differs by county and setting, therefore so must the approach taken to tackle AMR.

1. O’Niell J., Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, in The review on antimicrobial resistance. 2016, HM Government and the Wellcome Trust: London.

The paper “Antimicrobial resistance in human populations: challenges and opportunities” by S. Allcock, E. H. Young, M. Holmes, D. Gurdasani, G. Dougan, M. S. Sandhu, L. Solomon and M. E. Török has been published Open Access in Global Health, Epidemiology and Genomics and is available here.


Knowledge gaps in the epidemiology of Toxocara: the enigma remains


The latest Parasitology Paper of the Month is “Knowledge gaps in the epidemiology of Toxocara: the enigma remains” by Celia Holland.

Some parasites seem to have a Cinderella status. Down in the basement of the ugly stepmother’s house, they are working away, busily infecting many hosts but there is no handsome prince, in the form of generous research funding, to bring them to the ball. Despite the most welcome initiatives concerning Neglected Tropical Diseases (NTDs), human toxocariasis, with its worldwide distribution, remains strangely ignored. Why is this so? There is no doubt that its multiple routes of transmission to hosts, both domestic and feral, its cryptic disease picture in humans, problems with diagnosis and treatment and its widespread environmental contamination, all contribute to the challenge of researching this enigmatic helminth and to devising appropriate preventative and control measures.

However, that is not the full story. The number of investigators who make Toxocara their main focus is diminishing. Tragically, Huw Smith, of the Scottish Parasite Diagnostic Laboratory, passed away and several other leading figures, such as J-F Magnaval and Mervyn Taylor, have retired. We now need young, able scientists to contribute to the challenge. However, Peter Hotez remains a passionate advocate, raising awareness of Toxocara. He recently included the parasite in a ‘Viewpoint’ for JAMA Psychiatry, focusing on five infections affecting the American brain. From the veterinary perspective, Dwight Bowman and Paul Overgaauw are equally passionate in educating veterinarians about the zoonotic potential of Toxocara.

This is the background to my paper “Knowledge gaps in the epidemiology of Toxocara: the enigma remains”, a contribution to the One Health special issue in Parasitology and the BSP symposium. The enigma refers to the title of the book, Toxocara the enigmatic parasite, edited by Huw Smith and I back in 2006. We have made some progress since then. But, as outlined in my paper, there remain at least nine gaps in our knowledge, gaps that seem shocking when we contrast them with our knowledge of other major human parasites. For example, it seems inconceivable that we do not know what species of Toxocara contributes most to human exposure, Toxocara canis or T. cati and still lack information on the precise relationship between exposure and disease.

As outlined in the paper, what we urgently require is a One Health approach to the study of Toxocara and toxocariasis. I suggest an ideal scenario initially involving a single country or defined region, in which sources of infection in humans, other animals and the environment are comprehensively assessed. The relationship between seropositivity in humans and the extent of significant disease is also explored, as is the detection of eggs in the environment and larvae in paratenic hosts. The collection of such crucial baseline epidemiological data would provide the basis for an intervention study encompassing anthelmintic treatment and anti-fouling, with subsequent follow up. There is no doubt that such an approach would be logistically challenging and costly. But, for the first time, it would place Toxocara in a One Health context, and provide a framework for future prevention and control. Now is the time for major pharmaceutical companies, for whom veterinary anthelmintics is a lucrative line of production and sale, to join with the research community, by funding a significant One Health programme of research focused upon Toxocara.

Read the full article “Knowledge gaps in the epidemiology of Toxocara: the enigma remains” in full for free until 28th February 2017.

A centenary of Robert T. Leiper’s lasting legacy on schistosomiasis and a COUNTDOWN on control of neglected tropical diseases

The latest Parasitology Paper of the Month is “A centenary of Robert T. Leiper’s lasting legacy on schistosomiasis and a COUNTDOWN on control of neglected tropical diseases” by J. Russell Stothard, Narcis B. Kabatereine, John Archer, Hajri Al-Shehri, Louis Albert Tchuem-Tchuenté, Margaret Gyapong and Amaya L. Bustinduy. This blog post was written for us by Professor Stothard.

Typically, biomedical research and disease control in general is forward looking in focus. This is often typified in the aspirational goals and targets set by international health agencies, as bundled within progress-specific indicators. In 2012, for example, the WHO formulated the Neglected Tropical Diseases (NTDs) Roadmap which helped to set out future progress to sustain the drive to overcome the global impact of NTDs by 2020. With later formulation of the sustainable development goals (SDGs), this NTD agenda has been expanded but now framed in a 2030 perspective.

