Antibiotic resistance occupies centre stage on the global public health agenda as a “tragedy of the commons”. It affects developed and developing countries equally.
Antibiotic resistance develops when bacteria are not affected by antibiotics that previously inhibited or destroyed them and cured infection. It is a result of indiscriminate antibiotic use in human, animal and environmental health. This includes overuse, under-use and inappropriate use.
Infections caused by resistant bacteria result in illnesses lasting longer, as well as higher mortality rates. They also come with the increased risk of spreading infection and incur higher costs as patients seek alternative treatment.
Africa has high levels of poverty, increased risk factors for communicable diseases and one of the world’s worst HIV and AIDS burdens. These factors lead to extensive antibiotic use and subsequent resistance. What is known about the scale of the problem in Africa is set out in a World Health Organisation (WHO) report as well as a review of antibiotic resistance in sub-Saharan Africa.
The burden of antibiotic resistance is however under-estimated. African countries don’t have comprehensive national surveillance systems that quantify the problem in human health. There is also little or no surveillance in animal health.
Political will to address the problem of resistance only began to emerge after the 2011 World Health Day campaign. This included the launch of a six-point policy package.
This package, a precursor to the Global Action Plan on Antimicrobial Resistance, reframed the actions governments must take to improve the situation. All member states of the WHO adopted the plan in May 2015. Countries committed to develop and implement national plans by May 2017. The plan has five strategic objectives:
effective communication, education and training to improve awareness and understanding;
surveillance-based research to strengthen the knowledge and evidence base;
effective sanitation, hygiene and infection prevention to reduce the incidence of infection;
rational use of antimicrobials in human and animal health; and
sustainable investment to contain resistance. This includes investment in developing new medicines and diagnostics.
Several global, regional and national interventions have been implemented. A Global Antibiotic Resistance Partnership has been created with chapters in eight low- and middle-income countries.
The Alliance for the Prudent Use of Antibiotics has created chapters in 66 countries to improve access to antibiotics and to promote their appropriate use. ReAct, with networks in Latin America, Southeast Asia and Africa, launched a toolbox in 2015 to give guidance on how to address antibiotic resistance.
The EU has done the most in terms of regional initiatives with its comprehensive roadmap. In Southeast Asia the WHO has published a regional strategy while the WHO Africa Office is in the inception phase of developing a strategy for the continent.
The UK is furthest with its five-year plan. The US has published its National Action Plan and Australia has a framework to contain resistance. India’s Chennai Declaration has been commended as “a solution to antibiotic resistance in developing countries”.
South Africa takes the lead on the continent
South Africa is the first country in Africa to have published a strategic framework on antibiotic resistance. The framework sets four objectives:
to set up national and health governance structures to strengthen, coordinate and institutionalise interdisciplinary efforts;
to optimise surveillance and early detection to enable reporting of trends at local, regional and national levels;
to improve infection prevention and control to contain the spread of resistant microbes to patients. This focuses on hand hygiene and patient isolation; and
to promote the appropriate use of antimicrobials.
The framework acknowledges that it can only succeed if the country’s health system is strengthened. All interventions are underpinned by education, public awareness and a sustained communication and information campaign.
Antibiotics in agriculture
About 80% of all antibiotics are used in agriculture, mainly in food for animals. This has led to the global adoption of the “One Health” approach to antibiotic resistance. This encourages interdisciplinary collaboration and communication on health care for humans, animals and the environment.
This approach led to the GAP being developed in partnership with the UN’s Food and Agriculture Organisation, the World Organisation for Animal Health and the World Bank.
It will take strong political will to address the challenge of antibiotic resistance. It also needs sustained investment to understand the nature and extent of resistance. This in turn will inform treatment guidelines, antibiotic stewardship and infection prevention and control measures in humans and animals.
Everybody must get involved in the fight against antibiotic resistance: the public and private sectors, governments and the multinational pharmaceutical industry. Non-profit organisations, civil society, healthcare professionals and especially patients all have a role to play. It is time to suspend sectoral interests for the public good.