Setting up an antimicrobial resistance surveillance system in Burundi

The purpose of proposed solution is to set up a system for collecting, analyzing and transmitting antimicrobial stewardship data at community level in Burundi, in order to establish  robust antimicrobial resistance surveillance system using one health approach and kobo collect application. To ensure project's success, all levels must be involved.

KATIHABWA Ernest is head of programs at "Réseau Burundais pour la prévention et contrôle des infections" and one of the organization's founding members. He is also a public health expert.

Burundi has put in place a National Action Plan to fight against Antimicrobial Resistance 2020 to 2023. However, few activities have been carried out under this plan. Among weaknesses identified in 2020 was absence of a multi-sectoral network for epidemio-surveillance of human-animal-plant-environment interface.

The system for collecting, analyzing and managing data on antimicrobial resistance is not in place, and represents a major challenge to fight against antimicrobial resistance in Burundi.

For example, the scoping study on pharmaceutical waste management in Burundi, carried out by Niyonizigiye Pierre Claver in December 2023, shows that the National Multisectoral Technical Committee has not set up branches at provincial, communal and community level to be present wherever pharmaceutical waste is found (page 31: on: www.eacgermany.org). Similarly, the survey carried out by RBPCI in the city of Bujumbura (commune Mukaza) in November 2023 shows that 89% of Unused pharmaceutical products 
are thrown away with household waste (page 18 of the survey report).

The limited data available converge on the need for concrete action on antimicrobial resistance surveillance, through the implementation of a multi-sectoral data collection and analysis system, as well as related actions to limit the damage caused by antimicrobial resistance.

The solution will target community health workers, agricultural monitors and veterinary technicians, as well as local authorities, to involve them in the collection, analysis and transmission of antimicrobial resistance data in their respective communities. Focus groups will be organized before and during the project to understand their needs. These are generally community relays employed respectively by the Ministry of Health and the Ministry of Agriculture, Livestock and the Environment. They will be supervised by their line managers at communal, provincial and national level, with whom our team will collaborate. Activities aimed at building the capacity of these community relays and raising community awareness of the fight against antimicrobial resistance, as well as tablet equipment for online and real-time data collection and transmission, will be sent to the community relays. Data analysis and appropriation workshops will also be organized at communal and provincial levels. Finally, at central or national level, we will work with the relevant ministries to organize all these activities. Advocacy frameworks will be organized for the various decision-makers, using data collected at community level. All these activities will be carried out within the framework of the One Health approach, and at all levels.

Our solution is one of the government's priorities, but has not been implemented due to a lack of resources and knowledge. 

The solution will enable us to gain a good understanding of the AMR phenomenon and use it to guide AMR control activities, as well as to set up an AMR surveillance system at community level. This will prevent deaths and costs linked to AMR infections. 

In addition, the knowledge of the community and all the actors involved will be increased. 

Data from the community will also be published, and will be of use to the world in general, and to the sub-region in particular, which shares many of the same challenges. 

The solution will give a true picture of the country in the field of AMR, and this will constitute good practice for other countries sharing the same challenges. 

As part of the data collection, sampling and implementation of the AMR surveillance system from the community level, several structures/entities will benefit from the support and knowledge that will stay with them and all help to preserve the health of the beneficiary population. 

The impact of our solution will be seen as follows: 

1. Data on factors influencing AMR are regularly collected, and decision-makers understand the phenomenon of AMR at community level and use them to guide actions to combat it; 

The data collected will help the authorities of the Ministries concerned, the administrative authorities at various levels, actors in the one health field and, in a few words, the various decision-makers to become aware of the danger linked to AMR and to take appropriate measures to combat AMR in favor of the community.

2. An AMR surveillance system is set up at community level, enabling the implementation of activities aimed at reducing AMR at community level within the framework of one health.

With strong AMR monitoring system, the most disadvantaged people, such as street children, poor women and a large group of disadvantaged groups who used to collect leftover medicines from household garbage dumps and put them back on the black markets, will no longer have access to them. people who practiced self-medication by buying antibiotics without respecting protocol will be reduced. In a nutshell, the misuse of antimicrobials will be reduced, to  benefit of all sectors of population, especially the poorest.  

