---

Listen to this article

---

The World Health Organization (WHO) has included antimicrobial resistance (AMR) in its top ten list of public health dangers facing the human species. And looking at the numbers, it’s easy to understand why.

23,000 people die every year in the US due to AMR, same statistic sits at 25,000 in Europe and a whooping 700,000 in Africa.

In fact, it is projected that in 2050, there will be 10 million AMR-related annual deaths worldwide. 4.1 million of which expected to come from Africa.

Clearly something needs to be done.

It’s World AMR Awareness Week (WAAW) and the theme for this year is “Preventing Antimicrobial Resistance Together.”

To dissect this topic further we had a conversation with Dr. Tracie Muraya, a pharmacist and Senior Policy Officer at ReAct Africa, where she spends her waking hours preaching the gospel of stewardship and proper use of antimicrobial agents.

Dr.Tracie is extremely passionate about public health and AMR and she shares her unique insights about the topic.

---

How would you define antimicrobial resistance?

Antimicrobial resistance or AMR occurs when microbes including bacteria, viruses, fungi or parasites no longer respond to antimicrobial agents that have been previously known to be effective against them.

A phenomenon that occurs naturally but is fueled by misuse of antimicrobial agents. Whether it’s overuse or underuse, it boils down to inappropriate use of antibiotics.

To be clear AMR involves all classes of antimicrobial agents however for the sake of this conversation I’ll focus on antibiotics.

Why is it something we should care about?

When Sir Alexander Fleming was accepting his Nobel Prize for his 1928 discovery of penicillin, he did caution that using penicillin in the wrong way would eventually lead to a point where this drug would no longer work.

A bit of context.

Before the emergence of penicillin, people were dying from the most basic infections; minor wounds, pneumonia, they were all death sentences.  So, when it came along, penicillin was a lifesaver as it spared thousands of soldiers from deaths from gunshot wounds and other injuries acquired from the trenches.

Fast forward a couple of years later;

Antibiotics were all of a sudden, a gold mine that was attracting a lot of investments and therefore manufactured left, right and center. Unfortunately, with this, the issue of misuse became a reality.

Within a short period of time microbes started showing signs of resistance against these ‘new antibiotics.’

Sir Fleming’s prediction came true.

In the recent past discovery of new antibiotics has been far and between. At some point there was a 30-year gap where we didn’t see any antibiotic coming through. And even when new ones emerged, they were merely combinations of already existing molecular formulations.

What has happened is that we are now at an era where we’re seeing a dry pipeline of antibiotics.

Pharmaceutical companies have shied away from investing in products that they believe in a few years may become ineffective, triggering a dip in sales. At the end of the day, all businesses focus on the bottom line; a solid return on investment.

Consequently, we are facing a glooming reality that we might not have antibiotics moving forward. Essentially, a post-antibiotic era. Similar to the period before the Second World War, that was a pre-antibiotic era. If status quo remains as far as addressing antimicrobial resistance is concerned, then we will move to a post-antibiotic era where we will struggle to find effective treatment for common infections.

What will that mean?

In its simplest form, a paper cut may drive you six feet under.

A young mother giving birth through cesarean section in a low resourced setting where there’s poor infection prevention control and lack of prophylactic medication for infection prevention, will face the cruel possibility of death.

The consequences don’t just end there unfortunately; In Africa, non-communicable diseases (including cancer) have progressively emerged as a huge source of disease burden.

To treat cancer, antibiotics are needed because the patients’ immunity tend to become compromised. Making them vulnerable to opportunistic infections.

So as much as the anti-cancer medication may be effective, patients may still lose their lives due to lack of effective treatment options to manage the hospital or community acquired infections.

And there are many other scenarios similar to this.

Impact of AMR cuts across individuals, sectors and even regions. So, we all have to come together and do something about it. We all have a role to play.

How was your journey like leading you to the antimicrobial resistance space?

(Smiles) You know, I’ve been asked that question so many times, so I’ve had time to reflect on it.

Although I didn’t realize it at the time, my passion for public health started right from when I was a pharmacist intern in Kenya.

At that early part of my career, I quickly realized that our public health care system needed a lot of improvement. Similar to most African countries. Seeing patients who were unable to afford a prescription costing less than a dollar is an example of the scenarios that I witnessed and felt that something needed to be done.

Fast forward a few years later and I join the private sector- which was a whole other world altogether.  Patients were able to pay for six-month worth of antiretroviral prescriptions sometimes costing almost a thousand dollars.

A stark difference from what I had seen in public sector and honestly that just didn’t sit right with me.

So, I took up a course; Master’s in Public Health and once I graduated, I thought to myself, I think I’m done with the clinical/administration space.

I volunteered at an NGO, the Ecumenical Pharmaceutical Network (EPN) so that I could put in practice what I had learnt. In that sense develop the public health skills which I knew were vital for me to have any sort of impact.

Fortunately, they needed someone who had experience in HIV programmes, which I had. Volunteered for about six months trying to strengthen the HIV program. So, that’s how I got into it.

