By Professor Robinson Hammerton Mdegela – Sokoine University of Agriculture, Tanzania
Philomena, is a 30-year old woman living in one of the largest slum in East Africa. She has been coughing for the last three weeks and growing weaker by the day. She can hardly get out of her bed to ash her face and take a cup of porridge that her 6-year old daughter Matilda has prepared for her. Philomena’s partner, Joseph works in a mine in a neighboring country.
When her coughing began, she went to the local drug shop and purchased a few tablets that she started swallowing intermittently depending on how she was feeling on anyone morning. Her coughing persisted and became worse. Now she had fever and her appetite was really bad. She was losing weight rapidly and she kept to her house, fearing her neighbor would talk about her. She kept sending her daughter for more drugs. Then her sister visited from the city and noticed that matters were really bad. She suspected that Philomena was suffering from Tuberculosis (TB) and she was alarmed. She gave her a bath and organized transport to take her to the nearest big hospital where she was diagnosed with lung TB. She was put on a 6-month treatment course and given instruction on how to adhere on procedures that would help her recover well from the infection. Her sister was told to take Matilda to the hospital too so that she can be tested since she was living with her mother in a closed house.
After two months on treatment, Philomena stopped taking the drugs since she had started feeling better and was even able to work in her garden. Her sister had returned to her home in the city. However, Philomena was not yet free of the TB. When she started feeling sick again, she started taking the remaining drugs but she was not improving. Luckily, her husband Joseph came home for his leave and took her back to the hospital where she got the treatment. Tests were done and she was told her TB was no longer responding to the drugs she was given and she had to be sent to a bigger hospital for treatment.
Philomena’s story is not an isolated case; the rate at which patients are developing resistance to different categories of antibiotics is alarming. Antimicrobial agents formerly very effective in managing a broad range of infectious diseases, are no longer useable. The phenomenon is referred to as Antimicrobial Resistance (AMR) that imply development of resistance in microorganisms to antimicrobial agents to which it was previously sensitive.
The discovery of Penicillin - one of the world’s first and famous antibiotics - marked a true turning point in human history when finally, doctors had a tool to completely cure their patients from deadly infectious diseases. A wonder serendipitous discovery by Dr. Alexander Fleming in 1928 earned him a Nobel Prize in 1945. As Dr. Fleming famously wrote: “When I woke up just after dawn on September 28, 1928, I certainly didn’t plan to revolutionize all medicine by discovering the world’s first antibiotic, a bacteria killer. But I guess that was exactly what I did.”
Within 12 years (1928 - 1940) of research Dr. Fleming and other scientists turned this finding into nonpareil, with first patient treatment using Penicillin in 1941. Penicillin became very popular and useful in treatment of serious infectious bacterial diseases among Word War II soldiers. During 1950’s to 1960’s, more antibiotics and antimicrobial agents were discovered and continued to revolutionize healthcare, as bedrock of many of the greatest medical advances on the 20th Century.
Shortly after novel discovery of important antibiotics, resistance of microorganisms to antibiotics (antimicrobial agents) emerged and threatened many of advances in antibiotic discoveries and associated celebrities. For instance, the first use of penicillin for treatment of patients was in 1941 and resistance was reported in 1942. Similarly, Methicillin was introduced in 1960, and its resistance was reported in 1961. Such observations have demonstrated that the phenomenon is not new, rather newly and popularly reported. The emergence and spread of resistance to many of the antimicrobial agents that negate their effectiveness, is a global threat, being of concern both in developed and developing countries irrespective of its level of income and development as resistant pathogens do not respect borders.
The causes of antimicrobial resistance (AMR) in developing countries are complex and are rooted in practices of professionals and clients’ behaviors. Some of these factors include inappropriate prescription practices, inadequate education of users, limited diagnostic facilities, unauthorized sale of antimicrobials, lack of appropriate functioning drug regulatory mechanisms, and high usage of antimicrobials in animals without observation of withdrawal periods.
