East Africa Phage Bank

By 2050 the global antibiotic resistance crisis is expected to kill 10 million people annually--far more than the roughly 2 million deaths caused by coronavirus in 2020. Nearly 90% of the deaths from antibiotic-resistant infections will occur in developing countries in Africa and Asia. Developing nations cannot depend on receiving effective, still-to-be-developed drugs from industrialized countries; they need in-country solutions.

Phages are naturally-occurring antibiotic alternatives that can kill antibiotic-resistant bacteria. Phages were used to treat infections 100 years ago, before being supplanted by newly-discovered antibiotics. However, for decades the former Soviet Union kept a centralized phage collection. When a new bacterial strain emerged, this phage “bank” was screened and effective phages quickly deployed to treat infections. We aim to create a similar phage bank in East Africa, bringing together hundreds of phages that scientists across the region have already isolated. This will allow treatment of antibiotic-resistant infections and save lives.

When global epidemics occur, developing countries receive essential medicines much later than industrialized nations do. During the HIV/AIDS crisis, African countries were not able to procure the necessary quantities of antiretroviral drugs until 10 years after the US and Europe did. And while the US has more than enough coronavirus vaccines to fully vaccinate its entire population, African countries currently have enough for only 2-6% of their populations, courtesy of the WHO-associated COVAX program. 

Global health experts predict that one of the next pandemics will be caused by antibiotic-resistant infections, which are already responsible for 700,000 deaths each year. By 2050, antibiotic-resistant infections are expected to kill 10 million people annually -- five times more than the almost 2 million deaths caused by COVID-19 during the first year of this pandemic. Furthermore, approximately 90% of the deaths from antibiotic resistance will occur in Africa and Asia. 

If there is a similar delay in delivering new antibacterial drugs to developing countries, that could result in 9 million antibiotic resistance deaths each year. To avoid this crisis, developing nations need to create their own pipelines for effective antibiotic treatments. This is a daunting task, but there is precedent for accomplishing it.

Before chemical antibiotics were discovered, bacteriophages (phages) were used in the US, Europe and Asia to treat bacterial infections. Phages are viruses that exist in the environment, food and our bodies' microbiomes. Unlike other viruses, they kill bacteria but are harmless to human cells. Importantly, phages can kill antibiotic-resistant bacteria, can be easily isolated from contaminated environments, and are inherently quick and inexpensive to manufacture -- hence, particularly well-suited for applications in developing countries. 

For decades the Soviet Union stored a large collection of phages to kill many different types of bacteria. When a new bacteria emerged, this phage “bank” was rapidly screened and effective phages deployed to treat infections. The US-based company Adaptive Phage Therapeutics recently received FDA approval to test a similar approach. Indeed, phages are regaining popularity in industrialized countries, but phage expertise lags in developing countries. Phages for Global Health has been filling that gap by teaching developing world scientists how to isolate phages to kill problem bacteria in their countries. Now that there is a critical mass of phage researchers in East Africa, we propose to combine those collected phages into a centralized phage bank that could be used to rapidly respond to antibiotic-resistant outbreaks.

Our approach is to empower a network of East African scientists to manage the antibiotic resistance crisis in their region. As trusted in-country leaders, they can deliver phage products in ways that are culturally appropriate within their local social contexts. In fact, many of these phage researchers have initiated public engagement activities, dialoguing with key stakeholders -- farmers, butchers, regulatory authorities, consumers, etc -- about the potential benefits of phages, as well as soliciting input regarding how best to deliver phage products in distinct settings. It is also important for these scientists to isolate phages within their region, since bacteria vary in different parts of the world, and phages can adapt specifically to kill the local types of bacteria.

