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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
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AMR in the [South] African context
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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’
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Situational Analysis, 2011
S Afr Med J 2011; 8
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OXA-48-likeGESNDMVIM
Slide courtesy of Adrian Brink
KPCVIM
NDMKPCOXA-48-likeVIM
GES
OXA-48-likeGES
GESNDMVIM
WitbankNDM
NDM
Outbreaks involving carbapenemase resistance genes in South Africa
SAMJ 2012; 102(7): 599-601 J Clin Micro 2013; 51(1): 369-72
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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
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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
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Mendelson et al. S Afr Med J 2012;102(7):607-8
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Adult Infectious Diseases Specialists
Paediatric Infectious Diseases Specialists Microbiologists
Pharmacists
Family PractitionersAnimal Health
microbiologists & Veterinarians
Surgeons & Intensivists
Infection Control Practitioners
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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
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National AMR Working Group is formed under leadership of DG within Essential Drugs Programme
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National AMR Summit, October 2014
Challenge 4: Buy-in from all st
akeholders
who need to commit
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Antimicrobial Resistance National Strategy Framework 2014-2024
http://www.health.gov.za/index.php/component/phocadownload/category/199-antimicrobial-resistance
Background Framework
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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
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Challenge 5Development has clearly benefited
from collaboration
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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
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Staphylococcus aureus resistance to oxacillin (%MRSA)
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Challenge 6Creating national uniformity. Towards equitable access to
antibiotic stewardship expertise across the country
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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
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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
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https://www.openlearning.com/courses/clinical-antibiotic-stewarship-for-south-Africa
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National AMR Issues in Animal Health
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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
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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
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SA National Veterinary Surveillance and Monitoring Programme for Resistance to Antimicrobial Drugs
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Governance issues
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• 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
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http://www.health.gov.za/index.php/component/phocadownload/category/199-antimicrobial-resistance
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Communication channels for MAC-AMR
http://www.health.gov.za/index.php/component/phocadownload/category/199
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Raising Health Professional and Public Awareness of AMR and
interventions
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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
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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
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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
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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
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SAASP Working Group Leaders