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Surveillance of Antimicrobial Resistance in India: from research capacity building to policy Child Health Research Project...
Background   <ul><li>3-5 million people die annually due to ARI worldwide. </li></ul><ul><li>Most of them are children fro...
INCREASING PREVALENCE OF ANTIMICROBIAL RESISTANT MICROBES <ul><li>Community-acquired infections </li></ul><ul><ul><li>Mult...
INCREASING PREVALENCE OF ANTIMICROBIAL RESISTANT MICROBES <ul><li>Hospital-acquired infections </li></ul><ul><ul><li>Methi...
Outline <ul><li>Invasive Bacterial Infections Surveillance (IBIS) in India </li></ul><ul><li>Other CHR activities on antim...
IndiaCLEN AMR Studies
IndiaCLEN IBIS Objectives <ul><li>To describe the epidemiology of invasive  S.pneumo- </li></ul><ul><li>niae  and  H. infl...
IndiaCLEN IBIS Study Team  1993-2002 <ul><li>Coordinators:  Dr.Kurien Thomas, Dr.M.K.Lalitha & </li></ul><ul><li>Dr. Mark ...
IndiaCLEN IBIS & CAMR  Study Sites Chennai Delhi Vellor e Lucknow Nagpur Thiruvananthapuram  Mumbai CChennaihennai Chennai
INCLUSION CRITERIA IBIS <ul><li>IBIS Phase I, 1993 - 1997 </li></ul><ul><li>All children fulfilling the WHO criteria for p...
Phase I & II  No.  recruited Phase I 1993 - 1998 5,798 Phase II 2000-Aug 01 Total 1,458 7,256* No. of  S. pneu- mo  isolat...
IBIS Phase II Update Meningitis & Lobar Pneumonia Cases 41 8 8 6 7 5 7 # QC tests 183 29 101 9 8 11 25 #  S. pneumo 72 26 ...
AMR  S.pneumoniae Time Trends
Newer AMR Studies <ul><li>Questions: </li></ul><ul><li>Do hospital AMR patterns reflect community AMR patterns? </li></ul>...
IBIS Phase II Update  (2000 – Aug. 2001) Nasopharyngeal swabs from children without respiratory illnesses presenting at OP...
Community AMR Study Group  2000-2001 <ul><li>Coordinators:   Dr.M.K.Lalitha, Dr.Kurien Thomas </li></ul><ul><li>& Dr. Mark...
CAMR Study Design <ul><li>2-year community-based study involving AMR surveillance through nasopharyngeal colonizing strain...
CAMR Update  (Aug. 28, 2000 – Sept. 31, 2001) Center Delhi Lucknow Nagpur Trivan- drum Vellore Total # tested 851  900  55...
Comparison of AMR Patterns: Invasive  S. pneumo  vs. IBIS NP & CAMR data   (Thomas K & IBIS, 2002) IBIS p = 0.32 CAMR p = ...
Comparison of AMR Patterns: Invasive  H. influenzae  vs. IBIS NP & CAMR data   (Thomas K & IBIS, 2002) IBIS p = 0.06 CAMR ...
Serotype/serogroup distributions Invasive  S. pneumo  vs. CAMR isolates Serotype/group  IBIS Invasive  CAMR Isolates (n = ...
Conclusions <ul><li>Pneumococcal resistance to penicillin is currently low in the Indian subcontinent. </li></ul><ul><li>E...
Policy <ul><li>We need to take steps to reduce the problem of emerging penicillin resistance. </li></ul><ul><ul><ul><li>De...
Other CHR Activities  Related to AMR
Expansion of AMR Surveillance <ul><li>IndiaCLEN surveillance of MDR-TB </li></ul><ul><li>IndiaCLEN IBIS is part of the Asi...
Clinical Studies <ul><li>PCN-resistant  S. pneumo  in severe pneumonia in children:  in vitro – in vivo  relationships (L....
Prescriber education and feedback <ul><li>Implementation of standard treatment guidelines for ARI through various methods ...
Economic Aspects of AMR <ul><li>WHO-Global Forum on HR collaboration: “Interventions against antimicrobial resistance: a r...
From Research Capacity Building to Policy
The case of IndiaCLEN IBIS <ul><li>Long and short courses on research design, measurement and evaluation </li></ul><ul><li...
The Case of IndiaCLEN IBIS <ul><li>Generation of important scientific information. </li></ul><ul><li>Strengthening of the ...
The case of IndiaCLEN IBIS <ul><li>Establishment and improvement of Institutional Review Board </li></ul><ul><li>Promotion...
The case of IndiaCLEN IBIS <ul><li>Regular discussions and contacts with Ministry of Health & state officials on results a...
