Antimicrobial resistance in Africa

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What is the key takeaway from the new research on antimicrobial resistance published in The Lancet?

Authia Gray: The overall takeaway from the paper is that bacterial antimicrobial resistance, or AMR, is not just a problem for high-income countries, or countries with really high antibiotic consumption. As demonstrated in the paper, in Africa it is often the regions and the countries with fewer resources that are equally or more detrimentally affected. And in Africa, what we see is there is a really high burden of infections, as well as health care inequalities between the countries, that make AMR very difficult to surveil and to reduce.

What detailed findings deserve to be highlighted?

We estimated that there were just under 4 million infection-related deaths that occurred over the 12 month study period in which we were assessing AMR in Africa. Of these deaths, bacterial AMR made up for just over a quarter of them. With regard to the countries, Central African Republic, Lesotho, and Eritrea had the highest mortality rate associated with AMR, with over 200 deaths per 100,000 population.

And with regard to the pathogens, the four leading pathogens were Streptococcus pneumoniae, Klebsiella pneumoniae, and Escherichia coli, or E. coli as it's commonly known, and Staphylococcus aureus, with each one causing over 100,000 deaths.

What are the main challenges that the region faces in tackling antimicrobial resistance?

One of the main challenges is really the competition for public health funds, because as you may know, AMR is not the only public health crisis that Africa is facing. However, one of the things that we can take comfort in is that AMR reduction is complementary to infection reduction.

A lot of the benefits that have been seen through COVID-19, in terms of the expansion of surveillance sites, as well as the access to vaccines, are complementary also for reducing AMR. Additionally, another challenge is being able to fund and put together a national action plan.

National Action Plan is a framework that allows governmental and non-governmental agencies to work together to tackle a very large problem. AMR is one of those large problems. So a national action plan that addresses AMR will focus primarily on expanding access to primary health care resources, access to safe water, as well as sanitation, and also acquiring really crucial first line antibiotics, so that, altogether, with those components, we can prevent infections as well as treat the ones that are already there.

How do the findings for Africa compare to other regions in the world?

What we have found is that in Africa there is the highest mortality from antimicrobial resistance, despite Africa having the lowest prevalence of resistance compared to other regions. We believe that this is driven primarily due to the high burden of infection in the region.

Additionally, with regard to the pathogens, what is interesting is that Streptococcus pneumoniae and Klebsiella pneumoniae make up most of the burden, exceeding that of E. coli as well as Staphylococcus aureus.

Meanwhile, in other regions it is often E. coli and Staphylococcus aureus that are making up over half of the burden. And then finally, we see a really high prevalence of resistance to Trimethoprim Sulfamethoxazole, or Trim Sulfa, and is often in combination with Streptococcus pneumoniae.

While further study is required to know what the exact drivers are of this resistance, we do think that this could be related to using Trim Sulfa as an oral agent to treat pneumonia and urinary tract infections, and is also used as prophylaxis against opportunistic infections for those diagnosed with HIV.

What are the key steps that need to be taken to improve the situation regarding antimicrobial resistance in Africa?

I think that there are three key steps that would be beneficial to address AMR in Africa.

Firstly, really focusing our energy on reducing infection burden. This can be done through a number of ways, such as expanding access to primary health care services, vaccines, safe water and sanitation. But it is also important to improve the quality of the health care to prevent nosocomial infections.

Secondly, it is important to expand surveillance so that we have data, so we can make better estimates. And this involves expanding laboratories, their infrastructure, their capacity, as well as building microbiological facilities.

And finally, it is important to expand national awareness. So this involves creating national action plans that target AMR and utilize that collaboration between governments as well as non-governmental organizations.

How important is the fight against antimicrobial resistance for national governments and Africa CDC?

Dr. Yewande Alimi:
So one of the most important issues that Africa CDC are taking on is antimicrobial resistance.

Since the establishment of Africa CDC, as far back as 2017, the ministers of health of the African Union member states really prioritized antimicrobial resistance. And, as such, Africa CDC developed a strategic document, the Africa CDC Framework for Antimicrobial Resistance, really primarily focusing on four key objectives to be able to address antimicrobial resistance on the continent.

Of course, you must know that Africa has the highest burden around antimicrobial resistance, given the modeling results and some of the findings that we have also conducted with several of our partners.

As such, Africa CDC has really prioritized antimicrobial resistance, looking at four crucial areas. One is addressing issues around improvement of surveillance, not just of antimicrobial resistance organisms, but also understanding the rate and consumption of antimicrobials across the different African Union member states.

We've really adopted a One Health approach to ensure that surveillance is not just in the human health sector, but looking at states across the animal as well as plants, as well as the environmental health sectors.

We've also prioritized some strategies and interventions that look at delaying emergence, and this really focuses on issues around stewardship, treatment guidelines, understanding what the National Essential Medicines List look like and addressing issues of access.

We've also looked at the third objective of that strategic framework is around limiting transmission of antimicrobial resistance. And this really looks at preventive measures required to reduce infections, such as infection prevention and control, biosafety, biosecurity in agriculture, but also using vaccines, for example, to really reduce the need for people to consume antimicrobials.

And, of course, we mustn't forget addressing issues of WASH, as well as several other interventions required to reduce consumption of antimicrobials.

Lastly, is really around mitigating harm among patients already affected with antimicrobial resistant organisms. And this really looks at issues that we need to address when you think about diagnostic stewardship.

For example, what is the current capacity of bacteriology laboratories across the African continent? Is there a need for us to push for access to rapid diagnostic tests, for example? And as such, these are the things that Africa CDC, as well as African Union organizations, are addressing using a One Health approach.

Why is antimicrobial resistance such an important issue in Africa?

On the African continent it is pertinent to say that AMR is one of the biggest challenges that you can think about. Many people argue that, well, it seems to be very human health-centric. But I also raised the fact that, think about the rural farmers in the most remote part of Africa. Antimicrobials are important to them, means that they are source of living, which is trade, food animals, livestock, is being affected, means that if drugs don't work anymore, what happens to the most rural people in Africa whereby the livestock is the source of earning?

Think about the overall trade implications for the continent. Think about issues around plant health. Think about issues around the environment, wastewater, for example. AMR seems to be everywhere. Whether we agree or whether we, whether we can see it or whether we cannot, AMR is right there in our faces.

So for me, on how I approach, I understand, AMR is really that cross-cutting issue that can bring a stop, or regression, to the progress we have made when you think about modern medicine. So AMR really is a real great priority for African continent and it's really important that we are having conversations such as this, to really reflect the importance of antimicrobial resistance.

How critical to Africa’s response to AMR is improving surveillance and laboratory infrastructure?

It's impossible to do AMR surveillance without addressing the critical gaps around national laboratory networks for AMR surveillance. A critical finding that we were able to showcase is the fact that across 14 countries, only 1.3% of the laboratories have bacteriology capacity, already it shows the clear gap around the quality, the quantity of AMR surveillance data coming from the African continent, but really highlighting some priority areas for national government.

It's simply not acceptable that we don't have enough microbiology laboratories in Africa, and we have to ensure that we have enough resources to be able to ensure that basic utilities, equipment, workforce trainings, I'm thinking about career development, is available to create that sustainable environment for a AMR surveillance.

A few things that are quite important is really the need for national governments to prioritize a bacteriology capacity as a crucial cornerstone for AMR surveillance.