Situational analysis of antimicrobial resistance, laboratory capacities, surveillance systems and containment activities in Ethiopia: A new and one health approach.

Antimicrobial resistance (AMR) has become a health, environmental, and economic threat around the globe. It is rising in Ethiopia. This analysis was designed to determine the current status of AMR on major bacterial pathogens, laboratory capacities, surveillance systems, and containment activities in the country. Data were collected from published literature and then supplemented by interviews with ten experts from key stakeholders. Data collections were guided by the AMR Situational Analysis Tool developed by Food Safety Officers at the Food Systems and Food Safety Division of the Food and Agriculture Organization of the United Nations. Published articles indicated the presence of gaps in knowledge, attitude, and practices by health professionals, students, and the community. AMR rates among E. coli, Salmonella, Staphylococci, and Campylobacter isolates ranged from 3.69-88.41, 4.66-87.74, 17.03-85.08, and 8.41-86.63% to commonly prescribed antimicrobials, respectively. Microbiology laboratories are available. However, a considerable number of laboratories didn't have the basic equipment and consumables. AMR surveillance and reporting system have been established. The national strategic plan has been developed and updated three times. To contain AMR, a governance framework and regulations have been prepared. However, most of them were not fully implemented at all administrative levels. In conclusion, there was a high rate of AMR in the country; some activities have been conducted to prevent and contain AMR. However, more interventions and sustainable activities have to be performed to increase awareness, prevent and contain infectious diseases, rational use antimicrobials and generate more evidence in the country.

Prevalence of subclinical mastitis, associated risk factors and antimicrobial susceptibility of the pathogens isolated from milk samples of dairy cows in Northwest Ethiopia.

Subclinical mastitis (SCM) is a problem of dairy cattle worldwide that affects the income of dairy farmers and besides a health risk to humans. A cross-sectional study was carried out to estimate prevalence, identify risk factors of SCM and antimicrobial susceptibility test of bacteria isolated from SCM quarters. California Mastitis Test (CMT) positive milk samples were cultured and bacteria isolated. The isolated bacteria were checked for their antimicrobial susceptibility using Kirby-Bauer disk diffusion method. The study findings showed that 32.7% of the quarters and 60.1% of the cows were CMT positive. The isolated bacteria were 29.5% Staphylococcus aureus (S. aureus) and 9.3% Streptococcus agalactiae (Str. agalactae). In the risk factors study, cows from farms of poor hygiene, increased age and stage of lactation had higher odds of SCM. Of the isolated bacterial species, 75.7% and 71.4% of S. aureus isolates were resistant to the effects of penicillin and ampicillin, respectively. Streptococcus agalactiae were resistant to the effects of oxytetracycline (76.9%), streptomycin (61.5%) and cloxacillin (53.8%). Whereas the majority of S. aureus (98.6%) and Str. agalactiae (88.5%) were susceptible to the effects of gentamycin and Clindamycin respectively. In conclusion, SCM had high level of prevalence and associated risk factors with pathogens that were resistant to commonly used antimicrobials. Implementing strict preventive measures and limiting spread of pathogens is a preferred approach rather than treatment with antibiotics to control mastitis in the study area.

Study on identification, assay and organoleptic quality of veterinary medicines in Ethiopia.

BACKGROUND: Medicines of poor quality are currently prevailing problems undermining the quality of health care services in veterinary and human medicine. In this study, physico-chemical quality of veterinary medicines was evaluated. METHODS: A total of 959 veterinary medicines samples were collected during routine regulatory activities, i.e. pre-registration, re-registration, consignment checking and post-marketing surveillance, in Ethiopia. The samples were transported to Animal Products, Veterinary Drug and Feed Quality Assessment Centre (APVD-FQAC), which is the quality control laboratory of the Veterinary Drug and Feed Administration and Control Authority (VDFACA) and stored until analysis. The samples were subjected to visual inspection and chemical analysis following the United States, European or British Pharmacopoeias, or manufacturer's methods. RESULTS: The findings revealed that 12 (1.3%) of tested products showed defects in physical characteristics, packaging, or labelling information, while a total of 66 (6.9%) samples of the investigated products failed to comply with the Pharmacopoeias and supplier's specification limit set for assay. Of these, 60 samples did not comply with the minimum assay specification limit. CONCLUSION: Overall, 8.2% of the investigated veterinary medicine samples did not comply with the specification set for the investigated quality attributes and thus were categorized as of poor quality. This indicates the need for continued strengthening of regulatory functions.

