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  1. The National Antimicrobial Resistance Monitoring System

NARMS International Activities - Comments 2

by Tom Chiller, M.D., M.P.H.

DR. CHILLER: Thanks, Pat. Thanks. And I am just going to talk for about three or four minutes. And building on what Pat talked about we, obviously, at CDC do a lot of work with WHO Global Salm-Surv and, I think, have enjoyed tremendous success internationally. And have learned a lot and have partnered with a lot of people.

One of the things Global Salm-Surv does is it introduces you to many people at these training courses that are working in these diseases, working in surveillance, from all these different disciplines, as Pat mentioned. You learn things about them, you learn some of their needs, and you also get -- as with any training course, there is some people that sort of rise to the top because of their enthusiasm. Potentially, their financial support.

And those people, many times we end up partnering with further because they are very enthused and they might have to find local resources to do something else. And we are clearly trying to help these groups where we can in our own busy schedules move forward in different arenas.

And one of those arenas has, obviously, been in antimicrobial resistance surveillance. And so what I am going to talk about is the concept that we have been throwing around now for about a year and a half. And that is to form some sort of international collaborative working group. I don’t want to call it a network, we have too many networks in the world of health right now. So I look at it more as an international collaboration of people working in antimicrobial resistance surveillance; specifically, for enteric bacteria.

Because as we have all been hearing about yesterday, there are some very unique issues to enteric bacteria that are quite different from pneumococci and meningococci, and other things that we do look for resistance in in human health.


I just want to say the international work, just to make two points -- you guys have all heard these points before but, obviously, diseases have no national borders, as we all know. And that is a big, big reason that we are involved in emerging diseases and why we at the CEC are all over the world working on understanding how diseases emerge. And, of course, within that is how antimicrobial resistance emerges and disseminates around the world.

And in food safety, which we are all involved in by default now, is working with enteric pathogens -- I mean, that is a huge international issue and huge trade issue. And there is more and more support worldwide for doing good surveillance as a cornerstone and key to any food safety program. Even the Food and Agricultural Organization, FAO, has put as one of their core principles foodborne disease surveillance.

And so WHO Global Salm-Surv, we are approaching them and, hopefully, we will be working more with FAO to help build capacity for this foodborne disease surveillance around the world.


This is the map that Pat just showed, and I just re-show it to say that you can see that we are working all over the place. And, again, because of these various training courses, we have been able to meet partners and find people that are very enthused to move forward with their resistance surveillance work and foodborne disease surveillance work.


One of the things that has happened as a result of Global Salm-Surv is the formation of an international collaboration of burden of illness studies. As you know, FoodNet -- well, you don’t know -- but FoodNet, essentially, is done to try to understand the burden of illness because it is able to calculate a distinct number of disease within a distinct population. You have numerator and denominator data.

And then you are able to go out and survey the population, survey the hospitals and clinics and understand that pyramid of surveillance that I showed you. Understand what the different steps are and so you are able to calculate a burden of disease, using these sort of principles we have been able to estimate.

You know, there is one point -- you all heard the number, 76 million foodborne disease. All that kind of stuff. That is all based on estimations by building this pyramid. Well, other groups around the world and WHO has been pushing to understand the burden of foodborne diseases in parts of the world. Or, the ideal would be all over the world but that is, obviously, very difficult with 300 and some countries.

So building out of Global Salm-Surv training and the contacts we made, we formed a group called the International Collaboration of Burden of Illness Studies. Which is, essentially, a working group and there are now over 30 countries that are represented that are interested in conducting studies. This group has quarterly conference calls where you will get upwards of 30 countries represented.

They discuss protocols for doing these studies, they discuss results of studies, and discuss ways in which to analyze the studies and problems. They, actually, have had an annual meeting now for the second time. It happened this year in collaboration with the Enternet meeting -- and I will talk about Enternet in a second. Enternet is a European collaborative surveillance effort for foodborne diseases. And then they have even had some site visits to countries that want to start burden of illness studies, so have been able to provide support.

So this network, or this collaborative group, has been able to get together and talk and find a country that wants to do something. And they have been able to find people nearby that have experience in conducting these studies to actually go over and support the country that wants to begin one.


So in a similar sort of parallel fashion, we have been thinking about this idea for antimicrobial resistance. And we have done -- and Pat and Paula will point out the collaborative work with Mexico that they have been heavily involved in -- we have not -- but we have been involved in a lot of other places, and I am just listing a bunch here just to give you some ideas about the different things that we are involved in.

