Experts in East Africa Propose Equitable AMR Interventions
The effects of antimicrobial resistance (AMR), such as fewer treatment options for bacterial and fungal infections, disproportionately impact under-resourced countries. This is often compounded with a higher burden of disease and systemic health inequities in some regions. Considering this convergence, a One Health approach that incorporates policy support, workforce development and effective laboratory capacity-building is critical to mitigating the impact and spread of this global public health threat. A collaborative and informed strategy means meeting communities where they are, advancing sustainable interventions and listening to local microbiologists and health care professionals.
“We need to improve coordination across the globe, including providing scientists the opportunity to share their data to advance microbiology and bolster health equity,” said Wes Kim, Ph.D., Director of ASM’s Global Public Health Programs (GPHP). “It’s not just about creating equity for the sake of it; it’s also about learning from local experts.”
Here, experts from Ethiopia, Mozambique and Tanzania—countries in East Africa that face similar health inequities and observe many of the same drug-resistant microbes in their communities—offer advice and expertise on combating AMR. They emphasize the need for equitable and accessible health care resources and sustained laboratory and workforce development.
How Health Inequities Impact AMR
The health care landscape in East Africa is shaped by a complex interplay of socio-economic, geographical and systemic factors. For any location, health inequities are often created because of the unequal distribution of health resources. For countries in East Africa—like Ethiopia, Mozambique and Tanzania—rural communities have limited access to health centers and diagnostic facilities, let alone affordable care options, which can lead to worsened health outcomes.
“Access to care is uneven, with variations in what is available at different levels of health care services and a need to pay for services,” Mtebe Majigo, M.D., MMed, a senior lecturer of microbiology and immunology at Muhimbili University of Health and Allied Sciences in Tanzania, said. “These variations drive health choices for providers and patients and may affect the effort to combat AMR.”
With the steep cost of visiting a health care provider to treat an infection, many patients self-diagnose their suspected infection and opt to go directly to a pharmacist. In Ethiopia, for example, it is common to obtain an antimicrobial without a prescription from a health care provider.
“There is currently no standard restriction,” explained Surafel Fentaw, former ASM local consultant and lab lead for the Ethiopian Public Health Institute's (EPHI) national bacteriology and mycology reference laboratory (NRL) in Addis Ababa and regional sentinel laboratories in Adama and Bahir-Dar. “If I needed [or asked for] something, the pharmacy would just dispense it.” The assumption is that self-diagnosing will ultimately lead to reduced health care costs (i.e., skipping the physician’s office means the only cost is the pharmaceutical, which can be quite expensive on its own). However, this practice can have long-term negative effects. If the patient has incorrectly identified their infection, their condition will not only stay the same or worsen, but taking an antimicrobial they don’t need could further contribute to the spread of AMR. Even if the patient’s self-assessment is correct, the drug they are given might not be the most effective choice, and they might not be provided guidelines on the appropriate length of treatment.
Similar findings have emerged throughout communities in Tanzania and Mozambique, where, even with guidelines that stipulate antimicrobials should not be dispensed without a provider’s prescription, drugs are often provided at the patient’s request. One study conducted in Maputo City, Mozambique described how this practice puts pharmacists “between a rock and a hard place”—helping patients that cannot access care means bypassing regulations, and ignoring guidelines could mean poor health outcomes in the future.
A patient in Mozambique stands outside Nampula Central Hospital.
Source: American Society for Microbiology. For patients who can visit health facilities, gender and age bias may affect the likelihood of antimicrobial misuse and/or overuse. “[Complications related to AMR] seem to favor certain groups based on their health-seeking behavior,” said Agricola Joachim, M.D., MMed, Ph.D., a professor in the School of Diagnostic Medicine at Muhimbili University of Health and Allied Sciences, noting that children and people assigned female at birth visit health facilities more frequently than people assigned male at birth.
Microbes on the Watch List
While dozens of microbes are identified on “watch lists” for being resistant to antimicrobials, global health and microbiology experts in Tanzania, Ethiopia and Mozambique cited 11 pathogens as priority candidates for AMR surveillance.
Several culprits of health care associated-infections (HAIs) were noted, including Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa (especially for its role in ventilator-associated pneumonia) and Staphylococcus aureus (a common cause of skin and blood infections).
