Bridging the access gap to microbiology diagnostics is a critical part of the global response to antimicrobial resistance (AMR)
Dr Jane Cunningham is a Diagnostics Advisor with Medecins Sans Frontieres (MSF)’s Access Campaign. In this blog she takes a closer look at the important role of diagnostics in tackling antimicrobial resistance (AMR), and why we in MSF are advocating for improving microbiology diagnostic capacities in the places they are most needed, to be included as a priority in the plans for a global response to AMR, currently under discussion by UN member states. Her piece complements the previous blog in this series on MSF’s priorities for the UN High-Level Meeting on AMR taking place in September 2024. In this blog, we advocate for a process that focuses on ensuring global equitable access to existing and new antimicrobial health technologies.
AMR is recognized by the World Health Organization as a major global public health threat. It is estimated to have contributed to 4.95 million deaths in 2019 alone including 1.27 million deaths directly attributable to bacterial AMR [1].
MSF bears witness to the impact of AMR on vulnerable communities globally where our operations are located. We see babies affected with neonatal sepsis, people living with HIV presenting with complex opportunistic infections, severely malnourished children and victims of conflict needing reconstructive surgery; all facing the shared medical challenges in accurate diagnosis and effective treatment caused by AMR.
Current evidence suggests the likelihood of dying from AMR is estimated to be more than 1.5 times higher for individuals in low- and middle-income countries (LMICs) compared to those in wealthier countries [1]. MSF is familiar with this health inequity as a humanitarian medical actor that implements a diverse range of medical activities in many of the most inhospitable and impoverished places on the planet.
MSF projects include a full range of activities from basic primary health care and outbreak response for marginalised communities in low-resource settings, to sophisticated trauma and reconstructive surgery in conflict zones and everything in between across more than 70 countries. We have had to adapt and innovate tools and practice to provide the highest quality of care that we can in these difficult environments.
AMR is a critical challenge in all of these settings; poor vaccination coverage, weak hygiene and sanitation practices, limited health infrastructure and human resource capacity exacerbate the risk of AMR and contribute to the disproportionate impact of AMR on people living in low- and middle-income settings. Gaps in access to quality health care — and especially the lack of capacity to precisely diagnose drug-resistant infections — make AMR difficult to discern in resource-constrained MSF project settings. What MSF teams are seeing on the ground in our projects is alarming and provides just a glimpse of a vast landscape of undetected resistance. Due to the multifactorial nature of AMR, effective diagnosis and infection prevention and control (IPC), along with clinical management across human and animal health, are all essential components of the solution.
Among the many lessons of COVID, it was very clearly demonstrated that without access to accurate diagnostic testing, our ability to control infections is minimal. It’s a lesson that should be at the forefront of our approach to tackling the global threat of AMR.
However, the comparison with COVID does not include the added complexities of dealing with AMR. In contrast to vertical disease programmes, which target a single pathogen, e.g. COVID, TB or HIV, the term AMR encompasses a wide array of different pathogens and their resistance patterns to any given antibiotic. This makes effective diagnosis and control more challenging, not least because these pathogens can also exist in the wider environment and veterinary (One Health) contexts.[3] To state it simply, effective microbiological diagnostics allow an individual pathogen to be isolated from a sample such as a blood culture, cerebrospinal fluid, urine, or stool; identified; and then tested against a panel of antibiotics that may be used to treat them.
The Lancet Commission on Diagnostics [4] highlighted that despite diagnostics being central to health care, access to diagnostics is poor and inequitable in many parts of the world, with 47% of the global population having little to no access to adequate diagnostic testing. Delivering accurate microbiology diagnostics requires technical knowledge, and despite the complementary role of some point-of-care diagnostics, the bulk of diagnostic testing is still reliant on maintaining a centralised sustainable laboratory infrastructure. The many challenges of delivering microbiology diagnostics in resource-limited contexts are further confounded in the fragile and conflict settings where MSF operates.
