Superbugs, the next big pandemic

At 5pm on a Friday in April last year, Macknophear Mohammed,27, walked a kilometre to the labour ward at Kilifi County Hospital.

“This was my third born and I did not want to go into labour past curfew hours. The doctor examined me and confirmed that I was about to deliver,” she says.

The baby arrived at 4am but little did Ms Mohammed know what was to follow.

“Three days later, the infant developed jaundice,” she says.

According to the American Academy of Paediatricians, symptoms of newborn jaundice include the yellowing of the skin and eyes. It occurs when babies have a high level of bilirubin, a yellow pigment produced during the breakdown of red blood cells.

High levels of bilirubin can put a baby at risk of deafness, cerebral palsy or other forms of brain damage.

In older babies and adults, the liver processes bilirubin which then passes through the intestinal tract. A newborn’s liver may not be mature enough to remove bilirubin.

Increasing AMR levels

Experts say jaundice that persists longer than three weeks may be a symptom of an underlying condition. In many cases, however, the jaundice disappears in two to three weeks as a baby’s liver develops.

For Lawrence Bona, who is now a year and seven months old, this was not the case. Once discharged after treatment, Bona developed high fever and the antibiotics prescribed did not seem to be working.

“The hospital visits became frequent as he appeared to have developed resistance to antibiotics,” Miss Mohammed says.

She stopped going to hospital after being told Bona had pneumonia.

“We tried stronger and more expensive antibiotics but the fever would only subside for a day or two. I again took him to hospital where he was admitted on October 19 this year,” she says.

Hospital visits are now part of Ms Mohammed’s weekly routine.

“I spent about Sh100,000 on antibiotics and treatment until the child was discharged after two weeks. I hope the new treatment works,” she says.

According to the Centres for Disease Control and Prevention (CDC Kenya), antimicrobial resistance (AMR) is a significant global public health problem due to the overuse of antibiotics, widespread availability of fake or substandard medicines and poor infection prevention and control measures.

Researchers say a continued rise in AMR could lead to 10 million deaths every year and a three per cent reduction in global GDP by 2050.

The country is already experiencing increasing levels of AMR. A lack of systematic surveillance means the exact burden of the problem in Kenya is not known.

Resistance has been reported in key bacterial pathogens, including methicillin resistant Staphylococcus aureus (MRSA) from patients, reduced susceptibility of community acquired pneumococci; multi-drug resistant extended spectrum beta lactamase producing Salmonella typhimurium and Vibrio cholerae from outbreaks with increasing resistance to fluoroquinolones also seen in typhoid outbreaks limiting treatment options.

That is why the country in 2017 joined the global campaign against AMR. To combat the growing threat of AMR, the Ministry of Health and her partners developed a national surveillance system to detect resistant organisms.

Data from the system is being used to update treatment guidelines and promote additional research on AMR while Kenya also contributes to international surveillance efforts by submitting data to the WHO Global Antimicrobial Resistance Surveillance System (GLASS).

In 2017, the CDC and the National Public Health Laboratory Services (NPHLS) piloted the AMR surveillance system and assessed infection prevention and control practices at two public hospitals in Thika and Kitale.

Though basic laboratory equipment and information systems were in place, the assessment showed that testing and reporting capacities needed to be strengthened.

NPHLS developed work plans to improve capacity and partners are currently assisting with the programme. This includes training lab staff in microbiology testing methods, providing necessary reagents and updating information systems.

Data from the pilot sites were reported to the NPHLS.

“The system will be revised to incorporate lessons learnt from the pilot sites. The programme will expand over the next five years,” CDC Kenya says.

Experts say the surveillance systems on efficacy of antimicrobial agents used in TB, HIV/Aids and malaria need to be interlinked with the national AMR surveillance structure.

“It is notable that key antimicrobial-resistant food borne pathogens (E. coli, Salmonella enterica and Campylobacter spp) have occurred with increasing frequency as causes of diseases, ranging from mild gastroenteritis to life-threatening systemic infections such as those linked to non-typhoidal salmonella,” State researchers say.

Ms Ann Wanjiru Mwangi, the programme management officer at Students Against Superbugs Africa, told the Healthy Nation that memories of her father being in pain have defined her life.

 “I was five when I started noticing something was off. He used to take antibiotics. It got to a point the inflammations grew worse,” she says.

The Mt Kenya University Bachelor of Medicine and Surgery student says her father had his tonsils removed recently. Tonsils are the two oval-shaped pads of tissue at the back of the throat – one on each side.

Symptoms of tonsillitis include swollen tonsils, sore throat, difficulty in swallowing and tender lymph nodes.

Tonsillectomy involves an instrument being used to hold the mouth open, allowing the surgeon to reach the tonsils and remove them with a scalpel, laser or a heated instrument. Bleeding is controlled by cauterising the incision.

“Even after the operation, my father was still resistant to some antibiotics,” Ms Mwangi says.

“I also had the same problem, so I went for surgery around the same time as father. Unlike him, I responded well to the medication.”

Her father had to purchase stronger drugs, draining the family emotionally and financially.

“Father could not go to work. We used every coin we had on his drugs,” she says, adding that his situation motivated her to study medicine.

Superbugs are strains of bacteria, viruses, parasites and fungi that are resistant to most antibiotics and other drugs.

“ I do not want to see another family go through our experience. Had I known earlier, I would have told my father not to take antibiotics and go for surgery instead,” she says.

“I want to help others. That is why I have been doing research on this. Many people do not know antibiotics can lead to hospital admissions and other infections,” she says.