Antibiotics self-medication practices among health care professionals in selected public hospitals of Addis Ababa, Ethiopia.

BACKGROUND: Self-medication is the first option and response to most illness episodes. Use of antimicrobials without health care professionals' guidance may result in greater probability of inappropriate use, missed diagnosis, delays in appropriate treatment, pathogen resistance and increased morbidity. There is no sector in the health care community which is immune to drug abuse or misuse of which the worst offenders include physicians, nurses and pharmacy professionals. Self-medication among health care professionals may be an indicator that the health professional is neglecting his or her own health. This represents serious issues for both patients and the professionals. OBJECTIVE: To assess self-medication practices with antibiotics among health care professionals in selected hospitals of Addis Ababa, Ethiopia. METHOD: Facility based cross-sectional study was conducted from April to May, 2017 among 317 health care professionals. Convenient sampling technique was used to select study participants. Data were collected through self-administered questionnaire and analyzed using Statistical Package for Social Sciences software version 20. Binary logistic regression analysis was done to check the relationship between the dependent variable (antibiotic self-medication) and selected independent variables (sex, age, marital status, income, professional qualification and work experience). RESULTS: The prevalence of self-medication with antibiotics among health care professionals in one month recall period was found to be 72 (22.7%). The main reasons given for this practice were being familiar with the treatment options, 31 (43.1%) and need for rapid relief, 25 (34.7%). Respiratory problems, 29 (40.3%) and gastro intestinal problems, 28 (38.9%) were the most common illnesses for which self-medication with antibiotics was practiced while penicillins, 30 (41.6%) and fluoroquinolones, 29 (40.3%) constituted the two most commonly used antibiotics for the same. None of the variables had significant association with the practice of self-medication with antibiotics. CONCLUSION: Self-medication with antibiotics was common among the study participants. Efforts should be made by health authorities including Drug and Therapeutics Committee, Drugs Regulatory Authority, Hospitals' management and other stakeholders to ensure safe usage of antibiotics.

Multidisciplinary and multisectoral coalitions as catalysts for action against antimicrobial resistance: Implementation experiences at national and regional levels.

The multi-faceted complexities of antimicrobial resistance (AMR) require consistent action, a multidisciplinary approach, and long-term political commitment. Building coalitions can amplify stakeholder efforts to carry out effective AMR prevention and control strategies. We have developed and implemented an approach to help local stakeholders kick-start the coalition-building process. The five-step process is to (1) mobilise support, (2) understand the local situation, (3) develop an action plan, (4) implement the plan, and (5) monitor and evaluate. We first piloted the approach in Zambia in 2004, then used the lessons learned to expand it for use in Ethiopia and Namibia and to the regional level through the Ecumenical Pharmaceutical Network [EPN]. Call-to-action declarations and workshops helped promote a shared vision, resulting in the development of national AMR action plans, revision of university curricula to incorporate relevant topics, infection control activities, engagement with journalists from various mass media outlets, and strengthening of drug quality assurance systems. Our experience with the coalition-building approach in Ethiopia, Namibia, Zambia, and with the EPN shows that coalitions can form in a variety of ways with many different stakeholders, including government, academia, and faith-based organisations, to organise actions to preserve the effectiveness of existing antimicrobials and contain AMR.

Peer counselors' role in supporting patients' adherence to ART in Ethiopia and Uganda.

