Drug resistant infections are rising – Challenges and Hopes in sub-Saharan Africa

Yogandree Ramsamy^1,2,3*, Jamie Nunn⁴, Francesca Chiara⁴

¹ Medical Microbiology, College of Health Sciences, University of KwaZulu-Natal, South Africa; 
² National Health Laboratory Services, South Africa
³ Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, South
⁴ Drug Resistant Infections Priority Programme, Wellcome Trust
*Address correspondence to Yogandree Ramsamy.
Email: Ramsamyy@ukzn.ac.za, yogandree@gmail.com

Antimicrobial resistance (AMR) a global problem that jeopardizes the economic and social well-being of every individual (Essack et al., 2017). Irresponsible antibiotic use in humans and animals, poor infection prevention and control (IPC),  sub-optimal animal husbandry and biosecurity in the veterinary and medical fields has resulted in an era of untreatable bacterial infections (Mendelson et al., 2012).

Amongst low and middle-income countries (LMICs), especially those in sub-Saharan Africa, AMR is particularly challenging due to the extreme poverty and poor socio-economic circumstances exacerbating sickness and disease. Everyday challenges faced by healthcare systems in LMICs include understaffing, scarcity of healthcare personnel including medical specialists, overcrowding, poor access to lifesaving medication and absent information technology systems.

The African Context

The increased burden of infectious diseases is worsened by limited access to affordable, quality approved antimicrobials required to treat drug-resistant infections resulting in prolonged hospitalization, increased morbidity and mortality with associated financial implications (Founou et al., 2017). A lack of healthcare facilities in rural areas, expensive antibiotics and unreliable drug supply limits access to lifesaving antibiotics. Recently, the Global Antibiotic Research and Development Partnership (GARDP) has taken small steps to ensure equitable access to new antibiotics establishing public-private partnerships with governments, pharmaceutical and biotechnology industry, academia and civil society (Cox et al., 2017). GARDP has established a presence in Africa with a joint office with DNDi in South Africa, positioning it well to collaborate with local stakeholders within the continent (Basarab and Chibale, 2020).

Despite the global efforts in ensuring access to clean drinking water and improved sanitation as part of the United Nation’s (UN’s), sustainable development goals (SDGs), there are still many people, within rural communities lacking these essential services enhancing the spread of infections caused by MDROs (United Nations, 2015). As reported by UNICEF, almost 50% of the global population without access to safe drinking water lives in sub – Saharan Africa with around 700 million people lacking access to improved sanitation (UNICEF, 2015). Vaccination and IPC programs should be given high priority to limit the spread of MDROs and reduce antibiotic misuse and overuse (Duse, 2011). Vaccination coverage in Africa, currently inadequate, leaves room for improvement. With increasing drug-resistant infections and dwindling therapeutic options, Wellcome and the Bill and Melinda Gate Foundation, among others, have called for the development of vaccines targeting antibiotic-resistant bacteria (Klugman and Black, 2018).

Appropriate antibiotic prescribing requires the implementation of antimicrobial stewardship programs (ASPs) which has been challenging for many LMICs due to a lack of internal organization, human resources, funding and infrastructure (Cox et al., 2017). Laboratory support is crucial in the rapid diagnosis of infectious diseases, surveillance and monitoring of AMR. There are still significant gaps in the availability of AMR data in sub-Saharan Africa, however there has been commitment to improve laboratories capacity and to adopt adequate quality improvement processes. Quality assured diagnostics, reporting and clinical care is vital in ensuring healthy lives and promoting the well-being for all ages ( Davies et al., 2017). The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme is a competency-based management training programme created by US Centers for Disease Control and Prevention (CDC), in collaboration with the American Society for Clinical Pathology, the Clinton Health Access Initiative and the World Health Organization’s Regional Office for Africa (WHO AFRO). The programme consists of short courses combined with work-based applied learning projects ultimately aimed at achieving laboratory improvements that are measurable (Yao et al., 2016).

Against the background of the paucity of representative surveillance data, consortiums such as SEDRIC (Surveillance and Epidemiology of Drug-Resistant Infections Consortium) have established working groups to identify gaps and propose solutions to assist with global AMR surveillance focusing on  LMICs (Fukuda et al., 2018).  In 2019, SEDRIC held a global meeting attended by prominent researchers and stakeholders in AMR. This provided a platform for information sharing, collaboration and strategizing the development of surveillance networks to monitor AMR globally.