There is a lot of resistant Salmonella and Shigella out there, and we are involved in a lot of different country-specific projects to try to understand the movement of that Salmonella; both in the country and to our country, and to other countries for quinolone resistant Salmonella in the Phillippines. We have our share here now. Fiji, that we just heard of naladixic acid resistant Typhi. Nalidixic acid resistant Typhi is also not responsive clinically to Cipro, so that is a problem. It hasn’t been reported in the Pacific yet, but it looks like it is there.

Argentina has been very instrumental in a antimicrobial resistance network within the southern cone and within South America. We are very involved with them. Peru sent me a proposal two weeks ago to actually start their own NARMS. That sort of was out of the blue, and through discussions we have been having for the last couple of years, so that is sort of interesting.

I haven’t had a chance to read it yet, but there is, obviously, movement down there in South America. Similarly, Paraguay is trying to do something with PAHO on a pilot project to look at agricultural use of antibiotics.

We do a lot of work in Kenya. There is a lot of MDR Salmonella and Shigella there. Australia, we have worked with colleagues there and they, actually, have just found that their campylobacter, which is not resistant to floro-quinolones, but it looks like there is a budding resistance to macrolites. It is very interesting.

Bangladesh, incredibly resistant Shigella. Enternet, as we know, that is the European system that Pat mentioned that we work with. This represents all EU countries, so it used to be 17, now it is something like 27, 28. They meet once a year, but they also have a very good collaboration throughout the year in outbreaks of Salmonella and E. coli, and they are expanding to other enteric pathogens.

And then I just threw out Denmark as an example, the DANMAP Report, which we all sort of look at as one of the pinnacles of integrated reporting. We, obviously, worked with them and asked the questions about how they are doing and doing things and reporting on things.


So, some of the issues on the table for this international collaborative group would be to talk about emerging bacteria. I just showed a whole bunch of those. We all know those are emerging and resistance is emerging. And it would be nice to know about what other people are seeing.

Testing methods. I mean we, obviously, debate a lot about our own testing methods, but they need support and they have interesting testing methods that they are using. And to ultimately compare our data with Fiji, we need to understand how they are testing their bacteria for resistance. So being able to talk about that, maybe harmonize some methods to a certain extent, or understand what the world is doing will help us compare data.

And then issues of reporting which we have -- again, these are all issues that NARMS is tackling right now, but resistant versus non-susceptible. What is the rest of the world doing, or what are other groups that are involved in this doing? How do you define multi-drug resistance? There has been a lot of debate on that in enteric bacteria. We have some good definitions for it in some of the other bacteria, but in enteric bacteria, how do we define it, by drug, by class?

And then statistical issues, you know, do we put confidence intervals around things, do we not? How are other groups doing that? These are some really, really interesting issues that would be, I think, perfectly vetted in an international collaborative group that is specifically working in these areas. So these are some of the things that we would like to put on the table and to talk about at this group.


So, in putting together this collaborative effort, we have taken some first-steps. We introduced the concept at an Enternet meeting last year in June. We continued discussions this year in June about the format of this group at the Enternet meeting that happened this year. We plan on presenting and talking about forming it, and coming up with some plan at the Antimicrobial Resistance/Global Salm-Survmeeting that is going to be happening in Canada in September that Rebecca Erwin and Lei King are hosting.

And then, I said network, I should have said working group here, but the concept of actually launching this thing would happen in collaboration, or in conjunction, with the ICEID meeting at CDC in Atlanta in March of 2006. So that is sort of right now the proposed plan for how we are planning on moving forward.


Again, the format would be very similar to the International Collaboration of Burden of Illness -- at least we envision it -- in that it is a loosely affiliated group that meets quarterly on the phone, as many people that want to, that has an agenda that discusses some issues for an hour, an hour and a half, and that informs collaborative efforts outside of that, which we have all been doing. And then, potentially, could try to meet face-to-face once every other year, or something like that.

Again, the group would need to define how formal it wants to get. But there is just so many issues that we want to discuss and talk about, and there has been a strong sort of grassroots movement to get this group together that we are excited to try to make it happen.

And then now, I guess I will turn it over to Shaohua to talk a little bit about PulseNet.

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