Antimicrobial resistance is a growing public health crisis, especially in countries with fragile health systems, population displacement or ongoing conflict. In 2019 antibiotic-resistant bacteria directly caused an estimated 1.27 million deaths, and contributed to 4.95 million deaths, tolls that will continue to increase if no effective action is taken.
MSF’s approach to combatting antimicrobial resistance combines three pillars: infection prevention and control, microbiology and surveillance, and rational use of antibiotics via antibiotic stewardship. Several studies characterize patterns and prevalence of antibiotic resistance among MSF patients, from civilians wounded in Middle East conflicts to hospitalized neonates in Central African Republic and Haiti. New technologies developed by MSF and partners are expanding local capacity for rapid, accurate laboratory diagnosis of infections, so that clinicians can prescribe the right antibiotic for each patient. Other work assesses the practices and challenges related to optimizing rational antibiotic use within health facilities and communities.
If you're interested in learning more about MSF's work in antimicrobial resistance, view the full list of MSF's publications on the topic.
9 result(s)
Journal Article > ResearchFull Text
Antimicrob Resist Infect Control. 2024 August 15; Volume 13 (Issue 1); 89.
Skender K, Versace G, Lenglet AD, Clezy K
Antimicrob Resist Infect Control. 2024 August 15; Volume 13 (Issue 1); 89.
BACKGROUND
Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs.
METHODS
Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days.
RESULTS
Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan.
CONCLUSIONS
This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings.
Conference Material > Abstract
Rapoud D, Cramer E, Al Asmar M, Sagara F, Ndiaye B, et al.
MSF Scientific Day International 2024. 2024 May 16
INTRODUCTION
Antimicrobial resistance (AMR) is a major threat to public health and could cause 10 million deaths per year by 2050. Access to high-quality diagnostic tests is a key intervention to tackle AMR, leading to better patient care, provision of data for global surveillance, and more rational use of antibiotics. Despite technological advances, antimicrobial susceptibility testing (AST) interpretation is complex and requires expert clinical microbiologists, which are lacking in low- and middle-income countries (LMIC). To fill the gap, The Médecins Sans Frontières (MSF) Foundation developed Antibiogo, a smartphone-based application to support laboratory technicians with AST interpretation. We aimed to assess the clinical performance of Antibiogo in intended use settings as per European regulations for in-vitro diagnostic medical devices.
METHODS
Antibiogo combines image processing, machine learning, and expert system technologies for the provision of final results (S/I/R: Susceptible, Intermediate, or Resistant). In 2022, we assessed the clinical performance of Antibiogo according to European regulations in three microbiology laboratories in Jordan (MSF Reconstructive Surgery Hospital, Amman), Mali (MSF Paediatric Hospital, Koutiala), and Senegal (Pasteur Institute, Dakar). In each site, clinical AST performed for routine purposes was processed in parallel with Antibiogo. AST pictures and inhibition zone diameter values measured with Antibiogo were interpreted by an expert microbiologist who was masked to Antibiogo interpretation. We calculated S/I/R category agreement between the microbiologist and Antibiogo, as well as minor (mD), major (MD) and very major discrepancies (VMD).
RESULTS
We included 378 fresh isolates in the study, representing 11 different pathogens. The overall category agreement was 88.8% (95% CI 87.9–89.7), ranging per pathogen from 67.1% (63.2–70.8) (for Pseudomonas aeruginosa) to 98.1% (94.4–99.6) (for Haemophilus influenzae), with 10.2% (9.4–11.1) mD, 1.6% MD (1.2–2.3), and 0.25% VMD (0.08–0.59). From these results, Antibiogo was validated for 11 WHO priority pathogens. From an operational need identified, to proof of concept and evaluation, it became the first MSF CE-marked in-vitro diagnostic (IVD) test in May 2022. As of January 2024, it has been implemented in five MSF laboratories (in Central African Republic, Democratic Republic of the Congo, Jordan, Mali, and Yemen), and in public laboratories in Mali upon request from the Ministry of Health.
CONCLUSION
It will take 400 years to address the shortfall of microbiologists in LMIC at the present rate of training. In the meantime, technology can help fill the gap. In parallel to deployment of Antibiogo in additional countries and regions, developments are ongoing, and an improved version of the app will be released in 2024.
Antimicrobial resistance (AMR) is a major threat to public health and could cause 10 million deaths per year by 2050. Access to high-quality diagnostic tests is a key intervention to tackle AMR, leading to better patient care, provision of data for global surveillance, and more rational use of antibiotics. Despite technological advances, antimicrobial susceptibility testing (AST) interpretation is complex and requires expert clinical microbiologists, which are lacking in low- and middle-income countries (LMIC). To fill the gap, The Médecins Sans Frontières (MSF) Foundation developed Antibiogo, a smartphone-based application to support laboratory technicians with AST interpretation. We aimed to assess the clinical performance of Antibiogo in intended use settings as per European regulations for in-vitro diagnostic medical devices.
