Coordinated response is the need of the hour
Sadiq Abdullahi sells medicine at Kpana Market in Utako district of Nigeria’s capital Abuja. In his 30s, he has been selling drugs in that open space for more than three years; his ware include different brands of antibiotics such as amoxicillin, ciprofloxacin, metronidazole, penicillin and clindamycin.
Sadiq charges less than registered pharmacies: A card of amoxicillin goes for 150 Nigerian naira — less than $0.40 cents — while a registered pharmaceutical store would charge more than $1. The most striking thing: He never asks for a prescription and is willing to sell even two tablets, disregarding treatment guidelines.
Sadiq sources his drugs from sellers from areas like Suleja and Mararaba on the outskirts of Abuja. They claim to be agents of manufacturers.
These drugs do not have the National Agency for Food and Drug Administration and Control’s authentication codes for verification. Among his clients is Jumai Abdullahi, who wanted to buy ciprofloxacin because she believed she was suffering from typhoid. The vendor agreed to her diagnosis, saying that the weakness of joints and headache she complains of are common symptoms of typhoid.
A study Knowledge, risk perception and practices related to antibiotic resistance among patent medicine vendors in Sokoto metropolis published in 2018 showed that in rural northwestern Nigeria:
Sellers like Sadiq who promote irrational and indiscriminate use of antibiotics are one of the reasons for the high rate of antibiotic resistance in Nigeria.
Data from Nigeria National Action Plan for Antimicrobial Resistance (2017-2022) showed non-typhoidal Salmonella (NTS) had the following resistance:
Resistance on the rise
Lagos and Osun, both in south-western Nigeria, have recorded 100 per cent penicillin resistance in NTS. The document also listed high resistance rates in those places to gentamicin (89 per cent and 50 per cent respectively) and nalixidic acid (33 per cent and 100 per cent respectively).
Low resistance was, however, reported to newer generation quinolones. patients suffering from meningitis are not responding to cheap drugs like penicillin and this is increasing the cost of treatment, Garba Iliyasu, an infection disease expert at the Aminu Kano Teaching Hospital, said.
In five meningitis studies, 20 per cent of all N meningitidis isolates were resistant to chloramphenicol while 30.8 per cent were resistant to penicillin G, according to Antimicrobial Use and Resistance in Nigeria: Situation Analysis 2017 — a combined data from the federal ministries of health, environment and agriculture.
“Regarding H influenzae, resistance rates for penicillin G, chloramphenicol, ceftriaxone were found to be 66.7 per cent, 23.5 per cent, and 4.5 per cent respectively. For S.pneumoniae, the resistance rates were 45.2 per cent, 10.3 per cent and 1.7 per cent respectively,” the study stated.
Such resistance was visible in all kinds of diseases, said Adefolarin Opawoye another infection diseases expert at the same hospital. Drugs like ciprofloxacin and augmentin no longer works on patients infected by organisms that produce extended spectrum beta lactamases, he added. “Then you have to move on to more powerful substitutes such as piperacillin-tazobactam and meropenem.”
Opawoye recalled the case of patient who had an open-heart surgery abroad, caught an infection by a highly resistant organism and had to be on prolonged therapy with vancomycin, a powerful antibiotic.
“Unfortunately, this man lost his hearing after the treatment which is one of the side effects of this drug. He lived but became deaf,” the doctor said.
Weak data collection and documentation was weak in Nigeria, he said. According to the 2017 AMR country report, 63 studies on urinary tract infections (UTIs) in 26 states and capital Abuja, found resistance to all drugs commonly prescribed for UTI in the country.
Resistance rates were highest for ampicillin and cotrimoxazole, with most organisms showing 100 per cent resistance.
The microbiology department at Abuja’s National Hospital can now collect data on resistant agents and classes on the increase and condition that don’t respond to antibiotics, said Olalekan Oluleti, a clinical pharmacist and the lead pharmacist there.
Chaotic drug distribution
The root of antibiotic abuse and misuses was in Nigeria’s chaotic drug distribution system. “We have legislations, but archaic to the point of being ineffective,” Oluleti said, pointing out that they were a colonial relic: “If there is no enabling law, you can’t go after people who sell such drugs indiscriminately.”
Abubakar Bala Mohammed, director of Blueblood Veterinary Ltd, Abuja, expressed anger: “Some regulatory bodies don’t have the capacity to do the work they have been set up to do.”
An attempt to amend the obsolete Pharmacists Council of Nigeria Act Decree 91, 1992 — which became the Act of the National Assembly 2004 — failed: The Eighth Assembly passed the Bill but it was not signed into law by President Muhammadu Buhari for reasons many professionals do not know.
That amendment would have brought sanity into drug distribution by reducing access, putting the drugs in the custody of trained professionals and making it illegal for an untrained person to carry them or distribute them.
Frightening trend in livestock
The misuse of antibiotics was rampant in the livestock sector, like in Kenya.
The 2012 National Agricultural Sample Survey estimated Nigeria’s livestock as one of the largest in Africa, with:
The sector was one of the biggest consumers of antibiotics in the country.
Bala Mohammed, who has 25 years experience in veterinary practice in Abuja, said part of the problems has to do with the way farmers use antibiotics irresponsibly without consulting professionals.
Many livestock producers use antibiotics to boost growth in animals and to treat or prevent diseases from attacking without proper diagnosis or professional advice, said Dooshima Kwange, of the Department of Veterinary and Pest Control Services, Federal Ministry of Agriculture and Rural.
Many farmers mixed three-five antibiotics to the animals’ drinking water. The practice was widespread.
An Antibiotic Sensitivity Test (AST) from Animal Care laboratory, Abuja, for a commercial poultry farm on the city’s outskirts confirmed that nine antibiotics for the treatment of animals and birds were resistant to eight antibiotics: augmentin, oxytetracycline, fosfotrim, streptomycin, anicillin, enrofloxacin, gentamicin and furaltadone.
The only antibiotic standing is Colistin, which should not be used on animals.
Kwange predicted a more threatening future: By 2050, Nigeria’s population was estimated to reach 400 million. This would pressure the livestock production even more, culminating in increased interaction at the animal-human-environment interface.
Isaac Adewale, the country’s health minister, set up an AMR coordinating body at Nigeria Centre for Disease Control in November 2016. This followed the signing of a resolution to develop AMR NAPs that September by 193 countries at the United Nations General Assembly.
The ‘One-Health’ AMR Technical Working Group (TWG) at the NCDC was inaugurated in January 2017 for situation analysis on AMR and developed the NAP.
NCDC’s Inweregbu Stella said the centre conducted a situation analysis in 2017 and flagged:
The NCDC has established nine surveillance sites in various geopolitical zones to start collecting data on AMR. It, however, was yet to respond to a request for data, saying collection was still on.
Also, 25 university teaching hospitals and other laboratories across 21 of the country’s 36 states can also conduct antimicrobial sensitivity test (AST). Some of the labs, however, need major work to meet standards.
A coordinated response was necessary to avert a major health crisis, especially with an annual population growth rate of 3 per cent and a declining life expectancy of 53 years.
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