Extending political will into action in African LMICs: abating global antimicrobial resistance
Authors: Dickson Aruhomukama
Journal: The Lancet Microbe (2022)

Antimicrobial resistance remains a threat to human health globally.1Antimicrobial Resistance CollaboratorsGlobal burden of bacterial antimicrobial resistance in 2019: a systematic analysis.Lancet. 2022; 399: 629-655Summary Full Text Full Text PDF PubMed Scopus (302) Google Scholar Despite serious gaps in the data, the marked contribution made by African low-income and middle-income countries (LMICs) to the number of deaths due to antimicrobial resistance cannot be ignored.1Antimicrobial Resistance CollaboratorsGlobal burden of bacterial antimicrobial resistance in 2019: a systematic analysis.Lancet. 2022; 399: 629-655Summary Full Text Full Text PDF PubMed Scopus (302) Google Scholar Indeed, LMICs in Africa should be given even greater attention than ever before if we wish to achieve a "truly global response to antimicrobial resistance", as urged by Jacob Goldberg and colleagues2Goldberg J Clezy K Jasovský D Uyen-Cateriano A Leaving no one behind: the need for a truly global response to antimicrobial resistance.Lancet Microbe. 2022; 3: e2-e3Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar in The Lancet Microbe. Active surveillance is crucial in the fight against antimicrobial resistance.3Seale AC Gordon NC Islam J Peacock SJ Scott JAG AMR surveillance in low and middle-income settings—a roadmap for participation in the Global Antimicrobial Surveillance System (GLASS).Wellcome Open Res. 2017; 2: 92Crossref PubMed Scopus (64) Google Scholar Commendable efforts have been made by WHO's Global Antimicrobial Resistance Surveillance System programme and Africa Centres for Disease Control and Prevention to survey antimicrobial resistance in Africa.4Kariuki S Keddy KH Antonio M Okeke IN Antimicrobial resistance surveillance in Africa: successes, gaps and a roadmap for the future.Afr J Lab Med. 2018; 7: 924Crossref PubMed Scopus (8) Google Scholar However, studies and reports still imply that the systematic surveillance of antimicrobial resistance in most of Africa is limited.4Kariuki S Keddy KH Antonio M Okeke IN Antimicrobial resistance surveillance in Africa: successes, gaps and a roadmap for the future.Afr J Lab Med. 2018; 7: 924Crossref PubMed Scopus (8) Google Scholar, 5Varma JK Oppong-Otoo J Ondoa P et al.Africa Centres for Disease Control and Prevention's framework for antimicrobial resistance control in Africa.Afr J Lab Med. 2018; 7: 830Crossref PubMed Scopus (14) Google Scholar In reality, the majority of Africa's LMICs depend on data from independent research studies for estimating the prevalence of antimicrobial resistance.6Chaplain D Asutaku BB Mona M Bulafu D Aruhomukama D The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer.Antimicrob Resist Infect Control. 2022; 11: 23Crossref PubMed Scopus (2) Google Scholar These studies are typically done in the few existing clinical microbiology laboratories at national and regional health-care facilities in African LMICs, with too few studies done in facilities below the regional level.6Chaplain D Asutaku BB Mona M Bulafu D Aruhomukama D The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer.Antimicrob Resist Infect Control. 2022; 11: 23Crossref PubMed Scopus (2) Google Scholar All health-care facilities in African LMICs, irrespective of their size, need equal attention and inclusion in studies. They all experience similar challenges, such as lack of funds. One study evaluated antimicrobial susceptibility testing capacity in clinical microbiology laboratories at various health-care facilities in Uganda, reporting several challenges at the national health-care facility's laboratory. As this laboratory was the most resourced but still experienced difficulties, the authors suggested that the situation could be worse at laboratories at regional and smaller health-care facilities that were less well resourced.6Chaplain D Asutaku BB Mona M Bulafu D Aruhomukama D The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer.Antimicrob Resist Infect Control. 2022; 11: 23Crossref PubMed Scopus (2) Google Scholar National action plans for antimicrobial resistance might not have been adopted by many of Africa's LMICs. In those countries where the plans have been adopted, the question remains whether they have been properly implemented. Indeed, the adoption of national action plans for antimicrobial resistance shows that there is political will to implement these plans,6Chaplain D Asutaku BB Mona M Bulafu D Aruhomukama D The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer.Antimicrob Resist Infect Control. 