'Tunde [not real name], a small-scale building contractor diagnosed with prostate cancer, recently underwent surgery. He had educated his children, and they were employed, he owned his home, and made a decent income. Unlike most Nigerians 'Tunde could afford to schedule the excision of his cancer at a reasonably comfortable private hospital with an in-house consultant surgeon. The estimated costs of his procedure, which were shared with him in advance, were just within his budget and he should have been discharged within days of surgery. Instead, he stayed on the ward with a high fever, severe abdominal pain, and vomiting. Eventually, he was referred to a teaching hospital with more specialists on staff.
The feverish and disoriented 'Tunde who was taken to the referral hospital, showed signs of sepsis, a body's desperate internal fight against lethal germs that can leave survivors with life-long health issues. Tunde's new consultant physicians concluded that first-line antibiotics, used at the first hospital, were unlikely to effective. They performed a battery of tests and, while waiting for. the results, prescribed a combination of antibiotics typically reserved for difficult-to-treat infections. After two days of having these medicines dripping into his veins, 'Tunde's condition did not improve, but laboratory results offered some insight.
Navigating the Hurdles of Antimicrobial Resistance (AMR)
A stubborn greenish bacterium, known as Pseudomonas aeruginosa, resistant to all available antibiotics in the hospital pharmacy, was cultivated from Tunde's urine. The laboratory report indicated that two antibiotics, both with undesirable side effects, could work but neither medicine was available at the hospital. One of these expensive, so called 'reserve 'antibiotics, (that is, reserved for otherwise untreatable cases), was procured from elsewhere and used to flush 'Tunde's bladder. The other was prescribed to be injected into 'Tunde, all while he was still battling cancer. We hope that Tunde's health improved because of the new medications, but we will never know for sure. Two days after receiving the reserve antibiotics, due to the extended hospital stays, expensive tests, procedures, and treatments. Tunde's finances hit rock bottom. He discharged himself against medical advice and was lost to follow-up.
Many Nigerians struggle to get access to quality medical care, particularly for conditions like cancer, which must be managed by specialists, as well as the most common diseases like malaria and bacterial infections, which require antimicrobials. 'Tunde was relatively affluent and the medical care available in Nigeria was within his reach. But his health providers were disempowered by so-called extensively resistant bacteria. Antibiotics and other antimicrobial drugs (such as antimalarials) are among the most important inventions of the last century. They have worked so well, that we only notice them when they fail us, as in the case of 'Tunde's infection.
The World Health Organisation (WHO) recently began cataloguing the stories of people that have, like 'Tunde, struggled with the devastating but faceless phenomenon of antimicrobial resistance (AMR). Some infections for which treatment is commonly thwarted by antibiotic -- like typhoid or tuberculosis -- are typically contracted in the community but many, as in 'Tunde's case, are acquired in health care facilities. Unsurprisingly, the list of AMR survivors advocating for more attention to resistance includes several Africans, and Nigerians. However, most AMR stories from Nigeria are never told and, due to limited diagnostic testing, many are never discovered.
AMR threats go undiscovered
AMR has been discussed in specialised medical circles for decades. However, most people, including several frontline health workers, are unaware or under-aware of the threat it poses. In a research series on AMR in The Lancet, a major medical journal, I, along with AMR experts from around the world, highlight that an estimated 4.95 million people die each year with an AMR infection and 1.27 millions of these deaths are directly attributable to resistant bacteria. In Nigeria, because surveillance is just developing, the precise number of people with resistant infections is unknown. However, Nigeria's AMR surveillance system, which is coordinated by the Nigeria's Centre for Disease Control and Prevention (NCDC) shows that it is a major problem in Nigeria.
If no action is taken more people will succumb to resistant infections and those that recover will spend more time and money to get better. Surgery and other medical procedures will become riskier, and patients will die from potentially curable conditions, such as early-stage cancers. Nigeria will also not be able to win her battles against common diseases that have been eliminated in other parts of the world, such as malaria and typhoid fever.
