Why more attention must be paid to silent killer AMR -Expert
By Musa Umar Bologi
Dr. Nafiu Lawal is a Clinical Veterinary Microbiologist working at the Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Usmanu Danfodio University, Sokoto. He is an animal health specialist with special expertise in Anti-Microbial Resistance (AMR) and development, in the interview with Musa Bologi during a recent weeklong capacity-building workshop in Lagos for journalists and community-based organizations on AMR advocacy and media reporting, organized by the Fleming Fund Country Grant Antimicrobial Resistance Phase II in collaboration with Management Science for Health (MSH) with support from UKaid, highlighted the complexity of AMR, its transmission pathways, and the need for a collaborative approach to mitigate its impact.
Excerpts:
Q: What is AMR, and how does it affect humans and animals?
A: AMR stands for antimicrobial resistance. It refers to the resistance that pathogens, or harmful microorganisms, develop against the drugs we use to treat infections in both humans and animals. This resistance occurs when drugs are misused or overused – essentially abused. When this happens, the drugs we rely on to treat these infections no longer work. The pathogens find a way to make the drugs ineffective, which prevents them from killing the organisms and managing the disease.
In Nigeria, research has shown that nearly 80% of Escherichia coli (E. coli) bacteria are resistant to more than one drug, making them multi-drug-resistant. Additionally, 70% of Salmonella*m strains isolated from both human and veterinary hospitals are resistant to multiple antibiotics. For example, antibiotics like Amoxicillin, Penicillin, Gentamicin, and Streptomycin, which are commonly used to treat infections, no longer work on these resistant strains.
At the lab where I currently work, every single pathogen isolates we’ve examined has shown resistance to at least one antibiotic that’s still in use for treating human and animal infections. This indicates that AMR is a growing and serious problem. If we don’t address it, we could find ourselves back in the pre-antibiotic era, where common illnesses like a cold could be deadly, and a simple wound infection could lead to amputations. The economic impact would also be significant, as the cost of treating infections would rise, hospital stays would be longer, and patients might not be able to afford the necessary treatment.
The healthcare system would also feel the strain. Normally, a patient with an infection might recover in 7-10 days with proper treatment. But with antimicrobial-resistant pathogens, recovery could take 2-3 months. This extended stay means more hospital beds are occupied for longer, reducing the capacity to treat other patients. Ultimately, this will overwhelm the healthcare system, leading to situations where hospitals have no beds available for new patients.
Q: Is there any link between plants and animals when it comes to the spread of AMR?
A: Yes, there is a connection. AMR pathogens aren’t limited to humans and animals – they can also spread through the environment, including plants. When animals infected with antimicrobial-resistant pathogens produce waste, that waste can end up on farms, where it’s often used as organic fertilizer. In Nigeria, many farmers use animal dung as manure for growing vegetables. If the manure contains AMR pathogens, the vegetables can become contaminated.
Farmers might pick and eat these vegetables without washing them properly, exposing themselves to AMR pathogens. If these vegetables are sold in the market, the AMR pathogens could spread further, especially if the vegetables still have soil clinging to them. Unsuspecting customers who buy these vegetables and fail to wash them thoroughly could ingest the pathogens and become infected.
This cycle is why we emphasize a “One Health” approach to tackle AMR. This approach connects human, animal, and environmental health, and requires collaboration across multiple sectors, including the Federal Ministries of Health, Agriculture, Livestock Development, and Environment, to effectively combat AMR.
Q: You mentioned that drug misuse is a major factor in AMR. What role do healthcare providers play in this issue?
A: AMR is a widespread issue, and healthcare providers play a critical role in addressing it. They should never prescribe antibiotics without first conducting the necessary tests. However, in some cases, healthcare providers may prescribe antibiotics without proper diagnosis. As a healthcare provider, it’s important to identify the likely disease and take the appropriate samples for lab testing. This is known as a tentative or clinical diagnosis.
