Implementation of GLASS-AMR: An assessment in WHO's Eastern Mediterranean Region.

Background: Global Antimicrobial Resistance and Use Surveillance System-antimicrobial resistance (GLASS AMR) aimed to create national surveillance systems to estimate the extent and burden of AMR globally. Methods: We adapted the United States Centers for Disease Control framework to evaluate GLASS-AMR implementation in WHO's Eastern Mediterranean Region by (1) describing the system and (2) reviewing its key attributes using mixed methods. We reviewed GLASS documents, reports, manuals, Regional External Quality Assessment Scheme (REQAS) survey and progress reports submitted by WHO technical consultants over the years, analyzed the surveillance data generated in the Region and finally triangulated the key findings with selected national focal points from ministries of health. Results: All countries submitted to the GLASS at least once by 2022. Representativeness varied between countries, and the data management and reporting requirements were quite complex due to differences in the laboratory record keeping and data information systems. Patient selection process and insufficient laboratory quality assurance measures might have affected the sensitivity and quality of the data. Although in some respects the quality of data was better compared to other WHO Regions, there is substantial variation in quality and data completeness between countries within the Region. In terms of timeliness, the design of the system based on yearly reports meant that local feedback loops that would have guided timely local decision making did not always happen. GLASS demonstrated to be flexible with inclusion of new pathogens and specimen types. Conclusion: Variable level of quality across countries, and issues of sensitivity, representativeness, and timeliness issues might have affected the usefulness of the system to guide decision making. Implementing national AMR surveillance systems should focus on sustainability and generating and using good quality data for timely action.