CARE: COVID-19 and Antimicrobial Resistance in East Africa - impact and response
Lead Research Organisation:
University of St Andrews
Department Name: Sch of Medicine
Abstract
There is a growing worry that knock-on effects originating from the response to COVID-19 will cause greater threats to human health in the future. One such area is antimicrobial resistance (AMR) caused by the overuse of antibiotics (AB). Responding to COVID-19, governments have imposed restrictions on everyday life to stop the virus spreading. Whilst these may be successful in combating the virus, they are changing the way people seek medical help for infections, and the way in which people use ABs when they feel ill. In order to help make sure that ABs retain their effectiveness, we need to understand more about how COVID-19 is directly and indirectly impacting on AB use and availability in communities. To do this we are going to build on existing studies in Tanzania and Uganda. We will enrol patients who have symptoms of common diseases caused by bacteria, and find out about how they seek treatment and get and use ABs. In their communities, we will find out about the availability of ABs by interviewing doctors and sellers of ABs, and more widely, we will find out how community members have received and responded to health messages on COVID-19. Using this information we are able to assess change in the situation by comparing with our pre-COVID-19 research information from the same locations. This will help identify where behaviours have changed and whether antibiotics are been used unnecessarily, so that steps and measures can be identified and introduced that can help communities use antibiotics more effectively, and therefore reduce the risk of increasing AMR.
Technical Summary
There is mounting evidence that COVID-19 prevention measures are changing patient treatment-seeking behaviours for other illnesses. This includes changes in antibiotic (AB) usage which risks driving up antimicrobial resistance (AMR). This is a priority concern within LMIC countries, including those of East Africa, where the circulating pathogen population is responsible for a high burden of infectious disease. This project will address the knowledge gap of the impact that COVID-19 is having on AB usage and provision, and gather evidence to inform policy and interventions to reduce inappropriate AB usage. Employing an interdisciplinary approach, we will conduct a program of research in Uganda and Tanzania to investigate the extent to which COVID-19 has changed health-seeking behaviour for common bacterial illnesses and the availability and usage of ABs. We will target three interconnected AMR domains: Landscape - we will investigate the impact of COVID-19 on formal health care providers' and community drug sellers' experiences and attitudes to antibiotic provision and response to official COVID-19 advice; Patients - in health clinics we will enrol patients and examine how COVID-19 restrictions are affecting patient treatment seeking, AB use, and understanding of illness, and for a subset we will assess shifts in the AMR profile of urinary pathogens; and Communities - we will investigate how community members have received and responded to health messages on COVID-19 and how perceptions about illness and medications may have altered. Data will be compared to baseline data from our ongoing study that was collected in the study areas pre-COVID-19 to investigate changes in AB usage and provision and linkage to COVID-19 disease and/or interventions. A synthesis of the findings will be provided to a range of stakeholders from communities to governmental, to help improve AB stewardship activities and messaging as part of the pandemic response in East Africa and beyond.
Publications
Olamijuwon E
(2023)
Antibiotic dispensing practices during COVID-19 and implications for antimicrobial resistance (AMR): parallel mystery client studies in Uganda and Tanzania.
in Antimicrobial resistance and infection control
Sado K
(2024)
Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance: A study of urinary tract infection patients in Kenya, Tanzania and Uganda
in PLOS Global Public Health
Olamijuwon E
(2024)
Treatment seeking and antibiotic use for urinary tract infection symptoms in the time of COVID-19 in Tanzania and Uganda.