METHODS
Antibiogo combines image processing, machine learning, and expert system technologies for the provision of final results (S/I/R: Susceptible, Intermediate, or Resistant). In 2022, we assessed the clinical performance of Antibiogo according to European regulations in three microbiology laboratories in Jordan (MSF Reconstructive Surgery Hospital, Amman), Mali (MSF Paediatric Hospital, Koutiala), and Senegal (Pasteur Institute, Dakar). In each site, clinical AST performed for routine purposes was processed in parallel with Antibiogo. AST pictures and inhibition zone diameter values measured with Antibiogo were interpreted by an expert microbiologist who was masked to Antibiogo interpretation. We calculated S/I/R category agreement between the microbiologist and Antibiogo, as well as minor (mD), major (MD) and very major discrepancies (VMD).
RESULTS
We included 378 fresh isolates in the study, representing 11 different pathogens. The overall category agreement was 88.8% (95% CI 87.9–89.7), ranging per pathogen from 67.1% (63.2–70.8) (for Pseudomonas aeruginosa) to 98.1% (94.4–99.6) (for Haemophilus influenzae), with 10.2% (9.4–11.1) mD, 1.6% MD (1.2–2.3), and 0.25% VMD (0.08–0.59). From these results, Antibiogo was validated for 11 WHO priority pathogens. From an operational need identified, to proof of concept and evaluation, it became the first MSF CE-marked in-vitro diagnostic (IVD) test in May 2022. As of January 2024, it has been implemented in five MSF laboratories (in Central African Republic, Democratic Republic of the Congo, Jordan, Mali, and Yemen), and in public laboratories in Mali upon request from the Ministry of Health.
CONCLUSION
It will take 400 years to address the shortfall of microbiologists in LMIC at the present rate of training. In the meantime, technology can help fill the gap. In parallel to deployment of Antibiogo in additional countries and regions, developments are ongoing, and an improved version of the app will be released in 2024.
Journal Article > ReviewFull Text
PLOS Glob Public Health. 2024 April 16; Volume 4 (Issue 4); e0003077.
Monk EJM, Jones TPW, Bongomin F, Kibone W, Nsubuga Y, et al.
PLOS Glob Public Health. 2024 April 16; Volume 4 (Issue 4); e0003077.
Antimicrobial resistance (AMR) is a major global threat and AMR-attributable mortality is particularly high in Central, Eastern, Southern and Western Africa. The burden of clinically infected wounds, skin and soft tissue infections (SSTI) and surgical site infections (SSI) in these regions is substantial. This systematic review reports the extent of AMR from sampling of these infections in Africa, to guide treatment. It also highlights gaps in microbiological diagnostic capacity. PubMed, MEDLINE and Embase were searched for studies reporting the prevalence of Staphylococcus aureus, Eschericheria coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii in clinically infected wounds, SSTI and SSI in Central, Eastern, Southern or Western Africa, and studies reporting AMR from such clinical isolates. Estimates for proportions were pooled in meta-analyses, to estimate the isolation prevalence of each bacterial species and the proportion of resistance observed to each antibiotic class. The search (15th August 2022) identified 601 articles: 59 studies met our inclusion criteria. S. aureus was isolated in 29% (95% confidence interval [CI] 25% to 34%) of samples, E. coli in 14% (CI 11% to 18%), K. pneumoniae in 11% (CI 8% to 13%), P. aeruginosa in 14% (CI 11% to 18%) and A. baumannii in 8% (CI 5% to 12%). AMR was high across all five species. S. aureus was resistant to methicillin (MRSA) in >40% of isolates. E. coli and K. pneumoniae were both resistant to amoxicillin-clavulanic acid in ≥80% of isolates and resistant to aminoglycosides in 51% and 38% of isolates respectively. P. aeruginosa and A. baumannii were both resistant to anti-pseudomonal carbapenems (imipenem or meropenem) in ≥20% of isolates. This systematic review found that a large proportion of the organisms isolated from infected wounds, SSTI and SSI in Africa displayed resistance patterns of World Health Organisation (WHO) priority pathogens for critical or urgent antimicrobial development.
Journal Article > LetterFull Text
Lancet. 2023 November 9; Online ahead of print (Issue 23); 02508-4.
Moussally K, Abu-Sittah G, Gomez FG, Fayad AA, Farra A
Lancet. 2023 November 9; Online ahead of print (Issue 23); 02508-4.