Dr Evelyn Wesangula, who is in charge of the AMR programme at the ministry, says it occurs when micro-organisms are no longer suppressed or killed by antimicrobial agents.

“It means simple infections cannot be treated by the commonly available agents, resulting in increased length of hospital stay. Some micro-organisms that cause infections are resistant to antibiotics,” she says.

A person who develops multidrug resistance requires antibiotics of a higher class.

“That is expensive. The patient may end up dying,” Dr Wesangula says.

The expert adds that this is not a new problem.

“Penicillin began showing resistance a year after its discovery,” she says. 

This phenomenon continues to evolve but has been propagated by misuse of antibiotics as people throng pharmacies for self-medication.

“When prescriptions are done poorly or patients use drugs in an unintended way, it gives the micro-organisms a chance to become stronger,” she says.

“When laboratory results show one has 70 per cent resistance, it leaves doctors with little or no option to discard that drug and pick up another. Looking at our population and availability of these drugs, we are not as privileged as the West.”

If the cost of the drug is prohibitive, a patient is tempted to buy half a dose. Some never go back for a second dose. Exposing micro-organisms to lower doses makes them grow, mutate and develop resistance.

Studies show that if the situation does not change, some 10 million people will be dying a year, the highest of any other cause of death globally. Half of the deaths will be in Sub-Sahara.

“Approximately 4.5 million deaths due to AMR annually will occur in Sub-Sahara by 2050. The burden of infections is high in this region,” the ministry says in its policy plan.

“AMR threatens to reverse the gains made in the fight against HIV/Aids, TB and malaria in Kenya, where 50 per cent of the top 10 causes of death across all ages are infectious diseases.”.

Studies and surveillance systems show there is a big problem with antibiotics.

“We have been prompted to national action. The problem is also in animal health as livestock are being treated with antibiotics,” the ministry says.

The action taken is multi-sectoral. The Ministries of Health and Agriculture developed a set of interventions to address the problem in 2017.

Dr Mirfin Mpundu, a clinical pharmacist and director at ReAct Africa – a global network that brings together experts and key stakeholders to form technical working groups on antimicrobial resistance – told the Healthy Nation that superbugs will take over if we the world is not careful.

ReAct provides technical assistance in the development and implementation of national action plans.

“When one looks at the treatment failure, we also need to examine antibiotic production, overuse and misuse. These are the drivers of AMR,” Dr Mpundu says. 

Simple illnesses and upper respiratory tract infections are becoming impossible to treat because micro-organisms are learning to adapt and survive in the presence of antibiotics.

“This also includes surgery, cancer treatment as well as maternal and child illnesses as we lose the battle to AMR,” the expert says, comparing the coronavirus pandemic to AMR.

“Many see AMR as a silent pandemic because it is on an increase. We can only see its effects but it is a volcano that has just erupted.”

Dr Mpundu says the country needs to promote responsible and rational use of antibiotics.

Human and animal health

The two ministries recognised AMR as a priority following findings from status reports and other studies.

Following reports of alarming rates of antimicrobial resistance, community acquired infections and in agriculture, the Global Action Plan on AMR was adopted in 2015.

This followed decisions by the World Health Assembly, the Food and Agriculture Organisation Governing Conference and the World Assembly of OIE Delegates to combat the scourge.

Member states committed to developing national action programmes on AMR that are consistent with the Global Action Plan.

They also pledged to implement relevant policies and schemes to prevent, control and monitor AMR.

Kenya’s 2017 national policy on prevention and containment of antimicrobial resistance describes AMR as a global public health concern that is threatening the core of modern medicine and response to infectious illnesses.

“Effective antimicrobial drugs are vital for prevention and cure, protecting patients from potentially fatal diseases and ensuring treatment and procedures such as surgery and chemotherapy are provided at low risk,” the policy says.

 The misuse and overuse of antimicrobials in human medicine and food production have put nations at risk, considering that very few antimicrobial agents are in development.

Without concerted and immediate action on a national scale, Kenya stands to diminish the gains made in the fight against infectious diseases.

Data from sentinel sites indicate high rates of resistance for respiratory, enteric and hospital-acquired infections.

It shows many available antimicrobial regimens such as penicillin and cotrimoxazole are unlikely to be effective against common infections.

Antimicrobial resistance has been reported in E. coli isolates from beef and poultry, showing resistance to common agents such as tetracycline, co-trimoxazole, streptomycin, ampicillin, quinolones and third generation cephalosporins at varying frequencies.

The government has cautioned the public against misusing antibiotics.

Antimicrobial resistance occurs when disease-causing micro-organisms are no longer responsive to previously effective medicines.

 Their availability and use has been and is essential for public health, national wealth creation, food security, and food safety, human and animal welfare, protection of livelihoods and sustainability of animal and plant production.

“Antimicrobial agents play a key role in safeguarding human and animal health, food security and international trade,” the document says, adding that the health consequences and economic costs of AMR bring about a two to 3.5 per cent decrease (equivalent to $100 trillion) in GDP.

Dr Mpundu, Miss Mwangi and Dr Wesangula say people will use antibiotics properly if they have the right knowledge.

“The saddest thing in medicine is having no option for patients when they walk in due to a drug resistant problem. We have to change the way we handle antibiotics,” Dr Wesangula says.

“For this year’s World Antimicrobial Awareness Week themed ‘Spread Awareness, Stop Resistance’, which starts on November 18 and ends on November 24, the essence is to engage communities to spread simple messages on how to stop AMR.”

You cannot see it. I can actually be walking around with a multi-drug resistance organism in my hands and if I don’t wash them, I can spread it to another person who has lower immunity. That person will be infected.”

[email protected]