London School of Hygiene & Tropical Medicine

Antimicrobial resistance (AMR) presents a profound and growing threat to global health, and its impact is particularly acute in developing regions including sub-Saharan Africa. The region is grappling with a high burden of infectious diseases, compounded by weak healthcare systems, inadequate regulatory frameworks, and limited access to effective diagnostics and treatment options. Tackling AMR requires a multifaceted approach and in the case of sub-Saharan Africa this cannot be over emphasized. There is urgency in strengthening health systems, improving surveillance, ensuring the rational use of antibiotics, and fostering global and regional cooperation.  

In May 2024, MRC unit the Gambia at LSHTM in collaboration with the Ministry of Health The Gambia held a one-day symposium to discuss current issues on AMR in the country and in the sub-region and how these can be addressed in a one health approach. Among the topics discussed were three key areas:, strengthening health systems, promoting rational use of antibiotics and raising AMR awareness, and improving surveillance.   

The Gambia like many countries in sub-Saharan Africa has a healthcare system that is under-resourced and overburdened. This leads to delays in diagnosis and treatment, which in turn drives the misuse and overuse of antibiotics. Investing in healthcare infrastructure, training healthcare professionals, and ensuring access to essential medicines, can help improve the quality of care and reduce the reliance on broad-spectrum antibiotics as a catch-all solution for a variety of ailments. This is particularly important in tackling the growing threat of new-born infections from key multidrug resistant  bacteria including K. pneumoniae and E. coli that are becoming a growing threat to neonatal health in the region.  

Robust health systems are better equipped to implement and enforce infection prevention and control measures, which are essential in reducing the spread of resistant pathogens. Outbreaks of bacterial infections in neonatal wards in the country are becoming frequent indicating weak infection control measures.[1] A recent study across three health centres in The Gambia that investigated vertical acquisition of pathogenic bacteria among babies with early onset neonatal sepsis found a low prevalence of mother to child transmission during delivery.[2] This is an important finding which suggest that other sources such as the hospital environment may play a bigger role in early neonatal infections in the context of low resource settings like The Gambia.  

Irrational use of antibiotics is another important issue that was discussed. Over the past decade, there has been an over proliferation of local drug stores selling antibiotics over the counter even without a prescription. This is raising concerns about the misuse and overuse of antibiotics as many people use the drug stores as shortcuts to get treatment due to the inadequacies in the formal healthcare system. Public awareness campaigns are deemed necessary to educate communities about the dangers of AMR and the importance of using antibiotics only when prescribed by a qualified healthcare professional. However, in a country where the density of skilled health workers is a meagre 1.55 per 1000 population[,3] coupled with inadequate microbiology laboratory capacity, getting appropriate prescriptions is still far-fetched for the majority of the population. Additionally, healthcare workers must be trained on the principles of antimicrobial stewardship, which promotes the appropriate use of antibiotics to achieve the best clinical outcomes while minimizing the risk of resistance. A cross-sectional survey in 2016 that assessed AMR awareness among healthcare workers across 60 health centres in the country showed that 23% of the respondents were not aware that antibiotics are not effective against viral infections.[4] These were mostly nurses who represented 63% of the total respondents (225) [,4] and form the majority of the country’s skilled healthcare workers.[3] Similar problems were highlighted by representatives from the veterinary sector which is grappling with increasing use and misuse of antimicrobials in poultry and vegetable production.  

Improving surveillance is critically urgent for a better understanding of the scope and level of spread of AMR across the different facets of society in the country. Effective surveillance systems will enable the early detection of resistance patterns and the monitoring of antibiotic use, especially in the informal sectors which are currently not being monitored. Achieving this will require not only the technical capacity to conduct microbiological testing and sequencing but also the infrastructure to collect, analyse, and share data. This will require more coordinated efforts from key stakeholders including the medicines control agency, the national public health labs, the ministry of health, the ministry of agriculture, and regional and global collaborators. Enhanced surveillance will allow for more informed decision-making at all levels in the relevant sectors and can guide the development of targeted interventions to curb the spread of AMR. 

In conclusion, tackling AMR in sub-Saharan African countries like The Gambia requires a comprehensive and coordinated approach that addresses the unique challenges faced by the region. By strengthening health systems, improving surveillance, ensuring the rational use of antibiotics, and fostering global and regional cooperation, significant strides can be made towards controlling AMR. The stakes are high, but with concerted effort and  commitment, the country can protect the gains made in public health over the past few decades and pave the way for a healthier future. 

References 

1. Okomo, U., Senghore, M., Darboe, S., Bojang, E., Zaman, S.M.A., Hossain, M.J., Nwakanma, D., Le Doare, K., Holt, K.E., Hos, N.J., et al. (2020). Investigation of sequential outbreaks of Burkholderia cepacia and multidrug-resistant extended spectrum β-lactamase producing Klebsiella species in a West African tertiary hospital neonatal unit: a retrospective genomic analysis. The Lancet Microbe 1, e119–e129. 10.1016/S2666-5247(20)30061-6. 

2. Okomo, U.A., Darboe, S., Bah, S.Y., Ayorinde, A., Jarju, S., Karim Sesay, A., Kebbeh, N., Gai, A., Dibbasey, T., Grey-Johnson, M., et al. (2022). Maternal colonisation and early-onset neonatal bacterial sepsis in The Gambia, West Africa: a genomic analysis of vertical transmission. Clin. Microbiol. Infect. 0. 10.1016/J.CMI.2022.10.012. 

3. MOHG (2023). REPUBLIC OF THE GAMBIA MINISTRY OF HEALTH DIRECTORATE OF HUMAN RESOURCES FOR HEALTH (DHRH) HUMAN RESOURCES FOR HEALTH OVERVIEW.https://files.aho.afro.who.int/afahobckpcontainer/production/files/MoH_…. (accessed: 25 July 2024) 

4. Sanneh, B., Jallow, H.S., Singhateh, Y., Sabally, B., Sey, A.P., Woury Jallow, A., Jallow, T., Baldeh, I., Sambou, S.M., and Jah, S.L. (2020). Knowledge, attitude and practice of health care workers on antibiotic resistance and usage in the Gambia. GSC Biol. Pharm. Sci. 2020, 7–015. 10.30574/gscbps.2020.13.2.0177.