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Antimicro

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Antimicro

  1. 1. Surveillance of Antimicrobial Resistance in India: from research capacity building to policy Child Health Research Project Coordination Meeting January 2002
  2. 2. Background <ul><li>3-5 million people die annually due to ARI worldwide. </li></ul><ul><li>Most of them are children from the developing world. </li></ul><ul><li>Most common etiological agents involved with ARI S.pneumoniae and H.influenzae (~60%). </li></ul>
  3. 3. INCREASING PREVALENCE OF ANTIMICROBIAL RESISTANT MICROBES <ul><li>Community-acquired infections </li></ul><ul><ul><li>Multidrug resistant pneumococci </li></ul></ul><ul><ul><li>Drug-resistant H. influenzae </li></ul></ul><ul><ul><li>FQ- and ESC-resistant Salmonella </li></ul></ul><ul><ul><li>Multidrug resistant Shigella </li></ul></ul><ul><ul><li>FQ-resistant gonococci </li></ul></ul><ul><ul><li>Multidrug-resistant M. tuberculosis </li></ul></ul><ul><ul><li>Drug-resistant malaria </li></ul></ul><ul><ul><li>Drug-resistant HIV </li></ul></ul>
  4. 4. INCREASING PREVALENCE OF ANTIMICROBIAL RESISTANT MICROBES <ul><li>Hospital-acquired infections </li></ul><ul><ul><li>Methicillin-resistant staphylococci </li></ul></ul><ul><ul><li>Vancomycin-resistant staphylococci </li></ul></ul><ul><ul><li>Vancomycin-resistant enterococci </li></ul></ul><ul><ul><li>ESC-resistant Gram-negative bacteria </li></ul></ul><ul><ul><li>Azole-resistant Candida </li></ul></ul>
  5. 5. Outline <ul><li>Invasive Bacterial Infections Surveillance (IBIS) in India </li></ul><ul><li>Other CHR activities on antimicrobial resistance surveillance (AMR) </li></ul><ul><li>Integrating capacity building and policy recommendations into CHR’s research portfolio </li></ul>
  6. 6. IndiaCLEN AMR Studies
  7. 7. IndiaCLEN IBIS Objectives <ul><li>To describe the epidemiology of invasive S.pneumo- </li></ul><ul><li>niae and H. influenzae disease in India, specifically: </li></ul><ul><ul><li>- Antimicrobial resistance patterns </li></ul></ul><ul><ul><li>- Serotype distribution </li></ul></ul><ul><li>To identify alternative strategies for long-term surveil- </li></ul><ul><li>lance: to compare hospital surveillance on invasive </li></ul><ul><li>isolates to nasopharyngeal swabs from: </li></ul><ul><ul><li>- Community-based surveillance data </li></ul></ul><ul><ul><li>- OPD pediatric cases with afebrile illnesses </li></ul></ul><ul><li>Bank of isolates for future genotyping (in relation to </li></ul><ul><li>future vaccine strategies) </li></ul>
  8. 8. IndiaCLEN IBIS Study Team 1993-2002 <ul><li>Coordinators: Dr.Kurien Thomas, Dr.M.K.Lalitha & </li></ul><ul><li>Dr. Mark Steinhoff </li></ul><ul><li>Co-investigators: </li></ul><ul><li>Dr.N.K.Arora, Dr.Bimal Das (New Delhi) </li></ul><ul><li>Dr.Shally Awasthi, Dr. Amita Jain (Lucknow) </li></ul><ul><li>Dr.Madhuri Kulkarni, Dr. Meenakshi Madhur (Mumbai) </li></ul><ul><li>Dr.Niswade, Dr.A.A.Pathak (Nagpur) </li></ul><ul><li>Dr.Thomas Cherian, Dr.L.Jeyaseelan (Vellore) </li></ul><ul><li>Dr.M.Narendranathan, Dr.Indira Kumari, Dr.Kavita Raja (Trivandrum) </li></ul>
  9. 9. IndiaCLEN IBIS & CAMR Study Sites Chennai Delhi Vellor e Lucknow Nagpur Thiruvananthapuram  Mumbai CChennaihennai Chennai
  10. 10. INCLUSION CRITERIA IBIS <ul><li>IBIS Phase I, 1993 - 1997 </li></ul><ul><li>All children fulfilling the WHO criteria for pneumonia </li></ul><ul><li>X-ray evidence of pneumonia </li></ul><ul><li>Children suspected of pyogenic meningitis and undergoing LP showing polymorph leukocytosis. </li></ul><ul><li>Fever in children with malnutrition </li></ul><ul><li>Short duration fever </li></ul><ul><li>Subjects with laboratory isolation of S. pneumo or H. infl. </li></ul><ul><li>IBIS Extension Phase II, 1998 - 2002 </li></ul><ul><li>All subjects with suspected pyogenic meningitis </li></ul><ul><li>X-ray evidence of lobar pneumonia </li></ul><ul><li>Subjects with suspected septicemia with hypotension </li></ul><ul><li>Subjects with laboratory isolation of S. pneumo or H.influenzae </li></ul>