Journal Article > CommentaryFull Text
Antimicrob Resist Infect Control. 2023 September 4; Volume 12 (Issue 1); 89.
Truppa C, Alonso B, Clezy K, Deglise C, Dromer C, et al.
Antimicrob Resist Infect Control. 2023 September 4; Volume 12 (Issue 1); 89.
Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.
Journal Article > ResearchFull Text
Antimicrob Resist Infect Control. 2023 July 11; Volume 12 (Issue 1); 67.
Mambula G, Nanjebe D, Munene A, Guindo O, Salifou A, et al.
Antimicrob Resist Infect Control. 2023 July 11; Volume 12 (Issue 1); 67.
BACKGROUND
Antibiotic resistance is a significant public health problem and is responsible for high mortality in children and new-borns. Strengthening the rational use of antibiotics and improving the quality and access to existing antibiotics are important factors in the fight against antibiotic resistance. This study aims to provide knowledge on the use of antibiotics in children in resource-limited countries in order to identify problems and possible avenues for improvement of antibiotics use.
METHODS
We conducted a retrospective study in July 2020 and collected quantitative clinical and therapeutic data on antibiotic prescriptions between January and December 2019 in 4 hospitals or health centres in both Uganda and Niger, respectively from January to December 2019. Semi-structured interviews and focus groups were conducted among healthcare personnel and carers for children under 17 years of age, respectively.
RESULTS
A total of 1,622 children in Uganda and 660 children in Niger (mean age of 3.9 years (SD 4.43)) who received at least one antibiotic were included in the study. In hospital settings, 98.4 to 100% of children prescribed at least one antibiotic received at least one injectable antibiotic. Most hospitalized children received more than one antibiotic in both Uganda (52.1%) and Niger (71.1%). According to the WHO-AWaRe index, the proportion of prescriptions of antibiotics belonging to the Watch category was 21.8% (432/1982) in Uganda and 32.0% (371/1158) in Niger. No antibiotics from the Reserve category were prescribed. Health care provider’s prescribing practices are rarely guided by microbiological analyses. Prescribers are faced with numerous constraints, such as lack of standard national guidelines, unavailability of essential antibiotics at the level of hospital pharmacies, the limited financial means of the families, and pressure to prescribe antibiotics from caregivers as well as from drug company representatives. The quality of some antibiotics provided by the National Medical Stores to the public and private hospitals has been questioned by some health professionals. Self-medication is a widespread practice for the antibiotic treatment of children for economic and access reasons.
CONCLUSION
The study findings indicate that an intersection of policy, institutional norms and practices including individual caregiver or health provider factors, influence antibiotic prescription, administration and dispensing practices.
Antibiotic resistance is a significant public health problem and is responsible for high mortality in children and new-borns. Strengthening the rational use of antibiotics and improving the quality and access to existing antibiotics are important factors in the fight against antibiotic resistance. This study aims to provide knowledge on the use of antibiotics in children in resource-limited countries in order to identify problems and possible avenues for improvement of antibiotics use.
METHODS
We conducted a retrospective study in July 2020 and collected quantitative clinical and therapeutic data on antibiotic prescriptions between January and December 2019 in 4 hospitals or health centres in both Uganda and Niger, respectively from January to December 2019. Semi-structured interviews and focus groups were conducted among healthcare personnel and carers for children under 17 years of age, respectively.
RESULTS
A total of 1,622 children in Uganda and 660 children in Niger (mean age of 3.9 years (SD 4.43)) who received at least one antibiotic were included in the study. In hospital settings, 98.4 to 100% of children prescribed at least one antibiotic received at least one injectable antibiotic. Most hospitalized children received more than one antibiotic in both Uganda (52.1%) and Niger (71.1%). According to the WHO-AWaRe index, the proportion of prescriptions of antibiotics belonging to the Watch category was 21.8% (432/1982) in Uganda and 32.0% (371/1158) in Niger. No antibiotics from the Reserve category were prescribed. Health care provider’s prescribing practices are rarely guided by microbiological analyses. Prescribers are faced with numerous constraints, such as lack of standard national guidelines, unavailability of essential antibiotics at the level of hospital pharmacies, the limited financial means of the families, and pressure to prescribe antibiotics from caregivers as well as from drug company representatives. The quality of some antibiotics provided by the National Medical Stores to the public and private hospitals has been questioned by some health professionals. Self-medication is a widespread practice for the antibiotic treatment of children for economic and access reasons.
CONCLUSION
The study findings indicate that an intersection of policy, institutional norms and practices including individual caregiver or health provider factors, influence antibiotic prescription, administration and dispensing practices.
