Antimicrobial Resistance in Low and Middle Income Countries. An Analysis of Surveillance Networks. Report 2017.

Executive Summary

The burden of drug-resistant infections is increasing year on year. The largest numbers of lives that will
be lost as a result are predicted to be in low- and middle-income countries (LMICs)[1]. As well as
shouldering the bulk of the global burden of infectious diseases and drug resistance, surveillance
systems in LMICs tend to be weaker, mainly because passive surveillance cannot be integrated into
routine case-management of patients in most areas as health systems are too weak. This problem has
been circumvented in HIV, tuberculosis (TB) and malaria by designing vertical global surveillance
programmes which gather data intermittently to provide a snapshot of the situation. Even with this
approach results have been patchy. It is estimated that ~75% of the world’s multidrug resistant TB
(MDR-TB) cases go undiagnosed and only one third of malaria endemic countries were in compliance
with the recommended targets for antimalarial drug efficacy surveillance when last reported [2, 3].
Attempts to kick start global surveillance for resistance to commonly used antibacterial drugs have been
made in the past but generally without success [4-6]. The recent catastrophic Ebola epidemic in West
Africa has brought the need for surveillance for emerging diseases, in particular those caused by
zoonotic pathogens, into sharp focus as experience has shown the majority of these have their origins in
LMICs. This argues for adopting a ‘One Health’ approach to surveillance, taking into account disease
transmission dynamics between humans, animals and the environment.

As well as having weaker systems of surveillance for antimicrobial resistance (AMR) LMICs have fewer
resources to tackle the problem. The medical and veterinary workforces are smaller and less diversified
than in high income countries (HICs) and there is less regulation of antimicrobial drugs which are more
likely to be substandard, falsified or unregistered/unlicensed [7]. In the agricultural and farming sectors
there has been an increase in intensive production systems for pig and poultry in middle-income
countries in response to increased demand for meat accompanying economic growth [8]. These systems
are associated with substantial antimicrobial use.

Awareness of AMR and its impact is increasing globally but there is still a long way to go to change
ingrained behaviours and attitudes to antibiotic use and infection prevention to bring about the desired
impact to slow the spread of AMR. Availability of antimicrobials over-the-counter without prescription is
a likely driver for the spread of AMR in many LMICs but at the same time, large swathes of the
community, particularly in rural and semirural areas, lack access to antimicrobial drugs and healthcare.
This contributes to millions of avoidable deaths, such as the 0.6 million neonates who are estimated to
die from sepsis each year [9].

In recognition of the growing threat to health posed by drug-resistant infections, the Fleming Fund was
launched in March 2015 with the aim of strengthening surveillance and response capacity in LMICs. The
fund is a collaborative effort of the UK Government, the Wellcome Trust, the Bill and Melinda Gates
Foundation, the Institut Pasteur International Network and other partners. This report is the output of
one piece of scoping work to inform future Fleming activities.

The objective of this scoping work was to identify networks dealing with surveillance, monitoring and
analysis of resistance in low and middle income countries, including networks supporting quality
assurance, which currently exist or have existed over the last fifteen years and to suggest factors which
are important to achieving impact, success and sustainability.