Abstract
BackgroundAntimicrobial resistance (AMR) is a major global public health concern and its surveillance is a fundamental tool for monitoring the development of AMR. In 1998, the Nepalese Ministry of Health (MOH) launched an Infectious Disease (ID) programme. The key components of the programme were to establish a surveillance programme for AMR and to develop awareness among physicians regarding AMR and rational drug usage in Nepal.MethodsAn AMR surveillance programme was established and implemented by the Nepalese MOH in partnership with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) from 1998 to 2003. From 2004 to 2012, the programme was integrated and maintained as a core activity of the National Public Health Laboratory (NPHL) and resulted in an increased number of participating laboratories and pathogens brought under surveillance. The main strategies were to build national capacity on isolation, identification and AMR testing of bacterial pathogens, establish laboratory networking and an External Quality Assessment (EQA) programme, promote standardised recording and reporting of results, and to ensure timely analysis and dissemination of data for advocacy and national policy adaptations. The programme was initiated by nine participating laboratories performing AMR surveillance on Vibrio cholerae, Shigella spp., Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria gonorrhoeae.ResultsThe number of participating laboratories was ultimately increased to 13 and the number of pathogens under surveillance was increased to seven (Salmonella spp. was added to the surveillance programme in 2002 and extended spectrum β-lactamase producing Escherichia coli in 2011). From 1999 to 2012, data were available on 17,103 bacterial isolates. During the AMR programme, we observed changing trends in serovars/ species for Salmonella spp., Shigella spp. and V. cholerae and changing AMR trend for all organisms. Notably, N. gonorrhoeae isolates demonstrated increasing resistance to ciprofloxacin. Additionally, the performance of the participating laboratories improved as shown by annual EQA data evaluation.ConclusionsThis Nepalese AMR programme continues and serves as a model for sustainable surveillance of AMR monitoring in resource limited settings.
Highlights
Antimicrobial resistance (AMR) is a major global public health concern and its surveillance is a fundamental tool for monitoring the development of AMR
We present our experience of implementing a sustainable national AMR surveillance programme in Nepal
The programme started with a participatory planning workshop to build the programme team and to establish a forum for stakeholders (MOH/ Government of Nepal and key organisations -United States Agency for International Development (USAID), Nepal and Washington; Rational Pharmaceutical Management Project (RPM); USCDC (United States Center for Disease Control and Prevention, Atlanta, Georgia);ICDDR, B; and World Health Organisation (WHO)/Nepal)
Summary
Local setting Nepal is a low-income country (as determined by the World bank) with a poorly organised healthcare delivery system, suffering from resource limitations. The public health care system in Nepal has a limited laboratory capacity for bacterial culture and AMR testing (available only at some regional hospitals). The programme in Nepal was implemented by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) Dhaka, Bangladesh in collaboration with Rational Pharmaceutical Management Project (RPM) Arlington, VA, USA. The programme started with a participatory planning workshop to build the programme team and to establish a forum for stakeholders (MOH/ Government of Nepal and key organisations -USAID, Nepal and Washington; RPM; USCDC (United States Center for Disease Control and Prevention, Atlanta, Georgia);ICDDR, B; and WHO/Nepal). Each participating laboratory isolated and identified selected pathogens (all consecutive isolates) and performed AMR testing (selected antimicrobial agents for each pathogen using disk diffusion method [8]) and reported data monthly to NPHL and ICDDR, B and sent the isolates to NPHL. The WHO scoring system was followed for the EQA and confidential evaluation reports were sent to the laboratories
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