Dr. Evelyn Wesangula is an antimicrobial steward who has dedicated a huge part of her career to fighting antimicrobial resistance (AMR). She is currently the Senior AMR Control Specialist working at the East Central and Southern Africa Health Community where she supports implementation of National Action Plans for containments and prevention of antimicrobial resistance.
She has, for many years been the National Focal Person on antimicrobial resistance control in Kenya and championed for the development of a National Action Plan on Prevention and Containment of Antimicrobial Resistance in Kenya.
She is also a contributing author to the National Antimicrobial Stewardship guidelines for healthcare settings as well as development of Infection Prevention and Control strategic documents in Kenya.
On a global scale, she has worked as a consultant in various international health organizations centered around antimicrobial stewardship.
See below what she had to say about antimicrobial resistance.
How would you define antimicrobial resistance to a 10-year-old?
Microbes, which include bacteria, fungi, parasites and viruses have the ability to cause infection and disease.
When you develop such an infection, what would ideally happen – assuming you have a well-functioning immunity – is that your body would clear this infection.
But in the event this doesn’t happen, then you would require an antimicrobial agent.
Now, effective antimicrobial agents are able to step in and fight off the microbe and infection. However, in certain instances these microorganisms can develop ways of evading the action of these drugs, despite being administered in the correct doses.
When the microorganisms remain unresponsive, then we term that phenomenon as antimicrobial resistance.
What are the consequences of this?
One; you end up with severe illness.
Two; if you’re admitted in hospital, you will have a longer stay than initially projected.
Third; If you’re lucky and you survive, you will have to part with a lot of money since the commonly used, more affordable antimicrobial agents are no longer working. The doctor will have no choice but to prescribe a more expensive anti-microbial agent.
Fourth; If you can’t afford this newer more effective antibiotic for example, or your infection remains unresponsive, then death can happen.
How did your career journey lead you to antimicrobial resistance?
(Smiles) To be honest I haven’t really thought about it much.
So, a lot of my years in service have been dedicated to infectious diseases.
After internship, my first posting was in Malindi District Hospital where I was the first pharmacist in both the hospital and the county (district at the time).
At the facility level, I was heavily involved in the setting up of the HIV comprehensive care clinic and from that point, I began working very closely in both TB(Tuberculosis) and HIV management.
So, I continued to grow my passion in these diseases over a few years then I transitioned into the Malaria program (while still serving in different capacities).
From that point, I realized I had a passion in infectious diseases and so I applied to do a Master’s in Tropical and Infectious Diseases at the University of Nairobi. At the time, this was not one of those career paths that was chosen by pharmacy professionals.
In fact, we were the first cohort of pharmacists to do the course. I remember we were only two female pharmacists in the program and nobody understood why we were there. But the truth is, we were just both passionate about infectious diseases.
When I finished training, I ended up at the Jaramogi Odinga Odinga Teaching and Referral Hospital, (formerly the New Nyanza Provincial General Hospital).
To be honest, I felt a bit misplaced at the beginning, but eventually I found my space.
And that space was in the lab.
I spent a lot of my time in the lab because I had started to develop a passion in microbiology.
Progressively, I studied the patterns of antibiotic use at the hospital trying to correlate this with what was happening at the lab- particularly around culture sensitivity testing. From there I developed an interest in infection prevention and control (IPC).
So, I became part of the team that was strengthening IPC at the hospital as well as conceptualizing what an antimicrobial use program at the hospital would look like.
Before I could complete what we had started, I transitioned into teaching.
I started teaching at the Kenya Medical Training College (KMTC) and that is where I dived into antimicrobial resistance fully. I got an opportunity to coordinate the Global Antimicrobial Resistance Partnership-an initiative that brought together multisectoral experts including animal and plant health.
When the first situation analysis on antimicrobial use and resistance in Kenya was published, I realized I needed to do something about it.
I started looking for platforms to drive that agenda and I knew that we needed policy support but at the time, the Ministry of Health didn’t even have an active antimicrobial resistance program.
So, I started looking for opportunities.
The earliest opportunity that presented itself in terms of disseminating the findings, was the Infection Prevention and Control Program.
I spoke at almost every IPC program disseminating the data.
Through that, we developed the IPC strategy and one of the strategic objectives was to establish a national AMR committee from a one health perspective.
So when that was identified within the IPC strategy, the next natural thing was to have an AMR desk at the Ministry of Health and the rest is history.
I was appointed as a focal point for AMR, moved from KMTC and went to the Ministry of Health to establish the national AMR program.
In your current role in the East, Central and Southern Africa Health Community, how does your day to day look like?
My day-to-day revolves around understanding the different contexts of the countries I work in and providing technical support to the implementation of AMR national action plans depending on the individual country’s priority level. Based on these priorities, my goal is to help the country tailor solutions that will meet their needs.
I also spend time creating networks and mobilizing resources that will facilitate AMR control activities in the different countries I am involved in.
Why should the African continent in particular be keen on antimicrobial resistance?
