global_antibiotic_resistance_partnership_minutes_mozambique

Global Antibiotic Resistance Partnership Mozambique Inaugural Meeting 2-3 August, 2012

Summary The inaugural meeting of GARP-Mozambique was held on 2-3 August 2012. It brought together working group members and stakeholders for the first time. Identified priority areas for action were four-fold: antibiotic use and consumption, antibiotic quality, surveillance and infection prevention and control.

Background During 2009-2011, the Global Antibiotic Resistance Partnership (GARP) was initiated in four low- and middle- income countries – India, Kenya, South Africa and Vietnam - by the Center for Disease Dynamics, Economics & Policy (CDDEP), with a grant from the Bill & Melinda Gates Foundation (BMGF). GARP supports the creation of multi-sectoral national-level working groups whose mandate is to stimulate research and develop evidencebased proposals to encourage the introduction of measures to preserve antibiotic effectiveness, slow the spread of antibiotic resistance and improve antibiotic access where warranted.

The GARP network is growing; four additional countries will come on board during 2012 and 2013. Mozambique, the first of the “phase 2 countries” to get under way, held its inaugural meeting on 2-3 August 2012. What follows is a brief summary of this meeting1 and planned next steps.

Meeting overview A one-and-one-half-day inaugural meeting was held at the Hotel Cardoso in Maputo2. The first day provided an overview of GARP (general background and examples from other GARP countries, in particular Kenya and South Africa) and laid out the antibiotic landscape in Mozambique (data on resistance levels and trends, antibiotic regulatory framework, pharmacovigilance, infection control, etc.). Stakeholders from other organizations involved in related activities in Mozambique (World Health Organization, USAID, World Bank, AECID, DFID and Management Sciences for Health) participated in this first day of presentations3 and discussion. The working group alone met the second day to develop realistic goals for the coming two years and identify the specific activities that they would support. Subgroups were also formed to plan the work in the areas of antibiotic use and consumption, antibiotic quality, surveillance and infection prevention and control.

See complete agenda in Annex 1 See Annex 2 for participant list 3 Presentations can be found at https://sites.google.com/a/cddep.org/garp/presentations 1 2

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Working Group leadership and members The Mozambican Working Group is led by Chair Dr Betuel Sigaúque from the Centro de Investigação em Saúde de Manhiça (CISM) and co-Chair Dr Esperança Sevene from Eduardo Mondlane University. The fifteen working group members have a wide range of relevant expertise. There is some geographic diversity, with most members coming from Maputo and Manhiça and a few from elsewhere (such as Beira). Twelve members were present for the meeting.4 Dr Silvia Chicuecue, a Doctor of Veterinary Medicine by training and also based at CISM, will be the working group coordinator.

Overview of Day 1: Presentations Session 1: Opening The opening of the meeting was presided over by Fundaçao Manhiça Honorary Founder, Board of Trustees President and ex-Minister of Health of Mozambique, Dr Pascoal Mocumbi, who welcomed all participants, briefly spoke about the Mozambique experience of malaria drug resistance, relevant studies conducted within the geographic demographic surveillance area that Manhiça oversees and the importance of creating the GARPMozambique WG to increase interest in antibiotic use and resistance. Following Dr Mocumbi’s enthusiastic words of welcome, Hellen Gelband, CDDEP Associate Director, provided a brief overview of GARP experience (background, overview of phase 1 and future plans). Dr Antonio Assane, National Director of Medical Care, then formally opened the meeting on behalf of the Deputy Minister of Health, Dr Nazira Abdula. The Mozambican government commitment to the issue of antibiotic resistance was further evidenced when Dr Assane revealed that the Minister of Health, Dr. Alexandre Lourenço Jaime Manguele, had signed the New Delhi Call to Action to Preserve the Power of Antibiotics.5 Approximately seven journalists were present during this opening, from two different television networks (TVM and TOP TV), from a National Newspaper (Jornal Noticias) and from the ministry of Health’s communication team.

Session 2: Antibiotic resistance and GARP network Following a brief round of participant introductions, members from GARP-Kenya and GARP-South Africa shared their experience with specific GARP activities. Dr Sam Kariuki, chair of the GARP-Kenya working group, talked about the human and animal enteric resistance burden and trend data from Kenya. Dr Adriano Duse, chair of the GARP-South Africa working group, presented South Africa’s hospital infection prevention and control experience and future plans for surveillance strengthening. Dr Duse introduced the potential

The full list, with affiliation and areas of expertise is in Annex 2 This document has also been signed by Ministers or Deputy Ministers of Health from most other GARP countries (Kenya, South Africa and Vietnam) and Ghana. For text of the Call, see www.globalbacteria.org 4 5

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for cross-GARP country collaboration, with the longer-view term of creating a regional or Pan-African surveillance network.