Pathogens impacting the intestinal tract (and leading to acute diarrheal disease) include Escherichia coli, Salmonella spp. and Shigella spp. Enterococcus spp., which is commonly associated with urinary tract infections (UTIs), and Neisseria gonorrhoeae, which causes the sexually transmitted infection (STI) gonorrhea, have also been flagged.
With high-profile microbes identified, what’s next? Local experts advocate for sustainable efforts to monitor these microbial foes, equitably diagnose and treat patients and enhance best practice guidelines for AMR stewardship.
Opportunities and Strategies to Address the Global Spread of AMR
Strategies to combat AMR require collaborative and complimentary efforts that span multiple sectors. Microbiology experts based in East Africa provided the following recommendations:
- Improve awareness and education about AMR and its impacts, both in and outside of clinical settings (e.g., via community groups, journalists, health care providers, university students, social media, awareness campaigns, clinical training sessions). “At the health care provider level, there is awareness about AMR mainly in tertiary hospitals,” said Geremew Tasew, Ph.D. the Director of Bacterial, Parasitic and Zoonotic Diseases Research Directorate at the Ethiopian Public Health Institute. “However, the practice still lags and needs more effort, mainly on the overuse and misuse of antibiotics. At the community level, there still needs to be more awareness interventions.”
- Disseminate clear guidelines for both health care professionals and patients regarding appropriate antimicrobial use.
- Bolster current infection prevention and control (IPC) and stewardship programs in health care facilities.
- Increase access to quality lab supplies and infrastructure and introduce guidelines and policies for AMR reporting programs. “There needs to be more confidence among clinicians, as the laboratory often needs more quality supplies, which can contribute to inconclusive patient test results,” said Isabel Pinto, Ph.D., Director of the National Directorate of Medical Assistance (DNAM) at the Mozambique Ministry of Health.
- Improve access to health care resources, especially for under-resourced communities.
- Develop human-animal surveillance systems that support a One Health approach for addressing AMR.
- Improve access to clean water, which will in turn lead to better “sanitation and hygiene for both humans and animals,” said Sofia Omar Viegas, M.Sc. Ph.D., Deputy Director-General of Public Health Laboratories for the National Institute of Health of Mozambique.
- Strengthen guidance on antimicrobial use for livestock. “The irrational use of antibiotics in animals for treatment, growth promotion and disease prevention [contributes to AMR],” said Erick Komba, the Director General of Tanzania Livestock Research Institute (TALIRI). “Several studies have shown that there are high amounts of residues (e.g., tetracycline) in milk, cattle meat, broiler chickens and eggs.”
ASM's Global Public Health Programs (GPHP)
With opportunities to improve stewardship, health care access and laboratory capacity in mind, ASM is committed to cross-disciplinary collaboration with local experts and community leaders, sustainable funding efforts and implementing One Health-focused programs from concept to practice. “Part of advancing equity is getting everyone on board in terms of stewardship,” Kim, ASM’s GPHP Director, emphasized.
Since 2017, ASM has been instrumental in establishing the AMR surveillance network in Ethiopia. ASM local experts and consultants aided the Ethiopian Public Health Institute (EPHI) in developing the 2016-2020 AMR Surveillance Plan and supported basic microbiology diagnostics and AMR training at the national and regional levels. This training equipped staff with the knowledge and skills to sustain the surveillance system and routine microbiology lab services.
Surafel Fentaw supporting ASM’s AST training for EPHI’s NRL staff.
Source: American Society for Microbiology. Through structured mentoring and training, ASM worked with EPHI’s national bacteriology and mycology reference laboratory (NRL) in Addis Ababa and regional sentinel laboratories in Adama and Bahir-Dar to improve quality management. All 3 laboratories achieved 5-star status (the highest level) in the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA), contributing to the national accreditation of EPHI’s NRL in 2017. The staff members who were trained expressed that the ASM mentoring support made them feel more confident in their work and allowed them to continue teaching and instructing others in best practices in the lab. ASM’s training materials also helped them focus on improving quality assurance and competency building.