Our aim was to explore peer counselors' work and their role in supporting patients' adherence to antiretroviral treatment (ART) in resource-limited settings in Ethiopia and Uganda. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Two main categories with related subcategories emerged from the analysis. The first main category, peer counselors as facilitators of adherence, describes how peer counselors played an important role by acting as role models, raising awareness, and being visible in the community. They were also recognized for being close to the patients while acting as a bridge to the health system. They provided patients with an opportunity to individually talk to someone who was also living with HIV, who had a positive and life-affirming attitude about their situation, and were willing to share personal stories of hope when educating and counseling their patients. The second main category, benefits and challenges of peer counseling, deals with how peer counselors found reward in helping others while at the same time acknowledging their limitations and need of support and remuneration. Their role and function were not clearly defined within the health system and they received negligible financial and organizational support. While peer counseling is acknowledged as an essential vehicle for treatment success in ART support in sub-Saharan Africa, a formal recognition and regulation of their role should be defined. The issue of strategies for disclosure to support adherence, while avoiding or reducing stigma, also requires specific attention. We argue that the development and implementation of support to peer counselors are crucial in existing and future ART programs, but more research is needed to further explore factors that are important to sustain and strengthen the work of peer counselors.

Measuring adherence to antiretroviral treatment in resource-poor settings: the feasibility of collecting routine data for key indicators.

BACKGROUND: An East African survey showed that among the few health facilities that measured adherence to antiretroviral therapy, practices and definitions varied widely. We evaluated the feasibility of collecting routine data to standardize adherence measurement using a draft set of indicators. METHODS: Targeting 20 facilities each in Ethiopia, Kenya, Rwanda, and Uganda, in each facility we interviewed up to 30 patients, examined 100 patient records, and interviewed staff. RESULTS: In 78 facilities, we interviewed a total of 1,631 patients and reviewed 8,282 records. Difficulties in retrieving records prevented data collection in two facilities. Overall, 94.2% of patients reported perfect adherence; dispensed medicine covered 91.1% of days in a six month retrospective period; 13.7% of patients had a gap of more than 30 days in their dispensed medication; 75.8% of patients attended clinic on or before the date of their next appointment; and 87.1% of patients attended within 3 days.In each of the four countries, the facility-specific median indicators ranged from: 97%-100% for perfect self-reported adherence, 90%-95% of days covered by dispensed medicines, 2%-19% of patients with treatment gaps of 30 days or more, and 72%-91% of appointments attended on time. Individual facilities varied considerably.The percentages of days covered by dispensed medicine, patients with more than 95% of days covered, and patients with a gap of 30 days or more were all significantly correlated with the percentages of patients who attended their appointments on time, within 3 days, or within 30 days of their appointment. Self reported recent adherence in exit interviews was significantly correlated only with the percentage of patients who attended within 3 days of their appointment. CONCLUSIONS: Field tests showed that data to measure adherence can be collected systematically from health facilities in resource-poor settings. The clinical validity of these indicators is assessed in a companion article. Most patients and facilities showed high levels of adherence; however, poor levels of performance in some facilities provide a target for quality improvement efforts.

Voices on adherence to ART in Ethiopia and Uganda: a matter of choice or simply not an option?

This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: "Patients' competing costs and systems' resource constraints" and "Patients' trust in ART and quality of the patient-provider encounters." The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

Monitoring adherence and defaulting for antiretroviral therapy in 5 East african countries: an urgent need for standards.

OBJECTIVES: A cross-sectional survey was performed in 24 systems of care providing antiretroviral medications in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda to examine current practices in monitoring rates of treatment adherence and defaulting. RESULTS: Only 20 of 48 facilities reported routinely measuring individual patient adherence levels; only 12 measured rates of adherence for the clinic population. The rules for determining which patients were included in the calculation of rates were unclear. Fourteen different definitions of treatment defaulting were in use. Facilities routinely gather potentially useful data, but the frequency of doing so varied widely. CONCLUSIONS: Individual and program treatment adherence and defaulting are not routinely monitored; when done, the operational definitions and methods varied widely, making comparisons across programs unreliable. There is a pressing need to determine which measures are the most feasible and reliable to collect, the most useful for clinical counseling, and most informative for program management.