Global health actors have recently started to draw more attention to this complex problem and prioritise efforts to improve the quality and access to effective diagnostics. Examples include the Lancet Commission on Diagnostics [4] mentioned above, and the World Health Assembly Diagnostics Resolution in 2023.[5] The aim of both is to ensure access to safe, equitable, effective and quality-assured diagnostics through a comprehensive health-system approach that addresses all stages of delivering microbiological diagnostics. This requires an integrated approach across the value chain from the delivery of reagents and maintenance of technical platforms to ensuring adequately trained human resources.
MSF has a unique perspective on the complex implementation challenges in providing effective diagnostics in resource-limited and unstable contexts. We also have first-hand experience of where critical diagnostics and microbiological data are absent, and how that distorts policy decisions and research and development (R&D) priority setting. Addressing the need for improved access to diagnostics for AMR requires a combination of capacity building for conventional bacteriology laboratory infrastructure and technical training, alongside innovative approaches (for instance MSF’s Minilab and Antibiogo project) and advocating for continued R&D of technical solutions tailored to resource-limited contexts and challenging environments.
It is essential that any diagnostics infrastructure is integrated into both clinical and public health systems to maximise the benefit for both individual patient care and epidemiological public health needs. For example, from a patient-focused perspective, AMR diagnostic results need to be integrated into clinical pathways in an appropriate time scale to ensure results translate into changes in treatment, as well as IPC strategies alongside holistic patient care. Similarly, from a public health perspective, microbiological diagnostics need to be integrated into surveillance and alert systems to promote public-health decision making and broaden epidemiological understanding.
Addressing the weaknesses and inequities in diagnostics mentioned above will require broad multisectoral response strategies at national and international levels. Global actors have advocated for solutions including the development of costed systematic national diagnostics strategies, investment in skilled diagnostics work force, and advocating for appropriate regulatory frameworks to oversee quality and safety of diagnostics tools.
Ensuring the wider landscape supports the development and production of diagnostics relevant to LMICs is also important.[6] Opportunities here include appropriate legislative, administrative and policy measures to prevent anti-competitive pricing, and ensuring that where public resources and biobanks have contributed to innovative diagnostics solutions, this translates into equitable access for all.
The upcoming United Nations High-Level Meeting (UNHLM) on AMR in September 2024 presents a key opportunity to highlight the urgent need to support the development of diagnostic infrastructure as part of a global plan to tackle AMR. It’s an opportunity that the international community must take on board and address head on.
Our role as MSF is to ensure that the outcomes of the UNHLM reflect the needs and addresses the additional challenges posed by AMR to our vulnerable patient populations. Given the proven economic and public health impact for high-, low- and middle-income countries, there is a real need for significant improvement and collaboration in our approach to AMR globally. Strengthening diagnostic capacity is a critical part of this. While the challenges in delivering the outcomes of the previous UNHLM on AMR in 2016 have become increasingly apparent, there needs now to be a fresh and urgent commitment to ensure funded, transparent, deliverable, and accountable objectives are obtained from member states, global health actors and donors in 2024. We can’t afford to fail. The price of inaction is too high.
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References
1. Global burden of bacterial resistance in 2019: a systematic analysis. Murray et al. Lancet Vol 399, Issue 10325, 0629–655, 12 February 2022.
2. Antimicrobial resistance: tackling a crisis for the health and wealth of nations/ the review on antimicrobial resistance. O’Neill et al. 2014
3. United Nations. Bracing for super bugs: Strengthening environmental action in the One Health response to antimicrobial resistance. UN, Geneva 2023
4. The Lancet commission on diagnostics: transforming access to diagnostics. Fleming et al. The Lancet, Vol 398, No 10315. P1997–2050, 27 November 2021.
5. Resolution WHA 76.5. Strengthening Diagnostics capacity. WHA 76.5. In 76th World Health Assembly, Geneva, 30 May 2023.
6. Landscape of diagnostics against antibacterial resistance gaps and priorities. WHO, 20 August 2019.
