How we’re fighting antimicrobial resistance in South Africa
Urgent work needed to end this public health crisis
HIV, tuberculosis (TB) and sexually transmitted infections (STIs) have claimed too many South African lives. Today, defeating these diseases is a national priority, with the mission of the latest National Strategic Plan to get our country on track to eliminate them as public health threats by the year 2030. But what happens when the treatments we use to fight them no longer work?
This is a reality for many people who are already living with drug-resistant strains of many common infections. Antimicrobial resistance (AMR) occurs when bacteria, viruses, parasites or fungi evolve and become able to survive in the face of drugs designed to cure or prevent the infections they cause.
The World Health Organization (WHO) reports that an estimated 19,000 people in South Africa were estimated to have developed drug-resistant TB in 2016. Indeed, multi-drug resistant TB is South Africa’s biggest AMR problem – one caused by multiple factors, including inadequate diagnostic coverage, medicine stockouts, and patient adherence challenges.
But it’s not only TB. Treatments for HIV and STIs, malaria, and gastro-intestinal, urinary tract, and respiratory tract infections are all under threat. Bacterial infections that are resistant to multiple drugs are commonplace in South African hospitals.
People with these infections face longer, more uncomfortable treatment regimens, and have a lower likelihood of survival. Often, it is high-risk and vulnerable populations, including children, pregnant women and people with HIV that suffer the most.
Vanessa Carter became infected with an extensive MRSA (Methicillin-resistant Staphylococcus aureus) infection following a car accident in Johannesburg: “I had never heard of this superbug before, but as I became more informed, I learned that meant the bacteria causing infection in my face had become resistant to the antibiotics that were meant to heal me.”
One culprit in the rapid spread of AMR is the incorrect use of treatments, particularly in the case of viral infections. Every time a doctor prescribes – or a patient demands – a treatment based purely on symptoms, rather than on the results of a diagnostic test, the likelihood of perpetuating the spread of resistance increases. Common colds are often the result of a viral infection, which will not respond to antibiotics; there’s no point in prescribing them to treat a cold. Another problem is the lack of prevention and infection control measures to limit transmission of resistant infections.
Carter, lucky to have survived her MRSA infection, is now an activist and founder of Health Care Social Media South Africa and a Stanford University Medicine X e-Patient Scholar. She emphasises the need to change the way medicines are used, explaining that “we have to treat antibiotics and other antimicrobial medications as the precious resource they are. World health leaders have described antibiotic-resistant microorganisms as nightmare bacteria that pose a catastrophic threat to people in every country in the world, and South Africa is not exempt.”
Indeed, the global impact of AMR could be devastating. Estimates suggest that by 2050 it could result in ten million deaths per year across the globe and, according to the World Bank, have an economic impact that rivals the 2008 financial crisis. According to Miriam Schneidman, the World Bank’s Lead Health Specialist in the Africa Region, low- and middle-income countries will suffer the most: “Estimates have found that low-income countries could lose more than five percent of their GDP and an added 28 million people could fall into extreme poverty by 2050 under a high impact AMR scenario. AMR can impede our ability to meet our poverty and global development goals.”
Can South Africa lead the way?
With our vast experience in HIV and TB, can South Africa lead the way out of this scenario? The government has taken steps in the right direction. In 2015, the Department of Health published the Antimicrobial Resistance National Strategy Framework for South Africa, and our healthcare leaders are continuing to engage local and international organisations on this crucial topic.
On 30 January 2018, the South African Medical Research Council and my organisation, FIND (Foundation for Innovative New Diagnostics), jointly hosted an international conference in Khayelitsha, Cape Town — the first ever in the township — focusing on the role of diagnostic tests in inhibiting the spread of AMR in South Africa and beyond. This location underlined the importance of listening to and learning from front-line healthcare providers and their patients if we are to win the battle against AMR.
Clinicians and laboratory experts spoke alongside representatives from the South Africa Department of Health, Africa Centres for Disease Control and Prevention, Right to Care, Médecins Sans Frontières, private sector companies and others about the role of diagnostics in optimising the use of antibiotics, protecting novel medicines, and facilitating efforts to track the spread of resistance.
One of the key issues is the lack of affordable, rapid diagnostics for key infections, which are optimised for use in low-resource settings. Following the meeting, we published an “agenda for action”, noting that “lack of diagnostic capacity impedes antibiotic stewardship.”
WHO agrees. “Diagnostics are at the heart of the fight against AMR. Countries need affordable, accessible tests that can guide treatment for diseases like drug resistant TB or that can determine if childhood fevers are caused by bacterial agents and therefore merit use of antibiotics,” says Dr Soumya Swaminathan, Deputy Director-General (Programmes) at WHO. “We need more research and investment to develop these tools, and need to make sure they are linked to robust surveillance systems that cut across national borders.”
South Africa continues to lead research that will counter AMR, including the identification and implementation of new diagnostics. New partnerships, such as the freshly inked collaboration between SAMRC and FIND, play an important and urgent role in facilitating research and development, health systems strengthening and advocacy across the country, the region and beyond.
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Well done in highlighting the National Strategic Plan. At least it gives one hope, we are addressing this global health threat. It is interesting to read about Antibiotic Stewardship. Bacteria will continue to find ways of resisting antibiotics developed by humans. This is why the World Health Organisation has called out for aggressive action at all levels of society to keep resistance from developing and to prevent resistance that already exists from further spreading. In order to do this, humans need to change our behaviors in the ways that we maintain our health and hygiene. Not easy.
Some aspects that need consideration is the build-up of biofilm on all surfaces, including our body, not easy to eliminate. These biofilms are crevices for harmful bacteria and provide ample food for creation of antibiotic resistant infections. Using the incorrect cleaning agents, contributes greatly to this problem.
Research has been undertaken on external probiotics for cleaning and removal of biofilm, with excellent results. Biofilms have been implicated in more than 80% of chronic inflammatory and infectious diseases caused by bacteria. They are known to cause a variety of health problems, ranging from a common ear ache, asthma and allergens to a specific bacterial infection found in people living with a genetic disease called cystic fibrosis. I ask the question, why are we not talking about this? Perhaps the big brands have too much at stake in changing their product formulas. Something in addition to biofilm buildup, perhaps just as damaging is that these products are been washed into our water system, creating further havoc.
Thank you again for your interesting insights.
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