Journal Article > ResearchFull Text
BMC Pediatr. 2021 December 13; Volume 21 (Issue 1); 750.
Nebbioso A, Ogundipe OF, Repetto EC, Mekiedje C, Sanke-Waigana H, et al.
BMC Pediatr. 2021 December 13; Volume 21 (Issue 1); 750.
BACKGROUND
Infectious diseases account for the third most common cause of neonatal deaths. Globally, antibiotic resistance (ABR) has been increasingly challenging neonatal sepsis treatment, with 26 to 84% of gram-negative bacteria resistant to third-generation cephalosporins. In sub-Saharan Africa, limited evidence is available regarding the neonatal microbiology and ABR. To our knowledge, no studies have assessed neonatal bacterial infections and ABR in Central-African Republic (CAR). Therefore, this study aimed to describe the pathogens isolated and their specific ABR among patients with suspected antibiotic-resistant neonatal infection admitted in a CAR neonatal unit.
METHODS
This retrospective cohort study included neonates admitted in the neonatal unit in Bangui, CAR, from December 2018 to March 2020, with suspected antibiotic-resistant neonatal infection and subsequent blood culture. We described the frequency of pathogens isolated from blood cultures, their ABR prevalence, and factors associated with fatal outcome.
RESULTS
Blood cultures were positive in 33 (26.6%) of 124 patients tested (17.9% for early-onset and 46.3% for late-onset infection; p = 0.002). Gram-negative bacteria were isolated in 87.9% of positive samples; with most frequently isolated bacteria being Klebsiella pneumoniae (39.4%), Escherichia coli (21.2%) and Klebsiella oxytoca (18.2%). All tested bacteria were resistant to ampicillin. Resistance to third-generation cephalosporins was observed in 100% of tested Klebsiella pneumoniae, 83.3% of isolated Klebsiella oxytoca and 50.0% of tested Escherichia coli. None of the tested bacteria were resistant to carbapenems. Approximately 85.7 and 77.8% of gram-negative tested bacteria were resistant to first-line (ampicillin-gentamicin) and second-line (third-generation cephalosporins) treatments, respectively. In hospital mortality, adjusted for blood culture result, presence of asphyxia, birth weight and sex was higher among neonates with positive blood culture (adjusted relative risk [aRR] = 2.32; 95% confidence interval [CI] = 1.17-4.60), male sex (aRR = 2.07; 95% CI = 1.01-4.26), asphyxia (aRR = 2.42; 95% CI = 1.07-5.47) and very low birth weight (1000-1499 g) (aRR = 2.74; 95% CI = 1.3-5.79).
CONCLUSION
Overall, 77.8% of confirmed gram-negative neonatal infections could no longer effectively be treated without broad-spectrum antibiotics that are not routinely used in sub-Saharan Africa referral hospitals. Carbapenems should be considered an option in hospitals with surveillance and antibiotic stewardship.
Infectious diseases account for the third most common cause of neonatal deaths. Globally, antibiotic resistance (ABR) has been increasingly challenging neonatal sepsis treatment, with 26 to 84% of gram-negative bacteria resistant to third-generation cephalosporins. In sub-Saharan Africa, limited evidence is available regarding the neonatal microbiology and ABR. To our knowledge, no studies have assessed neonatal bacterial infections and ABR in Central-African Republic (CAR). Therefore, this study aimed to describe the pathogens isolated and their specific ABR among patients with suspected antibiotic-resistant neonatal infection admitted in a CAR neonatal unit.
METHODS
This retrospective cohort study included neonates admitted in the neonatal unit in Bangui, CAR, from December 2018 to March 2020, with suspected antibiotic-resistant neonatal infection and subsequent blood culture. We described the frequency of pathogens isolated from blood cultures, their ABR prevalence, and factors associated with fatal outcome.
RESULTS
Blood cultures were positive in 33 (26.6%) of 124 patients tested (17.9% for early-onset and 46.3% for late-onset infection; p = 0.002). Gram-negative bacteria were isolated in 87.9% of positive samples; with most frequently isolated bacteria being Klebsiella pneumoniae (39.4%), Escherichia coli (21.2%) and Klebsiella oxytoca (18.2%). All tested bacteria were resistant to ampicillin. Resistance to third-generation cephalosporins was observed in 100% of tested Klebsiella pneumoniae, 83.3% of isolated Klebsiella oxytoca and 50.0% of tested Escherichia coli. None of the tested bacteria were resistant to carbapenems. Approximately 85.7 and 77.8% of gram-negative tested bacteria were resistant to first-line (ampicillin-gentamicin) and second-line (third-generation cephalosporins) treatments, respectively. In hospital mortality, adjusted for blood culture result, presence of asphyxia, birth weight and sex was higher among neonates with positive blood culture (adjusted relative risk [aRR] = 2.32; 95% confidence interval [CI] = 1.17-4.60), male sex (aRR = 2.07; 95% CI = 1.01-4.26), asphyxia (aRR = 2.42; 95% CI = 1.07-5.47) and very low birth weight (1000-1499 g) (aRR = 2.74; 95% CI = 1.3-5.79).
