South Africa’s Perspective on AMR

Marc Mendelson @southafricanaspDivision of Infectious Diseases and HIV MedicineGroote Schuur Hospital, University of Cape Town

National Actions Contribute to a Global Solution • 3rd March 2016 • 17th ICID • Hyderabad

AMR in the [South] African context

Challenge 1Health barriers (which may differ) in

each country often need to be understood and addressed before the issue of antibiotic resistance

‘has room to breathe’

Situational Analysis, 2011

S Afr Med J 2011; 8

OXA-48-likeGESNDMVIM

Slide courtesy of Adrian Brink

KPCVIM

NDMKPCOXA-48-likeVIM

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WitbankNDM

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Outbreaks involving carbapenemase resistance genes in South Africa

SAMJ 2012; 102(7): 599-601 J Clin Micro 2013; 51(1): 369-72

The scale of antibiotic abuse started to become evident

Paruk et al. SAMJ 2012; 102(7): 613-6

1 patient simultaneously received:CloxacillinTeicoplanin Metronidazole AmikacinCeftazadime MeropenemLevofloxacin ErythromycinCo-trimoxazoleFluconazole

Challenge 2Maintaining impetus after the

situational analysis.Part of any intervention must be

empowerment of the country to take responsibility and ownership of

antibiotic resistance

Mendelson et al. S Afr Med J 2012;102(7):607-8

Adult Infectious Diseases Specialists

Paediatric Infectious Diseases Specialists Microbiologists

Pharmacists

Family PractitionersAnimal Health

microbiologists & Veterinarians

Surgeons & Intensivists

Infection Control Practitioners

Challenge 3Need to decide where to start.

Few countries can focus on multiple areas in the beginning.

South Africa went for hospitals as the seat of most resistance

National AMR Working Group is formed under leadership of DG within Essential Drugs Programme

National AMR Summit, October 2014

Challenge 4: Buy-in from all st

akeholders

who need to commit

Antimicrobial Resistance National Strategy Framework 2014-2024

http://www.health.gov.za/index.php/component/phocadownload/category/199-antimicrobial-resistance

Background Framework

Antimicrobial Resistance Governance

Enhance surveillance

Antimicrobial stewardship

Prevention including IPC

and vaccination

Impact: Rational Antimicrobial use and improved patient outcomes

Education and Communication/ Public awarenessHealth Systems Strengthening, Research, Education, & Communication

Challenge 5Development has clearly benefited

from collaboration

South African Antibiotic Consumption 3 sources of data

Animal use Human use Public useSource SARS import data

2010-2015IMS data 2000-2010 Supplier order

fulfillment data (CHAI)

Measurement Tons SU/1000 population SU and DDDs

Increase Pen/Strep 1 ton/y=141% increase

175% over 10y58% if exclude trimethoprim

Analysis ongoing

Other 4.1 tons/y=11% increase

Public 360%Private 21%

Excluded Local producedSection 21

No split CA v HASection 21

No split CA v HASection 21Out of contract ABs

Staphylococcus aureus resistance to oxacillin (%MRSA)

Challenge 6Creating national uniformity. Towards equitable access to

antibiotic stewardship expertise across the country

National Training Centres for Antibiotic Stewardship

• One week courses – daily AS rounds and taught component

• Teams of 3 – Prescriber + Pharmacist + Hospital Manager

• Targeted at underserved provinces first

Groote Schuur Hospital

1. BOYLES2. Dr TOM3. 20.09.1971 United Kingdom4a. 16.10.2014 4b. National5. Expires 15.10.2016

6. Division of Infectious Diseases & HIV Medicine, Groote Schuur Hospital, Cape Town

7. Level 10 – full antimicrobial prescribing

Web-based

ANTIMICROBIAL PRESCRIBING LICENSE

22 podcasts with CPD accreditation forms the backbone of the training

https://www.openlearning.com/courses/clinical-antibiotic-stewarship-for-south-Africa

National AMR Issues in Animal Health

In-feeds (69%)

Water soluble (12%)

Eagar et al. J S Afr Vet Assoc. 2012;83(1)

Parenterals (17.5%)

Intramammaries (4%)1. Penicillins (98%)

Other dosage forms (1.5%)

Antibiotics sold for animal health in South Africa, 2002 – 2004

Increasing colistin resistance in pathogenic E. coli in South African Poultry operations

V-Tech, 11th an 2016

19/24 E. coli strains w

ith MIC ≥4 l/ml fro

m last quarte

r of 2015

contained the MCR-1 gene conferring colisti

n resistance

SA National Veterinary Surveillance and Monitoring Programme for Resistance to Antimicrobial Drugs

Governance issues

• NAPHISA will enhance health system effectiveness– Support, expertise and advice to government to achieve

improvements in health of the population• Mandated to provide– Coordinated disease and injury surveillance– Research and training– Workforce development– Monitoring and evaluation of services and interventions

directed towards major health problems affecting the population

http://www.nioh.ac.za/assets/files/NAPHISA_BILL_FOR_COMMENT_39392_gon1092.pdf

http://www.health.gov.za/index.php/component/phocadownload/category/199-antimicrobial-resistance

Communication channels for MAC-AMR

http://www.health.gov.za/index.php/component/phocadownload/category/199

Raising Health Professional and Public Awareness of AMR and

interventions

Incorporating AS and IPC into the South African Health Calendar

World TB day Hand washing

and cough etiquette

24th March

World Immunisation

Week

World health day

Theme: Food safety

World Hand Hygiene day (health care

Professionals)WHO SAVE LIVES: Clean your hands

Campaign

Flu day/we

ek

Global Hand washing day

(general public)

Infection Control Week (health care

professionals and general

public)

Pharmacy week

World Antibiotic

Awareness Week

World Patient

Safety Day

24 –30 April

7 April

5th May June

15thOct

17-23Oct

1-8Sept

16-22Nov

9thDec

Involvement of (and with) international organisations

• WHO Global Action Plan forms template for national plans

• GHSA

– 5 work packages including lead country for lab strengthening

– One of lead countries R&D/Pipeline sub-working group

• CDDEP

– Technical advisor seconded to NDoH

– Collaborative work on mapping and technical support

• PHE/Commonwealth Twinning Program

– SADC collaborative meeting planned to share experiences and resources towards aiding countries in developing national plans

South Africa as a Hub for AMR Support

• Experience and strong leadership at NDoH (HIV, TB, Malaria), WHO (ABR - DG), GHSA (5 work packages) & Twinning Programs

• National Public Health Institutes of South Africa (NAPHISA) – NHLS/NICD Surveillance

• South African Antibiotic Stewardship Programme – one health, expertise, leadership & training

• Clinical trials capability – basic science, therapeutics, diagnostics and vaccinology

Acknowledgements

National Dept of Health

•Ms Precious Matsoso (DG)

•Dr Anban Pillay (DDG)

•Gavin Steel

•Khadija Jamaloodien

•Janine Munsamy

•Kim Faure (CDDEP)

•Stephanie Berrada (SIAPS)

SAASP Co-chairs

•Adrian Brink

•Moritz van Vuuren

All of our Partners

SAASP Working Group Leaders