When bugs fight back : Antibiotic resistance in Tz

Dar es Salaam. When the cholera outbreak was at its peak late last year, Dr John Ngeleja, a medical officer, resisted the temptation to swallow antibiotics as a way of protecting himself from the water-borne disease.

He feared the worst could happen in the future if he surrendered to the use of the medications. So he opted for simple approaches such as proper hand-washing and wearing protective gears as the best strategy to protect himself from acquiring cholera from his patients.

Dr Ngeleja was among health workers handling cholera patients at the Mburahati Cholera treatment camp in Dar es Salaam. The World Health Organization (WHO) had warned healthcare workers against “irrational use of antibiotics” in an effort to curb antibiotic resistance.

Dr Ngeleja was taking the WHO warning seriously as he dealt with cholera patients. The government had also passed a similar warning to all medics who were dealing with the cholera patients across the country.

“According to health care guidelines, we were not supposed to protect ourselves using the antibiotics. But not many health workers followed the guidelines at that time,’’ says the medic.

His fear—and that of some other doctors in his team—was that the use of the antibiotics at the time would later result in a wave of antibiotic resistance in Tanzania. He says, “By then, not many health workers [across the country] were keen on that.’’

Dr Thabit Mweyombela, who also worked in cholera treatment camps testifies that a number of health workers took some antibiotics. Since the country had not dealt with a cholera outbreak for many years, the guidelines were not much publicised and only few health workers could care about the threat of antibiotic resistance, explains Dr Mweyombela.

“But then there are also the majority of people in the community who could easily take antibiotics such as ciprofloxacin or erythromycin without a doctor’s prescription when they felt stomach pains,’’ he adds.

Researchers in Tanzania fear that if patients and their doctors continue abusing antibiotics, some of the commonest bacterial infections may soon become completely untreatable.

Since August last year, more than 250 people have died in a cholera outbreak in the country. It began in Dar es Salaam before spreading to upcountry regions. More than 16,000 victims were also hospitalized during the outbreak according to the Ministry of Health.

History shows that after previous cholera outbreaks, a wave of resistance of bugs against antibiotics followed in Tanzania. Some of the antibiotics such as tetracycline, ampicillin and chloramphenicol antibiotics were rendered ineffective against the bacteria that cause cholera.

A microbiologist from the Catholic University of Health and Allied Sciences (Cuhas), Prof Steven Mshana, believes that a similar wave of antibiotic resistance may have already occurred following the recent outbreak.

“It’s during such outbreaks that clinicians prescribe a lot of antibiotics to patients but also use the same medications to protect themselves—the drugs are therefore overused,’’ he explains.

Prof Mshana says that studies done in the past indicate that this occurred between 1997 and 1999 in the country. This has prompted concerns among experts that the same pattern would be repeated in the recent outbreak.

While health workers may have contributed to the problem, patients have their role as well. The tendency of people to seek antibiotics over the counter and later prescribe to themselves goes unabated.

Prof Mshana says that there are now more people self-medicating—much to the concern of many researchers. He refers to this tendency as an “irrational use of the antibiotics.”

One medical officer in Dar es Salaam, Dr John Ngowi, recently said that when it comes to prescribing antibiotics, everyone in Tanzania seems to turn into a “doctor” for common cold, cough or even urinary tract infections.

He says it is difficult for people to understand that they could go to a health clinic with a feeling of body malaise and leave without any medication—even after a series of medical tests.

“Some patients may force you [the doctor] to prescribe antibiotics even when it is not necessary,’’ he says. However, there is more to that.

While patients benefit more when they build a trust relationship with a health worker, some studies suggest that patients need to be watchful of the experts they go to.

One study, done three years ago, titled: “Knowledge among drug dispensers and antimalarial drug prescribing practices in public health facilities in Dar es Salaam,’’ further revealed “inappropriate’’ dispensing practices in the city.

About 84.6 per cent of drug dispensers were found to have poor knowledge regarding the basic information required from patients before dispensing recommended an-imalarial drugs.

The researchers recommended regular on-the-job training and continuing education be provided to drug dispensers and prescribers in public health facilities.

But also, the mushrooming of private health clinics in the city has been under scrutiny after some studies alerted in the past years that some health centres were raising their revenues by over-prescribing injections and other antibiotics.

A study published in the Asian Pacific Journal of Tropical Medicine noted that some medicines offered in form of injectable were overprescribed in many developing countries including Tanzania—warning that the demand and use of injections for antibiotics was driven by both the health care providers and the patients.

Professor Mshana adds that there is an urgent need for the government to revise the country’s policies on the use of antibiotics. “I think it is high time surveillance systems were also put in place for tracking resistant bugs and the way antibiotics are used in the country,” he says.

“There is no policy on antibiotic use and disposal in Tanzania. Community members can easily access antibiotics without prescription and medics can also prescribe the medications without restrictions,’’ adds the don.

According to a recent study carried out by experts from the National Institute for Medical Research (NIMR) and the Southern African Centre for Infectious Diseases Surveillance (SACIDS), bacteria have developed resistance against first line antibiotics—the cheaper options for people in Tanzania.

Titled: “The threat of antimicrobial resistance in Tanzania: Time for bold actions,” the study shows that people who were opting for ampicillin [first-line antibiotic] which costs only Sh500 for each vial of 500mg, are now forced to go for more expensive antibiotics such as Meropenem, which costs Sh25,250 for each ampule of 1gram.

According to Professor Mshana, it means that majority of the poor people cannot afford the expensive antibiotics, so they stick to the first line medications which are slowly losing potency due to resistance.

Some of the most common bacterial strains, such as Eschelicia Coli, which are known to cause Urinary Tract Infections (UTI) are circulating in humans, animals and the environment and their persistence is due to the increasing levels of global antibiotic resistance.

A study done at Muhimbili National Hospital (MNH), shows that the rate of resistant microorganisms causing UTI was reported to be 45 percent in the year 2010. But also, the rate of resistance of the bacteria causing pneumonia—the leading cause of death among children under the age of five—to the antibiotic co-trimoxazole, was about 80 percent in the year 2013.

The threat of resistance is also being felt by agencies fighting Tuberculosis in Tanzania. The country is still struggling with low-quality infrastructure in the diagnosis and control of TB.

The coordinator for Tuberculosis and Leprosy programs from the World Health Organization, Dr Neema Simkoko, said in Dar es Salaam recently that Tanzania had now started experiencing the “worst” forms of multi-drug resistant TB due to lack of good surveillance systems.

Dr Simkoko was alluding to an incident last year, where one person diagnosed with the worst form of drug resistant TB— x-DR TB—entered the country from South Africa before he could be detected by the public health authorities.

She noted that a strong public health system would be required to deal with challenges of antibiotic resistance—especially when it comes to fighting Tuberculosis.

“We [in Tanzania’s health system] are supposed to diagnose 500 patients in a year but now we diagnose only 120 annually. This needs to be stepped up in order to tame the disease early,” she said.

The WHO’s first report to look at antibiotic resistance globally, reveals that the threat of antibiotic resistance is no longer a prediction for the future.

Released in 2014, the report says that antibiotic resistance is happening right now—in every region of the world and has the potential to affect to anyone, of any age, in any country.

“Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill,” said Dr Keiji Fukuda, WHO’s Assistant Director-General for Health Security.

The report, launched in Geneva two years ago, reveals that key tools to tackle antibiotic resistance, such as basic systems to track and monitor the problem, do not exist in many countries.

While some countries have taken important steps in addressing the problem, every country and individuals needs to do more, says Dr Fukuda.