While looking to the future, we should not forget to occasionally glance back at the past; for it is here where we review and contextualise previous successes and failures. Indeed, progress is rarely smooth and is often a stuttered march through time. Just over a hundred years ago, the then state-of-the-art biomedical research culminated in clarification of the lifecycle of the African schistosome. With it, precious knowledge was brought forth to the world, opening up a new vista on schistosomiasis, a terrifying waterborne illness, and signposting a cardinal era in future disease control. In some small celebration of this achievement, I thought it time to reflect upon this, placing its significance in today’s world.

I previously had some understanding of the stature that Robert T. Leiper had in parasitology when I was based at the Natural History Museum (NHM) and London School of Hygiene and Tropical Medicine (LSHTM). Although Leiper died the year before I was born, many times did I look at his portrait in oils hanging in the LSHTM’s main stairwell. His face often brought to life by an anecdote retold to me, often either tart or sweet in equal measure, when visiting a senior colleague on the 4th floor who had had first-hand dealings with him.

Upon more detailed investigations into his life, while searching the LSHTM and NHM archives, I was privileged to read his meticulous hand written notes. Moreover, viewing his black and white photographs transported me to China and Egypt of old and delving deeper, I became beset within the melancholies of Antarctic exploration and First World War tragedy. Without doubt, I strongly sensed Leiper’s fiery energy and dogged determination which enabled him to go the extra mile where others would not, and help him solidify the importance of fundamental parasitological research within tropical medicine.

During this exercise, I remembered that control of schistosomiasis in theory is relatively easy; it can be curtailed by very simple water hygiene measures that Leiper himself pioneered. Sadly, putting this into practice is still out of reach for millions in sub-Saharan Africa and in Uganda intestinal schistosomiasis is still rife within lakeshore communities where Leiper once worked. As Director of COUNTDOWN, an implementation research consortium funded by DFID, UK, I hope this article reminds us that ‘old’ advice still needs appropriate tailoring within the control practices of today, and to embellish the aspiration that everyone, child or adult, has the daily right to safe water.

Read the review paper “A centenary of Robert T. Leiper’s lasting legacy on schistosomiasis and a COUNTDOWN on control of neglected tropical diseases” which has been published Open Access here.

Announcing the publication of the first papers in GHEG

GHG blog image - cover
We are delighted to announce the publication of the first papers in Global Health, Epidemiology and Genomics. As GHEG is fully Open Access, these papers, and all papers published in the future, are freely accessible online. Here we provide a brief summary of our first three publications.

 A forum for global population health, technological advances and implementation science
 Manjinder Sandhu

A welcome editorial by our Editor in Chief, marking the launch of Global Health, Epidemiology and Genomics. Dr Sandhu highlights the strengths of the broad interdisciplinary scope of the journal and its international editorial board and invites the global health community to engage and contribute to the journal so that it becomes a valuable, practical and informative resource.
Read the full article here


favicon Study Profile: The Durban Diabetes Study (DDS): a platform for chronic disease research
 Thomas Hird et al.

A study profile of The Durban Diabetes Study (DDS), an on-going population-based cross-sectional survey of an urban black population in Durban, South Africa. The DDS was established to investigate a broad range of lifestyle, medical and genetic factors and their association with diabetes. It provides a rich platform for investigating the distribution, interrelation and aetiology of other chronic diseases and their risk factors, which can be utilised for other research studies.
Read the full article here


Favicon long Capitalizing on Natural Experiments in Low- to Middle- Income Countries to Explore Epigenetic Contributions to Disease Risk in Migrant Populations
 J. Jaime Miranda et al.


