Keeping anti-microbial resistance in check in the face of a pandemic

November 24, 2020

The COVID-19 pandemic has almost brought the world to its knees and the global community has focused all its attention on fighting and ending the disease. As at mid-November, there were 54.2 million confirmed cases with more than one million deaths worldwide. According to the latest reports, Africa has about 1.4 million confirmed COVID-19 cases and about 24,500 cumulative deaths. As a result, health systems – many of which are already overburdened- are coming under immense pressure and strain as they try to cope with the extra load.

The World Health Organization (WHO) has emphasized the need to maintain focus on other important health issues during the pandemic. This will ensure that essential services such as immunization are maintained and gains made in the fight against HIV/AIDS, tuberculosis, malaria and non-communicable diseases are not lost as a result of COVID-19. Antimicrobial resistance (AMR) is among these important health priorities that should not be put on the side-lines as the COVID-19 fight rages on. AMR is defined as a ‘situation where drugs become ineffective against disease-causing germs that previously they were effective against’. In 2015 the WHO declared AMR a threat to global public health, and endorsed a global action plan as a guide to tackling the problem. While many countries are working to adapt these guidelines into their national action plans (NAP), shifting health priorities during the pandemic may eclipse AMR prevention and control hence affecting progress and possibly erode current gains.

Kenya is currently among the countries bearing the highest burden of COVID-19 on the continent with about 70,000 cumulative cases and 2,200 cumulative deaths reported by mid-November. Consequently, the health system is increasingly coming under immense pressure to keep up with the prevailing situation. A health system cannot be effective if most of the available antimicrobials are ineffective against the common causes of morbidity and mortality. With the growing levels of hospitalization of long duration and intubation, hospital-acquired infections are expected to rise and therefore in a context of high levels of AMR, the clinical outcomes are likely to be poor. Evidence has linked poor antimicrobial use (AMU), increased availability of counterfeit medicines and poor infection control measures to high AMR prevalence and common pathogens in human and animal health in Kenya. However, a lot is still unknown on the link between changing food systems, agriculture and AMR. A scoping review was conducted by APHRC, Newcastle University, and University of Malawi to synthesize evidence on changing food systems, the poultry sector, and AMR to aid intervention on AMR stewardship and control in agriculture in sub-Saharan Africa (SSA) – particularly Kenya and Malawi. To commemorate the 2020 World Antimicrobial Awareness Week (WAAW), we present key findings from the review, and their implications on the fight against AMR. Based on the findings, we give some recommendations to keep AMR in check during the COVID-19 pandemic and beyond.

Our scoping review followed the framework developed by Arksey and O’Malley (2005) to identify the role of changing food systems with a specific focus on poultry production, distribution and consumption in SSA in the development and transmission of AMR. The following main themes emerged:

Misuse or irrational use of antimicrobials (AM)

A vast variety of antimicrobials (AM) are used in agriculture in most countries, the majority of which are also used in human health. It is very probable that misuse or overuse of AM increases the likelihood of bacteria developing resistance which may be transferred to humans through the food chain, including poultry meat and products such as eggs. Our review revealed that AM overuse in poultry farming is widespread in SSA mainly as treatment, prophylaxis and growth promotion agents and is a primary driver of the accumulation of harmful resistance genes or residues in the animal reservoir. Farmers mainly obtain AM from agro-veterinary stores or veterinary shops without prescription or advice from animal health professionals, and the sale of AM is unregulated in some settings. In the same breath, farmers were less informed of the potential threat that improper use of AM poses on human health with regards to AMR, did not keep records of the AM used in poultry farms, were not aware of AM withdrawal periods, and did not administer proper dosage of AM.

Knowledge, attitudes and practices in poultry production

Evidence also indicates the use of banned or restricted AM in poultry farms is common. Most farmers employed AM as prophylaxis in their farms and vaccination of birds was not a popular option. Some possible pathways of AMR transmission from poultry production included contaminated poultry products, infected poultry, and discharging of contaminated feces into the environment. Cultural and regional differences in knowledge, attitudes, and practices regarding AMU were identified. For instance, farmers in urban areas exhibit higher AMU compared to those from pastoralist and rural communities.

Evidence of AMR to common bacteria from poultry isolates

There is an implication on the transfer of AMR from animal sources to human health during the COVID-19 pandemic. On the one hand, declining use of formal health services due to the overburdening of the health system unable to take in patients; fear of hospital-acquired infections; and inability to afford care as a result of the economic effects of the pandemic. It is expected that self-medication and antimicrobial misuse through the purchase of AM over-the-counter among the population will increase during the pandemic. On the other hand, increased use of AM in patients with or suspected to have COVID-19 could lead to worsening the AMR situation.

Call to action

Kenya launched its AMR National Action Plan in 2017 as a guide for coordinated response against AMR and has strategic objectives to guide the AMR containment policy. Key objectives of the plan include improving awareness and understanding of AMR, strengthening surveillance and research programs, improving sanitation, hygiene, and preventive measures, optimizing the use of antimicrobials in animals and humans, and developing an economic case which accounts for the country needs and for a sustainable investment on medicines, diagnostics, vaccines and other interventions. However, some challenges exist such as limited finances and human resources, poor infrastructure, weak supply chains for laboratory consumables, attitude and behavior of patients, health workers, animal farmers and the public, and lack of political will.

During the COVID-19 pandemic, restrictions to movement, shifting health priorities and pressure on the health system could shift the focus on AMR and therefore delay the gains on the control of ‘superbugs’. However, efforts should be made to adapt and step-up efforts to address AMR during this time, in line with NAP activities. For instance, through the ‘One Health’ approach, antimicrobial stewardship and surveillance programs in agriculture and public health should be sustained to monitor and regulate AMU and AM transmission patterns. In addition, infection prevention and control activities in the environment as well as healthcare settings should be stepped-up, especially at the bottom of the primary healthcare pyramid. As pressure increases on national laboratories to deliver COVID-19 test results, provisions should be made for continued testing of AMR using agricultural, environmental and clinical samples.

There is also need for advocacy and awareness of AMR, sustainable and safe farming practices and judicious AMU at the national and community level should also be put in place particularly in community settings to educate farmers and the general public thus minimizing AMR risk. Finally, financial and technical investment is required to adapt and strengthen public health systems during the pandemic and promote research to keep up the fight against AMR and fulfill the commitments and targets stipulated in the national AMR containment plan.