The Solutions

Multiple strategies such as leadership, international collaboration and national policies are needed to address AMR in sub-Saharan Africa. The WHO has set out a framework for the development and monitoring of countries following the implementation of National Action Plans (NAPs) (WHO, 2016). A success story was that of Ghana’s, leveraging both internal leadership from its  Ministry of Health and international support from Swedish International Development Agency through Action on Antibiotic Resistance (ReAct) in the development and launch of its NAP in 2018 highlighting the vital role played by strong political will and international support for AMR related activities (Opintan, 2018).

Developing the following  areas  are critical to successfully address AMR: 1) creating awareness, training and education of healthcare workers and community in AMR, 2) access and availability  to quality assured diagnostic testing, pathogen surveillance and the implementation of ASPs, 3)  local and international support towards the production, distribution, access and dispensing of antibiotics, 4) healthcare systems strengthening prioritizing immunization efforts and IPC measures such as hand hygiene, 5) ongoing, multi-sectorial collaboration between policy makers, academia, professional bodies, public-private sectors, non-profit organizations and civil society and 6) multidisciplinary partnerships between human, veterinary and environmental sectors to address AMR in a One Health context.

AMR is a global and urgent problem of pandemic proportions requiring the attention of multiple stakeholders and strategies to save lives.

References

 Basarab, G and Chibale K. 2020. Bringing antimicrobial research and development to Africa – the time is now. Available at https://revive.gardp.org/bringing-antimicrobial-research-and-development-to-africa-the-time-is-now/. Accessed on 22/6/2020.

Cox, J. A., Vlieghe, E., Mendelson, M., Wertheim, H., Ndegwa, L., Villegas, M. V., Gould, I. & Levy Hara, G. 2017. Antibiotic stewardship in low- and middle-income countries: the same but different? Clinical Microbiology and Infection, 23, 812-818.

Davies, J., Abimiku, A. l., Alobo, M., Mullan, Z., Nugent, R., Schneidman, M., Sikhondze, W. & Onyebujoh, P. 2017. Sustainable clinical laboratory capacity for health in Africa. The Lancet Global Health, 5, 248-249.

Duse, A. G. 2011. The Global Antibiotic Resistance Partnership (GARP), South African Medical Journal 101, 551-552.

Essack, S. Y., Desta, A. T., Abotsi, R. E. & Agoba, E. E. 2017. Antimicrobial resistance in the WHO African region: current status and roadmap for action. Journal of Public Health, 39, 8-13.

Founou, R. C., Founou, L. L. & Essack, S. Y. 2017. Clinical and economic impact of antibiotic resistance in developing countries: A systematic review and meta-analysis. PloS One, 12, 1-18.

Fukuda, K., Limmathurotsakul, D., Okeke, I. N., Shetty, N., Van Doorn, R., Feasey, N. A., Chiara, F., Zoubiane, G., Jinks, T., Parkhill, J., Patel, J., Reid, S. W. J., Holmes, A. H., Peacock, S. J., Surveillance & Epidemiology of Drug Resistant Infections, C. 2018. Surveillance and Epidemiology of Drug Resistant Infections Consortium (SEDRIC): Supporting the transition from strategy to action. Wellcome open research, 3, 59-59.

Klugman, K. P. & Black, S. 2018. Impact of existing vaccines in reducing antibiotic resistance: Primary and secondary effects. Proceedings of the National Academy of Sciences of the United States of America, 115, 12896-12901.

Mendelson, M., Whitelaw, A., Nicol, M. & Brink, A. 2012. Wake up South Africa! The antibiotic ‘horse’ has bolted. South African Medical Journal, 7, 607-608.

Opintan, J. A. 2018. Leveraging donor support to develop a national antimicrobial resistance policy and action plan: Ghana’s success story. African Journal of Laboratory Medicine, 7, 825-825.

UN General Assembly, Transforming our world : the 2030 Agenda for Sustainable Development. 2015. Available at:         https://www.refworld.org/docid/57b6e3e44.html. Accessed 12/06/2020.

UNICEF, UNICEF urges swift action, ‘robust financing’ to close water and sanitation gaps in sub-Saharan Africa. 2015. Available at:
https://news.un.org/en/story/2015/12/518222-uniceurges-swift-action-robust-financing-close-water-and-sanitation-gaps-sub#.VnHKyDbhjVo. Accessed 22/06/2020.

World Health Organisation. Antimicrobial resistance: a manual for developing national action plans.  2016. Available at https://apps.who.int/iris/handle/10665/204470. Accessed on 27/05/2020.

Yao, K., Luman, E. T., Nkengasong, J. N. & Maruta, T. 2016. The SLMTA programme : transforming the laboratory landscape in developing countries. African Journal of Laboratory Medicine, 5, 1-8.