Author: Dr Andrew Kambugu, Executive Director at the Infectious Diseases Institute (IDI) and Co-lead of the CAMO-Net Uganda Hub.
WHO Regional Strategy for NAP Implementation and Monitoring: A Push in the Right Direction in the Efforts to Control AMR
As the co-lead for the Uganda National Hub of the Centres for Antimicrobial Optimisation Network (CAMO-Net), I took great interest in last week’s World Health Organization Regional Committee for Africa meeting, where more than 1000 health experts and African ministers met in Botswana to discuss the health challenges facing our continent.
At the meeting, African nations endorsed a regional strategy to accelerate action against antimicrobial resistance (AMR), which is a cause for great optimism.
It’s indisputable that AMR is now an established pandemic and a threat to global health security1. There is also glaring evidence that low resource limited settings, particularly Sub-Saharan Africa, disproportionately bare the AMR burden, while efforts to set up surveillance systems and control strategies have not progressed as desired2. The World Health Organization Regional Committee for Africa’s strategy to expedite the implementation and monitoring of National Action Plans (NAP) is therefore a timely push in the right direction3. We receive this development with a lot of optimism and hope that it will result in the leadership, coordination and investment urgently needed to consolidate the early gains in AMR surveillance in the region.
As I read through the strategic focus, I am keen to see the low-hanging fruits that can be harnessed in this fight. It’s clear that the immediate gains will not come from new antimicrobials nor massive vaccination for common infections. Irrational use of antimicrobials promotes the selection of resistant microbes4 and poor infection prevention and control (IPC) practices allow the spread of the resistant microbes, especially in hospital acquired infection1. This situation unveils robust antimicrobial stewardship (AMS) and IPC programmes guided by robust evidence on the burden, distribution, and drivers of AMR as the tangible low hanging fruits for this region.
Effective AMS programmes require robust diagnostic stewardship, including microbiology laboratory infrastructure and human resources to detect AMR. The task in this direction is very clear, based on the Mapping Antimicrobial Resistance and Antimicrobial Use Partnership (MAAP) report that indicated that only 1.3% of the 50, 000 medical laboratories in 14 participating countries were able to provide bacteriology services5. Beyond laboratory-based testing, point of care diagnostics to differentiate bacterial from viral infections in out-patient settings would be a game changer in antimicrobial prescriptions6. Research and development efforts need to focus on this as they also strive to provide new antimicrobials, which would enable robust AMS programmes to thrive for longer.
Creating awareness and enhancing knowledge in antimicrobial use are critical in driving the stewardship agenda. However, these need to go beyond the current focus on prescribers and target both the prescribers and the consumers of the antimicrobials. Practices such as self-medication, medication sharing, and human use of veterinary formulation among others, which are drivers of AMR, are very rampant and need urgent attention7,8. Education geared towards prescribers should emphasise health promotion as a low hanging fruit to reaching out to the consumers of antimicrobials. Consumers of antimicrobials in the form of patients and caregivers constantly go through the hands of prescribers, presenting a golden opportunity for prescribers to create awareness in the consumers. The community level interventions would require sustained, systematic and meaningful community engagement to enact meaningful change in the use of antibiotics in these communities9.
Sustainable investment in the AMR response requires governments in the region to get involved as clearly elaborated in the guiding principles in the strategy. However, interesting governments to provide the required leadership and investment would require a clear description of the burden and health and economic consequences of AMR. The AMR related clinical outcomes including mortality and morbidity (years of life lost due to a disease or condition (YLL) and years lived with disability (YLD)) as well as the economic burden of AMR related to the increased cost of healthcare need to be determined at all levels in member countries10. Once these are known, they can then guide healthcare planning and resource allocation.
Guiding policies and regulations are a critical requirement rather than the exception to create a conducive environment for implementation of AMS and IPC programmes. This is another area that has severely lagged behind, hindering progress in AMR control. The magnitude of the problem is well highlighted in the strategy. Only eight of the 31 member countries have a national AMS policy and only nine have adopted the AWaRe classification to guide antimicrobial prescription3. Moreover, only a few countries have a One Health policy or a national drug use policy3. Lack of the appropriate policies perpetuates practices such as irrational use of antimicrobials in agriculture, use of animal formulations in humans and vice versa, counterfeit medicines, and non-prescription based access to antimicrobials, which are key drivers of AMR.
So, whilst the current situation across Africa requires much improvement, these encouraging announcements by the World Health Organization are a cause for great optimism. I believe things will soon start to improve, and as part of CAMO-Net, we have already taken the first steps towards developing a comprehensive understanding of how best to address AMR, and help to optimise the use of antimicrobials across Africa and the rest of the world.
References
1. WHO. Antimicrobial resistance. [Internet]. Nov 2021.
2. Murray C J L, Ikuta K S, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022 Feb;399(10325):P629-55.
3. WHO. Regional strategy for expediting the implementation and monitoring of national action plans on antimicrobial resistance, 2023–2030 in the WHO African Region: report of the Secretariat. [Internet]. 2023 Jul.
4. Carl Llor, Lars Bjerrum. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf. 2014 Dec;5(6):229–41.
5. Africa-CDC. Mapping Antimicrobial Resistance and Antimicrobial Use Partnership (MAAP) Country Reports. [Internet]. 2023 Jul.
6. S S, Numan A, S C. Point-of-Care for Evaluating Antimicrobial Resistance through the Adoption of Functional Materials. Anal Chem. 2022 Jan;94(1):26–40.
7. Afari-Asiedu S, Kinsman J, Boamah-Kaali E, et al. To sell or not to sell; the differences between regulatory and community demands regarding access to antibiotics in rural Ghana. Journal of Pharmaceutical Policy and Practice 2018;11(30).
8. Tang KL, Caffrey NP, Nóbrega DB, et al. Restricting the use of antibiotics in food-producing animals and its associations with antibiotic resistance in food-producing animals and human beings: A systematic review and meta-analysis. , . . The Lancet Planetary Health. 2017;1(8):e316–e27.
9. WHO. No time to Wait: Securing the future from drug-resistant infections. [Internet]. 2019.
10. Painter C, Faradiba D, Chavarina KK, al e. A systematic literature review of economic evaluation studies of interventions impacting antimicrobial resistance Antimicrob Resist Infect Control. 2023;12:69.
