Antibiotic resistance: How Zambia is trying to reign in AMR

Antibiotic abuse dog the country like many of its counterparts in Africa

By Violet Nakamba
Published: Friday 24 January 2020

Malimakau entered the Lusaka pharmacy sneezing his nose off. “I need something for a cold / headache,” he told the pharmacist, wiping his runny nose with his hand. The pharmacist asked whether the man had a fever and gave him a pack of Amoxicillin — an antibiotic — an antihistamine and some antacids.

Malimakau said he has been treating common cold this way for as long as he can remember. Melody Malawo, also a resident of the Zambian capital, too easily gets antibiotics whenever she feels feverish, has a cough or flu.

“When I go to a hospital, they also give me antibiotics. Now I just go to the nearest chemist or pharmacy and avoid the trouble of staying long hours at the clinic or health centre,” Malawo said.

This is common in Zambia: Pharmacists or those who manage the pharmacy counters — with or without qualifications — are performing dispensing medicines, a job of doctors, contributing to antibiotic resistance.

Antibiotics were prescribed irrationally and used to treat diseases like cough and flu, which are not caused by bacterial pathogens, said Jereme Kanika, a pharmacist in Lusaka. Many pharmacies operated outside the law, not registered with the Zambia Medicines Regulatory Authority, he added.

The resistance came at a cost to the patient. “Penicillin is the cheapest and readily available antibiotics. When penicillin fails to work on a patient, we introduce them to a strong and expensive antibiotic. Even though it is available in all government hospitals, it cannot be used as there is resistance,” Kanika said.

Data on antimicrobial resistance (AMR) in Zambia was limited, said Kennedy Malama, permanent secretaryat the country’s Ministry of Health.

The data that is available shows an increasing trend of microorganisms developing resistance to antimicrobial drugs. Notable among these are multi-drug resistant tuberculosis, human immunodeficiency viruses resistant to antiretroviral drugs, Plasmodium resistance to anti-malarial drugs, and fungal species showing indications of resistance to antifungal drugs.

The country has developed a multi-sectoral National Action Plan (NAP) on AMR, which sets out priority actions and strategies to address factors influencing the development and spread of AMR in the Zambian context.

A key area recognised in Zambia’s AMR NAP is the need to set in place mechanisms for the systematic and coordinated generation, collection and analysis of data. It was handed over to the World Health Assembly in May 2017 and was officially launch that November by the ministers for health, fisheries and livestock as well as water development sanitation and environmental protection.

Its focus

  1. Improving awareness and understanding of AMR through effective communication, education and training 
  2. Strengthening knowledge and evidence base through surveillance and research
  3. Reducing the incidence of infection through effective sanitation, hygiene and infection prevention measures
  4. Optimising use of antimicrobial medicines in human and animal health
  5. Developing economic case for sustainable investment, taking account needs of all countries; increasing investment in new medicines, diagnostic tools, vaccines and other interventions

The country is trying to address antibiotics misuse and has developed a draft antimicrobial stewardship policy and an implementation framework being piloted in five health care facilities at all levels.

This framework follows the World Health Organisation’s AWaRe (Access, Watch, and Reserve) categorisation. It guides on which antibiotics can be accessed at each level — those to be watched, those that should be under lock and key, those to be prescribed by a particular cadre and approved by a special antimicrobial stewardship committee after confirmation of  causative organism for the indication being treated. 

The ministry also put in place an AMR plan of action for 2017-2027 to gives strategies on prevention. This looks at the one health approach policy.

To oversee and coordinate implementation, there is national AMR Coordinating Committee comprising specific focal point persons as well as civil society, cooperating partners and faith-based organisations. This committee is chaired by director ZNPHI and co-chaired by director veterinary services and supported by a secretariat.

Implementation of the NAP is done in a multi-sectoral manner. Some funds for implementation come from the GRZ allocation to ZNPHI. Zambia also benefits from the Unitd Kingdom’s Fleming Fund, which assists countries to collect high-quality data on prevalence of AMR and drug resistant infections and on the use of antimicrobial medicines in human and animal health.

To improve data, the government invests in public health laboratories, medical laboratories and providing necessary requisites for health workers to routinely check the sensitivity and effectiveness of these drugs.

This is in line with the Zambia National Health Strategic Plan (2017-2021). The health ministry also provides point-of-care testing to the rest of the health centres and some health posts. The aim is to ensure accessible laboratory services (National Biomedical Laboratory Strategic Plan 2018-2022).

A National Integrated AMR Surveillance Strategy too has been developed to coordinate the collection of AMR data across all relevant sectors. This strategy sets the framework for strengthening knowledge and the evidence base on AMR through surveillance and research. 

AMR threatens Universal Health Coverage and many sustainable development goals (SDG) mandated by the United Nations such as ending poverty and hunger and ensuring healthy lives.

For example, SDG 1 on ending poverty is difficult to achieve as AMR strikes the poor the hardest. The cost for treating a resistant bacterial infection is more. 

Zambia has also taken steps to protect the environment from antibiotic residues.

Zambia Environmental Management Authority (ZEMA), established in 2011, is among agencies that ensures adherence to regulations standards and guidelines set in the disposal of medical waste. It provides guidance and expertise on environment management aspects of reversing AMR.

The he guidance and intervention includes sound disposal of obsolete / expired medicines / pharmaceutical products (classified hazardous); the safe use of antibiotic in agriculture and aquaculture, ZEMA Director, Operations, Maxwell Nkoya said.

ZEMA used the Environmental Management Act No.12 of 2011 and the Environmental Management (Licensing) Regulations No.112 of 2013.

It is concerned with a wide variety of matters regarding environmental protection including air quality control, waste management, hazardous waste and other substances harmful to the environment such as pesticides and ozone-depleting substances.

The approval of methods and sites where obsolete or expired medicines/pharmaceutical products are disposed of is a sole mandate of ZEMA. 

The ZNPHI has embarked on systems and network strategy where in addition to the national public health laboratory other labs will be leveraged on to form regional and national networks.

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