1 BSI (range of 10% to 42%), SSI (2% to 75%), UTI (7% to 53%), VAP (19%), GIT (4%) and SST (4% to 83%) 2 Varies by medical patients 25.6% and surgical patients 12.4%. Key: SSI – surgical site infection; NN - neonatal Abubakar et al (2022) found from the 15 Africa studies that surgical site infection was the most common HAI and accounted for 41.6% of all HAIs, followed by bloodstream infection and respiratory tract infections/ pneumonia. The highest rates were found in the ICU (25.2%– 100%), followed by neonatal ICU/ward (7.0%–53.6%) and pediatric medical ward (2.7%– 33.0%). The prevalence of HAIs in Eastern and Southern Africa region ranged between 11.4%– 28.0% and 7.6%–13.5%, respectively.

Based on this evidence, it is appropriate to use the pooled estimates reported in the metaanalysis by Abubakar et al (2022), unless a meta-analysis has been conducted in a single country with sufficient studies informing it. Hence, for eight countries the HAI rate of 12.76% is used, while for Ethiopia the meta-analysis generated HAI rate of 17%. In sensitivity analysis, lower and higher values of half and double the baseline rate are used.

# 2. Proportion of HAIs that are antimicrobial resistant (AMR)

Harant (2022) assesses the transparency and accountability of national action plans on antimicrobial resistance in 15 African countries, including Ethiopia, Kenya, Tanzania and Uganda. In country responses, Ethiopia and Kenya have full AMR surveillance, while Kenya and Tanzania have partial surveillance. WHO (2020b) also reports on Madagascar, Mozambique, and Sudan. WHO’s global report gives global rates of AMR without disaggregation by region or by country.

Systematic reviews of antimicrobial drug resistance in Sub-Saharan Africa show that antimicrobial resistance varies widely for different first- and second-line drugs and across geographies from 0% to over 80% (Leopold et al, 2014; Tadesse et al, 2017; Kariuki et al, 2021). Annex 2 provides details of these are other studies.

Murray et al (2022) report a systematic analysis of the global burden of bacterial antimicrobial resistance in 2019 and produce modelled estimates for resistance of several important pathogens to frontline drugs. The following data extracted focus on the nine countries in the study for selected frontline drugs:

- Meticillin-resistant Staphylococcus aureus is 10%-30% in most of the 9 countries, and 30%-40% in Ethiopia and 50%-60% in Sudan.

- Isoniazid and rifampicin co-resistant (excluding XDR) Mycobacterium tuberculosis is <5% for all of Africa.

- Third-generation cephalosporin-resistant Escherichia coli is 20%-40% in most of the 9 countries, and 40%-50% in Kenya and Uganda, 50%-60% in Ethiopia and 60%-70% in Sudan.

- Carbapenem-resistant Acinetobacter baumannii is variable across the 9 countries: <5% in Uganda, 10%-40% in most of the 9 countries, 40%-50% in Tanzania and Kenya, and 60%-70% in Sudan.

- Fluoroquinolone-resistant Escherichia coli is 20%-30% in Tanzania and Mozambique, 30%-40% in Angola and Kenya, 40%-50% in DRC, Madagascar and Uganda, and 50%60% in Ethiopia and Sudan.

- Carbapenem-resistant Klebsiella pneumoniae is <5% in most of the 9 countries, 5%10% in Sudan and 10%-20% in Ethiopia.

- Third-generation cephalosporin-resistant Klebsiella pneumoniae is >50% in all countries, and >80% in Ethiopia, Mozambique, and Sudan.

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