Learning from IPC strategies for COVID-19 to mitigate AMR in rural Nigerian communities
– by Rachael Osagie

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The coronavirus disease (COVID-19) pandemic has revealed many areas of public health preparedness that are lacking, especially in lower- and middle-income countries. This reinforces the importance of preventative measures such as improved hygiene and sanitation conditions as well as public awareness and education in maintaining human health.

Antimicrobial resistance (AMR) is an emerging and serious public health threat in both developed and developing countries. Findings from a survey in Nigeria showed that about a third of the general public consume antibiotics obtained without prescription. There is an overall poor understanding of antimicrobial resistance and/or proper use of antibiotics. Although not surprising, but very disturbing, is the high prevalence of self-medication reported in studies conducted in different populations across Nigeria, and the fact that the two most commonly self-medicated drugs were analgesics and antibiotics.

I have observed that state health agencies, in strong partnership with local government health authorities, have changed the narrative for infection, prevention and control strategies at the community level.

Monitoring and controlling AMR is particularly challenging in developing countries because of multiple factors. These include lack of surveillance systems, limited resources, poor adherence to infection control measures, injudicious use of antibiotics, and limited availability of antibiotics.

During public health emergencies like the ongoing COVID-19 pandemic, primary healthcare workers are often the most credible source of information in the community. However, I have found that the same community healthcare providers who provide credible information to individuals and communities to comply with infection prevention and control (IPC) measures to reduce the transmission of COVID-19 may themselves lack basic knowledge and information on AMR transmission and related IPC measures.

Strong partnerships with local communities facilitate IPC measures

In my role as a facilitator for my state in the training of health workers in healthcare facilities on COVID-19 preparedness, I have observed that state health agencies, in strong partnership with local government health authorities, have changed the narrative for IPC at the community level. This change is seen in the aggressive public awareness campaigns in local dialect about the strategies for IPC of COVID-19. These same strategies, if sustained and supported, could be used to reduce AMR. The community-based strategy employed in raising the level of awareness for COVID-19 is known as cascaded training and capacity building for COVID-19 preparedness and response for community-based healthcare providers. This has been supported and funded by various donor agencies. The training contains information on how health workers can:

• Educate traditional and religious leaders and other community stakeholders on COVID-19 spread and IPC measures.
• Demonstrate, practice, monitor and supervise good hand hygiene as well as the use of personal protective equipment (PPE) in households, health facilities and public structures.
• Share updates on the current COVID-19 situation with community members using simple non-technical language.
• Deploy the use of information, communication and education materials on COVID-19 in homes of influential community members.
• Use local language to raise public awareness without raising panic on COVID-19 containment.
• Conduct contact tracing which is a standard procedure implemented during an outbreak to determine the extent of the outbreak by identifying and maintaining contact with persons who were exposed to a confirmed case.
• Apply digital interventions as vital resources in the current public health emergency (e.g. for infection control, home-based diagnosis, screening, public health surveillance and epidemiology).

Translating current hygiene measures into long-term behaviour changes

Use of antimicrobial soaps and disinfectant cleaners by members of the community and in the hospital has increased hugely over the last few months during the COVID-19 pandemic. Higher usage is likely to continue and may even remain high following the outbreak due to changes in infection and control policy or individual habits. I think these increased and improved hygiene practices may reduce the spread of AMR, which would be a very positive outcome. Significant reductions in travel may also have an impact on the spread of AMR.

Findings from a survey in Nigeria showed that about a third of the general public consume antibiotics obtained without prescription. There is an overall poor understanding of antimicrobial resistance and/or proper use of antibiotics.

Stronger hand hygiene, appropriate aseptic technique as well as consistent maintenance of clean hygienic medical facilities, equipment and practices could limit the spread of drug-resistant microorganisms. This would reduce antimicrobial misuse and overuse. The thoughtful and thorough surveillance arising from COVID-19 interventions would also assist with this. It would also be beneficial to link into the existing COVID-19 human and material structures by establishing important partnerships with local and state health authorities to address AMR. These organisations can address AMR across a range of settings, including hospitals, long-term care facilities, outpatient settings, and the community, and can collaborate with veterinary medicine and animal agriculture partners to support antibiotic stewardship outside of healthcare.

Collaborative efforts led by state health agencies working with existing community leaders/influencers rather than national political leaders can lead to a greater impact on reducing emergence, transmission, and spread of AMR. The global issue of AMR will persist beyond the COVID-19 pandemic and understanding of some of the impacts the management strategies employed globally had or will have on AMR in the clinic, the environment and regarding public awareness should be investigated. While we still have a lot to learn from this pandemic and how changed behaviours will affect AMR, it’s safe to say that everybody should keep washing their hands.

References

1. Levy SB . The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers. Cambridge, USA, Perseus Publishing; 2002
2. World Health Organisation (2020) Preventing antimicrobial resistance through infection control.
3. Mahmood S, Hasan K, Carras MC and Labrique A (2020): Global Preparedness Against COVID-19: We Must Leverage the Power of Digital Health List JMIR Public Health and Surveillance .6(2);e18980
4. World Health Organization (2020) Online training as a weapon to fight the new coronavirus 
5. Chukwu E.E., Oladele D.A., Awoderu O.B., Afocha E.E., Lawal R.G. et al. (2020): A national survey of public awareness of Antimicrobial resistance in Nigeria. Antimicrobial Resistance and Infection Control 9:72 
6. Akinlade KA, Akinyemi JO, Fawole OI(2015): Knowledge of hazards of antibiotics self-medication by mothers for under-fives in rural community of South-West Nigeria. African Journal of Medical Sciences 44(4):303-309