Once the lab processes the sample, the microbiologist will conduct a microbial culture and sensitivity test. This test determines which antibiotics the pathogen is susceptible to and which it’s resistant to. The doctor will then receive this information and prescribe the appropriate treatment.
Sometimes, doctors may prescribe antibiotics based on their clinical judgment, but ask the patient to undergo lab testing. In such cases, the patient may start taking the medication while awaiting lab results. If the test results show that a different antibiotic would be more effective, the doctor will adjust the treatment accordingly. This is called antimicrobial stewardship.
Q: What about pharmacists? How do they contribute to tackling AMR?
A: Pharmacists also play a key role in preventing AMR. If a customer comes into a pharmacy with symptoms like a headache and fever and asks for antibiotics, the pharmacist should ask for a doctor’s prescription before dispensing any medication. This helps ensure that antibiotics are only used when necessary and appropriately prescribed.
Q: How can individuals help reduce AMR?
A: For individuals, the most important thing is to follow the doctor’s prescription carefully. If your doctor prescribes an antibiotic, be sure to take it as directed, completing the entire course even if you start feeling better. Skipping doses or stopping the medication early can expose pathogens to suboptimal levels of the drug, allowing them to develop resistance.
Antibiotics should be taken exactly as prescribed. If a doctor tells you to take two tablets three times a day for five days, it’s because the drug needs to reach a certain level in your body to be effective. If you don’t follow the instructions, some pathogens may survive and develop resistance.
Additionally, it’s crucial to maintain good personal hygiene, such as washing your hands after using the toilet, before eating, and after touching surfaces where many people have been. Practicing these simple hygiene steps can significantly reduce the spread of resistant pathogens.
Q: How do you think livestock and poultry farmers contribute to the spread of AMR?
A: One common practice among poultry farmers in Nigeria is that, on the day they expect chicks to be delivered, they already have sachets of antibiotics dissolved in water, waiting for the chicks to drink. This means that, from day one, the chicks are exposed to antibiotics, as the farmers’ primary concern is to reduce mortality among the chicks. They ensure that every single day the chicks are exposed to antibiotics to prevent illness. The resultant effect is that this leads to the accumulation of antibiotics in the chicks’ bodies.
The implication is that, if the chicks are broilers, for example, and they grow with high concentrations of antibiotics in their bodies, the antibiotic residue will be stored in their muscles. As a consumer, if you eat the broiler, you may ingest some of the antibiotic residues. The pathogens in your body will then be exposed to this small concentration of antibiotics, which may not be sufficient to kill the microbes in your stomach. While it may not harm us immediately, it can lead to the development of antibiotic resistance. Therefore, the farmer’s practice directly contributes to the development of resistant pathogens in consumers.
This also applies to those keeping dairy cattle. If antibiotics are used indiscriminately, the milk may contain antibiotic residues. When consumed, these residues are passed into the body. To reduce this, farmers should consult professionals. Veterinarians can provide advice before they introduce antibiotics to their livestock, and between batches, they should ensure proper cleaning of their pens, removing organic manure and using disinfectants to minimize harmful pathogens. Furthermore, sourcing birds from reputable suppliers, where the birds are vaccinated, can help prevent illness in the first place.
Farmers should also seek guidance from environmentalists and animal scientists on proper composting techniques for using animal dung as organic manure. By ensuring proper composting, even if there are pathogens in the manure, they will be killed. This ensures that farm produce does not carry harmful animal pathogens.
Q: What policies has the government put in place to curb the spread of AMR?
A: One of the policies the Nigerian government has implemented is the National Action Plan (NAP) on AMR. If we achieve even 50% implementation of this plan, the problem of AMR could become a thing of the past in Nigeria. Awareness is the first pillar of the NAP in the fight against AMR. If the public is aware and changes their behaviour, a market woman, for example, may stop using antibiotics indiscriminately. If a doctor prescribes drugs without conducting a laboratory test, she will be bold enough to ask, “Won’t you first ask me to take a test?” This kind of awareness helps hold healthcare providers accountable and ensures that proper procedures are followed.
