South Africa’s war against superbugs

Ronel Sewpaul, CNS Correspondent, South Africa
What if the medicines that are used to treat our illnesses became ineffective over time? What if the hitherto curable diseases become untreatable? The peril of antimicrobial resistance (AMR) that is looming large, has already started taking its toll and is likely to escalate if not addressed urgently.

Antimicrobial resistance is the ability of bacteria, viruses and parasites that cause infections to become resistant to the medicines used to treat them, such as antibiotics, antivirals and anti parasites. Standard treatments then become ineffective, leading to persistent infections that may spread further. Microorganisms that develop antimicrobial resistance are often referred to as ‘superbugs’.

AMR is silent tsunami, requiring urgent action, says Dr Haileyesus Getahun, Coordinator of the United Nations Interagency Coordination Group (IACG) on Antimicrobial Resistance. The group supports governments across the world in implementing strategies to address AMR, thus coordinating global action against this avoidable epidemic.

Globally, AMR is linked to an estimated 700,000 deaths per year and this figure could rise to 10 million deaths in the next 35 years. Resistance has emerged in microbes used to treat a range of infections, thereby threatening the ability to treat common infectious diseases and raising healthcare costs. For example, drug resistance in TB is well known. As per WHO’s Global TB Report 2018, multi drug resistant TB (MDR-TB) increased alarmingly from 490,000 cases worldwide in 2016 to 558,000 cases in 2017. Moreover, only 50% of the MDR-TB patients are successfully treated. Data on HIV and malaria drug resistance has started emerging only recently. Over 34,000 deaths are attributable to HIV drug resistance in sub-Saharan Africa alone. These findings are particularly relevant for South Africa, which has an HIV prevalence of 12%, and also has a very high TB burden, as well as high rates of community and hospital-acquired infections.

Drug resistant microbes are present in humans, animals, food, and the environment. Hence, AMR can spread from (i) person to person, (ii) via the food chain through consumption of meat/agricultural products, and (iii) waste disposal of antibiotics and animal waste into the environment. While AMR occurs naturally over time, often by genetic mechanisms, it is being accelerated by inappropriate use of antimicrobials in people and animals, and this requires urgent attention.

The irrational use of antibiotics, including their overuse for minor infections, through self medication and misuse, are key drivers in the spread of AMR across countries including South Africa, explained Professor Natalie Schellack from the Division of Clinical pharmacy at the Sefako Makgatho Health Sciences University in Pretoria, who conducts research on AMR consumption. She mentioned that improving the prescribing and dispensing of antibiotics is imperative. However this can be challenging within South Africa’s two-tiered healthcare system- the public sector that caters to the majority of South Africans (about 84%, 42 million people), and a private sector that is only affordable by a minority (about 16% of the population, 7 million people).

World Antibiotic Awareness Week takes place in November each year. It aims to educate the public and health providers on the correct use of antibiotics, such as the importance of completing the prescribed course and first seeking medical advice before taking antibiotics.

Since 2012, South Africa made major progress in its efforts to combat AMR. The South African Antibiotic Stewardship Programme (SAASP), a multi-disciplinary group of experts in human and animal health, with support from the National Department of Health, developed the country’s AMR National Strategy Framework 2014-19. One of the framework’s main objectives is to promote optimal antimicrobial use in human and animal health. South Africa has published antimicrobial stewardship guidelines, and is finalising guidelines for AMR prevention and control in hospitals.

Surveillance data on antimicrobial use and resistance is key to informing AMR strategies and aligning with the Global Action Plan on AMR. South Africa enrolled in the Global Antimicrobial Resistance Surveillance System (GLASS) in 2016, which supports standardized collection, analysis and sharing of AMR data among countries, and includes laboratory surveillance methods.

Antimicrobial consumption data is scarce in African countries including South Africa, mentioned Prof Schellack. A study by the Centre for Disease Dynamics, Economics & Policy in 2011 found that antimicrobial procurement data for South Africa was available from the private sector but focused exclusively on antibiotics, and that collection of antimicrobial consumption data in the public sector was in its infancy. Prof Schellack and colleagues found that public sector data could be obtained from contract data from tenders when the government solicits bids from suppliers. A reliable consumption surveillance tool linking information between the pharmacies, prescribers and laboratories is yet to be established.

Many countries in Africa with low antibiotic use still have high resistance rates. Garance Upham, Vice President of the World Alliance against Antibiotic Resistance (WAAR), explained that poor waste disposal, water pollution and poor infection prevention/control in healthcare facilities, help in spreading AMR. She stressed the importance of adequate water and sanitation services, and basic hygiene in hospitals and communities in low resource settings.

In animal husbandry, antibiotics are frequently used as growth promoters for livestock and poultry, apart from treating diseases. Studies have found that antibiotic use in livestock production is associated with AMR in bacteria that are common to humans and animals, explained Michaela van den Honert, a researcher at University of Stellenbosch, who is investigating AMR in livestock and wildlife farming. A study by Moyane and colleagues found that some antibiotics for growth promotion in food producing animals that are banned in other countries are still being used in South Africa. There is a need for improved surveillance and regulation of antibiotic use in food-producing animals.

South Africa has embraced the WHO’s ‘One Health’ approach to addressing AMR at the human, animal and environmental levels, and has been successful in mobilising key stakeholders from health and agriculture to develop and steer its AMR strategy. It is clear that prioritised research, surveillance, and regulatory actions must be a dynamic process, if we are to make gains in the war against superbugs.

Ronel Sewpaul, Citizen News Service - CNS
November 12, 2018

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