Rogier van Doorn: Antimicrobial resistance in Vietnam

My name is Rogier van Doorn. I'm a clinical microbiologist, I worked at OUCRU for 16 years, now director of the OUCRU Hanoi unit. We lead a program with about 50 people doing research on antimicrobial resistance.

The logical consequence of the wide availability of antibiotics is that there is a lot of resistance among bacteria, because if you keep exposing them, they become resistant slowly. We suspect that more than 1.2 million people die every year from the consequences of antibiotic resistance, and perhaps even 5 million if you take the indirect effects into account as well. That is higher than most diseases that we deem relevant like cancer or other big infectious diseases.

We started our research programme on AMR in 2009 with a situation analysis on AMR in hospitals, taking data from their laboratories and their pharmacies to quantify the extent of resistance and use of antibiotics in the hospitals. From there we realized that the lion share of antibiotics was actually used in the community because of the availability of antibiotics over the counter. We wanted to have a focus on work in the community as well. One of our principal investigators, Dr Sonia Lewycka, set up a program where she does exactly that. She has done a number of intervention trials where she makes a rapid test that can tell a doctor, or a nurse, or any other prescriber whether a patient really needs antibiotics or not, because normally a patient will come with an infection, perhaps, and doctors have no way to see whether it's an infection that requires antibiotics. With this test they can, so that means if that test is negative you don't have to give antibiotics. She showed in two trials that when you do that, antibiotic use actually goes down. Because most antibiotics are used there, that's really important. One of the tools to target antimicrobial resistance, also from the WHO Global Action Plan, is a strategy called antimicrobial stewardship, which basically is a set of guidelines and tools that you can implement in a hospital for doctors, nurses, pharmacists to prescribe antibiotics more wisely, more appropriately. Dr Vu Thi Lan Huong who's also one of our Principal Investigators is leading a program on that in OUCRU Hanoi.

ACORN is a surveillance project that I am running together with Paul Turner who works in Cambodia. When we look at surveillance data that is currently available, most of it is based on the bacteria whereas, if we think of AMR as a problem that needs to be solved, we think about humans and patients. What we try to do in ACORN is combine the data that we have from bacteria with some information about the patient so that you can not only see of all bacteria which ones are resistant, but you can also see how that works for different patients’ groups. If you know that, you can generate information that is much more useful for doctors immediately, when they are treating their patients, if you have those data sets combined. We have done a pilot in three countries in Southeast Asia that showed that it was feasible and that our assumptions that the data was more useful were correct, and now we're running it in nine countries across Africa and Asia. We have about 35,000 patients enrolled and we've got a couple more months to do, and then we'll look at the data again to see if our assumptions are still correct, but also to look at which of the data we are collecting are the most important, so that we can hopefully make it even more simple than it is now and roll it out further.

A lot of the work that we've been doing actually started by working directly with the Ministry of Health by gathering information that became the situation analysis for Vietnam that informed the National Action Plan. We've been receiving funds from the UK government, the Fleming funds to establish a surveillance network and a reference lab. They have both become nationalised, so they are now the national surveillance network and a national reference laboratory. We try to involve the Ministry of Health in a lot of the work that we do, in our community research programme and also in our antimicrobial stewardship research programme. We have direct involvement of people from the Ministry of Health or the Department of Health. We convene meetings with them, so we make sure that there is a continuous dialogue between what we do and what they need, to ensure impact of our work.

The WHO has recently issued a 600-page book with treatment protocols for most common infectious diseases, and also with a classification system for antibiotics called AWaRe: Access Watch and Reserve. A 600-page book is great, but you also need to be able to see if it works. So, we are part of a consortium that's going to try and implement a few of the protocols of that book in five countries in Africa and Asia, to see if people use those protocols to treat patients, whether that actually leads to better, more appropriate use of antibiotics according to that classification and better health outcomes.

This interview was recorded in January 2024.