  11. 11. Phase I & II No. recruited Phase I 1993 - 1998 5,798 Phase II 2000-Aug 01 Total 1,458 7,256* No. of S. pneu- mo isolates 307 183 490 * 58% < 2 y.o.; 92% children
  12. 12. IBIS Phase II Update Meningitis & Lobar Pneumonia Cases 41 8 8 6 7 5 7 # QC tests 183 29 101 9 8 11 25 # S. pneumo 72 26 26 1 16 2 1 # H. influenz. 308 3 152 38 9 0 106 # other fluids 1,117 355 168 102 199 196 97 # CSF samples 1,458 385 398 141 209 196 129 # re-cruited TOTAL Trivan-drum Vellore Nag-pur Mum-bai Luck-now Delhi
  13. 13. AMR S.pneumoniae Time Trends
  14. 14. Newer AMR Studies <ul><li>Questions: </li></ul><ul><li>Do hospital AMR patterns reflect community AMR patterns? </li></ul><ul><li>Are there alternative strategies for long-term AMR surveillance? </li></ul>Studies to address these questions: - Phase II IBIS: afebrile children in OPD - CAMR: school children
  15. 15. IBIS Phase II Update (2000 – Aug. 2001) Nasopharyngeal swabs from children without respiratory illnesses presenting at OPD 159 (20%) 32 45 0 5 48 29 # S. pneumo 106 (13.4%) 38 16 0 6 31 15 # H. influenz. 793 100 164 3 140 166 220 # of NP swabs TOTAL Trivan-drum Vellore Nag-pur Mum-bai Luck-now Delhi
  16. 16. Community AMR Study Group 2000-2001 <ul><li>Coordinators: Dr.M.K.Lalitha, Dr.Kurien Thomas </li></ul><ul><li>& Dr. Mark Steinhoff </li></ul><ul><li>Co-investigators: </li></ul><ul><li>Dr.N.K.Arora, Dr.Bimal Das (New Delhi) </li></ul><ul><li>Dr.Shally Awasthi, Dr. Amita Jain (Lucknow) </li></ul><ul><li>Dr. Dipty Jain, Dr Fule (Nagpur) </li></ul><ul><li>Dr.Indira Kumari, Dr Ramani Bai (Trivandrum) </li></ul>
  17. 17. CAMR Study Design <ul><li>2-year community-based study involving AMR surveillance through nasopharyngeal colonizing strains of S. pneumoniae and H. influenzae </li></ul><ul><li>A total of 1,200 children per center per year </li></ul><ul><li>Cross-sectional surveys carried out at intervals of 3 months </li></ul><ul><li>August 2000 – July 2002 </li></ul>
  18. 18. CAMR Update (Aug. 28, 2000 – Sept. 31, 2001) Center Delhi Lucknow Nagpur Trivan- drum Vellore Total # tested 851 900 550 472 1,220 3,993 # S. pneumo 211 157 117 83 352 920 # H. infl. 94 54 51 64 47 310 # + both 181 26 26 107 285 625 Colonization rates (%) 57.1 31.6 35.3 53.8 56.1 48.3
  19. 19. Comparison of AMR Patterns: Invasive S. pneumo vs. IBIS NP & CAMR data (Thomas K & IBIS, 2002) IBIS p = 0.32 CAMR p = 0.08 IBIS p = 0.07 CAMR p = 0.001 IBIS p = 0.3 CAMR p = 0.005 IBIS p = 0.2 CAMR = 0.001 IBIS p = 0.9 CAMR p = 0.3 94 91 97 47 32 32 93 95 97 98 100 100 99 100 100
  20. 20. Comparison of AMR Patterns: Invasive H. influenzae vs. IBIS NP & CAMR data (Thomas K & IBIS, 2002) IBIS p = 0.06 CAMR p = 0.001 IBIS p = 0.3 CAMR p = 0.2 IBIS p = 0.001 CAMR p = 0.001 IBIS p = 0.04 CAMR p = 0.001 IBIS p = 1.0 72 87 93 45 46 57 53 87 86 80 65 36 100 100
  21. 21. Serotype/serogroup distributions Invasive S. pneumo vs. CAMR isolates Serotype/group IBIS Invasive CAMR Isolates (n = 407) (n = 1,064) 1 24.6% - 6 10.8% 7.3% 19 6.3% 10.2% 7 5.2% - 5 4.2% - 14 3.7% - 4 2.9% 2.9% 18 2.9% - 3 1.5% 4.0%
  22. 22. Conclusions <ul><li>Pneumococcal resistance to penicillin is currently low in the Indian subcontinent. </li></ul><ul><li>Emerging penicillin resistance is a cause for concern and needs attention (0%-6% in last 7 Years) </li></ul><ul><li>Both H.influenzae and S.pneumoniae show high levels of resistance to co-trimoxazole which is the drug currently recommended by the ARI program. </li></ul><ul><li>Currently available 9- or 11- Valent vaccines provide ~70% coverage for the under 5 year age group </li></ul><ul><li>Nasopharyngeal swabs have potential as alternative strategy for AMR surveillance </li></ul>