A commentary on the value of epigenetics as a tool for understanding differential disease risk in migrant populations. The authors highlight the merit of exploring migrant chronic disease risk in low- to middle-income countries, particularly in the context of rural-to-urban migration, with increasing urbanisation in this setting.
Read the full article here
More articles will be published in the coming weeks, and you can be notified when new articles are published by signing up to content alerts here. Here’s a preview of what’s coming soon:

  • H3Africa Multi-Centre Study of the Prevalence and Environmental and Genetic Determinants of Type 2 Diabetes in Sub-Saharan Africa: Study Protocol
    Kenneth Ekoru et al.
  • Regulatory Developments in the Conduct of Clinical Trials in India
    Dhvani Mehta and Ranjit Roy Chaudhury

GHEG accepts original research articles, brief reports, structured reviews and commentaries as well as protocols, research resources and analysis. We are waiving the Article Processing Charge for all articles submitted to GHEG before the end of 2016. We invite contributions from a range of disciplines:
Epidemiology, Clinical trials, Genetics, Observational studies, Qualitative studies, Anthropological studies, Social science, Community intervention, Health systems, Health services, Population genetics, Population history.
For further information on the journal and how to submit please visit our website. Or if you wish to submit your manuscript directly please visit:

Global Health in 2015 – via Global Health, Epidemiology and Genomics

Global health review word cloud

This post was written by Anna Louise Barr andoriginally posted on the Global Health, Epidemiology and Genomics blog – read more at:

A review of the year’s most notable global health news stories, events and research breakthroughs, and a look towards future challenges in 2016 and beyond.

This year has seen a number of milestones achieved in the fight against infectious diseases. For the first time, a malaria vaccine has been approved and recommended by the World Health Organization (WHO) for pilot implementation. If deemed safe and effective, the vaccine will be a positive step forward in the fight against malaria in Africa, where the specific species that the vaccine targets is most prevalent and is responsible for the deaths of 500,000 people annually. In June, Cuba became the first country in the world to eliminate mother-to-child transmission of HIV and syphilis. Furthermore, UNAIDS announced that, globally, the spread of HIV has been halted and reversed, with 15 million people now currently receiving antiretroviral therapy. These two achievements represent an important breakthrough in the prevention of HIV transmission and realising the goal of an AIDS-free generation. In September, WHO announced that Nigeria was no longer a polio-endemic country; just two countries (Pakistan and Afghanistan) have yet to stop polio transmission.

In West Africa, transmission of Ebola has ended in Sierra Leone, however, 19 months after the first case was reported, cases are still arising in Guinea and Liberia, and vigilance remains high in the region. Recent studies have detected the virus in semen, and other immune privileged sites, several months after infection, leading to some concern regarding possible sexual transmission of the virus. The risk is deemed low, but considering the unprecedented scale of the epidemic and numbers of survivors, the WHO and the US Centre for Disease Control and Prevention have continued to encourage the promotion of safe sex practices. A vaccine for Ebola has also been developed and is close to approval.

2015 marked the end of the Millennium Development Goals (MDGs). During the 15 year initiative, the MDGs successfully galvanised political will, resulting in unprecedented efforts to reduce global poverty. Extreme poverty declined by more than half and reductions were seen in the proportion of undernourished people in developing regions and the number of out-of-school children of primary school age. Globally, the mortality rate of children under-five more than halved and maternal mortality fell by 44% worldwide. Yet not everyone has benefitted equally; the poorest and most disadvantaged in society have quite often been left behind.

The 2030 Agenda for the Sustainable Development Goals (SDGs), which were launched this year, hopes to build on the MDGs and address these inequalities. It is an ambitious set of new goals, 17 in total with 169 targets altogether, centred on the vision of development through equality and the implementation of sustainable economic, social and environmental policies. Unlike the MDGs, health no longer takes centre stage, with only goal three, ‘ensure healthy lives and promote well-being for all at all ages’, specifically addressing it. Whilst other goals have health related targets, addressing risk factors such as poor sanitation and malnutrition, there is some concern that there is no coherent vision for health in middle- and high-income countries where the health burden is predominantly from non-communicable diseases; risk factors such as unhealthy diet, obesity and inadequate physical exercise are not addressed.(1) The overall successes of the MDGs inspires hope that the same collective action and funding commitment will be directed towards the SDG agenda maintaining the momentum required to take on the global health challenges ahead.


1. Murray CJ. Shifting to Sustainable Development Goals–Implications for Global Health. The New England Journal of Medicine. 2015;373(15):1390-3.


Only One Flu Shot? Maybe!

Can you imagine not having to get a flu shot every season? Apparently two independent teams of doctors have been imagining the same thing.

The two independent research groups have released findings that this could be a reality someday.

It has been notoriously difficult to formulate a vaccine against all forms of influenza for a number of reasons. One thing that makes the virus so difficult is that influenza is a shape shifter that can, and does, mutate and change quickly and repeatedly. This means that even if a person develops immunity through an earlier year’s flu shot, he might not be immune to the latest strain of the virus.

