Surveillance Policy Implementation & Interventions for Tackling AMR

Creating a new data ecosystem incorporating community microbial and citizen related data to recognize and proactively respond to resistance in Northeastern Nigeria, in areas recovering from humanitarian crisis. The ecosystem will support the development of adaptive antibiograms which better incorporate seasonal trends, demographics and risks while accounting for data gaps.

Dr. Okechi Ogueji, Senior Health Quality Manager

International Rescue Committee (IRC) Nigeria.  

Livelihood loss associated with protracted conflict in North east Nigeria have predisposed conflict-affected persons in communities to use unlicensed health vendors who prescribed poly-antimicrobial. In Nigeria, AMR is particularly pronounced on account of multiple factors; high rates of infections not controlled by other means, poor quality antibiotics in circulation, lax regulations governing antimicrobial use in humans and animals, prevalent drug abuse among livestock keepers, unregulated disposal of waste in dumpsites, inadequacies in surveillance systems and lack of ongoing education regarding antimicrobial use for prescribers and users. A Pfizer Foundation-funded KAP survey in the Northeast region conducted by IRC in November 2021 showed 1% of prescribers scored 80% on AMR focused KAP, and 6% scored 80% on knowledge attitude and behavioural assessment. 90% of those surveyed reported having taken an antimicrobial in the month before coming into the clinic, and  about 90% reported their youngest child had taken an antimicrobial in the month before seeking care. For livestock, improper use of antimicrobials increases the risk and development of antimicrobial resistance, posing a growing concern to One Health. AMR repercussions are profound, treatment failures often necessitate prescription of expensive, less affordable advanced antibiotics, thus perpetuating antimicrobial resistance prevalence in the population.

General public, including livestock keepers: An IRC survey revealed 90% respondents reported use of unprescribed antibiotics before seeking clinic care. 35% of community members reported contact with live livestock/poultry, of which, 52% reported giving antibiotics to these animals. IRC will conduct awareness campaigns to promote responsible and appropriate human and livestock antimicrobial use among the general public.

Government Ministries and agencies:  IRC's existing work on One Health in AMR and impact on policy, showcased with the development of TWG has already brought together these diverse areas. IRC will advocate and facilitate more AMR policy formulation, funding, and implementation and full adoption/implementation of One Health approach in addressing AMR. 

Regulatory Bodies/Environmental Agencies: Advocate for stronger monitoring and implementation of regulations governing antimicrobial use in both human and animal health. Implement proper waste management practices to prevent environmental contamination and resistance spread.

Healthcare Providers: Conduct ongoing education for healthcare providers to improve prescription practices, raise awareness about AMR, and encourage responsible antibiotics use. 

Researchers and Surveillance Systems: Create a data ecosystem through collaborations with researchers and inhouse AI, which will enable predictive analytics to better contextualize surveillance data and better predict the need for antibiotics clinical decision support system.

Our solution aimed at aiding the process of design and update of Antibiotics Therapeutic Guideline, through the development of State Antibiogram for efficient, effective antibiotics usage, improved AMR testing capability, and monitoring resistance pattern through a simplified digital system and contextualization with clinical decision support development, using machine learning approaches to bring in demographics and clinical findings into antimicrobial decision making based on the antibiogram in conjunction with national government protocols. 

Direct outputs of our work, aligns with The Trinity Challenge's requirements. Firstly, development and dissemination of versatile data tracking tools, validated by a successful pilot project, contribute to the public knowledge. Secondly, the digital data tool will capture, community-wide antimicrobial consumption and suspected resistance, GIS tracking, referral linkage and valuable resources accessible globally. 

The process will be supported by community-level social mobilization & education, community and social media AMR campaigns, and citizen scientist network. It focusses on fortifying documentation and implementation of State and National Action Plans on AMR.  Collaboration with State AMR technical working groups and the NCDC, contributes to the public good of policy development and implementation. Our approach addresses immediate challenge of AMR and provides globally accessible public goods, benefiting the well-being of communities.