The global projection in terms of AMR-related deaths by 2050 is 10 million annually. Half of that number is expected to be in Africa. This disproportionate burden is driven by weak health systems, poor infrastructure and high levels of poverty.
For us it’s a double-edged sword.
It’s not just about the microbes and the inability to treat infections. It’s about our capacity to even access and afford general health care and medicines when we need them. How many people are able to pay for culture sensitivity tests?
Additionally, patients are unable to pay for basic lab diagnostic tests leading them to self-medication, thinking that it’s the cheaper option. But in the long run, it becomes more expensive.
Let me give you a simple example.
If you have a patient today who’s admitted in the intensive care unit. And they he has a prescription of a reserve antibiotic like meropenem. This could cost the patient a hundred thousand shillings or more.
Assuming this is not the only medication he is on, his hospital bill will inevitably skyrocket.
So, I’m passionate about AMR because I know what it means for the common person who is unable to afford or access the most effective antibiotic when they need it. In a setting where care is not readily available and the infrastructure is weak, we need to be particularly careful how we handle our reasonably priced antibiotics.
If people are struggling to access care, then the sustainable development goal on eradication of poverty is unachievable. Access to healthcare for all as well becomes a pipe dream because the truth is; if one can’t pay for his or her healthcare, then there’s a problem.
If you’re talking about the SDG on tackling hunger(Goal 2: Zero Hunger) , and I cannot sustain my food production system because there’s a lot of use of antibiotics in feed for growth promotion. So, you can see it’s a cycle that is not ending.
The environment also we are talking about access to clean water, but if we have industries that are discharging effluent into our water bodies, what are we saying in terms of achieving our SDGs?
For us in sub–Saharan Africa, our levels of income are low, so we are unable to meet some of our very basic needs. Therefore, we need to make sure as much as possible, we are using our antimicrobial agents in an optimal way so we are not caught flat-footed.
What activities are happening continentally to improve AMR surveillance and strengthen stewardship?
Honestly, I must thank all the implementing partners that have come in to support AMR efforts in different ways.
Even before countries started working on their national action plans, the World Bank came in to support laboratory infrastructure across several countries in the Eastern and Southern Africa.
Later, as countries took on the global action plan and began to develop their own national action plans, at the AU (African Union) level we established a common position by Heads of States in Africa on antimicrobial resistance.
The African Union through the Africa CDC has been able to support quite a lot of initiatives in building capacity for antimicrobial resistance.
From the laboratory network through partnerships with the Africa Society for Laboratory Medicine, the East Central and Southern Africa Health Community, West African Health Organization (WAHO), and SADEC (Southern African Development Community) in the South. All this working together and mobilizing resources to build capacity at various levels-through training or development and harmonization of guidance documents
Then Fleming Fund has been one of our largest investors in AMR surveillance, helping for example in building capacity for laboratories, purchasing equipment, reagents and also building capacity in many countries.
Countries including Tanzania, Uganda., Ethiopia, Kenya, Zambia, Malawi and many more have all benefited from the Fleming Fund.
There are also projects supported by the USAID.
React Africa have also been champion advocates from a civil society perspective.
We still have big gaps in terms of what needs to be done but we are on the right path.
Some Governments have been slow in terms of allocating budgets to support antimicrobial resistance. That has slowed the initiatives.
But when they will come in and augment what partners are doing the countries will be able to do much more. We are definitely not where we were five years ago but there’s still so much to do.
Research and building a case for investment around antimicrobial resistance is still an area more effort needs to be put.
What does One Health mean to you?
One Health means different sectors coming together and working from a shared vision to achieve a common goal. In our context, it involves bringing together human, animal and plant health, as well as the environment, moving in the same direction towards prevention and containment of antimicrobial resistance.
The goal is to ensure that all sectors play a key role in prevention and mitigation of the effects of antimicrobial resistance.
One Health approach is critical because four sectors can do much more than one sector can ever do.
In terms of resource mobilization, reach, scope of activities a lot can be achieved.
I mean even at the global level, we no longer talk about the Tripartite, now it’s Quadripartite. Food and Agriculture Organization, the World Health Organization, the Animal Organization, the World Organization for Animal Health, and the United Nations Environmental Program.
I believe we need to start building this concept of One Health right from school, including it in the curricula as well as in continuous medical education, for those already graduated.
What role do community pharmacies play in antimicrobial resistance?
I see community pharmacies as gatekeepers and therefore critical players.
They’re the first point of contact with the community-hence gatekeeper because they hold the decision as to whether to let someone in or not. When a patient comes to their premises, they have the power to either support the optimal use of antimicrobial or encourage misuse.
Community pharmacy personnel have the knowledge on antimicrobial agents and resistance. They understand for example what happens when a patient walks away with half a dose of amoxicillin administering one stat dose of ceftriaxone or even dispensing an antibiotic for a viral infection.