Alix Beith from CDDEP talked about the Drug Resistance Index (DRI a tool that - in a single number – captures pathogen resistance levels and quantity and type of antibiotics used in a given setting (ward, health care facility, region, country). The DRI can be followed over time to monitor trends in resistance and determine how effective the bundle of antibiotics available and being used in a given setting is, and how this effectiveness is changing (if the DRI is falling, this may be the result of effective stewardship program implementation).

Session 2 concluded with a presentation by Dr Jordi Vila, from the Hospital Clinic de Barcelona-CRESIB and GARP-Mozambique international advisor, who gave a keynote speech on the ecology and epidemiology of antibiotic resistance, with a specific emphasis on European data.

Sessions 3 and 4: Antibiotic Resistance in Mozambique The next session focused on the experience of Mozambique. Dr Lucilio Williams discussed an increase in the number of informal drug shops in urban Mozambique, which sell antibiotics. He highlighted high patient demand, lack of diagnostic/counseling training of pharmacy technicians, little effective community education and poor storage conditions as problems related to these shops.

Dr Sigaúque set out the “resistance scene” in Mozambique, presenting the limited information available on resistance levels and trends by pathogens in community and hospital settings. Data representing the entire country are limited, but Manhiça systematically collects blood and cerebrospinal fluid (CSF) from admitted children (<15 years of age). This data is used for clinical management and integrated with the invasive bacterial infection surveillance, as well as the resistance of the most used antibiotics in hospital settings. Data demonstrate high-level resistance among the most frequent etiologies of bacteremia to the most commonly used antibiotics. During ensuing discussion, it was suggested that the group focus on 1) determining resistance prevalence in both hospital and rural settings and 2) identifying (as part of the situation analysis process) the main drivers of resistance in Mozambique.

Dr Felecidade Sitoe spoke about drug procurement, registration and quality control procedures. While registration norms are generally followed specially within the National Health Service, quality control is weak. The pharmaceutical department has a quality control lab that does a few tests for specific drugs. Other drugs are periodically sent to partner’s countries like Vietnam, South Africa and Portugal for testing. Dr Sitoe explained that the Ministry’s Pharmaceutical Department is currently assuming a stronger regulatory role, and is investing in the lab to improve the quality control of all drugs.

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Dr Sevene spoke about the historical background and current status of pharmacovigilance (PV) and rational use of drugs in Mozambique. The national PV network has grown considerably in recent years and now has delegates in all provinces. Reporting of adverse events is both passive and active and needs further strengthening. There seem to be few specific studies on rational use of drugs; a more thorough search will be conducted as part of the situation analysis.

Dr Chavane provided a brief overview of the EPI program, past vaccine introduction in Mozambique and future plans. PCV10 will be introduced in March 2013 and rotavirus introduction is planned for 2014. As PCV13 is likely to be introduced in 2014-2015, discussion revolved around the potential to introduce PCV13 in one zone and pilot it against PCV10. The challenge of emerging serotype replacement was also discussed.

Dr Olga Novela spoke about the MoH infection control and prevention program, which began in 2003. Using a set of checklists, infection control performance against a number of ward-specific indicators is now regularly checked in 140 health units (different level hospitals and health centers, including health posts) throughout the country. Dr Olga Perovic presented next on antibiotic resistance in populations with high rates of HIV infection. She spoke about South Africa, in particular, and elsewhere, but made the point that relatively little is known about this important group. She also spoke briefly about vaccine-preventable diseases, as well as opportunistic infections and epidemic-prone diseases.

Overview of Day 2: Discussion The Working Group used the second half-day to brainstorm about key technical areas to focus on, possible activities in each area and next steps.

Development of the draft situation analysis – SITAN – (by end November 2012) and the final situation analysis (by end March 2013) is a priority, as a good understanding of the strengths and weaknesses of the Mozambican landscape in terms of antibiotic access, use and resistance emergence and transmission is essential to developing effective recommendations. Dr Silvia Chicuecue, GARP-Mozambique coordinator, will begin gathering relevant information from WG members, other experts and elsewhere. The following was agreed: The WG will prioritize four technical areas for research and policy recommendations: 1. Antibiotic use and consumption 2. Antibiotic drug quality 3. Surveillance 4. Infection prevention and control

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The WG will also address antibiotic costs and potential savings with proposed interventions as a means to influence decision-making. There are no economists on the WG, however, and expertise in health economics in Mozambique is very limited.6 During the meeting we also discussed the possibility to strengthen the Mozambique national WG by sharing protocols with other regional countries and establishing regular conference calls with other GARP members. We also discussed the possibility to extend or involve other stakeholder or partners with a particular interest in the four technical antibiotic resistance areas prioritized by the WG.

6 The CDDEP team agreed to explore possible options to support the WG in this area. One possibility might be to conduct economic analysis from CDDEP offices in New Delhi and/or Washington DC

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