By Fred Ezeh, Abuja
Dr. Mary Alex-Awelle, Head, Department of Medical Microbiology and Parasitology, University of Port Harcourt Teaching Hospital (UPTH), has raised the alarm over escalating antibiotic resistance crisis in Nigeria, warning that it poses a severe threat to public health.
In an interview in Abuja, Alex-Awelle, who also serves as chairperson of Nigeria’s Core Group for Policy Briefs Development Steering Committee under WHO RADAAR’s Evidence-Informed Policy Network (EVIPNet), cautioned that Nigeria risk running out of effective treatments for common infections due to increasing antibiotic resistance.
She also highlighted the roles individuals particular pharmacy operators and patent medicine vendors could play in tackling the menace of antimicrobial resistance (AMR) in Nigeria.
Anti-Microbial Resistance (AMR) was recently described as a “silent pandemic.” How big or small is the issue of AMR in Nigeria?
The problem of AMR in Nigeria is huge. We already know that AMR is a global problem, but lower and middle income countries like Nigeria are disproportionately affected by AMR, and that’s because we face a high prevalence of infectious diseases.
A recent study conducted by the Global Research on AMR reported that Nigeria ranks 19th out of 204 countries that are significantly affected by AMR. So, that tells us how much of a burden AMR is in the country. One of the problems that were highlighted recently was the issue of inadequate laboratories to test people, and also the behavioural pattern of the population not actually going for laboratory tests before taking drugs.
As an expert in AMR, what is the laboratory trend as regards the antimicrobial resistance?
I am a clinical microbiologist, and as one, I deal with these organisms myself directly. So, I can tell you that it is truly a challenge because I process them, and I see the results in real time. Though we have laboratories, the government needs to fund them, adequately, and build more capacity of the people working there. Working in the laboratory is like working on a computer. It is garbage in, garbage out. If we don’t receive quality specimens, we can not deliver quality results for the clinicians to use in making informed judgment and treatment for their patients.
On the other hand of the patients, we are in a society where patients pay out-of-pocket for medical treatment, including laboratory investigations, which are extremely expensive. With the majority of our population living below the required economic standard, it is difficult for them to cope with paying for these investigations as well as paying for treatment. As a result, many people resort to self-medication. They prefer to buy medications without consulting the doctor without going for laboratory investigations.
Who role does medicine vendors and pharmacies play in the AMR crisis?
Many of them are not helping us in this fight. I often advocate that they should enforce diagnostic and antimicrobial stewardship. This means that they should encourage patients to, first, visit diagnostic centres for test for medication. Afterwards, they should proceed to see a doctor for proper consultation.
If the patient does not need to be given an antibiotic or an antimicrobial, the doctor should be the one to decide based on the outcome of the laboratory test. That way, we could save the few effective antimicrobial agents that are in the market. If we use them only when necessary, and in the correct way, then they are preserved, and they would work for us.
What is the place of research in AMR response and management?
People expect that if a particular drug, a particular microorganism, is resistant to a particular antimicrobial, you should develop better and stronger antimicrobials to treat it. Research has a very great role to play, but you don’t just move to research because the organism is resistant to a particular antimicrobial. There are other alternatives already in existence that could be used to treat such an infection. That’s why we are saying that antimicrobials should be used with prescriptions. It means that the patient should go and see a doctor.
The medical doctor will assess the patient and prescribe the necessary treatment or recommend the necessary investigations. The laboratory will come up with the results, including what we call the pathogen, which is usually the microorganism that is causing the disease, as well as the antimicrobials to which that pathogen is susceptible.
What role do you think individuals can play to combat AMR issues?
Everybody has a role to play in the fight against this AMR, which is becoming a “silent global pandemic.” Pharmacies and patent vendor operators have a big role in this because they own the stores where medicines are sold. We need to recognize the fact that we are all Nigerians, and all of us have a role to play.
On the part of the patent medicine vendors, what they actually need is to be properly educated and to be made aware of their role in combating AMR. We can not chase them out of business, but we can improve what they do by taking the message to them. They should not prescribe antimicrobials. They should demand a prescription whenever a case is presented. The government needs to engage with them, educate them properly, give them regulations, tell them how far they are expected to go, and when to refer patients upwards. Pharmacies should actually get registered and properly monitored by the Pharmaceutical Council of Nigeria (PCN) and NAFDAC.
That’s the right thing to do so they are able to get access to quality medications. Also, when individuals go to the pharmacies to procure antimicrobial agents or medicines, the pharmacist should request a prescription, which is evidence that a doctor saw the patient and recommended that medicine or those antimicrobials If everybody takes their own role and responsibility seriously, we will succeed in the fight.
Do you recommend punitive measures for defaulter-pharmacists or patent medicine vendors?
I think it’s actually the responsibility of the governments to do that. But it shouldn’t be a punitive measure per se. Nevertheless, the government needs to enforce the necessary regulations. The government needs to insist on all the regulations. First of all, the government needs to make these people aware that there are regulations to abide by. Are they even aware in the first place?
So, this is the time to shout and to make noise that there are regulations. If there are regulations, where are they? Do they have access to these regulations for them to read it for themselves and see where they come in and how they come in. And then to have people that truly go about ensuring that these regulations are implemented. I think if we start from there, it will not only improve.
The government adopted a One Health Approach to the issue of AMR. How effective is that?
Yes, there’s a one health approach to this AMR because it’s time to rise against AMR in Nigeria. We have all realized and agreed that AMR is a major problem. It is everybody’s problem, and it is us, everybody, that will join hands together with the government to tackle AMR through our behaviours and practices.
As regards the AMR, it has been recognized that there is an interconnectedness between human health, animal health, and the environment. The environment includes our water bodies and how we handle waste. There’s something called emerging and re-emerging infectious diseases. These diseases have come through changes in the ecosystem. That’s how the environment has come to play. When the changes in the ecosystem disturb the natural habitats of animals, making them quit where they should normally be found, in the bushes, in the forest, and then come closer to humans, then we have what is called zoonotic diseases. There are several of them, like HIV, AIDS, Lassa fever, Ebola, Marburg, and Mpox, among others. Scientists have recognized that it is not sufficient to only take care of human health.
If you take care of human health, there are the animals, there is the ecosystem, there are the water bodies that we use, and then we excrete our wastes into. When organisms get into these spaces, like water and soil, there are residues. Like when drug-resistant microorganisms get into these spaces, there are residues remaining. Again, humans and animals go back to those spaces by activities. For instance, grazing. Cows are animals that graze.
These organisms are also found in plants. Then, the animals pick up these organisms when they graze. Humans go back to eating these animals, and It becomes a vicious cycle. Taking care of just one side does not solve the problem, hence the One Health concept, which involves integrating human health with animal health with environmental health all at once. This is an approach towards tackling AMR as well.
International partners are championing AMR campaigns in Nigeria. How can government support?
First, I want to commend the Nigerian government for recognizing and owning up that AMR is actually a rising challenge. Why do I say that? The Nigerian government, because they recognize it is a problem, brought a group of stakeholders together to come up with the National Action Plan 2.0 on AMR, which was launched in October last year. It tells us that the Nigerian government recognizes that AMR is a problem. So, this national plan contains strategies and activities that the government intends to implement in combating AMR. One of them is education and awareness of all stakeholders, particularly health-seeking Nigerians. There are priorities and objectives in the document, like funding and improving diagnostics and surveillance. The government should also pay more attention to capacity building for the laboratories and improve surveillance. And, of course, putting more funds into the activities that have been identified in combating AMR. More Nigerians come in contact with these antimicrobials through patent medicine stores and pharmacies and sometimes private hospitals.