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Solving the superbug crisis requires thinking ‘outside the lab’

The current trends of antimicrobial use can entail “a reversal of the public health gains of the past century, and the economic growth, development, and poverty reduction these gains enabled”, warns a recent World Bank report. The numbers back this up.

Caption: C-reactive protein test being conducted: Credit: Dr. Marco J Haenssgen

Currently 700,000 people die of resistant infections every year with experts estimating this number to increase to 10 million by 2050 if we do not slow down the rise of resistance.  Consequently, hundreds of millions of pounds (e.g. the Fleming Fund, the Wellcome Trust, and Nesta’s Longitude Prize) are being invested to solve this superbug crisis.

New diagnostics are a key area of research, with a finger-prick test known as C-reactive protein (CRP) testing gaining attention for its ability to identify bacterial infections requiring antibiotics. A negative test result would indicate that no antibiotics are needed to treat the illness (even though a viral infection might be present). An exciting development, but caution is required. Having an effective test is one thing, ensuring it’s used is another.

In recent research conducted with the University of Oxford, the London School of Hygiene & Tropical Medicine found that complex local notions and wider factors such as perceived risk or one’s socioeconomic status can work against test uptake, and even prevent entire groups from accessing the service.

Exploring cases in Yangon, Myanmar and Chiang Rai in Thailand, we found that healthcare staff generally trusted the new diagnostic technologies and used it to reassure themselves about their treatment decisions. However patients’ lifestyles, cultural beliefs around illness and treatment, and one’s ability to afford certain healthcare providers were common barriers to accessing or correctly understanding the test.

From the Thailand healthcare workers’ perspectives, the test does help them to come down to new policy-imposed prescription limits. But there are also other factors that direct healthcare workers away from the test results, for example when patients cannot afford to come back to the health centre for follow-up visits. Nurses would then rather over-prescribe antibiotics and knowingly contribute to the resistance problem than risk their patients’ lives.

Extra complexities on the patient side exist too. Most people in both settings do not think about illness in terms of bacteria and viruses, rather having their own knowledge about what causes illness. When new knowledge about the test’s purpose is introduced, it is quite easy for patients to develop their own interpretation of the test. For example, we saw many patients who believed it to be a comprehensive blood test to find any disease. This could lead to patients thinking they are free of all disease when there is a negative result, although this may not be the case.

Furthermore, patients may not even receive the test due to poverty and time constraints. In remote mountain villages in Thailand, there is no guarantee patients can get to clinics because they are too far away or roads are dangerous. Myanmar patients were more likely to buy cheap sets of unlabelled medicines from nearby grocery shops and pharmacies (so-called “medicine cocktails”) in order to feel better immediately or to avoid taking time off work.

Overall, the new diagnostic test interacts with existing behaviours and solutions, which can make the test perhaps more, perhaps less effective than planned – depending on the context. Diagnostic tests for doctors and nurses cannot alone solve the problem of antibiotic over-prescription. Social research must go hand-in hand with clinical research to ensure that medical interventions introduced into routine care have the desired positive impact.

Publications

Khine Zaw, Y., Charoenboon, N., Haenssgen, M. J., & Lubell, Y. (2018). A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon. American Journal of Tropical Medicine and Hygiene. DOI: 10.4269/ajtmh.17-0906 Available online at:

Haenssgen, M. J., Charoenboon, N., Althaus, T., Greer, R. C., Intralawan, D., & Lubell, Y. (2018). The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Social Science & Medicine, 202, 1-12. DOI: 10.1016/j.socscimed.2018.02.018