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: http://gheg-journal.co.uk/blog/

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.

Reference:
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.

The challenges of big data in low- and middle-income countries: from paper to petabytes

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Generation of digital data has expanded exponentially over the last decade, inspiring visions of data-driven healthcare and precision medicine. But the promise of big data is tempered by today’s reality in low resource settings: weak health systems and limited governance structures complicate its application. Many of the countries in greatest need continue to struggle to collect vital statistics on births and deaths, with epidemiological data of variable reliability typically coming from only small, sentinel sites. However, with the falling cost of aggregating and coordinating resources and services electronically, big data stands to deliver disproportionately large benefits to low- and middle-income countries (LMICs). Effective targeting of interventions is increasingly important when the availability of resources is limited.

The collection of individual level information – a prerequisite for big data – is fraught with ethical, regulatory and procedural challenges. Of widespread concern is the risk of breach of privacy, and, as a result, the thought of digitised and centralised repositories of personal records instils fear in many. This concern is further amplified when information is about individuals in vulnerable populations and communities. Even very basic health data – ethnicity, reproductive health history, sexually transmitted infections, diseases with a genetic basis, or risk exposures for disease – has the potential for misuse, leading to discrimination, personal danger or death. The risk of accidental or intentional breaches of data security may be increased with limited literacy, high corruption, or rapid technology transition. In many LMIC settings, legislation supporting the privacy and security of information is frequently underdeveloped and rarely enforced. Robust data sharing guidelines between LMIC stakeholders are often lacking, hampering big data solutions and compromising those in play.

The persistent tension between disease-specific (‘vertical’) programs and health-system (‘horizontal’) focused approaches remains unresolved. Big data arguably fits best with a horizontal approach, potentially improving data for a breadth of diseases to support the new Sustainable Development Goals. However, global health remains a siloed undertaking, often driven by disease specific interests. Ensuring inclusive data collection, dissemination and application is critical for maximizing big data’s potential.

Informed, reflective and resourced stewardship is critical to enable positive outcomes from health big data in LMICs. Unfortunately, the global health community has a patchy record of cohesive and inclusive governance of technical developments. Optimising the application of big data is much more than establishing confidentiality safeguards and minimum standards. A broad effort to establish enforceable interoperability standards is imperative to creating meaningful insight.

Big data’s mechanism of action is magnification; sheer size makes risks and benefits larger. This magnification is greater in low resource settings where big data are most needed and most vulnerable to fragmentation and misuse. Conscious and committed leadership, analysis and technical guidance are needed to minimise these risks. Complexities should not be underestimated; the shift from paper to petabytes in LMICs is a seismic change. Shepherding that transition provides an opportunity for global health institutions to demonstrate governance.

Image caption: “Logo for the Big Data for Health in Africa meeting, hosted by the African Partnership for Chronic Disease Research in Entebbe, Uganda on 3rd-4th November 2016. An initiative building capacity and expertise in Big Data and data science to ensure that African countries are able to capitalise on the scientific  technical, social and economic benefits of this new global industry”

Free Content about the Zika Virus Now Available

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Just 8 days after the public health emergency was declared, this content regarding the Zika virus has been written, reviewed, edited, and released as a freely available resource.

On February 1st, the World Health Organization declared a Public Health Emergency of International Concern related to clusters of microephaly cases in some areas affected by the Zika virus. Like the Ebola virus, there had been very little funding and research on Zika until the recent emergency and associated media and scientific attention – there is therefore a dearth of information and there is neither a vaccine nor prophylactic pharmacotherapy available to prevent Zika virus infection.

In response to concern over the effects of Zika virus infection in pregnant women, the medical publishing team at Cambridge University Press commissioned a brief summary of current evidence and recommendations. Just 8 days after the public health emergency was declared, this content has been written, reviewed, edited and released as a freely available resource. The content has been provided by Professor Bernard Gonik, Fann S. Srere Chair of Perinatal Medicine, Wayne State University School of Medicine.

Released in advance as a freely accessible public resource, this content is part of High-Risk Pregnancy: Management Options – a forthcoming updateable online product from Cambridge University Press. Like all of the content in High-Risk Pregnancy: Management Options, the Zika section will be regularly updated as new information arises.

Read about the Zika Virus Here

 

Announcing the publication of the first papers in GHEG

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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: http://mc.manuscriptcentral.com/gheg.

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

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This post was written by Anna Louise Barr andoriginally posted on the Global Health, Epidemiology and Genomics blog – read more at: http://journals.cambridge.org/gheg

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.