Thereafter, NGO world being what it is; where you can shift from one programme to another, I ended up in the AMR space.  While in this new space I realized; this is something I’ve been dealing with since I started my career. 

Even back then, in hospital practice when I was the chief pharmacist at the Mombasa Hospital, I had overseen the development of the hospital’s antibiotic treatment guidelines and policy to reshape how antimicrobial agents were used at the hospital.

How were they used?

Just like many hospitals, the consultant doctors would from the onset go for the ‘big guns’-the reserve antibiotics-like meropenem. When there was no clear justification that this was necessary.  At the time, I would just comply and issue these drugs.

Thinking about it now, I was contributing to AMR in a negative way(sighs).

Sadly, it’s the same in many other hospitals where pharmacists get intimidated and fail to speak against inappropriate use of antibiotics. Especially when the culture is propagated by senior doctors.

It’s therefore a goal of mine to ensure that young pharmacists are not pushed around, like I was back then, to create this monster called antimicrobial resistance. A monster that is claiming the lives of patients and our colleagues alike.

---

READ ALSO: Dr. Christabel Khaemba : Patient Safety In Africa Through Pharmacovigilance (africanpharmaceuticalreview.com)

---

What does your day-day job look like as a senior policy officer at ReAct Africa?

So, on a normal day, to be honest, it depends on what hat I’m wearing. I could be directly involved in an on the ground project or in the back-end in a policy driven initiative.

For example, in Kenya I lead some antimicrobial stewardship programs. Currently we’re heavily involved in Makueni County where we work with a very supportive leadership to promote rational use of antimicrobial agents.

So, I try getting into the trenches involving myself with the stewardship projects, interventions and activities that help reduce misuse of these medicines.

This entails going to the facilities, of course in collaboration with the county AMR, and Infection Prevention Control (IPC) focal persons. Carrying out baseline surveys to see how the facilities are equipped to handle infections and how they use the antibiotics.  

Thereafter we forge a way forward and hit the ground running.

Capacity building is also a close feature in the scope of work I do. It’s important for us to ensure that the hospital teams we work with are able to sustain the efforts we have started together. The truth of the matter is that myself as Tracie representing ReAct Africa whether it’s technical or financial support we will exit at some point and focus on a different project elsewhere.

It shouldn’t mean that just because we have pulled out, then everything has to go back to where it was. That’s why capacity building and empowerment is really at the core of the work we do.

The aim is to catalyze action on AMR globally.

Without creating awareness and building capacity around the different facets that directly and indirectly affect AMR then it won’t be fruitful.

Without proper capacity, you’re leaving a huge lacuna when you exit and the project gains will fail in the long-run.

When it comes to policy, my work centers around advocacy; lobbying, networking and creating those relationships that are paramount to success through the One Health approach.

I must say I am quite passionate in advocacy. Whether it’s to the policy makers, healthcare workers, administration, consumer groups, all of it, I enjoy it.

The only thing I’d say is to advocate efficiently, you have to always keep yourself informed on the different events happening across the world.

There is no short cut: you have to be well-versed with the current affairs and developments happening around you.

For instance, the Ukraine war resulted in food insecurity in our region, which in turn negatively impacts on immunity and health, which could then lead to increased infections and consequent use of antimicrobials and hence AMR.

Policy influence is quite dynamic; so, if you snooze, you lose (laughs).

Do you think antimicrobial agents, including antibiotics, should be used in agriculture?

It would be an outright lie to say that we should not use antibiotics within the animal and fisheries sector.  You might as well then say humans shouldn’t also use antibiotics.

That being said, there are guidelines in place that inform when and how these antimicrobials should be used in these sectors.

Use of these medicines in animals is guided by the Codex Alimentarius. If the animal is unwell for example, a qualified veterinarian who has made a diagnosis can go ahead and prescribe antibiotics.

There’s absolutely nothing wrong with that.

The problem comes in when we misuse.  For example, the inappropriate use of antibiotics as growth promoters.

This practice has become quite rampant mainly due to misinformation and weak regulatory enforcement. For example, I know there are pharmacies that dispense colistin– a reserve antibiotic, to farmers to help hasten growth of poultry.

So, what happens is that people end up consuming chicken or eggs containing antimicrobial residues. Microbes in their bodies end up being exposed to sub-optimal levels of colistin encouraging resistance. When they are admitted in the ICU needing the same antibiotic, there is a high chance it won’t work leading to preventable death.

We have to advocate for appropriate use of antimicrobial agents both in humans and animals.

On the positive side, there are institutions like Kenchick (a poultry company in Kenya) that are doing their part. In fact, it was recently recognized by the International Poultry Council as the only company in Africa that operates within clear antimicrobial stewardship principles as outlined by the Poultry Council.

Are there any myths related to use of antimicrobial agents that you would like to burst?

One: We always need antibiotics when we are unwell.

Vaccination is a core element in preserving public health and for most regions the uptake has been promising. I say this because vaccines fundamentally ensure that we are not severely affected by disease when we do get an infection. Both in humans and animals.