For the first year, we'll be concentrating on collecting and analyzing all the data, and then disseminating this data to the administrative authorities, sector managers concerned by one health, and all the players in this field. Over the course of the year, we'll also be putting in place or updating the tools needed for regular data collection, training and awareness-raising, in a nutshell to set up a strong and effective AMR surveillance system integrated into routine activities. This will involve target areas throughout the country, in 18 provinces of Burundi, in order to get a global picture. 

In the second year, we will begin to set up community-based AMR surveillance systems in 6 of the country's target provinces. 

For the third year, in addition to the 6 provinces, we will add 3 other provinces where AMR surveillance systems will be set up and operational according to the data found during the first year. 

Each time, priority will be given to provinces with greater needs than others, based on the data collected and analyzed. 

The data available from research on AMR points to a lack of concrete action at community level to combat AMR. 

For example, the survey organized by RBPCI in November 2023 in Bujumbura ( Mukaza commune) shows that 75% of respondents claim to have no knowledge on AMR. The same survey shows that 89% of respondents dispose of leftover medicines with household waste. 

The scoping study on pharmaceutical waste management in Burundi, carried out from June to December 2023 in Burundi shows that all wholesalers (100%) indicated that they do not collect unused pharmaceutical products from citizens or their customers, as there is no obligation to do so.

Overall, Burundi has very little data on AMR, and worse still, very little action on AMR at community level. To ensure proper monitoring and evaluation, the baseline for data on AMR at community level will be established, which will be carried out at the start of the project with data collection at community level, and in the middle of the second year with the mid-term evaluation. At the end of the project period, a final evaluation will be carried out to measure the extent to which results have been achieved. 

The first obstacle is the resistance of certain key players, accustomed to working without regard to AMR control standards, as well as a lack of awareness of its effects on the population. To overcome this obstacle, we'll be emphasizing the involvement of all the players concerned, and above all taking the time to raise awareness/explain the effects of AMR. We will use a participatory methodology to move forward with all parties. We also work with the administrative and security authorities, so that we can sometimes force recalcitrant offenders to respect the law. In addition, support and advocacy will be provided to put in place a good system for combating AMR, given that the environment is conducive to the establishment of legal frameworks for combating AMR. 

The second obstacle is limited financial and technological resources, which will prevent us from reaching all the targets we set ourselves. To counter this obstacle, we will be in constant contact with financial partners in this field, and more specifically with Trinity Challenge. We'll be working on representative samples wherever possible, to ensure efficient management according to the financial resources available. 

Burundi is the poorest country in the world, with 87% of the population living on less than of USD 1.9/day according to the World Bank, and a GDP per capita of USD 309.1 in 2022 according to the IMF, compared to USD 274.0 in 2021. In 2021, The country was ranked 187/191 in terms of human development (HDI).

In In this context, the Burundian Infection Prevention and Control Network is a Organization founded by a team of young, dynamic and highly committed people professionals to contribute to the fight against antimicrobials resistance.

However, we are confronted with major obstacles in the form of a lack of financial and material resources to realize our vision. The field of AMR remains unknown even to most donors, and when we approach donors to explain our vision, they specify that it is not among their priorities. That's why we want to make connections with partners who understand the need and the danger of AMR. 

As far as equipment is concerned, the availability of modern data collection tools and samples within the framework of one Heath and support for travel to gain easy access to the field will be of great benefit to us. 

To implement our solution, RBPCI will collaborate primarily with the Ministry in charge of Health, the Ministry in charge of Agriculture, Livestock and the Environment, and the Ministry in charge of Territorial Administration, focusing on their laboratory and research or data management services. In addition, United Nations agencies such as WHO, FAO and UNEP will also be our key partners in implementation, to better ensure that international policies in this field are properly applied within a single health framework.

In addition, we will be collaborating with Africa CDC, our traditional partner.

To ensure community ownership, we're going to involve local associations working in the field of laboratories, animal and environmental health in our activities, in order to strengthen them in this area.

Associations of women farmers, batwa and many other underprivileged categories will be targeted and involved in our activities so that these people can be the first to change their behavior, as they are the first victims of AMR.

Finally, our organization will collaborate with any other actors working in the field of AMR who are willing to cooperate.