  23. 23. Policy <ul><li>We need to take steps to reduce the problem of emerging penicillin resistance. </li></ul><ul><ul><ul><li>Development guidelines in use of antibiotics by the health profession. </li></ul></ul></ul><ul><ul><ul><li>Control of drug availability including veterinary use </li></ul></ul></ul><ul><li>There is need to systematically continue monitoring antimicrobial resistance. </li></ul><ul><ul><ul><li>to evaluate interventional policies </li></ul></ul></ul><ul><ul><ul><li>to guide rational treatment in individuals </li></ul></ul></ul><ul><li>The cost-effectiveness of introducing pneumo vaccine as part of EPI program in children and in the high risk population should be evaluated in India. </li></ul>
  24. 24. Other CHR Activities Related to AMR
  25. 25. Expansion of AMR Surveillance <ul><li>IndiaCLEN surveillance of MDR-TB </li></ul><ul><li>IndiaCLEN IBIS is part of the Asian Network for Surveillance of Resistant Pathogens (ANSORP) study group with the work on S.pneumoniae and H.influenzae </li></ul><ul><li>IndiaCLEN IBIS has initiated regional collaboration in South Asia with ICDDR,B on antimicrobial resistance </li></ul>
  26. 26. Clinical Studies <ul><li>PCN-resistant S. pneumo in severe pneumonia in children: in vitro – in vivo relationships (L. America-WHO) </li></ul><ul><li>Using clinical treatment failures to monitor AMR (Pakistan-WHO) </li></ul><ul><li>Efficacy of various antibiotic options (drugs, duration) for pneumonia and bacterial meningitis (WHO, IndiaCLEN/ISCAP) </li></ul><ul><li>Improvement of diagnosis and treatment guidelines for ARI (WHO, INCLEN) </li></ul>
  27. 27. Prescriber education and feedback <ul><li>Implementation of standard treatment guidelines for ARI through various methods of dissemination (Vietnam, Indonesia-ARCH) </li></ul><ul><li>Education of private physicians, drugstore clerks, paramedics (Philippines, Nepal-ARCH) </li></ul>
  28. 28. Economic Aspects of AMR <ul><li>WHO-Global Forum on HR collaboration: “Interventions against antimicrobial resistance: a review of the literature and exploration of modelling cost-effectiveness”, RD Smith et al. 2002 </li></ul><ul><li>Educational interventions that include cost considerations in decision-making and treatment (ARCH) </li></ul>
  29. 29. From Research Capacity Building to Policy
  30. 30. The case of IndiaCLEN IBIS <ul><li>Long and short courses on research design, measurement and evaluation </li></ul><ul><li>Long-term collaboration with U.S. investigators—technical (esp. laboratory techniques and QC), procurement of supplies, analysis and writing </li></ul><ul><li>“ Learning by doing”—research management, continuous quality improvement (epidemiology, laboratory, multicenter data management) </li></ul>
  31. 31. The Case of IndiaCLEN IBIS <ul><li>Generation of important scientific information. </li></ul><ul><li>Strengthening of the Network for research </li></ul><ul><li>Infrastructure development for continuing long-term AMR surveillance in the country. </li></ul><ul><ul><ul><li>Laboratory strengthening. </li></ul></ul></ul><ul><ul><ul><li>Reference center development </li></ul></ul></ul><ul><ul><ul><li>Data management and quality control </li></ul></ul></ul>
  32. 32. The case of IndiaCLEN IBIS <ul><li>Establishment and improvement of Institutional Review Board </li></ul><ul><li>Promotion of partnerships and linkages (USAID CHR partners, ANSORP, GAVI) </li></ul><ul><li>Discussions with Indian Council on Medical Research for sustained support for AMR surveillance </li></ul><ul><li>The birth of INCLEN ChildNET </li></ul>
  33. 33. The case of IndiaCLEN IBIS <ul><li>Regular discussions and contacts with Ministry of Health & state officials on results and implications of research findings </li></ul><ul><ul><li>Treatment guidelines for ARI </li></ul></ul><ul><ul><li>Disease surveillance in India </li></ul></ul><ul><ul><li>Vaccination strategies </li></ul></ul>

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