Contact details: Bernard Bett (bernard.bett@cgiar.org). International Livestock Research Institute, Nairobi - Kenya.
Background
Antimicrobial resistance is a major health challenge worldwide. Field studies and hospital records suggest that there is a high prevalence of antimicrobial-resistant bacteria in various parts of Kenya. The burden of antimicrobial resistance has, however, not been determined due to lack of reliable surveillance data. A recent study reported that there are over 200 antibiotic-resistant genes in the country1, with a significant proportion of these being mobile genetic elements that are transmissible between different species of bacteria.1
There is limited understanding on the factors that promote the occurrence, maintenance and transmission of antimicrobial resistance but it is believed that misuse of antimicrobials, high incidence of infectious diseases and lack of access to quality healthcare are some of the key drivers. Socio-economic practices, including local and international travel, are also thought to aid the dissemination of antimicrobial-resistant bacteria. Kenya has formulated intersectoral teams and coordination mechanisms to address this challenge.
This brief outlines the status of antimicrobial resistance surveillance and control in the country. These topics will also be discussed during this meeting as a case study to represent low- and middle-income countries which the CGIAR Antimicrobial Resistance Hub will work with to strengthen national capacities for antimicrobial resistance interventions.
Evaluation and planning
Antimicrobial resistance surveillance aims to monitor antimicrobial use and detect occurrence and spread of antimicrobial-resistant bacteria. The Ministry of Health has already rolled out a surveillance strategy that will recruit 28 hospitals as sentinel surveillance sites by 2022. By the end of 2018, two of these sites had been used to pilot the system and two more will be launched by the end of 2019. The initial situation analysis conducted in the country showed a high rate of resistance for respiratory, enteric and hospital-acquired infections, especially to the widely available antibiotics like penicillin and cotrimoxazole2. The antimicrobial resistance secretariat plans to collate additional data from research studies conducted in various institutes.
In the livestock sector, a surveillance protocol has been developed and reviewed. Research surveys show that resistance is prevalent in Escherichia coli isolates from beef and poultry and this is against commonly used drugs, namely, tetracycline, cotrimoxazole, streptomycin, ampicillin, quinolones and third-generation cephalosporins, in that order. Multidrug-resistant Staphylococcus aureus, including methicillin-resistant S. aureus, has been isolated from milk samples from lactating animals in northern Kenya3. In that study, resistance to tetracycline was highest (67%), followed by ampicillin, oxacillin, clindamycin, cephalexin, erythromycin, kanamycin and ciprofloxacin, in that order. Surveys on knowledge, attitudes and practices on antimicrobial use show that antibiotics are generally used to treat a wide range of syndromes in livestock, even those that do not deserve to be treated with these drugs.
Not much work has been done on antimicrobial resistance in aquaculture and agriculture. More work is also needed to determine the role of the environment in maintaining antimicrobial-resistant bacteria. Metagenomic and phylogenetic analyses are therefore required to better understand transmission patterns of antimicrobial-resistant bacteria in these environments, given that they serve as important points of contact between people, livestock and wildlife. Hotspots identified should be mapped to inform the deployment of risk-based interventions.
Interventions
A lot of effort has been devoted to creating an enabling environment for antimicrobial resistance prevention and control; for example, the implementation of antimicrobial resistance control policies and multisectoral fora. There have also been media campaigns to raise awareness of antimicrobial resistance4,5.
Kenya has ratified the 68th World Health Assembly resolution that recommended the adoption of the Global Action Plan on antimicrobial resistance developed by the World Health Organization, the World Organization for Animal Health and the Food and Agriculture Organization of the United Nations. One of the goals of the resolution was that all member countries would, by 2017, develop their respective national action plans aligned with the objectives of the Global Action Plan. This marked a critical step in the control of antimicrobial resistance in Kenya.
Kenya’s National Action Plan was launched on 13 November 2017 during the World Antibiotic Awareness Week. The plan6 provides a collaborative and interdisciplinary framework for managing antimicrobial resistance and prioritizes (i) awareness raising through communication, education and training, (ii) strengthening the evidence base for tracking antimicrobial use and resistance through improved surveillance and research, (iii) reducing the incidence of infection through effective sanitation, hygiene and infection prevention measures to limit reliance on antimicrobials, (iv) optimizing antimicrobial use in human and animal health and (v) developing an economic case for sustainable investment taking into account the needs of the country and investments in new medicines, diagnostic tools and vaccines. The plan should now be used to guide a coordinated response to limit antimicrobial use and curtail the transmission of antimicrobial-resistant bacteria.
Anchoring and scaling
Partnerships, policies, legislations and funding are some of the critical requirements for anchoring and scaling up of antimicrobial resistance interventions. Implementation of the National Action Plan is led by the National Antimicrobial Stewardship Interagency Committee in partnership with the antimicrobial resistance secretariat and the intergovernmental committee. The antimicrobial resistance secretariat works with the Ministry of Health, the Ministry of Agriculture, Livestock, Fisheries and Irrigation, universities, research organizations, civil societies and other relevant actors. With the establishment of a devolved governance structure, counties are expected to play an active role in implementing policies developed by the national government. The current policy, therefore, provides for the establishment of county antimicrobial stewardship interagency committees and county technical working groups.
The National Action Plan espouses One Health approaches to antimicrobial resistance prevention and is supported by multiple laws governing antimicrobial use such as the Pharmacy and Poisons Act, the Food, Drugs and Chemical Substances Act, the Medical Practitioners and Dentists Act, the Animal Diseases Act, the Public Health Act, the Pest Control Products Act and the Veterinary Surgeons and Veterinary Para-Professionals Act.
Most of the work on antimicrobial resistance that is currently being implemented in Kenya is funded by multiple development partners. Plans are being made to secure sustainable funding, mainly through the relevant government departments.
More Information
1. Naval Research Laboratory. 2017. High prevalence of antibiotic resistance in Kenya. ScienceDaily, 11 July 2017. https://www.sciencedaily.com/releases/2017/07/170711121501.htm
2. Kariuki, S. Research on antimicrobial resistance and One Health perspective in Kenya.
3. Omwenga, I. et al. 2018. Prevalence and antimicrobial resistance profiles of Staphylococcus aureus isolated from raw milk in pastoral areas of Northern Kenya. Presented at the 15th International Symposium of Veterinary Epidemiology and Ecology, Chiang Mai, Thailand, 12–16 November 2018.
4. The World Antibiotic Resistance Awareness week is celebrated annually in November.
5. National Antimicrobial Resistance Symposium in Kenya. https://www.reactgroup.org/news-and-views/news-and-opinions/year-2018/national-amr-symposium-in-kenya/
6. National Action Plan on Prevention and Containment of Antimicrobial Resistance, June 2017. https://www.afro.who.int/publications/