Therefore, it does not necessarily mean that immediately we get an infection, that directly translates to a shot of an antibiotic. In certain instances, your strengthened immunity may be good enough to clear the microbe.

Two: A scratchy throat equals a dose of antibiotics.

 Majority of upper respiratory infections including cold and flu are viral. Antibiotics such as amoxicillin don’t have a role to play in these scenarios. Viral infections should be let to run their course while managing symptoms or use antiviral agents when applicable.

Sidenote: I remember a lot of people discovered azithromycin during the covid pandemic and they preferred it mainly due to the once-a-day 3-day dose duration. This opened a can of worms.

Three: antimicrobial injections are stronger and are preferred.

Yes, you’ve been diagnosed with a bacterial infection, but it doesn’t mean that an injectable antibiotic is the only thing that will work.  If the patient doesn’t have a severe infection, is able to eat, swallow and retain food and water, why should they be put on injectable antibiotics?

The interesting thing is that sometimes when we assess patient files, we find a patient who is on oral paracetamol tablets and amoxiclav injection. Why?  I mean they should both be oral dosage forms, no?

There is a difference between how antibiotics are dispensed in European countries compared to Africa. In those countries you need a prescription but locally you access these medicines over the counter. What’s happening there, is it a policy problem or an implementation problem?

Implementation for sure. 

I’ll give you the example of Kenya; people come to benchmark not only just on medicine use but also many other policies. I mean, we’ve got the brains, the skill and the know-how to produce beautiful policies. And then what happens after, we put them in our shelves and we forget about them.

Really, it’s the implementation, enactment and enforcement of the relevant laws that is missing.

As pharmacy professionals we should remain firm when implementing guidelines on rational use of medicines. No-one should ever pressure you to dispense or issue an antimicrobial agent that is inappropriate for the patient.

We should also have integrity when dispensing these medicines. I understand sometimes we could be in the middle of harsh economic times but that doesn’t mean all of a sudden doing the right thing goes out of the window. Self-policing is key.

And it can be done, I mean look at our neighbors, Rwanda and Ethiopia, you can’t just walk into a pharmacy and buy antibiotics without a valid prescription.

Are there continental efforts in the fight against AMR?

The Africa Union through Africa CDC, and in collaboration with the regional Quadripartite : The Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO), the World Organization for Animal Health (WOAH), the UN Environment Programme (UNEP)) have done considerable work in Africa.

For example, in 2017, Africa CDC developed the Africa CDC Framework for Antimicrobial Resistance Control in Africa – later endorsed by the Africa Union Assembly as the Africa Union Framework for Antimicrobial Resistance Control in Africa (2018 – 2023).

Their strategy revolves around four areas – improve surveillance of AMR organisms and antimicrobial use, delay emergence of resistant infections, limit infection transmission and mitigate harm among patients infected with AMR organisms.

Africa CDC, through its AMR task force has also overseen the development of other guiding documents for the region, such as The African Antibiotic Treatment Guidelines for Common Bacterial Infections and Syndromes.

What these guidelines do is to guide healthcare providers with best practices on antimicrobial selection, dosage and duration of treatment for infections. It covers both adult and pediatric patients. Also, the Framework for One Health Practice in National Public Health Institutes, to address prevention and control of zoonotic diseases.

Africa CDC is also working closely with Regional Coordinating Centers and economic blocs to address antimicrobial resistance. So, there’s a good blueprint, a framework of the way things are supposed to work through the Africa Union-Africa CDC within our region in collaboration with the Quadripartite.

Africa CDC works as well with the Quadripartite regionally to ensure that governance and coordination is taking on a regional approach and then trickle down to the different countries. So, a lot is happening. It’s just that now countries (member states) also have to walk the talk.

So, being World AMR Awareness Week, what message would you want to put out?

We all have a role to play when it comes to antimicrobial resistance.  It’s just about understanding what that role is and being consistent.

What this means is that we don’t limit our AMR advocacy messages to just the WAAW week (18th-24th November) where it’s all blue everywhere with all the right messages, then after that what happens? Silence.

The message relayed must be on a continuous basis. 

If you take nothing else home, just realize that AMR knows no borders. Think back to the COVID pandemic that affected all regions of the world. AMR is no different.

People call it the silent pandemic but I don’t agree with this. Because it’s there, faceless yes, but it’s there and the effects are devastating.

Ideally, a country performing well should have a drug resistance index (a qualifier for a country’s status on AMR) of less than 25%. Unfortunately, in Africa according to a study done in 2019-2020, no country in the study recorded a DRI below 50%.

Meaning, there’s a high chance that the antimicrobial medicines in our continent are already not effective or are losing their ground.

So, AMR knows no boundaries, color, race or status.  If a resistant bug knocks on your door, then you better pray. Pray that the necessary ammunition is available to fight it.  And if it is available, do pray that you have the finances and resources to access it.

So, let’s act now and “prevent antimicrobial resistance together.”

---

Did you find this article informative? Subscribe for more.