Towards national systems for continuous surveillance of antimicrobial resistance: Lessons from tuberculosis

Drug resistance to microbes, including bacteria, viruses, fungi, and parasites, has reduced the treatment options for newly diagnosed infections [1]. The World Health Organization (WHO) recommends a core set of actions to control AMR, including surveillance to continuously monitor trends in AMR [2–4]. Surveillance is essential to (1) understand the prevalence and susceptibility patterns to inform national treatment guidelines, (2) understand individual-level transmission risk factors to reengineer health systems and community-based approaches, and (3) characterize population-level transmission networks to reduce emergence and spread of resistant organisms. To date, periodic surveys and studies have been widely used to generate these vital data.

Standardized AMR tools can help low- and middle-income countries ascertain biases in different surveillance approaches and guide them to an appropriate selection based on their pathogen(s) of interest, objectives, and context. This guidance is available for TB. On the other hand, not all surveillance approaches have been fully described for HIV, malaria, and priority bacterial pathogens. DST in clinical care also plays a key role in system development, as routinely generated genotyping data can be leveraged for national systems for continuous surveillance when DST is clinically indicated. In addition to potentially informing national decisions, continuous surveillance has increased geographical granularity. McIntosh and colleagues were able to detect a resistance outbreak in a district and characterize districts with higher resistance due to poor health system access or higher migration of drug-resistant bacteria [5]. This novel use of spatial analysis helps local programs “see” where AMR resistance is accumulating and monitor trends over time, providing a potentially powerful tool to guide control and prevention efforts. This use of AMR surveillance data may need further encouragement and promotion. Moreover, routinely generated genotyping data have been used to characterize sources of transmission and guide prevention efforts. Having these data available as an early warning could allow swift action and mitigate perpetuation of AMR strains. Therefore, regardless of whether a final policy decision is taken based on continuously generated data, more countries may find it worthwhile to explore the use of continuous AMR surveillance as part of national strategies to contain AMR.