Heidi Hopkins

This paper reflects upon the experience of the Fleming Fund in designing and implementing One Health antimicrobial resistance (AMR) programs in 25 countries and identifies practical lessons for the design of future One Health programs. The Fleming Fund experience highlights key priorities for implementing One Health effectively within AMR programs–though many of the insights should be applicable to other contexts as well, such as emerging infectious diseases and health security. One Health should be treated as an approach to problem framing and action rather than a program output, with flexibility for national adaptation. Meaningful implementation requires sustained investment beyond human health, particularly in animal and environmental sectors, to avoid symbolic engagement. Surveillance systems should consider both the role of the sector and sector-specific needs, supported by capacity for joint interpretation and use of evidence. The costs of multisectoral coordination should be explicitly resourced and both formal governance mechanisms and informal professional networks recognized as essential for building trust, sustaining collaboration, and translating data into policy-relevant action.

Background: This paper builds on the other papers in this series to present high-level lessons learnt and considerations for the future of antimicrobial resistance (AMR) surveillance and its contribution to action on AMR in low- and middle-income countries. Methods: Participatory synthesis involved engagement with individuals who had worked within and alongside the Fleming Fund from a range of organizations and geographies, to scope and solidify lessons learnt and future considerations relevant to a wide range of donors, partners, and policy makers or implementors. Contributors were invited to join a Writing Group, which included individuals from academia, clinical sciences, applied public, animal, environment, and food sciences health, as well as senior scientists and administrators from 14 organizations. The synthesis was informed by contributions to 4 virtual workshops and 3 drafts of the manuscript. Authors read and commented on the drafts, several wrote and referenced sections, and all gave substantive feedback with their reactions to the draft conclusions as consensus was built. Results: Over nearly 10 years, the Fleming Fund achieved significant improvements in AMR surveillance. Analysis of the barriers and enablers across settings and systems highlights key lessons for how surveillance is positioned, funded, used, and innovated upon. The success of future AMR surveillance and its sustainability relies on planning within resource constraints for a sharpened system that focuses the scope, frequency, and depth of data to inform action, technical, and architectural developments directions to streamline investment and financing that supports country-led sustainable approaches. Conclusions: Investment in AMR surveillance and broader AMR actions has yielded substantial progress. Expanded domestic public financing, large-scale private sector engagement, or enhanced multilateral support will be needed to ensure recent gains are sustained. Progress will require well-designed, targeted, and cost-effective investments to maintain current capacity while enabling further system strengthening.

Background: Drawing on the Fleming Fund's work to strengthen antimicrobial resistance (AMR) surveillance across Africa and Asia during 2018–2026, this article provides one of the first syntheses of AMR surveillance data use in low- and middle-income countries. Methods: A participatory synthesis for narrative review was conducted to summarize experience across administrative levels (facility, subnational, national, and regional). Results: Data use was most evident at the facility level, in human health systems where resistance patterns, antimicrobial use, and clinical data increasingly informed antimicrobial stewardship, infection prevention and control, and other quality improvement initiatives. Data use in other sectors required different approaches. At the national level, Fleming Fund investments were associated with revisions of treatment guidelines, updates of essential medicines lists, and regulatory measures, primarily through improved governance and policy communities. Regional platforms supported member country data use at the national level. Subnational data use was undertaken in countries with decentralized health systems. Across levels, data use pathways driven by local priorities helped surveillance inform action. Conclusions: Fleming Fund experience suggests that surveillance is more likely to inform action when data use is built into system design. Continued investment will be needed if AMR surveillance is to improve policy and practice in low- and middle-income countries.

Background: An estimated 390 million dengue virus (DENV) infections occur per year, 70% in the Western Pacific and Southeast Asia. A prototype rapid diagnostic test (RDT) (NS1, immunoglobulin M [IgM]/immunoglobulin G [IgG]; DengueDx, Mologic) was evaluated for accuracy and ease of use for dengue diagnosis at Mahosot Hospital, Vientiane, Lao People’s Democratic Republic. Methods: Five hundred twenty-six sera collected in 2017 and 2018 from patients hospitalized with suspected dengue were included. Prototype RDT results were compared to NS1 and IgM enzyme-linked immunosorbent assays and/or real-time reverse-transcription polymerase chain reaction as reference assays and to Bioline dengue RDT (NS1, IgM/IgG) as comparator. The accuracy of the image-based result interpretation (RDT scan or photograph) at day 0 and after a delay of 7 days was evaluated. Five technicians were observed when performing RDTs and interviewed on their perception of the ease of use. Results: The overall sensitivity and the sensitivity for NS1 detection alone were significantly lower for the prototype RDT (65.2% [95% confidence interval {CI}, 59.3%–70.8%] and 44.6% [95% CI, 38.0%–51.4%], respectively) than for the Bioline RDT (76.7% [95% CI, 69.1%–83.2%], z-test P = .014; and 66.7% [95% CI, 57.5%–75.0%], z-test P < .001, respectively). The positive predictive value of the prototype RDT for detection of NS1 was >90%. Only half of the positive results were found positive when reading results from images. Correlation of >98% for positive results was obtained between reading at day 0 and reading at day 7. During ease of use assessment, when performing the Bioline RDTs the participants made fewer errors and were more satisfied than when performing the prototype RDTs. Conclusions: Improvement in test sensitivity and in device design would adapt the prototype RDT for Laos and similar contexts. Optimization of the prototype RDT is warranted and further evaluation in different healthcare settings would provide a more accurate estimation of the value of this RDT for dengue surveillance in remote areas.

