Fighting anti-microbial resistance – through education

As world leaders made a commitment in the UN this September to tackle the root causes of antimicrobial resistance, a health project in China was already underway to do just that.

It was only the fourth time in the UN’s history that the General Assembly had taken up a health issue in this way, signalling the fundamental threat that anti-microbial resistance (AMR) is seen to pose for human health, development and security.

But long before this new commitment by governments, health research projects have been finding ways to make a difference. Among them is the Communicable Diseases Heath Service Delivery (COMDIS-HSD) consortium, led by the University of Leeds and funded since 2011 through the UK government’s Department for International Development.

The project in China was one of many undertaken by COMDIS-HSD in Guangxi province, one of China’s poorest provinces, located in the South West of the country. A randomised controlled trial, it was testing whether a bespoke training and education programme for doctors and patients could reduce unnecessary prescription of antibiotics for children with upper respiratory infections (URIs) – essentially sore throats and coughs.

The context for the project was a Chinese Ministry of Health regulation, issued in 2012, to limit the use of antibiotics. This is an important aspect of the approach used by COMDIS-HSD, according to co-Director, Professor John Walley.

“We don’t turn up in a country with a change in policy or practice that we’ve devised here in Leeds and ask if we can test it out,” he says. “The interventions we trial are developed with national ministries of health and local expertise to turn existing health policies into practice. Everything is designed to be specific to that national and cultural context, and tested within existing healthcare systems – so from the start the research is being undertaken by Ministry officials and practitioners in local health centres, rather than simply by us. This ensures that improvements are sustainable and will be rolled out by the Ministry at a national scale.”

As in many low and middle income countries, overuse of antibiotics in healthcare is common in China. In 2012, the national Ministry of Health reported that the average person consumed 138g of antibiotics per year, 10 times the rate in the USA.

Most URIs are viral – so not suitable for treatment with antibiotics – and children will usually recover by themselves. However, particularly in rural areas of China, the default response of general practitioners has been to administer antibiotics, often more than one and usually by drip. This causes unnecessary distress to the child, is costly to the health service and increases the risk of children developing anti-microbial resistance.

The trial involved 25 township hospitals, which provide mainly primary care. Twelve of the hospitals were randomised to receive the training and education programme, and thirteen were randomised to the control arm.

Training was provided to all hospitals to strengthen accurate diagnosis and reporting, to ensure that valid data was returned across the trial. In those hospitals randomised to receive the wider education programme, the approach targeted both doctors and parents or carers, as Professor Walley explains.

“As a practising GP, I know from experience how difficult it is to tell concerned parents that you’re not going to prescribe antibiotics for their child,” he says. “When we reviewed the literature to see what kind of interventions were most effective in changing prescribing practice, it was clear that the best approach is to educate and empower doctors, so they have the confidence not to give antibiotics, but also to educate those looking after the child, so they understand and accept the doctor’s decision.”

In the township hospitals designated to receive the training and education programme, doctors were provided with a new operational handbook, based on Chinese antibiotics use guidelines, the UN/WHO Integrated Management of Childhood Illness (IMCI) guidelines and the UK’s National Institute for Health and Care Excellence (NICE) guidelines. Doctors were also given bespoke training, including lectures, case discussions and Q&A sessions, to help them understand and implement rational use of antibiotics.

Simple printed materials were also created for doctors to give to parents and carers during the consultation, which explained what antibiotics could and should not be used for, including the risks of antibiotic resistance. These were supplemented by videos that played in waiting areas, which carried the same messages.

All the materials were developed by a technical working group that included all partners on the project team: the University of Leeds, the China Global Health Research and Development – a local NGO – and the Guangxi Autonomous Region Centre for Disease Control and Prevention.

“The clinical guidance for diagnosing a condition will be the same, whatever country you’re in, but that needs adapting for the local context, taking into account both the health system, culture and language,” says Professor Walley. “That’s why this collaborative approach is so important.”

Each month during the six-month trial, the research team analysed data from each hospital on their prescription rates for childhood URIs. The results were communicated to doctors during regular hospital staff meetings, with the aim of encouraging behaviour change through peer review.

The full results of the trial are still being collated, but interim findings indicate a significant drop in antibiotic prescriptions in those hospitals where the education and training programme was put in place, compared to the controls.

Although projects like this start small, because of the particular model used in COMDIS-HSD, their eventual impact can be substantial. An intervention to improve tuberculosis (TB) treatment, trialled by the consortium in Pakistan, has been rolled out across both Pakistan and Nepal. The result is that 300,000 people with TB now receive better care and a further 200 million are protected from contracting the disease.

Says Professor Walley: “We hope that this project in Guangxi province follows the same trajectory, helping to avoid China’s 300 million children from being put at unnecessary risk of developing resistance to antibiotics.”