Deliberate action to fight antibiotic resistance in Nigeria: World Antibiotics Awareness Week 2019

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Since the discovery of Penicillin in 1928 by Alexander Fleming, antibiotics have continued to play a critical role in healthcare. Not only are they used to treat infections caused by various strains of bacteria, they are also used to prevent bacterial infections during surgery and in the event of accidents.

However, these life-saving medications are increasingly becoming less effective as antibiotic resistance continues to be on the rise. According to the Centre for Disease Control (CDC), antibiotic resistance is the ability of bacteria to resist the drugs (antibiotics) designed to kill them. The resistance develops mainly as a result of the misuse or overuse of antibiotics. Antibiotic resistance results in the deaths of more than 35,000 people annually in the United States alone. However, there are no available studies in Nigeria that define the extent of antibiotic resistance, although data on antimicrobial resistance (AMR) rates of disease-causing organisms provides a rough proxy.

Worldwide, the World Health Organisation (WHO) estimates that antimicrobial resistance kills more than 700,000 people every year, a disturbing number that could rise to 10 million by 2050. A situation analysis on antimicrobial use and resistance in Nigeria released by the federal ministries of health, agriculture and environment in 2017 has shown high resistance rates of 70% – 100% to some antibiotics in certain states of the country. In a country where infectious diseases are a major cause of morbidity and mortality, especially among children, this figure is of great concern. For instance, studies on samples from 120 children under five years of age from South-South Nigeria reported 100% resistance to penicillin and cotrimoxazole antibiotics. To commemorate the 2019 antibiotics awareness week, here are few ways the rising scourge of antibiotics resistance can be halted.

Image source: AMSA International

Regulatory agencies must take responsibility
Nigeria has health regulatory agencies such as, the Pharmacists Council of Nigeria (PCN) and National Agency for Foods, Drugs Administration and Control (NAFDAC), that have the responsibility of regulating the entire drug value chain, including antibiotics. These agencies ensure the rules are adhered to in the manufacture, distribution, handling and storage of drugs. Yet the powers of the agencies have not been applied consistently, especially in the areas of distribution and handling. This has resulted in the chaotic open drug markets across the country.

From Onitsha to Kano, medications including antibiotics which ordinarily require the prescription of a trained and licensed healthcare provider are sold in trays and wheelbarrows on streets and market squares, mostly by individuals who have not undergone any form of medical training. Because of the nature in which they are displayed, the medications are also exposed to the scorching sun, which often results in them losing their potency.

In communities and neighbourhoods, some patent and proprietary medicine vendors (PPMV) and community pharmacists prescribe and sell antibiotics to residents without carrying out the required tests. PCN and NAFDAC must ensure untrained and unlicensed individuals do not have access to the purchase of any medication, not only antibiotics. The major open drug markets across the country must be regulated. Pharmaceutical manufacturing and distributing companies must be made to only sell their medication to licensed retailers and strict penalties must apply to violators. Professional associations like the Pharmaceutical Society of Nigeria (PSN) and the Association of Patent Medicine Vendors (APMV) should also be made to regulate their members to only dispense antibiotics when necessary tests are performed, and prescriptions given to the patients.

Health workers at all health facilities must strictly adhere to the rationale prescription of antibiotics. Photo credit: Nigeria Health Watch

Nigeria has been tacking antimicrobial resistance, using a “One Health” approach that takes into account the interconnectedness between human health, animal health, and the environment. In 2017, the Federal Ministries of Agriculture, Environment, and Health developed the National Action Plan for Antimicrobial Resistance, which aligns with the Global Action Plan. Progress is currently being made in the implementation of the strategic plan, with support from the Fleming Fund in strengthening AMR surveillance and building laboratory AMR capacity.

Healthcare workers should prescribe only when necessary
As much as antibiotic resistance can result from the indiscriminate sale of antibiotics in the open drug market, it often develops from indiscriminate prescription. It is generally advisable that antibiotics should only be prescribed after necessary culture and sensitivity tests are conducted on the patient’s samples. These tests are often ordered and done at the health facilities, giving health workers the ultimate decision-making power. For antibiotic resistance to be checkmated, health workers at all health facilities must strictly adhere to the rationale prescription of antibiotics, which means only prescribe after testing. At the point of dispensing antibiotics, patients should be informed of the dangers of not completing their drugs.
 
The public should know the dangers of antibiotic misuse
To many Nigerians, antibiotics only include the brands known as Ampiclox and Augmentin. Some people believe Flagyl (Metronidazole) is just a drug that stops diarrhoea and makes watery stool firm. Yet Flagyl is actually one of the most potent antibiotics used in the treatment of bacterial infections. The versatility and diversity of antibiotics give us options for treating various infections. People’s unwillingness to find out if they have a bacterial infection or something else before proceeding to get antibiotics is one of the many reasons for antibiotic resistance. Easy access plays a large part for sure, but there will never be supply without demand.

Image source: WHO

In the event a healthcare provider tests and prescribes antibiotics, not all people complete the treatment. Usually, antibiotics are taken for a minimum of five days. However, the symptomatic effects of antibiotics usually start within hours, which makes some people stop taking the medication after a few doses because they feel better. This allows the bacteria that has not been eliminated or whose growth has not been halted to develop resistance to the exposed antibiotic.
 
Regulatory agencies, professional bodies and civil society organisations must sensitise the public of the dangers of self-medicating with antibiotics or non-completion of treatment. This can be achieved through sustained, deliberate and targeted campaigns in schools, market squares, places of worships, community groups and others. Unless people know the danger of antibiotic misuse and begin to appreciate the consequences, the danger of more strains of bacteria becoming resistant to antibiotics will continue to grow.
 
The conversation around antibiotic awareness week centres around one key phrase; deliberate actions. We must be deliberate in ensuring that our communities are aware and alert to the dangers of antibiotic resistance. Health workers must be deliberate in prescribing antibiotics only after the proper tests have been done. Without deliberate action by regulatory agencies, we cannot win the resistance fight. Every step Nigeria takes must be deliberate if we are to win.

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