There are few leptospirosis incidence studies despite such estimates being central to accurate burden of disease estimation. We used data from the multicenter Febrile Illness Evaluation in a Broad Range of Endemicities (FIEBRE) study to make leptospirosis incidence estimates from new sites. Febrile patients aged ≥2 months in Laos, Malawi, Mozambique, and Zimbabwe were enrolled and underwent standardized clinical and exposure assessment. Acute and convalescent sera were tested by Leptospira microscopic agglutination test and acute plasma by lfb1 polymerase chain reaction (PCR). Participants with ≥4-fold rise in antibody titer between acute and convalescent sample, or Leptospira PCR positive for the lfb1, had confirmed leptospirosis. Leptospirosis incidence was estimated after adjusting for incomplete enrollment of febrile patients, availability of paired sera, and use of study healthcare facilities by febrile patients based on healthcare utilization data from community controls. Leptospirosis incidence (95% CI) per 100 000 population per year was 1302 (1011, 1677) in Laos, 1337 (874, 2044) in Malawi, 187 (85, 409) in Mozambique, and could not be calculated for Zimbabwe. Sensitivity analysis restricted to pre-COVID years of 2018 and 2019 produced similar estimates of incidence to that of the whole study period. Leptospirosis incidence was high at the Laos, Malawi, and Mozambique sites and at the upper end of published incidence estimates from the Asia and Africa regions. We recommend more leptospirosis incidence studies be done in areas lacking data to strengthen leptospirosis global burden of disease estimates and to stimulate progress on diagnosis, management, and control.

This study has employed a mixed methods approach that combined qualitative data collected during field visits with quantitative programme data, including sample throughput, procurement records, point prevalence surveys of antibiotic prescribing, and cost data (associated with microbiology and AMR surveillance) collected through the Technical Assistance for Data and Evidence Use Regional Grant (TADE Africa) and the Zambia country grant.

This study has employed a mixed methods approach that combined qualitative data collected during field visits with quantitative programme data, including sample throughput, procurement records, point prevalence surveys of antibiotic prescribing, and cost data (associated with microbiology and AMR surveillance) collected through the Technical Assistance for Data and Evidence Use Regional Grant (TADE Africa) and the Zambia country grant.

Towards a One Health AMR Surveillance System: protocol for active AMR surveillance in commercial broiler and layer chicken populations for the Fleming Fund Grants Programme.

The Fleming Fund has supported antimicrobial resistance (AMR) surveillance capacity building in Zambia since 2018. In the human health sector, this support contributed to substantial improvements in laboratory infrastructure, equipment, workforce development, quality assurance, governance, and the routine use of data. These investments were associated with measurable gains in diagnostic capacity, sample throughput, laboratory performance, and antimicrobial stewardship (AMS) practices. The example of Livingstone Teaching Hospital (LTH), which has benefitted from the programme, illustrates how targeted investments can mature into functional surveillance systems that support clinical decision-making, influence prescribing behaviour, and inform policy. Our analysis shows that surveillance capacity can be established relatively rapidly when investments are well-sequenced and aligned with national priorities. However, sustaining and fully realising these gains is significantly more challenging. Recurrent costs, particularly consumables and equipment maintenance, remain heavily donor-dependent, while procurement failures, staff turnover, uneven engagement by clinicians, and reliance on individual champions reduce system resilience and efficiency. Cost and output analysis across sentinel sites also demonstrated economies of scale, with higherthroughput and more mature laboratories achieving lower costs per sample. Once laboratories move beyond the set-up phase, the principal sustainability challenge is no longer capital investment, but reliable financing for recurrent inputs, particularly consumables, equipment maintenance, and staff time. Without stronger domestic financing and more reliable procurement systems, recent gains risk erosion after donor support ends. At the same time, the Fleming Fund has created durable assets that provide a strong platform for future AMR-related interventions, including functional laboratories, skilled personnel, governance structures, and routine data flows. The central conclusion of this review is that sustainability is not only a financing issue, but a systems-alignment challenge. The long-term value of AMR surveillance depends on whether countries can embed diagnostic services, procurement, stewardship, and data use into routine, trusted, and financed health-system functions.

Background: We investigated the prevalence, diversity, and risk factors for acute leptospirosis in the Febrile Illness Evaluation in a Broad Range of Endemicities (FIEBRE) study. Methods: Febrile patients aged ≥2 months in Laos, Malawi, Mozambique, and Zimbabwe underwent a standardized clinical and exposure assessment. Acute and convalescent serum were tested by Leptospira microscopic agglutination test (MAT) and acute plasma by lfb1 polymerase chain reaction. A ≥4-fold rise in antibody titer, or a single reciprocal titer ≥800, or Leptospira PCR positive defined confirmed leptospirosis. The identity of possible infecting strains was investigated by MAT and sequencing of PCR products. Results: Of 7851 febrile participants enrolled, 134 (1.7%) had confirmed leptospirosis: 88 (4.6%) in Laos, 17 (1.0%) Malawi, 7 (0.3%) Mozambique, and 22 (1.2%) Zimbabwe, and 23 (0.8%) had supportive evidence of leptospirosis. Participants with leptospirosis had greater odds of headache (adjusted odds ratio [aOR] 2.20, P < .001), rash (aOR 1.45, P < .001), conjunctivitis (aOR 3.33, P < .001), and jaundice (aOR 1.75, P < .001); and had greater odds of being older (aOR 1.02 per year, P < .001), working in rice fields (aOR 6.24, P < .001), drinking river water (aOR 5.11, P = .001). Predominant reactive Leptospira serogroups were Ballum and Icterohemorrhagiae at African sites, and Australis in Laos. Identified species were Leptospira borgpetersenii, L. interrogans, and L. kirschneri. Conclusions: Leptospirosis was a cause of febrile illness at all sites. Some clinical features helped to identify patients with leptospirosis. Interventions related to rice field work and river exposure may prevent disease. Diverse Leptospira serogroup reactivity was observed and may suggest potential hosts.