Imagine that 120 million people out of Nigeria’s 240 million population are aware of AMR. That alone would significantly reduce the spread of AMR through increased public vigilance.
Secondly, there is a need to integrate AMR education into school curricula. Primary, secondary, and university students should be taught about AMR. This education would foster greater awareness and potentially lead to innovative solutions that help mitigate AMR.
Take research, for example. Since the 1960s, many of the antibiotics we use today are modifications of drugs discovered between 1928 and the 1960s, the “golden era” of antibiotics. Very few new antibiotics have been discovered since then. All the current antibiotics are variations, such as the different generations of cephalosporins. But now, even cephalosporins—part of our last-resort antibiotics—are showing resistance. Research into new medicines is therefore a critical part of the third pillar of the NAP.
The fourth pillar of the NAP is surveillance. Hospitals should ensure that when samples are submitted to labs for investigation, they look at the profiles of isolated pathogens and report this data to the national surveillance system. By doing this, we can track which pathogens are resistant to certain drugs. Policymakers can use this information to develop location-specific treatment guidelines. For example, in Lagos, we could identify which pathogens are most prevalent, their resistance patterns, and which drugs are effective. This localized data can help inform disease management protocols both in human and veterinary medicine.
The next pillar in NAP2 is stewardship. This involves the collective efforts of healthcare professionals, pharmacists, drug companies, and patients. Everyone has a role to play in managing AMR.
Infection prevention is another important aspect of NAP2. Individuals should be educated on basic hygiene practices, such as washing hands before eating or after using the toilet, taking regular baths, and wearing masks in crowded places.
By implementing NAP2, even achieving a 50% implementation rate, AMR in Nigeria could be significantly reduced.
Q: Some of the solutions outlined involve funding. What do you think the role of policymakers is in ensuring that these initiatives are successful?
A: Policymakers play a crucial role in ensuring that AMR is incorporated into the budgets of the relevant ministries under the One Health framework. This will allow for the proper funding of AMR-related activities, such as awareness campaigns, infection prevention measures, and research into new drugs. By allocating funds for AMR, the government ensures that activities like media outreach, research, and the improvement of diagnostic services are financially supported.
Additionally, treatment for AMR should be included in the national health insurance scheme to ensure that people can access the necessary care. Currently, the health insurance scheme only covers complicated diseases, leaving out many conditions that are more common. By incorporating AMR-related treatments into health insurance, the government can ensure that patients receive the necessary care without financial strain.
There is also a need to improve healthcare services in government facilities. At present, 65% of healthcare services in Nigeria are provided by private hospitals, leaving only 35% for public hospitals. The government must integrate private healthcare providers into their policies, ensuring that the public has access to high-quality diagnostic services, including those related to AMR.
I commend the Nigerian government for establishing the AMR Coordinating Committee, led by the NCDC and other relevant ministries. The National Action Plan (NAP1) was implemented from 2017 to 2024, and now we have NAP2, which will guide our activities from 2024 to 2028. This demonstrates the government’s commitment to addressing AMR.
Right now, surveillance efforts are improving, with private-sector laboratories being integrated into the system. The Fleming Fund has been instrumental in this regard, particularly in the animal health sector. Thanks to their support, several laboratories have been equipped for AMR surveillance.
This March, we are heading into the field to actively search for pathogens. The Fleming Fund has been instrumental in equipping laboratories and providing consumables for active surveillance. However, sustainability is key. Without continued government support, these efforts may not last. The government must ensure that the infrastructure built for AMR surveillance is maintained and properly funded.
The government must also support private-sector laboratories, which, unlike profit-driven entities, may struggle to maintain such services on their own. The government must take ownership of the AMR project to ensure its long-term sustainability.
