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No. 49, 20 April 2021

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ReAct Africa and South Centre bring together African civil society organizations to advance actions on antimicrobial resistance (AMR)

From 24 to 26 of March, ReAct Africa and South Centre co-organized a virtual workshop for civil society with the theme “Increasing CSOs Participation to address AMR and contribute to the global development agenda."
During the three days, civil society organizations (CSOs) from the African region met -virtually- to learn about antimicrobial resistance (AMR) in the context of the COVID-19 pandemic, and the need to address AMR exposure and transmission across humans, animals, the environment and food systems. The workshop also offered space to learn from advocacy efforts in HIV/AIDs, communication strategies through social media, and experiences designing innovative materials. CSOs showcased their work, including their involvement in implementing national action plans. International agencies participated in the workshop, including Africa Centres for Disease Control and Prevention (CDC), the tripartite organizations in their regional capacity (World Health Organization (WHO), Food and Agriculture Organization (FAO), and World Organisation for Animal Health (OIE)), and the United Nations Environment Programme (UNEP). These provided valuable information on their work in the region and at the country level to support actions to address AMR.



Opening of the conference and the work of intergovernmental organizations in the African region to address AMR
At the conference's opening, Mirfin Mpundu, the Director of ReAct Africa, welcomed the participants and stressed the need for CSOs to provide input to the AMR agenda at the national, regional, and global levels. He also stressed the crucial role that CSOs play in awareness, catalyzing action in communities and holding organizations and governments accountable for their commitments and their role in supporting government policies and programs to control AMR. 
Carlos Correa, Executive Director of the South Centre, emphasized the critical collaboration between the South Centre and CSOs, including the ReAct network. He emphasized the connection between development and AMR and the vital need to address AMR to ensure that development efforts are not jeopardized.
Yewande Alimi, from Africa CDC, reminded participants of the long experiences that African CSOs have in transforming policies and practices through their active engagement and advocacy. She also noted their meaningful engagement in communities and education in different health challenges such as HIV/AIDS, malaria and tuberculosis, and how these experiences can be used in the AMR space.
The second panel of the day highlighted the activities of the intergovernmental organizations. Laeticia Gahimbare from the WHO regional office for Africa provided an overview of the activities in addressing AMR in the region and the ongoing collaborations with CSOs such as ReAct. She also encouraged CSOs to utilize the available documents and resources for their work on AMR. Chadia Wannous from OIE provided a presentation on AMR drivers in the animal sector and the challenges on the implementation of the national action plans in the region, particularly because of funding constraints.
Irene Ouba from FAO provided an overview of their work at the regional level and highlighted their experiences with farmer field schools in Ghana and Kenya. These schools aim to encourage farmers to use antimicrobials responsibly and support AMR control through discovery-based learning. Some of the results from these schools include farmers relying on animal health workers for antimicrobial use and an increase in biosecurity practices. Some of the results observed include reducing morbidity and mortality in their animals and reducing the money spent on antimicrobials. From UNEP, Levis Kavagi explained about antimicrobials in the environment and how resistance mechanisms drive adaptation and help organisms survive. He also emphasized the critical role of preventing AMR by using antimicrobials responsibly and ensuring their correct disposal, and the need to increase surveillance and monitoring, particularly of wastewater.
On the theme of AMR in the context of the COVID-19 pandemic, Marc Mendelson, Professor of Infectious Diseases and Head of the Division of Infectious Diseases & HIV Medicine at Groote Schuur Hospital, University of Cape Town (UCT), provided a presentation outlining critical issues such as the increase of inappropriate prescriptions at the hospital level driven in part by the inability to diagnose bacterial infections accurately. He also highlighted the critical role of infection prevention and control (IPC) and the need to keep it a high priority. Communication was also another issue highlighted in improving dissemination of information and how we can be more effective when speaking about AMR.



