WAAW 2023: The Fleming Fund puts global AMR first, together  

A plaque on the side of the Saint Mary’s Hospital in Paddington, London, UK, commemorates the discovery of penicillin, the first antibiotic, in 1928. Fungal spores, blown by the wind, landed on Sir Alexander Fleming's Petri dishes killing the bacteria he was growing leading to a revolution in medicine.

Now, in 2023, antibiotic resistance threatens to unravel the many gains resulting from his discovery. The Fleming Fund, named after Sir Alexander, is in its seventh year supporting AMR surveillance in Africa and Asia to provide data and evidence helping combat AMR. For World AMR Awareness Week, Dr Toby Leslie discusses the problem and how surveillance is integral to the unified solution of, this year’s theme, ‘preventing antimicrobial resistance together.’

Fleming Fund regional grant, led by the African Society for Laboratory Medicine (ASLM), QWArS project microbiology professionals from Eswatini. Credit: ASLM.

Image shows: Fleming Fund regional grant, led by the African Society for Laboratory Medicine (ASLM), QWArS project microbiology professionals from Eswatini. Credit: ASLM.

“Antimicrobial resistance (AMR) is a serious problem because drug-resistant bacterial infections are not only more difficult for doctors to treat, but also increasingly common,” says Dr Toby Leslie, Global Technical Lead for the Fleming Fund at Mott MacDonald, the fund’s Management Agent. “Worryingly, the rate at which the problem is growing is outpacing our ability to deal with it.”

AMR happens when bacteria can survive contact with antibiotics – a problem that touches 13 of the Sustainable Development Goals and one of the top 10 global health threats defined by the World Health Organization. Low- and middle-income countries suffer from a higher burden of infectious diseases and greater problems of AMR.

The Fleming Fund, founded by the UK Government’s Department of Health and Social Care, targeted countries mostly without systematic AMR surveillance systems.

“We started supporting the development of in-country systems to track priority bacteria causing illnesses treated by different antibiotics - a complicated ‘drug-bug’ matrix,” explains Dr Leslie.

The Fleming Fund also supports systems for animal health as bacteria can transfer between animals and humans. However, data on antibiotic resistance is hard to interpret in silos, so combined monitoring systems for antibiotic use in humans, animals, and agriculture were set up.

Adjo Mfodwo, Fleming Fund Regional Coordinator in West Africa at Mott MacDonald.

“With a solid grasp of the AMR landscape, countries can make effective evidence-based decisions on the size and type of the problem; and how to mitigate or manage it, added Dr Leslie. “By generating good-quality data on bacterial diseases, patterns of resistance, and antibiotic types used, this can then be analysed and used in response.”

Strengthening global AMR surveillance

Operating across 24 African and Asian countries since 2016, by 2023 the Fleming Fund supports around 270 laboratories – making it one of the largest laboratory programmes in the world. 

The programme supports animal and human health laboratories and surveillance sites, providing the equipment and skills to undertake bacterial culture, isolation, identification, and drug resistance testing. The regional grants workstream adds a vital suite of technical support for quality assurance systems, skills development, animal health, One Health, and policy data use.

“By building laboratory capacity and surveillance systems, we have strengthened the global AMR workforce, country governance, leadership, awareness and understanding. Turning these cogs results in available quality data that did not exist before,” said Dr Leslie.

Nineteen of the Fleming Fund priority countries are enrolled in the WHO’s Global AMR Surveillance System; up from two in 2016; 16 submitted AMR data since operation. The quantity of data has significantly increased, including more sample types, bacteria species, and surveillance sites. 

Sustainable vision

Sustainability is at the forefront of the Fleming Fund’s vision; working with grantees and Governments to give decision-makers the information to influence and change health policy, practice, and programming.

Since the start of phase I in 2016, 20 of the 22 countries receiving investment under the Fleming Fund programme made considerable progress in their surveillance systems, improving laboratory capability, data quality, and use.

“This shows how far we've come; it’s a major achievement in terms of global health,” said Dr Leslie.

The Fleming Fund also supports fellowships from Senegal in West Africa to Timor-Leste and Papua New Guinea in South East Asia. The fellowship scheme provides medium and long-term professional support to practitioners from within the surveillance system, supporting more than 180 fellows from 120 Institutions.

“As an important sustainability measure, the fellows are inside the surveillance system, working at the specialist scientific level required to tackle this complex issue and become leaders in their fields,” added Dr Leslie.

The Fleming Fund’s work is also underpinned by improving the AMR workforce, with around 40,000 training attendances of practitioners across human and animal health, as well as supporting the economic cases to sustain surveillance and diagnostic services.

AMR samples analysed at Fleming Fund-supported Central Veterinary Lab in Kathmandu, Nepal. Credit: FHI 360.

Laying the foundations

The basis of the surveillance system is the hospitals producing and using AMR data to improve patient care, which is then transferred to national reference laboratories, contributing to national databases.  Typically, there is an equivalent database for animal and environmental health sectors; samples collected from terrestrial or aquatic animal species, such as chicken or shrimp, and surrounding environments.

This data is reviewed by each country’s AMR Coordination Committee and shared internationally to measure AMU and AMC (antimicrobial use/consumption) across both systems.

“Incorporating findings and evidence into policy recommendations can be a long and winding road - but the data can be more readily used at the local level - by doctors, pharmacists, and microbiologists for better patient treatments, or by veterinarians and farmers to reduce antibiotic use in animals.”

“The data generated across the Fleming Fund’s three main programme workstreams: country and regional grants and fellowship scheme is only useful if used in practice,” explains Dr Leslie.

Phase I laid the foundations for the AMR surveillance programme, putting in place the blocks to build upward for phase II, with operating laboratories generating high-quality data addressing specific issues. For example, exploring patient groups (e.g., newborns, or cancer patients), gender and equity, private sector, AMR surveillance economics, and disease burden. 

“With a complex subject, we must learn to walk before we can run, added Dr Leslie. “Maintaining the service quality and work in phase I is paramount, and with the AMR issue deepening, we must prioritise to generate data on country-specific health problems that have a real impact on lives and livelihoods and the health systems relied upon.”

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