References

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

 

Perspectives on HIV/AIDS and “getting to zero” – via Global Health, Epidemiology and Genomics

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HIV/AIDS is a global killer that affects an estimated 37 million people worldwide.(1) Despite success in reducing the burden of HIV, we are now facing treatment challenges due to resistance and are still without a cure or a vaccine for HIV. These issues must be addressed if we are to realise the goal of “getting to zero” HIV cases and deaths.(2)

Sub-Saharan Africa (SSA) has the highest global burden of HIV, with an estimated 25.8 million adults and children living with the condition. Asia, the Pacific region, Eastern Europe and Central Asia also have a considerable burden of HIV. Of the 1.2 million global AIDS-related deaths in 2014, 790,000 occurred in the SSA region and 240,000 occurred in the Asia and the Pacific region.(1) Thus HIV remains a major cause of ill-health and premature death globally, disproportionately affecting low- and middle-income countries.

Access to antiretroviral therapy (ART) has rapidly increased over the past decade, which has led to a notable decline in HIV associated morbidity and death in SSA. It is also believed that overall HIV incidence has been reduced. However, this is not the case for some high risk groups, such as men who have sex with men, where incidence is thought to be on the rise.(3) Thus, it is important to galvanise education and prevention strategies, particularly targeted to these high risk groups to reduce the number of new HIV cases.

There are currently more than 30 antiretroviral drugs approved for use in the majority of developed countries.(4) The latest therapies have improved efficacy, fewer side effects and are easier to administer. However, despite these improvements, there remain issues surrounding drug-specific side effects and interactions with other drugs. We are still without a cure or a vaccine for HIV and treatment of HIV is further hindered by the emergence of drug-resistant pathogens. The development of novel drugs is therefore central to the continued success of HIV therapy, globally. Several drug strategies have been developed or proposed, including antibody therapies and newer classes of antiretrovirals. A better understanding of biological processes underlying HIV disease progression would facilitate efforts to develop novel HIV treatment strategies. It is clear that combinations of current and novel drugs will be required for effective long-term HIV control.

Surveillance will be instrumental in the identification of new and existing cases of HIV to enable the targeting of treatment and control interventions. Fortunately, we have the tools to rapidly detect cases of HIV at the point of care. HIV rapid diagnostic tests (RDTs) are non-invasive and provide results in less than 30 minutes. Scaling-up the use of RDTs will help to identify new cases of HIV and will be particularly valuable in the detection of hotspots of epidemic infection. However, more sensitive and specific tests are still needed, particularly to detect cases of acute infection.

In order to achieve the target of “getting to zero”,(2) integration of surveillance, case detection and diagnosis, treatment and case management will be essential. In light of ART resistance, it will be evermore crucial to incentivise vaccine development initiatives to prevent establishment of infection in the first instance. New treatment strategies, novel HIV therapeutics and the scaling-up of HIV prevention strategies will also be essential if we are to reduce HIV infections and deaths to zero.

Key references:
1. Joint United Nations Programme on HIV and AIDS (UNAIDS). 14 July 2015. www.unaids.org/sites/default/files/media_asset/MDG6Report_en.pdf.
2. Joint United Nations Programme on HIV/AIDS (UNAIDS). Getting to Zero 2011-2015 Strategy. Geneva, Switzerland, 2010.
3. World Health Organization. Global Update on the Health Sector Response to HIV, 2014. Geneva, Switzerland, 2014.
4. FDA. 2014. Antiretroviral Drugs Used in the Treatment of HIV Infection. (Accessed 22 August 2015) http://www.fda.gov/ForPatients/Illness/HIVAIDS/Treatment/ucm118915.htm.

 

This post was originally posted on the Global Health, Epidemiology and Genomics blog – read more at: http://journals.cambridge.org/gheg

 

People Might Be Living Longer, But They’re Also Sicker Longer

A study researched all major diseases in 188 countries and found that while people are living longer, they are also sicker longer.

While life expectancy has increased,  because of improvements in general health and substantial developments towards curing and fighting diseases like tuberculosis and malaria, healthy life expectancy has not increased as fast.

The study was published in The Lancet journal and was headed by Theo Vos, a professor at the Institute of Health Metrics and Evaluation at the University of Washington told Reuters, “The world has made great progress in health, but now the challenge is to invest in finding more effective ways of preventing or treating the major causes of illness and disability.”

The study took into consideration chronic ailments like heart and lung diseases, diabetes, disabilities, and injuries and other detractors from quality of life. The study found that global life expectancy rose by 6.2 years, from 65.3 in 1990 to 71.5 in 2015, while healthy life expectancy only rose by 5.4 years. However, the study also found that there were a lot of difference between countries in terms of both healthy life expectancies and in rates of change.

For instance, Nicaraguans and Cambodians have seen an increase from 1990 of 14.7 and 13.9 years while Bostwana and Belize saw a decline of 1.3 years. Japan had the highest of highest life expectancy at 73.4 years while Lesotho had the world’s lowest at 42 years.

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