“The support of ASM is not only time and technical support provided, but they are always there for us,” Amete Mihret Teshale, a microbiologist at EPHI’s NRL and former ASM Young Ambassador of Science, said. “Time will not be enough to thank ASM for all their contributions and support they have given to our profession, and I shall stop here by saying that ASM is the backbone of microbiology in Ethiopia.”
To support the establishment of continuing education and professional development, ASM initiated the Extension Community Healthcare Outcome (ECHO) program in the region, which promoted regular interaction and real-time exchange of information between the NRL and the sentinel sites and enabled the program's continuity under EPHI's responsibility. ASM also empowered trained microbiologists to take concrete steps toward improving scientific knowledge by facilitating international scientific exchange programs, allowing Ethiopian staff to gain international experiences, including encouragement to submit abstracts and present their work at the ASM Microbe, ASM’s flagship annual conference.
A lab technician in Mozambique tracks test results at Nampula Central Hospital.
Source: American Society for Microbiology. Between 2010-2015, ASM worked alongside local experts to improve tuberculosis (TB) surveillance laboratories in Mozambique. After 3 years of ASM-sustained training and mentoring efforts to the TB National Reference Lab (NTRL) in Maputo, the lab became the first to hold ISO 15189 international accreditation. For patients, laboratory accreditation ensures that the test results are delivered quickly and accurately, which ensures proper diagnosis and treatment of disease. For the broader community and health system, accreditation provides a guarantee of quality. This accreditation engenders confidence that the data collected is reliable. In the following years, from 2015-2020, ASM helped TB regional reference labs in Beira and Nampula meet important laboratory milestones, with Nampula obtaining ISO 15189 accreditation in 2020.
“[ASM’s] support [helped create] a foundation [and a] culture of quality in all lab activities performed that will be implemented in all public health emergencies,” said Viegas at the National Institute of Health of Mozambique.
Through its local experts, ASM also focused on delivering customized microbiology training to enhance antibiotic susceptibility testing in Mozambique. The training further developed clinical laboratory quality control and external quality assurance systems by equipping over 100 lab technicians across all 9 country provinces. As a result, antibiotic susceptibility testing was decentralized to reach Mozambique's geographic regions, contributing to the country's response to AMR and COVID-19 testing.
“With the support received, it was possible to train technicians and elaborate on guidelines for microbiological techniques, as well as [standardize testing procedures] and the acquisition of means and procedures,” Pinto of DNAM at the Mozambique Ministry of Health said. “We were also able to design a strategy of revitalization of the area of microbiology.”
Since 2009, ASM has supported microbiology laboratory diagnostic services in Tanzania. This commitment extends to 11 regional laboratories, enhancing their capabilities and fostering local expertise in laboratory mentorship. ASM also supported laboratories in Tanzania in collecting and reporting animal surveillance data to global databases, which had not previously been done in the region.
More recently, through the Fleming Fund, ASM is enabling the execution of Tanzania's National AMR Surveillance Framework. This involves building laboratory capacity to generate top-tier microbiological data for patient care and to facilitate surveillance efforts across human and animal domains.
“These initiatives have greatly impacted combating AMR by improving the quality of laboratory service and the ability to generate AMR data to inform policy,” Majigo of Muhimbili University of Health and Allied Sciences said.
Maintaining the Momentum
The weight of addressing AMR should not be on a single profession, country or sector. Effectively combating AMR will require a collaborative, sustained global effort that draws from local expertise and community needs. Local experts asserted that beyond writing and enforcing antimicrobial stewardship guidelines, access to laboratory diagnostics and health centers must improve so that a patient does not have to choose between a diagnosis or treatment.
In This Issue:
- Lessons From a Decade of Antimicrobial Resistance Policy
- Growing Resistance: How Plant Agriculture Contributes to AMR
- Understanding the Risks of Antifungal Resistance
- Experts in East Africa Propose Equitable AMR Interventions
- Wastewater As a Key Driver of AMR
- Exploring a One Health Approach to AMR in Pakistan
- Federally Qualified Health Centers Lead AMR Stewardship
- Updating Breakpoints in Antimicrobial Susceptibility Testing
- Hunting for Antibiotics in Unusual and Unculturable Microbes
- What's Hot in the Microbial Sciences