Epidemiology of AMR, One Health approach and learning from successful campaign strategies
Day two of the conference had two sessions. The first session focused on the epidemiology of AMR, food systems and AMR in the environment. The second session highlighted successful campaigns, including learning from the HIV/AIDS pandemic, social media, the elaboration of innovative awareness materials and nutrition and agroecology.
Anna Zorzet from ReAct Europe delivered a presentation of the epidemiology of AMR. She emphasized that antibiotics are indispensable in treating several life-threatening bacterial infections such as pneumonia, sepsis, and meningitis and that one can still get a resistant bacterial infection even if you have never taken antibiotics. Drivers of AMR include bacteria evolution, antibiotic use (in humans, animals, and the environment), inadequate hygiene practices, and environmental factors. The situation is dire, with 214 000 babies dying every year from sepsis caused by resistant bacteria, and one child globally dies every third minute from this preventable AMR issue. Resistant bacteria are found in children in every region of the world, showing that this is a global issue. She also observed that a ReAct 2020 Survey to 400+ physicians with 22% respondents from African countries showed some of the top reasons for neonatal sepsis treatment failures, including resistant pathogens (54%) and lack of diagnostics to identify sepsis quickly (42%).
Victor Yamo from World Animal Protection delivered a presentation on AMR and sustainable food systems. He emphasized that a sustainable food system is a food system that delivers food security and nutrition for all in such a way that the economic, social and environmental bases to generate food security and nutrition for future generations are not compromised. He also noted that factory farming generally uses antibiotics in animals for several reasons, including the growth of animals, treatment of infections and prophylaxis and metaphylaxis. Therefore, there is a need for the industry to improve animal welfare and the responsible use of antibiotics. He also mentioned the need to increase transparency for consumers in supply chains, increase efforts to reduce food waste, and implement more precise food labels and increase efforts to improve farm animal welfare standards.
Rajeshwari Sinha from Centre for Science and Environment, India, provided a presentation focused on waste, AMR, and the environment. She emphasized the importance of increasing collaboration of the point sources such as farms, factories, households, community and health care settings, and increased monitoring in rivers, groundwater, and agricultural soil. Sinha noted that even though the environmental aspect is included in many of the AMR National Action Plans, its implementation is complex. She also stressed the need for more data. Also, she explained that historically environmental regulators have focused on pesticides and heavy metals and therefore don't necessarily have the microbiology training needed for AMR.  Furthermore, there are gaps in global and technical guidance and standards, and these are urgently needed. Unless there is more attention directed to the environmental aspect and resources, there can't be a truly One Health approach to tackling AMR.
The discussions after the presentations emphasized the need to empower consumers on the issue of antimicrobial use in the animal industry. Participants stressed the need for more data on the use of antimicrobials in animals in the African region and the importance that organizations such as WHO and FAO promote livestock production practices that use fewer antimicrobials.
In the second segment, Vanessa Carter, founder of Healthcare Communications and Social Media South Africa, spoke about content marketing for online advocacy. She shared her experience as a survivor of an extensive multi-drug-resistant infection. As a result of this, she used her marketing training and started working on advocacy and improving communication and public awareness of AMR. She explained that content marketing promotes interest creatively and that for advocacy to be effective, messages need to be creative and straightforward. She also noted that it is essential to bear in mind that there is competition for online traffic from thousands of sources. Therefore the communication of AMR needs to be easy for the consumers of the information to understand. She also provided some examples from other companies that could help CSOs think about how messages are delivered.
On nutrition, agroecology, and sustainable agriculture, Magdalena Ackerman from Society for International Development talked about the importance of the intersection between food, health, agriculture and the environment. She also emphasized the need to increase advocacy for agricultural methods that are good for the environment, adequate nutrition and diet, and less antimicrobial use.
About advocacy strategies and learning from the experiences of HIV/AIDS, Rev. Jane Ng’ang’a from INERELA+ Kenya presented key advocacy lessons from HIV/AIDS in Kenya, including grassroots social mobilization to harness health promotion, meaningful involvement of communities, and designing and implementation of people-centered responses. The successful advocacy areas include advocacy for better access and sustainability of ARVs and advocacy for utilization of new prevention technologies (PrEP, PEP) and policy development and reviews. She also emphasized that CSOs that want to increase AMR advocacy could look into strategies that HIV/AIDS have used, such as roundtable meetings with key leaders, media briefings and conferences, processions/ mammoth walks and letter writing by children. Multi-sectoral partnership with the government, private sector, development partners and communities has equally been a plus in their HIV/AIDS advocacy journey.
David Mpanju, former president of Makerere University medical students’ association, 2018/19, presented on designing innovative materials for advocacy. He mentioned that a challenge with AMR communication is how to make AMR relatable to the community. He spoke about his experience developing a comic book called “The unseen world” while he was still a medical student at the Makerere University. His comic targeted secondary students to advocate awareness around AMR. Some of the lessons of making the comic include that the messages should be motivating to the public and inform them on AMR. The messages need to be simple and should be tailored to suit a specific target audience.
During the conference, three group discussions were held for participants to interact and explore the topics presented. Some of the highlights from the group discussions include:

  • The importance of social media for communication in AMR and the need to increase training for CSOs to understand how best to use the tools and so that effective awareness and advocacy messages can be developed.
  • Community engagement is critical, as illustrated by the example of HIV/AIDS. Therefore, there is a need to include knowledgeable community health volunteers to help design messages adequately to their contexts. Also, CSO networks that are well trained are needed to mobilize the AMR response.
  • There is also the need to change the evidence we are presenting as we advocate for AMR. Most of it is technical and communicates evidence that forecasts AMR's impact in the future rather than the present devastating effects of AMR. This does not have the intended effect on policymakers and populations at large.
  • More information and awareness are needed about the link between animal welfare, animal health, and demand for antimicrobials. Furthermore, it is crucial to explore more on the connection between agriculture, disruption of ecosystems and biodiversity loss, the increase in human and animal diseases, and how they are linked to AMR's rise.

CSOs’ national experiences on addressing AMR
Day three started with Tapiwanishe Kujinga from The Pan-African Treatment Access Movement (PATAM) presenting their work in Zimbabwe. Prior to the presentation, a moment of silence was observed for the late Dr. Sekesai Zinyowera, the AMR focal point in Zimbabwe and an AMR champion in Africa.
PATAM has collaborated extensively with the government and relevant stakeholders as well as CSOs in the AMR project.  In June 2016, a One Health meeting was organized, which created a solid foundation for drafting the AMR National Action Plan. Some of the activities PATAM has initiated in the AMR project include organizing two Continual Medical Education (CME) events for doctors, organizing radio and television appearances on AMR and related topics, organizing a public lecture at the University of Zimbabwe, resource mobilization and providing technical support to other partners on AMR education and awareness. Since 2016, it has also involved itself with activities during the commemoration of the annual World Antimicrobial Awareness Week (WAAW). The yearly events include newspaper articles on AMR, radio and TV appearances, joint lectures for nurses and veterinary extension workers and One Health stakeholder sensitization meetings.
Megan Mario Crios from MUSUHUM (Mouvement Universel pour la Survie de l'Humanité) presented his experience working in Niger and Benin. As a CSO involved in AMR, MUSUHUM focuses on two aspects, preventive and curative. In prevention, they do a lot of sensitization towards hygiene since they have very many water, hygiene and sanitation problems in Niger and Benin. They also conduct water and hand disinfection training, free distribution of consumables (bleach, aqua tabs) and epidemiological surveillance of infectious diseases and antibiotic consumption in their centers. They also provide accessible consultations at low cost and prescriptions by qualified agents to avoid self-medication or inadequate prescriptions. There is also the supply of quality and low-cost generic antibiotics to patients and pharmacies. They carried out continuous training of prescribers on good practices. Their greatest strength as a CSO is that they understand the community's health situations within which they work. The communities have been substantially involved in the activities and campaigns. Some of the challenges for their work include lack of AMR specialists, lack of an autonomous, state-of-the-art laboratory and overcrowding of their health centers. The sporadic campaigns have limited effectiveness and are difficult to evaluate and assess. Most events are canceled due to low resources. They look forward to creating a national and a regional framework with CSOs since most CSOs work independently and in isolation; hence, there is no unity of strength.

The experience in Ghana was presented by Bashiru Boi Kikimoto, Veterinary and Public Health Specialist. He spoke about his experience working with the poultry sector. The AMR project in Ghana is focused on four key areas in the veterinary perspective: antimicrobial use, antimicrobial resistance, antimicrobial residues and washout period. Their key technical and financial partners in these focal areas include the University of Cape Coast, FAO, OIE, and the Fleming Fund. They have also been part of developing a Farmer Field School. He noted that even though Ghana has about 360 CSOs, only a handful are involved in the AMR fight. They include the Antimicrobial Resistance Coordinating Committee (AMRCC), Women in Poultry Value Chain and Ghana Poultry Network. 

