Experts in East Africa Propose Equitable AMR Interventions

The . This is often . 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.

A lab technician at the INS National TB Reference Lab in Mozambique. — A lab technician in Maputo, Mozambique at INS National TB Reference Lab applies new skills acquired from ASM's tuberculosis training.
Source: 海角社区app.

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,” , 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, .

“There is currently no standard restriction,” explained Surafel Fentaw, former 海角社区applocal 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 and , 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 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 outside Nampula Central Hospital in Mozambique. A patient in Mozambique stands outside Nampula Central Hospital.
Source: 海角社区app. 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 , 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 , , (especially for its role in ventilator-associated pneumonia) and (a common cause of skin and blood infections).

Pathogens impacting the intestinal tract (and leading to acute diarrheal disease) include , and , which is commonly associated with urinary tract infections (UTIs), and , which causes the sexually transmitted infection (STI) gonorrhea, have also been flagged.

Lastly, , the causative agent of meningitidis, and , which causes community-acquired pneumonia, can be resistant to 1 or more antimicrobials.

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 .
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 .
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, 海角社区appis 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.

海角社区appGPHP Director Wes Kim is honored for his work in Tanzania. — ASM's GPHP Director Wes Kim receives a certificate of appreciation for support in combating AMR in Tanzania.
Source: 海角社区app.

Ethiopia

Since 2017, 海角社区apphas been instrumental in establishing the AMR surveillance network in Ethiopia. 海角社区applocal 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鈥檚 AST training for EPHI鈥檚 NRL staff. Surafel Fentaw supporting ASM’s AST training for EPHI’s NRL staff.
Source: 海角社区app. Through structured mentoring and training, 海角社区appworked 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 海角社区appmentoring 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 海角社区appis 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 海角社区appYoung Ambassador of Science, said. “Time will not be enough to thank 海角社区appfor all their contributions and support they have given to our profession, and I shall stop here by saying that 海角社区appis the backbone of microbiology in Ethiopia.”

To support the establishment of continuing education and professional development, 海角社区appinitiated the , 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. 海角社区appalso 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 海角社区appMicrobe, ASM’s flagship annual conference.

Group photo of attendees at an AMR surveillance meeting in Ethiopia. — EPHI-ASM-CDC kickoff collaborative for AMR surveillance support in Ethiopia.
Source: 海角社区app.

Mozambique

A lab tech at Nampula Central Hospital in Mozambique. A lab technician in Mozambique tracks test results at Nampula Central Hospital.
Source: 海角社区app. Between 2010-2015, 海角社区appworked 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 . 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, 海角社区apphelped 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, 海角社区appalso 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.”

Tanzania

Since 2009, 海角社区apphas supported microbiology laboratory diagnostic services in Tanzania. This commitment extends to 11 regional laboratories, enhancing their capabilities and fostering local expertise in laboratory mentorship. 海角社区appalso 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 , 海角社区appis 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 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.

Author: Leah Potter, M.S.

Leah Potter, M.S., joined the 海角社区app as the Communications Specialist in 2022. Potter earned a Bachelor of Arts degree in journalism and mass communication from The George Washington University and a Master of Science degree in health systems administration from Georgetown University.

海角社区app

海角社区app