Heiman Wertheim: Clinical research in low and middle-income countries

I’m Heiman Wertheim, I’m a clinical microbiologist, a medical doctor trained in clinical microbiology. I was trained in the Netherlands and then I moved to Vietnam in 2006, to OUCRU in Hanoi and I developed the unit there. Our main focus is drug resistant infections and a wide variety of other diseases that we’re also studying.

We started in 2006 focusing on severe influenza infections, but we saw a lot of drug resistant infections caused by bacteria - these people are failing antibiotics that we consider should work - and then we re-focused what we were doing on what is actually causing drug resistant infections and what we can do about them. We also saw many people come into hospital for reasons unrelated to infections but because of mechanical ventilation they get pneumonia, so the local immune system is damaged, then they get a hospital-acquired infection which is drug resistant and these people are failing standard therapies.

If you look at more of a community level, the problem is that there is very little diagnostics being done, but we see people coming into hospital with drug resistant infectious acquired in the community. We diagnose them with resistant bugs, we think it’s really high but probably in the community it’s a bit less of a problem. But still it’s there and we only see in the hospital the cases that failed, so we do not really know the burden of drug resistant infections in the community.

Even in the Netherlands which has one of the lowest rates of resistance and lowest rates of antibiotic use, and also in the UK, you see all the problems coming from outside: people travelling and coming back with resistant bugs. I have seen such cases so it’s really happening, it’s not like something that may happen in the future it’s actually happening now. I don’t think you can only focus on your own country, you really should be able to go where it has the highest burden and try and do something there, because one way or another it’s going to come to Europe. That is why we’re studying drug resistance in Asia, and I think it’s an important place to do something not just on individual patients but also on policies, and really make a change not just for Vietnam but a change for global health.

The nice thing about Hanoi is that it’s close to the Ministry of Health, so anything that we find also has an impact on policy. Rather than focusing on just individual patients or doing clinical trials, we also think how we can engage with policy makers and make a change on a larger scale.

The main change in our research in the last 5 to 10 years? We moved from hospital-based research into the communities. We are doing clinical trials and looking at how rapid diagnoses can help bring down antibiotic use in a community. As you can see in the communities, if you come in with an upper respiratory tract infection which doesn’t require an antibiotic, by looking at a biomarker rather than looking for a specific pathogen, a rapid test gives a result in 3 to 5 minutes, and we found that this was really helpful in bringing down antibiotic use by 20%. This 20% reduction is probably an underestimate because many primary health care centres were not always compliant because they had a stock of antibiotics that they still needed to get rid of, which is very interesting because it shows that we also have to take into account procurement procedures for these clinics.

We should fund this research as drug resistance is a global health issue, it’s now called by the United Nations a global crisis. You can’t just focus on our own country, you need to take a global approach, with the knowledge and expertise that we have, work with the local people and strengthen their capacity, make them feel responsible and engage them and make them take the lead.

In OUCRU, Hanoi, we work closely with the National Institute of Health and Epidemiology which is the public health authority. What we do is focus on public health issues and how our work from the laboratory impacts on what is happening with patients or communities. For instance we had a measles outbreak, even though the government says there’s a very good coverage for measles, we saw through our prevalence data that people are not protected enough which explained the outbreak, showing that the work we do in the lab can help and make a change for public health.