Research groups from at least 13 institutions across Kenya, Rwanda, Tanzania and Uganda are conducting phage research and have already isolated more than 400 phages. Many target bacteria causing infections like antibiotic-resistant tuberculosis, pneumonia, and diarrhea -- some of the leading causes of death in developing countries. Other phages kill bacteria that contaminate food products such as meat, fish, dairy or agriculture crops, which can cause illnesses in people. Thus, using phages to reduce product losses in those industries could contribute to economic health in the region, in addition to saving thousands or even millions of lives.

In establishing the East Africa Phage Bank, we are partnering with phage scientists from the US and Europe -- including those in the former Soviet Union -- who can share their expertise on topics such as updating and maintaining a phage bank, manufacturing phages at scale, and formulating phages for specific applications. By providing specific technical support, these collaborators aim to help streamline and accelerate the work being done by the East African phage scientists.

Based on its expected global death rate, the antibiotic resistance crisis will be the largest infectious disease emergency that our world has encountered in modern history, killing at least five times more people each year than coronavirus, HIV or tuberculosis have. And with 90% of the antibiotic resistance deaths expected to occur in developing countries in Africa and Asia, the resulting health inequalities will be overwhelming unless novel solutions are implemented. A regional phage bank administered by local public health scientists and governments represent one such solution, with preliminary proof of concept already demonstrated in the former Soviet Union.

While this project has not yet been implemented in East Africa, the overall concept has been tested in the former Soviet Union, where the government used a centralized phage bank for decades, led by our partners at the Eliava Institute (now in the country of Georgia). Furthermore, many of the key pieces of the project are already in place in East Africa, including:

• Phages have been isolated by teams of project partners throughout Kenya, Rwanda, Tanzania and Uganda

• Support exists from several East African governmental Ministries, which would help oversee future utilization of the phage bank

• Reliable storage facility is available, initially at the US Army Medical Research Directorate – Africa, with plans to transfer to an East African institution once ready

• Phage experts from the US and Europe are engaged as collaborators and advisors in phage bank management, manufacturing, and applications in people and agriculture

Most efforts to address antibiotic resistance focus on prolonging the effectiveness of existing antibiotics or financially motivating new drug innovation through the conventional drug development process. While both approaches can help to some extent, neither will truly provide a long-term solution. The former approach -- ensuring that antibiotics are only used when medically appropriate -- will just delay the inevitable: all current antibiotics will eventually become ineffective. And the second approach -- incentivizing pharmaceutical companies to make novel drugs for “third world” diseases -- is considered futile by many global health leaders because of the expense. 

We believe that phage-based drugs can provide a solution since they could be (1) developed cheaper and faster than conventional drugs, (2) designed to minimize future resistance (through several documented methodologies), and (3) produced with relatively simple equipment that is readily available to developing world scientists. Furthermore, the creation of a centralized phage bank could enable regional governmental agencies to respond quickly and cost-effectively to outbreaks caused by antibiotic resistant bacteria, rather than relying on receiving drugs from pharmaceutical companies elsewhere in the world.

This is a consortium that brings together East African scientists who are isolating phages locally and phage experts from the US and Europe who have experience with managing phage banks and developing phage products for applications in people and agriculture. The nonprofit organization, Phages for Global Health (PGH), serves as the overall coordinator. To our knowledge PGH is the only organization worldwide specifically working to bring phage technology to developing countries.

PGH began scientific capacity building in Africa in 2017 when only a handful of scientists on the continent had conducted any phage research. Hence, the initial mission was to build up phage knowledge and experimental skills. Through a series of hands-on laboratory training workshops hosted in Uganda, Kenya and Tanzania, PGH has taught cohorts of East African scientists how to isolate phages from local sources and begin to develop those into antibacterial products. Each of those scientists has then taught phage biology to an average of 15 others through their home institutions, resulting in more than 1100 regional scientists being introduced to phage therapy.

A driving principle of our work is that in-country scientists, who are familiar with the specific bacterial diseases in their region as well as the cultural norms, will be best suited to deliver phage products to people in their countries. At the same time, African scientists can benefit from the expertise of phage scientists in the US and Europe, many of whom have been conducting phage research for decades.