A large portion of the human immune response to the flu is directed against a portion of the protein hemagglutinin called the hemagglutinin head. In the last twenty years scientists discovered that some people were able to fight a large swath of flus because their immune systems could develop antibodies that targeted the hemagglutinin stem. Even so though, the human immune system still often cannot keep up with the rapidly mutating stem. This could be partially due to the fact that the stem is hidden while the head is exposed.

Knowing this, the two independent research teams took two different approaches to almost identical notions. With idea to help the body create more stem-specific antibodies in order to help battle more types of influenza, each team decided to focus exclusively on the hemagglutinin stem. Their idea was to create stem-only antigens to incorporate into vaccines, effectively ignoring the hemagglutinin head.

This proved a very difficult task, “Flu is a very large virus with lots of parts. It’s very hard to build a small piece without screwing things up,”  Andrew Ward told the Los Angeles Times a structural biologist at Scripps Research Institute. In order to create a stable molecule and not disrupt the response they wished-for for the antibodies, they could not have a single atom out of place.

Incredibly, the two teams were able to create stable molecules and were able to use them to create vaccines which they tested on mice and monkeys and mice and ferrets respectively. They were both able to elicit certain protection in varying degrees.

This, by no means, means that a universal flu vaccine will be available in the short term. However, it paves the way for a type of booster shot that could be available at some point in the future and more protection against the flu than current shots, which only can protect against 3 or 4 strains, says Ward.

Cambridge launch new open access journal – Global Health, Epidemiology and Genomics

GHG blog image - cover

Cambridge unveils new Open Access journal – Global Health, Epidemiology and Genomics (GHEG)

Cambridge University Press is delighted to announce a major new open access journal, Global Health, Epidemiology and Genomics (GHEG), dedicated to publishing and disseminating research that addresses and increases understanding of global and population health issues through the application of population science, genomics and applied technologies.

Global Health, Epidemiology and Genomics is the Press’s second Open Access journal in the field of global health, joining Global Mental Health which launched in 2014. Spanning both non-communicable and communicable diseases, GHEG will specifically integrate epidemiology, genomics and related technological advances in the global health context. Topics relevant to GHEG will include studies, methods and resources relating to global population health, disease aetiology, variation in disease susceptibility, drug resistance and surveillance, health care and health care systems, pharmacogenomics and stratified medicine, as well as the challenges of implementing new developments into clinical practice and the community, globally. In addition to more traditional Original Research and Review Articles, GHEG will support submission of Resources and Analyses that provide a framework for integrating and facilitating genomics and global health studies.

The Editor-in-Chief of GHEG is Dr Manjinder Sandhu, head of the Global Health Group based at the University of Cambridge and the Wellcome Trust Sanger Institute. The international Editorial team includes recognised leaders in global health, epidemiology and genomics from around the world who have taken a lead in shifting attention and action to global health and populations, as well as a wider Editorial Board that will reflect and emphasize the broad scope of the field.

Dr Sandhu said, “I am committed to making GHEG an innovative, engaging and practical resource for the global health research community through which we can publish new scientific research, exchange ideas within and across our related disciplines and share resources to facilitate efforts to increase our understanding of human health and shape effective disease management worldwide.”

Professor Alex Brown, Deputy Director of the South Australia Health & Medical Research Institute (SAHMRI) and one of the journal’s Associate Editors commented, “I am delighted to be involved with GHEG, an exciting venture which recognises the relevance and importance of the work being undertaken in the field of global health, epidemiology and genomics and the widespread benefits to be gained by applying technological advances and innovations to research into population health including within disadvantaged population groups. By facilitating discussion and encouraging the sharing of resources GHEG looks to actively support contributions in these areas.”

Katy Christomanou, Publishing Director for STM Journals at Cambridge University Press, added, “This launch affirms our long-term commitment in the global health field and reflects our strong investment in maintaining and extending our successful presence in this area. We are highly enthusiastic at the prospect of working alongside such an outstanding editorial team.”

Global Health, Epidemiology and Genomics will be hosted on Cambridge’s industry-leading platform, Cambridge Journals Online (CJO). The Journal will benefit from a range of the latest author services including article level usage metrics and Altmetric data. In addition, for articles submitted during 2015 and 2016, Cambridge University Press will waive all article processing charges.

For more information please visit the journal website:


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