in Journal of global health
Description | In our patient cohort we observed an increase in the levels of antibiotic resistance in pathogens causing urinary tract infections (UTIs), in comparison to UTI patients recruited in the same sites in Uganda and Tanzania before the pandemic. When we investigated the whether drug sellers were adhering to COVID-19 preventive measures and were vigilance to COVID-19 symptoms in clients, we found that this was low low. From our mystery client studies in both countries, we found that were high levels of sales of antibiotics without prescriptions being provides and also provision of partial courses of antibiotics. Both of these practices are sub-optimal for antibiotic stewardship, and the evidence from our work has been shared with policy makers and is leading to changes in policy and practice. |
Exploitation Route | Findings from CARE have be disseminated to collaborators, stakeholders and the wider community. As such, it has provided a depth of understanding of the impact of COVID-19 on AMR not currently available in East Africa. In the short-term, this will allow policy makers to access information they can use to improve prescription practice and improve antibiotic stewardship. Local dissemination event and community dialogs resulted in action plans that will continue to improve understand, knowledge and practice at the community level. |
Sectors | Healthcare |
Description | In Tanzania, evidence from CARE on poor dispensing practice was presented in late 2022 to the Ministry of Health and the National AMR multi-sectoral coordination committee. The Chief Pharmacist is alarmed by the extent of poor dispensing practice. As a result he decided that the current 5-week training course for Accredited Drug Dispensing Outlets (ADDOs) is inadequate. New regulations for ADDOs are being considered by Parliament and no new ADDOs can be registered until the training program is extended to include a section on AMR stewardship. The revised regulations will consider who should be allowed to run ADDOs and how performance will be monitored. We are working with the Ministry of Health to draft training material for ADDOs and pharmacies. |
First Year Of Impact | 2022 |
Sector | Healthcare |
Impact Types | Policy & public services |
Description | CARE/HATUA evidence on dispensing practice presented to Ministry of Health resulted in development of enhanced training program for Accredited Drug Dispensing Outlets in Tanzania |
Geographic Reach | National |
Policy Influence Type | Influenced training of practitioners or researchers |
Description | Towards Improvement of Diagnosis and Patient Management of Urinary Tract Infection in Lower Health Facilities in Tanzania |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Description | Urgent Need to Address Antimicrobial Dispensing Practices by Drug Outlets in Tanzania |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Description | Urgent Need to Improve Antimicrobial Dispensing Practices by Drug Outlets in Uganda |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Description | CARE Policy Engagement Event |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | The CARE Research Consortium organised a one-day online policy engagement event on 23 August 2021 for senior policymakers in Tanzania and Uganda - see below. The consortium outlined the objectives of the study and discussed preliminary findings, including the results of mystery client surveys on antibiotic seller behaviour and practice. Dr Majigo Mtebe, Chairperson of National Antimicrobial Surveillance and Research Prof Seni Jerimiah, Chairperson in National Antimicrobial Stewardship Mr Stanley Mwita, ADDO training team representative Mr Kissa Mwamwitwa, TMDA drug registration and research Ms Siana Mapunjo AMR focal lead Prof Atek Kagirita, Assistant Commissioner Public Health Laboratory, MoH Dr Ziras Lali, WHO Uganda Office Dr William James Tamale Bitatule, NDA Dr Helen Ndagije, NDA Dr. Peter Ssebutinde, District Health Officer, Mbarara Musa Sekamatte, Senior Epidemiologist, National One Health Platform Coordinator, MoH Dr Novat Ntwungubumwe, Acting Executive Secretary of the EAHRC |
Year(s) Of Engagement Activity | 2021 |
Description | District and community level inception meeting at Uganda study site. |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Professional Practitioners |
Results and Impact | Prior to commencing patient recruitment, CARE's research team in Mbarara, Uganda organised a district inception meetings at the field site to engage local communities and seek support. The participants include service users and practitioners and key political and administrative stakeholders. The inception meetings outline the CARE study (COVID and AMR). This early engagement leads to increased knowledge and buy-in from the local community. |
Year(s) Of Engagement Activity | 2021 |
Description | Presentation to the UKRI MRC-funded COVID Circle Researcher Community |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Dr Emmanuel Olamijuwon of the CARE Consortium in St Andrews presented preliminary findings from the CARE Mystery Client Study to the COVID Circle Researcher Community on 25 November 2021. The session was titled: Unblocking barriers to pandemic research: expectations for global partnerships and collaborations. Funders from the Wellcome Trust, Department of Health and Social Care, UK Research & Innovation (UKRI), UKRI Medical Research Council (MRC) and Elrha were in attendance. |
Year(s) Of Engagement Activity | 2021 |