Our robust strategy in Northeastern Nigeria against AMR is poised to significantly benefit vulnerable populations. IRC's extensive surveys and QOC assessments showcase a deep understanding of challenges faced by communities and healthcare stakeholders. Published research on the NCDC website and a pending JMIR publication underscores our commitment to evidence-based solutions. Our holistic approach confronts the escalating AMR threat through an integrated monitoring system spanning the one health family. Versatile data tracking tools, validated by a successful pilot project, are set for electronic upgrades using tools like CommCare. The strategy involves crafting a comprehensive data tool for community-wide antimicrobial consumption. Community-level initiatives, supported by AMR SBCC training manual, establish a resilient network for promoting awareness and responsible AMU. 

This will enhance diagnostic surveillance, through reinforcing AMR testing and initiating a State antibiogram, and scaling from lessons learned. Dissemination of key findings at state and national levels will impact policy and action plans. Collaboration with AMR technical groups at state and National levels will create a synergistic impact that aims to mitigate AMR on vulnerable populations through education, awareness, and improved healthcare practices. This integrated approach, backed by evidence from previous project and publications, signifies a comprehensive and impactful strategy against AMR.

Our strategy to scale our impact will leverage the lessons learned from our robust approach. Over the next 1-3 years, we plan to expand our reach and enhance the effectiveness of interventions to create a transformative influence on society.

Establishment of Antibiograms:

Year 1: Strengthen existing surveillance systems by incorporating additional data sources and enhancing reporting mechanisms. We will advance data tracking tools for antibiotics resistance surveillance and facility, community and livestock use patterns and sentiment data through electronic upgrades using CommCare to collect data required to initiate a state antibiogram.

Years 2-3: Pilot antibiogram implementation in a few healthcare facilities in MMC, Jere, and Gwoza. Provide technical assistance and training to ensure accurate data collection using CommCare.

Scale up antibiogram implementation to a broader network of healthcare facilities. Advocate for policy changes requiring mandatory antibiogram reporting.

Increased Public Awareness on AMR/AMU:

Year 1: Launch targeted public awareness campaigns through various media channels and social networks. Collaborate with community leaders and the state MoH to disseminate information.

Years 2-3: Extend awareness programs to 20 schools (secondary and tertiary), 4 workplaces (NAFDAC, BOSEPA, FMAFS and MoH), and 12 community events. Leverage social media platforms to amplify the reach of the campaign.

Success in this project would be measured by clearly defined indicators such as:

• Quantity of data generated and collected electronically to create an Antibiotic Resistance (AMR) antibiogram for Borno State. The quantity and quality of data collected from routine care in PHCs and UMTH and secondary health facility was not readily available before. Quality will be monitored by contamination rates, critical alerts sent and timeliness of alerts, and geographic and clinic coverage and balance. This antibiogram will be instrumental in developing Therapeutic Antibiotic Guidelines, contributing to the fight against AMR.
• Number of facilities where antibiogram and resultant clinical decision support tool usage is being implemented.
• Number of people reached with targeted public awareness campaign on AMU/AMR.
• Number of healthcare workers, including both Ministry of Health (MoH) and private providers, as well as community healthcare workers participating in AMR training, advocacy sessions, and workshops.

1) Limited financial support for health service provision is a key barrier in Nigeria. A small percentage of the state budget goes into health sector, hence most health facilities lack basic drug including antibiotics, laboratory equipment, reagent and supplies for basic investigations. This requested funding will focus on combatting AMR, while other IRC-implemented projects funded by different donors will support provision of drug, infrastructural repair, health worker capacity building.

2) High underlying rate of infection triggering antimicrobial use with few diagnostics available will continue to drive AMR and remains a constant barrier. To overcome this barrier, our goal is to ensure that infections are reduced and that antimicrobials are targeted to the infections that are needed, avoiding prolonged courses or unnecessary or mistargeted antimicrobials.   

• National Centre for Disease Control (NCDC)
• Borno State Ministry of Health
• Borno State Ministry of Agriculture
• Borno State Environmental Protection Agency
• Borno State Ministry of Animal Resources and Fisheries
• Borno State Primary Healthcare Development Board
• Borno State Hospital Management Board
• National Agency for Food and Drug Administration
• University of Maiduguri
• University of Maiduguri Teaching Hospital
• University of Maiduguri Veterinary Teaching Hospital
• Borno State Veterinary Hospital
• Pharmaceutical Society of Nigeria
• Association of Medical Laboratory Scientists of Nigeria

Through the Partnership and Program Development, IRC.