Globally, there is a growing concern over antimicrobial resistance (AMR) which is estimated to account for more than 700,000 deaths per year worldwide. According to WHO, if no appropriate measures are seriously taken to halt its progress, AMR threatens to cause ten million deaths annually and loss of about US$100 trillion by 2050, making it a top item on the global health security agenda. On the other hand, due to lack of data, it is rather difficult to estimate a corresponding loss that will occur in Africa. Communications and public awareness on consequences of AMR in low-income and middle-income contexts remain largely un-documented. The understanding of complexities related to antimicrobial resistance (AMR) and its magnitude in Africa is hampered by few and limited data on surveillance of drug resistance. Overall, there is invisible investment in research, prescriptions without laboratory diagnosis, self-medications and accessibility to antibiotics over the counter, sharing of drugs by family members, cessation of treatment as soon as patients start feeling better, poor record keeping by farmers, and weakness in regulatory oversight. As a result, there is incomplete and inadequate data reflecting the true extent and magnitude of the problem.
Despite such limitations however, the available data suggest that the African region shares the worldwide trend of increasing antimicrobial resistance. Poor environmental sanitation accelerates the incidence and prevalence of infectious diseases and consequently high demand and usage of antimicrobial agents. Moreover, there is increasing demand for meat, milk and eggs from intensive agriculture sustained by high levels of antimicrobial agents. Lack of diagnostic facilities is among the major causes of treatment of infectious diseases without laboratory diagnosis. Perceived tangible economic losses paralleled with no compensations during withdrawal periods compromises ethical, norms and moral obligations by farmers. Inexistence of consumers’ organizations and platforms for their rights and lack of incentives to producers that adhere to good agricultural practices and regulations puts consumers to much higher risks of exposure to antimicrobial agents. Testing for antimicrobial agents and respective residues in animals before slaughter as well as in meat, eggs and milk at the farm gate or in the market is not practiced in most of the African developing countries. Biosecurity principles that are well elaborate and applicable in large-scale production systems do not apply in African settings where the majority of livestock keepers are smallholders. Thus there is need to carry out research on innovative ways that would enhance containment of pathogens and where necessary to adhere to principles governing rational use of antimicrobial agents. Considering that these factors and other drivers for AMR in developing countries vary from those in developed countries, intervention efforts should address the African context and focus on the root causes specific and relevant to this part of the world.
Since the threat for AMR is global, interventions that are being implemented in different parts of the world are also global in nature and in harmony with the Tripartite Partnership between the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE). All these speak with one voice and advocate collective action to minimize the emergence and spread of AMR. The aim is to ensure that antimicrobial agents continue to be effective and useful to cure diseases in humans and animals. This can only be achieved through awareness creation, training and education; strengthened capacity for surveillance and real time burden estimation; establishment of appropriate policies, institutional and regulatory frameworks and networks such as OHCEA with interest to address AMR agenda; promotion and implementation of strategies to enhance infection prevention and control in public health as well as biosecurity principles in animal health; responsible and prudent use of good quality antimicrobial agents while fighting against counterfeit products; and investment in research and discoveries of new products. Sharing of data and good practices is of paramount importance. Use of platforms such as Global Antimicrobial Resistance Surveillance System (GLASS) and Assessment Tool for Laboratories and Antimicrobial Surveillance Systems (ATLAS) advances by WHO and FAO respectively are gaining popularity and are being implemented in different parts of Africa. Addressing the rising threat of AMR requires a holistic and multi-sectoral ‘One Health’ approach because antimicrobials used to treat various infectious diseases in animals are similar to those used in humans. Resistant bacteria arising either in humans, animals or the environment have the potential for spread among all these sources, and from one country to another. AMR does not recognize geographic or human/animal borders. The spread of antibiotic resistance is at higher pace than the rate of discovery and introduction of new products thus calling for need and efforts to preserve the precious available ones using One Heath approach. The One Health approach brings together professionals from different disciplines and domains to examine and address complex health challenges. Antimicrobial Resistance is a complex public health challenge that threatens global health security. It is therefore one of the key areas of discussion that will be focused on by academics, policymakers, students, practitioners and other professionals during an international One Health meeting in Kampala this July. The meeting is convened by One Health Central and Eastern Africa; a network of schools of public health, veterinary medicine and environmental health, working to develop capacity for One Health.
There is hope that such meetings can come up with innovative approaches to manage antibiotic use behaviors like in the case of Philomena will be strengthened to stem the development and explosion of antibiotic-resistant microorganisms and the global health threats that come with this phenomenon.