One prescription at a time: Tackling antimicrobial resistance in Liberia
Photo: Antibiotics sold without prescription on local markets in Liberia | Health Focus.
Antimicrobial resistance is now one of the biggest challenges to global public health. German development cooperation has been working to tackle the problem in Liberia – how can the lessons learned be carried forward?
Suffering from a severe chest infection, Josephine travelled many miles in a crowded bush taxi to reach the JJ Dossen Memorial hospital in Harper City in south east Liberia. When she eventually saw the doctor she insisted on getting antibiotics because she didn’t want to go back empty-handed. She also asked for drugs for other family members and their various unspecified illnesses. Even though he was unsure if antibiotics would help because he did not have access to laboratory services to identify the cause of Josephine’s infection, the doctor prescribed the drugs.
Meanwhile, in the local vegetable market all sorts of drugs – many counterfeit – are stored in buckets with no temperature controls and sold ‘over the counter’ without prescriptions. Challenged by the local medical director that the pills he was selling could kill people, one vendor laughingly replied: ‘Yes, we are killing some, and healing others!’
Liberia, of course, is not an exception: Unregulated prescription of antibiotics is a problem in many parts of the world – and this comes at a huge cost.
AMR has become a global threat…
Systematic misuse and overuse of essential antimicrobial drugs has drastically undermined their effectiveness. According to The Lancet (January 2022) antimicrobial resistance (AMR) is now one of the leading causes of death globally, with the highest burden falling on low-resource countries such as Liberia. According to Professor Frieder Schaumburg, Director of the Institute of Medical Microbiology at the University of Münster, Germany, and an external adviser to the Liberia project, ‘it is very clear that AMR will kill millions of people in low- and middle-income countries in the coming years – ten times as many as in higher income countries’ (see O’Neill, 2016, Tackling drug-resistant infections globally).
In May 2015 the World Health Assembly (WHA) warned that the AMR crisis ‘threatens the very core of modern medicine’ and undermines effective responses to infectious diseases. With no new products currently in the pipeline and growing AMR, the world is ‘heading towards a post-antibiotic era in which common infections could once again kill.’ To avert this frightening trajectory the WHA adopted a global action plan which aims to improve awareness and understanding of AMR through effective communication, education, training, monitoring and research. How is this put into action in countries like Liberia?
Documenting learnings for GIZ’s Sector Network Working Group on Global Health Security
GIZ’s Working Group on Global Health Security advocates a ‘One Health’ approach to health security and health systems strengthening. Comprised of multidisciplinary experts dedicated to facilitating evidence-informed policy for the detection, prevention and control of infectious disease, it meets regularly to share information, gather base-line knowledge and hold discussions through thematic workshops.
According to Damien Bishop, Speaker of the Group, ‘you can’t have health security without resilience, and you can’t have resilient health sectors without health systems strengthening.’ In the past, says Bishop, global health security has often been a ‘knee-jerk reaction’ to health crises such as AIDS, Ebola, and more recently COVID and, he argues, ‘We can’t go back to this situation.’
By documenting its learning on Healthy DEvelopments, the Group wants to build institutional memory and facilitate links with other partners to ensure that the lessons learned from projects like the one covered in this article are sustained. ‘It’s a work in progress’, says Bishop – but vital if the work already done on AMR and other global security issues is not simply going to be lost.
…that needs to be tackled at local level.
In 2018, Liberia adopted a national strategy on AMR and requested technical assistance from the Liberian-German health programme, implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ). A good working relationship with the Ministry of Health had already been established in the context of the project’s collaboration on pandemic prevention and health systems strengthening, and as part of this, a focus on developing Liberia’s laboratory capacities (see this feature article for more detail). GIZ brought in Health Focus GmbH to set up an antimicrobial surveillance and stewardship (AMS) project with Partners in Health (PIH) – who have a long track record of working in Liberia and could, it was hoped, ensure the short project’s sustainability, and University Hospital Münster who provided academic and technical expertise.
The idea was that they would jointly focus on the development and implementation of local treatment guidelines for antimicrobial therapy, on the training of prescribers and on regular monitoring of prescription practices on ward rounds. The project also strengthened laboratory capability and trained technicians to test for antibiotic resistance (see below).
‘If you can do it in the most difficult areas, it should be easier elsewhere’
The aim of the project was to demonstrate how better stewardship of antimicrobials can bring about improvements in clinical care even in the most challenged health-care settings. Building on work already done by the German health programme in the region, the AMR project was launched in three hospitals in three difficult-to-reach counties in the southeast of Liberia, i.e. the JJ Dossen Memorial hospital in Maryland, Rally Time Hospital in Grand Kru and Fish Town Hospital in River Gee. ‘It takes two to three days to reach these counties by road during the rainy season,’ says Dr Abraham Alabi, a Nigerian microbiologist specialising in infectious diseases and the lead technical adviser for the AMR collaboration. ‘If you can do it in the most difficult areas, it should be easier to do it elsewhere.’
Under Dr Alabi’s guidance, the AMR team conducted a series of trainings and workshops to promote understanding and awareness of AMR and to highlight the benefits of correct prescription practices and prudent use of antibiotics.
Improving diagnostics to ‘identify the enemy’
Training and knowledge is not always enough to change doctor’s behaviour. It can be difficult for them to know what to prescribe if there are no laboratory tests available to determine what is wrong with patients and target the right therapy. ‘Drugs were given on a trial-and-error basis and patients were suffering,’ says Dr Alabi. Patients such as Josephine also demand antibiotics without understanding that incorrect or inappropriate use can be harmful.