Progress towards universal health coverage, already too slow, could be lost because sick patients will need more expensive or non-existent medicines to treat resistant infections. Cheaper medicines used routinely today will have to be replaced with more expensive options that have more or worse side effects. We may face dilemmas in which doctors would hesitate to remove a cancer or perform life-saving caesarian sections because of the risk of death by infection. All of us are at risk, with newborn babies, the elderly, and severely ill individuals, those most vulnerable to infections, needing the greatest protection.
One of the main reasons why AMR is widespread, is the misuse of antibiotics -- in human medicine but also in agriculture. Antibiotic overuse and misuse have allowed resistant variants of germs to proliferate. While there is rampant overuse of antibiotics in many parts of the world, many people, especially Nigerians, who require antibiotics, do not have access to them. An even greater fraction of our patient populations has no access to laboratory testing that is essential for determining who needs an antimicrobial and which one would work best. Therefore, as we reduce the inappropriate use of antibiotics that has exacerbated resistance, we must increase access for those that have infections but cannot access the right medicines.
New treatments are essential
It is vital that we discover new treatments that can kill the germs that are resistant to current antibiotics. We must advocate for and invest in drug innovation models that lead to low-cost solutions to infection. Scientists doing this sort of research at Nigerian Universities and research Institutes are underpaid and underfunded, with insufficient infrastructure to bring promising initial discoveries to advanced testing and, ultimately, the clinic. The private sector, which typically drives drug development is pulling out of antibiotic research, and out of Nigeria. The drug discovery and development incentive structure need to change if Nigerians are to have access to treatments for infections in the coming decades.
Adequate investment in new antibiotic discovery will help in the future. But there is a lot we can do right now to control AMR. Most Nigerians lack access to safe water or sanitation. As reported in a previous Nigeria Health Watch posting, as many as 48 million Nigerians use open defecation[VI1] some or all the time. This places us at risk of faeco-orally-transmitted infections, including typhoid, diarrhea, and cholera, all which impact millions of Nigerians. The risk of contracting these infections exacerbated by flooding, becoming more frequent due to climate change. Open defecation also enables antimicrobial-resistant bacteria to spread from person to person.
Improving WASH to tackle AMR
According to the Lancet series on AMR, implementation of Water, Sanitation, and Hygiene (WASH) interventions could prevent a quarter of a million deaths each year, caused by antibiotic-resistant infections, in addition to protecting people from faeco-orally transmitted diseases. Proper infection prevention and control interventions in health care facilities has the potential to save another 337,000 lives. Ensuring universal access to high-priority vaccines for babies and children has the potential to prevent another 181,500 deaths from antimicrobial-resistant infections.
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Nigeria recently adopted vaccines for pediatric pneumonia and rotavirus diarrhea. These vaccines help prevent some antimicrobial-resistant infections, reduce the spread of the infections and the use of antibiotics, which fuels resistance. These vaccines, along with others, need to be more extensively distributed to protect vulnerable children. There are now oral cholera vaccines, but global shortages have limited their use during the current cholera outbreak in Nigeria, one of many reasons why we need to step up and make our own vaccines. There is extensive data that shows that typhoid is highly endemic in Nigeria. Typhoid conjugate vaccines have been rolled out in countries including Liberia, Malawi, and Zimbabwe, which have a lower burden and/ or less evidence of their need than Nigeria. Nigeria needs these vaccines to reduce the health burden and death toll and to control antibiotic-resistant infections.
Later this year, Nigeria's leaders will join others at the United Nations General Assembly (UNGA) to discuss what should be done about AMR. To effectively address a complex issue like AMR on a global scale, aside from finance and getting politicians on board, we need global targets to hold countries accountable. In the Lancet series, my colleagues and I propose that a United Nations resolution on AMR contains goals to reduce deaths from drug resistance by 10%. This can be done, in part, by reducing inappropriate use of antimicrobials for human health by 20% and reducing inappropriate use in animals by 30%. We call these the 10-20-30 by 2030 goal. It is ambitious but achievable and essential for preserving our ability to treat infections, an essential component of health care in Nigeria and around the world.
Iruka N. Okeke is a pharmaceutical microbiologist and is currently a professor at the College of Medicine, University of Ibadan, Nigeria.