2022; 11: 23Crossref PubMed Scopus (2) Google Scholar but the majority, if not all, of these countries have relied solely on funding from outside their borders for plan implementation.7WHOComprehensive review of the WHO global action plan on antimicrobial resistance—volume 1: report.https://www.who.int/publications/m/item/comprehensive-review-of-the-who-global-action-plan-on-antimicrobial-resistanceDate: Aug 31, 2021Date accessed: February 11, 2022Google Scholar Given the uncertainty of this funding,7WHOComprehensive review of the WHO global action plan on antimicrobial resistance—volume 1: report.https://www.who.int/publications/m/item/comprehensive-review-of-the-who-global-action-plan-on-antimicrobial-resistanceDate: Aug 31, 2021Date accessed: February 11, 2022Google Scholar the attitude that funding for implementation of these plans in LMICs should be solely external is, in modest writing, wrong. Local funding to support the implementation of national action plans for antimicrobial resistance is essential and should be encouraged. Perhaps it is also time to champion funding from the private sector in Africa's LMICs. We need to extend the political will that already exists into more action. Clinical microbiology laboratories in Africa's LMICs must be funded locally to boost their capacity to drive the surveillance of antimicrobial resistance.6Chaplain D Asutaku BB Mona M Bulafu D Aruhomukama D The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer.Antimicrob Resist Infect Control. 2022; 11: 23Crossref PubMed Scopus (2) Google Scholar Developing the required standard operating procedures, training laboratory staff, ensuring the steady supply of materials needed to perform antimicrobial susceptibility testing, and installing automated reporting systems is crucial and must be done alongside the other aims of the national action plans.6Chaplain D Asutaku BB Mona M Bulafu D Aruhomukama D The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer.Antimicrob Resist Infect Control. 2022; 11: 23Crossref PubMed Scopus (2) Google Scholar Regarding expensive diagnostic methods, one would wonder if it is time to review how antimicrobial resistance is tested for in Africa's LMICs. Since the introduction of Sanger sequencing in 1977,8Sanger F Nicklen S Coulson AR DNA sequencing with chain-terminating inhibitors.Proc Natl Acad Sci USA. 1977; 74: 5463-5467Crossref PubMed Google Scholar sequencing technology has notably evolved.9Heather JM Chain B The sequence of sequencers: the history of sequencing DNA.Genomics. 2016; 107: 1-8Crossref PubMed Scopus (501) Google Scholar Although initially costly for Africa's LMICs, this evolution has seen the emergence of cheaper sequencers.10Jain M Olsen HE Paten B Akeson M The Oxford Nanopore MinION: delivery of nanopore sequencing to the genomics community.Genome Biol. 2016; 17: 239Crossref PubMed Scopus (37) Google Scholar The substitution of costly culture-based methods with cheap sequencing for the surveillance of antimicrobial resistance is now an option for LMICs in Africa. Even the governments of Africa's LMICs where national action plans have not been adopted have strategies in place to fight antimicrobial resistance. However, the question remains as to whether there is political will to implement these plans. Perhaps Africa's LMICs also need to develop more Specific, Measurable, Achievable, Realistic, and Time-bound (known as SMART) plans that include roles for both governments and the private sector. The use of national action plans and other plans, with sustained funding from governments and the private sector, can help in the fight against antimicrobial resistance. Therefore, the political will that already exists in Africa's LMICs needs to be expanded into further action by allocating sustainable budgets to ensure systematic implementation of the core elements of national action plans for antimicrobial resistance, especially laboratory-based surveillance of antimicrobial resistance. The sustained availability of data on antimicrobial susceptibility testing can help to prevent and reduce the burden of antimicrobial resistance in African LMICs, thereby contributing to global efforts against antimicrobial resistance. I declare no competing interests.