CONCLUSION
Overall, 77.8% of confirmed gram-negative neonatal infections could no longer effectively be treated without broad-spectrum antibiotics that are not routinely used in sub-Saharan Africa referral hospitals. Carbapenems should be considered an option in hospitals with surveillance and antibiotic stewardship.
Journal Article > ReviewFull Text
Confl Health. 2021 April 6; Volume 15 (Issue 1); 21.
Kobeissi L, Menassa M, Mousally K, Repetto EC, Soboh I, et al.
Confl Health. 2021 April 6; Volume 15 (Issue 1); 21.
BACKGROUND
Antibiotic resistance (ABR) is a major global threat. Armed and protracted conflicts act as multipliers of infection and ABR, thus leading to increased healthcare and societal costs. We aimed to understand and describe the socioeconomic burden of ABR in conflict-affected settings and refugee hosting countries by conducting a systematic scoping review.
METHODS
A systematic search of PubMed, Medline (Ovid), Embase, Web of Science, SCOPUS and Open Grey databases was conducted to identify all relevant human studies published between January 1990 and August 2019. An updated search was also conducted in April 2020 using Medline/Ovid. Independent screenings of titles/abstracts followed by full texts were performed using pre-defined criteria. The Newcastle-Ottawa Scale was used to assess study quality. Data extraction and analysis were based on the PICOS framework and following the PRISMA-ScR guideline.
RESULTS
The search yielded 8 studies (7 publications), most of which were single-country, mono-center and retrospective studies. The studies were conducted in Lebanon (n = 3), Iraq (n = 2), Jordan (n = 1), Palestine (n = 1) and Yemen (n = 1). Most of the studies did not have a primary aim to assess the socioeconomic impact of ABR and were small studies with limited statistical power that could not demonstrate significant associations. The included studies lacked sufficient information for the accurate evaluation of the cost incurred by antibiotic resistant infections in conflict-affected countries.
CONCLUSION
This review highlights the scarcity of research on the socioeconomic burden of ABR on general populations in conflict-affected settings and on refugees and migrants in host countries, and lists recommendations for consideration in future studies. Further studies are needed to understand the cost of ABR in these settings to develop and implement adaptable policies.
Antibiotic resistance (ABR) is a major global threat. Armed and protracted conflicts act as multipliers of infection and ABR, thus leading to increased healthcare and societal costs. We aimed to understand and describe the socioeconomic burden of ABR in conflict-affected settings and refugee hosting countries by conducting a systematic scoping review.
METHODS
A systematic search of PubMed, Medline (Ovid), Embase, Web of Science, SCOPUS and Open Grey databases was conducted to identify all relevant human studies published between January 1990 and August 2019. An updated search was also conducted in April 2020 using Medline/Ovid. Independent screenings of titles/abstracts followed by full texts were performed using pre-defined criteria. The Newcastle-Ottawa Scale was used to assess study quality. Data extraction and analysis were based on the PICOS framework and following the PRISMA-ScR guideline.
RESULTS
The search yielded 8 studies (7 publications), most of which were single-country, mono-center and retrospective studies. The studies were conducted in Lebanon (n = 3), Iraq (n = 2), Jordan (n = 1), Palestine (n = 1) and Yemen (n = 1). Most of the studies did not have a primary aim to assess the socioeconomic impact of ABR and were small studies with limited statistical power that could not demonstrate significant associations. The included studies lacked sufficient information for the accurate evaluation of the cost incurred by antibiotic resistant infections in conflict-affected countries.
CONCLUSION
This review highlights the scarcity of research on the socioeconomic burden of ABR on general populations in conflict-affected settings and on refugees and migrants in host countries, and lists recommendations for consideration in future studies. Further studies are needed to understand the cost of ABR in these settings to develop and implement adaptable policies.
Journal Article > CommentaryFull Text
Lancet Microbe. 2020 June 1; Volume 1 (Issue 2); e56-e58.
Natale A, Ronat JB, Mazoyer A, Rochard A, Boillot B, et al.
Lancet Microbe. 2020 June 1; Volume 1 (Issue 2); e56-e58.