As gatekeepers, community pharmacies have the authority required to control how the community consumes medication. It’s just about prioritizing the patient’s health over profits because as I mentioned to you, resistance doesn’t discriminate who it affects.
And that is why, when we developed the regional guidelines on antimicrobial stewardship for the countries in East and South Africa, we went beyond just the hospital. Because we know pharmacies play a critical role in public health in the continent as the first stop in seeking healthcare.
Even at the National level (in Kenya), the antimicrobial stewardship guidelines are not limited to the hospital. There’s a component for community pharmacies. So, it’s important for these key stakeholders
Why is it so easy to access antibiotics over the counter in a country like Kenya, yet this is unacceptable in for example European countries? Is it a policy issue?
(Smiles) That’s a very interesting question.
It’s definitely not a policy issue, its simply lack of enforcement of already available regulations.
Antibiotics should not be sold over the counter under any circumstances.
And there are two ways to correct this.
One: the regulator should enforce what the policy says. “Prescription Only Medicines” should be prescription only medicines.
Two: Self-regulation.
We should make an effort to self-regulate, especially at the community pharmacy level.
We shouldn’t wait for the regulator to come and impose policies on us. We should take initiative and do what’s right, prioritizing client’s health over the business.
What message do you have for health workers about antimicrobial resistance?
As a health worker, you are the authority when it comes to matters health.
One of the key questions that has come back to us many times is what if the patients prefer this antibiotic? What if the patient has asked for the antibiotic?
Let me ask you as the health worker, who’s the authority? Who knows what’s best for the patient?
So, the first thing I want to emphasize is education and advocacy.
Take time to educate your patients when they come to you.
If you’re the nurse, you’re administering medicine, be consistent and administer according to the prescription.
If you’re the doctor who’s prescribing, are you taking time to speak to your patients regarding their illness, the drug you prescribe, and why it’s important for them to adhere to the dose that you’ve given them?
As the pharmacist, you need to understand that a lot of information will come from you. You’re the person who Interacts with the patient at the end of that chain. When all has been said and done, in that healthcare system, the last person who hands over this medicine to the patient is the pharmacist.
Let’s take time. When we did rational use medicine surveying, sometimes patient encounters at pharmacies are at times one minute or less.
Patient encounters with the doctor-five minutes. How much information can you pass on as a pharmacist, within a minute? How much information can you pass on as a doctor within five minutes?
Everyone needs to understand their role and play their part.
Secondly, I believe compliance to Infection Prevention and Control is a cheap intervention.
It can be done by everyone. Every infection prevented is an antimicrobial agent spared.
And one of the simple infection prevention and control interventions I would recommend and emphasize on is hand hygiene.
Hand hygiene has been neglected in many of our healthcare settings. And we see adherence rates as low as 10 percent in healthcare settings.
Up to 80 percent of all healthcare associated infections can be limited if hand hygiene is adhered to. So if we comply to that, then we are able to reduce the transmission of multidrug resistant organisms.
Hospital acquired infections account for high consumption of reserve antibiotics. They are very expensive to treat and very difficult to manage. And I say this because our 2023 report on the top five microorganisms isolated in this setting are all associated with health care associated infections.
Klebsiella pneumoniae; Acinetobacter baumannii, Pseudomonas aeruginosa, E.coli, and Staphylococcus aureus These are very difficult to manage, especially in the healthcare setting.
On rational use of antimicrobial agents;
Sometimes as healthcare workers, we are the worst patient.
We are the ones who actually drive AMR, in our own setting. So, let’s be custodians for these drugs. And I think when we do that, then it will be better for everyone else. Of course, keep spreading the word.
And if you’re able to carry out operational research in your healthcare setting, use this data to inform decisions that are being made in your respective settings, each of us has a role to play.
Let’s also use community health workers for advocacy initiatives in the community.
And the public?
First, don’t self-medicate. Please take the opinion of your healthcare provider.
When unwell, visit the hospital and allow the doctor to do the prescribing.
Don’t make Dr. Google your best friend because I promise you, you will treat things that are not there. If you persist with self-medication, you will jeopardize your future since when you will eventually need these antibiotics, they may turn out to be ineffective.
So, avoid over the counter purchase of antibiotics.
Second, please don’t give pressure to your healthcare provider. These qualified professionals know the treatment protocols and are able to provide the best treatment options for you.
Thirdly, practice hygiene and vaccination for both yourself and the animals you may be keeping. This is key in infection prevention.
Start with basic practices such as hand-washing.
Let’s accept that we have a problem. Let’s accept that we have been part of the problem and we definitely hold the solution
Did you find this video informative? Subscribe for more.
Interviewer:
Bevin Likuyani is a Pharmacist with a MPharm (Pharmacoepidemiology & Pharmacovigilance) and MBA (Strategic Management) from School of Business, University of Nairobi). He is a Certified Supply Chain Pharmacist. (American Association of Supply Chain Management) and content writer on pharmaceutical related topics. Email: bevin@africanpharmaceuticalreview.com LinkedIn