Gilles Van Cutsem from MSF (Médecins Sans Frontières/Doctors Without Borders) gave a brief update on an AMR study from an MSF hospital in Kinshasa in the Democratic Republic of the Congo, called Centre Hospitalier De Kabinda. The data was obtained from a study done between February 2019 and April 2020. MSF conducted 810 blood cultures in patients with HIV with suspected sepsis or invasive bacterial infections. They found that 85% of the germs identified were resistant to most first-line antibiotics. 64% of the organisms causing the infections were Salmonella Typhi, which is often encountered in HIV patients, however these were also resistant to antibiotics. The study found very high resistance rates at the community level and high rates of multidrug-resistant, hospital-acquired infections. He emphasized the need for infection prevention and control and continuous monitoring to understand AMR's impact in HIV patients.    
Analyzing challenges and opportunities for CSOs to tackle AMR
The last panel of the workshop focused on addressing practical questions and challenges faced by CSOs working in AMR. The panel's moderator was Emmanuel Kabali from FAO, and the panel discussants were Mirfin Mpundu from ReAct Africa, Viviana Munoz Tellez from South Centre, and Hayat Seid, who is the AMR focal person in Ethiopia. The discussants provided many reflections on the role of CSOs and the learnings from the workshop. Below are some of the highlights from the discussion:
  • The role of CSOs as crucial stakeholders in AMR work has been highlighted and their engagement needs to increase. The challenge is to expand the space for CSOs and increase their contributions in tackling AMR. CSOs are doing work in many countries and thus, there is a need to share more of such experiences with the world. CSOs are well-positioned locally because of their understanding of the local context.
  • In 2013/2014, when ReAct Africa started, very few CSOs were involved in AMR. However, more and more CSOs are now getting in and filling in the gaps, but there are still not enough CSOs at the country level. There is a lot of work to be done in-country, and CSOs need to form a critical mass that can increase AMR's advocacy at the regional and even global level. There is also a need to interest other CSOs that are not working now on AMR to get them involved and to add their voice.
  • At the height of COVID-19, one could not enter any building without compulsory specific measures. Several ministries e.g. health, transport, communication, all came together to fight COVID-19. The same collaborative spirit was seen in countries; hence CSOs can learn that multi-sectoral collaboration can work.  Furthermore, COVID-19 has also proven to be an equalizer, meaning anyone can get infected just like AMR, thus strengthening our health and food systems.
  • COVID-19 has brought in significant IPC measures and CSOs should strive to maintain them to strengthen the AMR work.
  • There is a need to engage CSOs in prevention and containment activities, such as engaging in baseline assessments and gathering evidence to table to the leaders and policymakers. There is also a need for CSOs to engage in technical committees in government and involve themselves in advocacy, such as during the World Antimicrobial Awareness Week. CSOs can also engage in pre-service and in-service training of professionals in AMR matters.
For the closing remarks, the co-organizers, ReAct Africa and South Centre, thanked the participants for sharing their knowledge and expertise. On the way forward, Mirfin Mpundu reiterated the need for a sustained collaboration of CSOs in the African region and leveraging the opportunities that COVID-19 has provided.  He also emphasized that CSOs should learn from the lessons and best practices of other health issues such as the case of HIV/AIDS and the need to expand knowledge on animal health, farming practices, and the role of the environment in AMR. He noted that one of the biggest challenges countries are facing is implementing the National Action Plans. Hence, there is a need for a supportive role of civil society in implementing and bringing the AMR issue at different levels. Finally, he reaffirmed that the AMR landscape needs more people to push a more robust response and encourage CSOs to continue their AMR work.

Author: Mirza Alas is Programme Officer of the Health, Intellectual Property and Biodiversity Programme (HIPB) of the South Centre.
SOUTH CENTRE NEWS ON AMR is an e-newsletter service of the South Centre providing news and information on issues relating to Antimicrobial Resistance.

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