‘Antimicrobial stewardship is about the prudent use of antimicrobials. You have to choose the best substance wisely,’ says Professor Schaumburg ‘To choose wisely you need first to identify your enemy: Without diagnostics you do not know what to hit.’
One of the project’s first steps was to establish a fully-functioning microbiology laboratory, where none existed before. In October 2019 the first lab of its kind opened at JJ Dossen Memorial hospital, providing culture and antimicrobial susceptibility testing from blood, urine, stool and swabs using international standard operating procedures. The lab serves all three hospitals in the AMS pilot project, with specimens transported by motorbike from Rally Time and Fish Town hospitals to JJ Dossen. German development cooperation and Partners in Health also provided equipment such as autoclaves, microscopes, reagents etc. and trained technicians to follow quality improvements aimed at international accreditation, as well as to perform vital ARM susceptibility testing.
‘Everyone could see the impact’
A couple of weeks after giving birth a woman returned to the hospital with an infected caesarean section wound. First, she was given antibiotics without prior identification of the bacteria causing the infection, but her condition did not improve. So samples were sent to the newly established microbiology lab which quickly identified the bacteria that caused the infection. The woman was then given suitable drugs tailored to the specific bacteria and her condition quickly improved. ‘It was a breakthrough moment because there and then everyone could see the impact,’ says Dr Alabi. ‘Since that time doctors have become much more careful in the way they prescribe antibiotics. From this concrete experience and the trainings we conducted they have understood that it is important to identify the right drugs and that antimicrobial resistance is a threat to humankind.’
‘People will embrace change it if they see positive results,’ concurs Professor Schaumburg. ‘The main lesson from this project is that it is possible to implement AMS projects even in very challenging and remote areas with good planning, training and incentives, and the cooperation of government and local staff.’
The improvements were remarkable, both in the selection of effective antibiotics, as well as the proper usage and adherence to ensure the course of antibiotics was followed through to the end. The end of project evaluation found that the selection of appropriate antimicrobials had improved from 34.5% (107/310) to 61.0% (189/310). Samples from almost 80% of patients with infectious diseases requiring microbiological analysis for their appropriate treatment had been sent to the laboratory for this analysis; and the condition of around 92% of these patients had improved three days after receiving appropriate antimicrobials.
Setting up national and local AMS steering committees
A national AMR-AMS Steering Committee had been established in November 2019 involving all major stakeholders such as the Ministry of Health and development partners such as WHO and GIZ. The committee, which is chaired by a former Chief Pharmacist of Liberia, meets on a bi-monthly basis to monitor AMR and prescription practices and has now integrated lessons learned and the methodology of the AMS project.
Each of the three hospitals has also established (with various degrees of success, depending on human resource restraints) their own multidisciplinary committees, which regularly conduct ward rounds to intervene as necessary with regard to use of antibiotics and systematically collect clinical, microbiological and epidemiological patient data.
‘A thirst for knowledge’ after the project
Although German funding for the AMR pilot came to an end in January this year, now there is a ‘thirst for knowledge’ from medical professionals about AMR who want to know more about the problem and how it can be tackled, says Johanna Schulte, GIZ’s Health System Strengthening and Epidemic Prevention & Gender Focal Point for Liberia. Now, she says, there is a stronger sense of awareness of the problem and ownership of the AMR stewardship measures that have been put in place.
With support from the project, the Government of Liberia was also able in 2021 to submit data for the first time to the WHO’s global AMR surveillance system (GLASS). Despite these considerable advances, however, the remaining challenges are still enormous – and the biggest of these is how to sustain efforts in resource-limited setting.
A promising first step
Professor Schaumburg argues that a two- to three-year project is not long enough to address an issue of this magnitude and importance. However, he believes that the project was ‘definitely worth doing’ because it showed how AMR interventions can be successful, even in the most difficult situations. It was also, he says, a good example of south-south collaboration between Liberia and experts from Nigeria, Tanzania and Gabon who came to Liberia to conduct trainings and provide technical advice. However, he’s worried that even though the project results were a promising first step, they could easily be reversed given the Government of Liberia’s limited financial options to continue the work. Even if Germany can no longer support the project, he hopes that other organisations will pick up the baton and continue this vital work. The lessons learned from it have just been published as academic paper:
Professor Schaumburg believes that long-term success in tackling AMR depends on fundamental improvements to proper sanitation, access to clean water, vaccination coverage, better living conditions and good governmental practices – in other words a holistic ‘One Health’ approach that includes, amongst many factors, animal as well as human health, better resources and trained staff as well as better governance –. He recalled running one workshop in Harper when there was no electricity or water for a couple of days: ‘You can build and equip a lab, but if you are not able to wash your hands, it’s a problem.’
Nevertheless, as a result of the AMS project, JJ Dossen memorial is now in a much better position to tackle such challenges and capable of continuing the improvements through regular ward rounds and AMR testing. The hospitals at River Gee and Grand Kru however, still require and will get, and until mid-2023, further support to make the improvements sustainable and enable them to continue to send samples for analysis at the laboratory at JJ Dossen. Emmanuel Agu, the County Pharmacist at JJ Dossen Memorial hospital, says he and his colleagues are trying hard to ‘keep the spirit’ of the AMR project going, with the reduced support they are now receiving before the project funding ends in June 2023: ‘We have to continue to encourage our colleagues to follow better prescription practices for the sake of the patients and for the sake of the world that we live in today because AMR is a serious threat to humankind.’