Assessment of antimicrobial resistance laboratory-based surveillance capacity of hospitals in Zambia: findings and implications for system strengthening.

BACKGROUND: A well-established antimicrobial resistance (AMR) laboratory-based surveillance (LBS) is of utmost importance in a country like Zambia which bears a significant proportion of the world's communicable disease burden. This study assessed the capacity of laboratories in selected hospitals to conduct AMR surveillance in Zambia. METHODS: This cross-sectional exploratory study was conducted among eight purposively selected hospitals in Zambia between August 2023 and December 2023. Data were collected using the self-scoring Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) tool. FINDINGS: Of the assessed facilities, none had full capacity to conduct AMR surveillance with varying capacities ranging from moderate (63% (5/8)) to low (38% (3/8)). Some of the barriers of AMR-LBS were the lack of an electronic laboratory information system (63% (5/8)) and the lack of locally generated antibiograms (75% (6/8)). Quality control for antimicrobial susceptibility testing (AST), pathogen identification and media preparation had the lowest overall score among all of the facilities with a score of 14%, 20% and 44%, respectively. The highest overall scores were in specimen processing (79%), data management (78%), specimen collection, transport and management (71%), and safety (70%). Most facilities had standard operating procedures in place but lacked specimen-specific standard operating procedures. CONCLUSION: The absence of laboratories with full capacity to conduct AMR surveillance hinders efforts to combat AMR and further complicates the treatment outcomes of infectious diseases. Establishing and strengthening LBS systems are essential in quantifying the burden of AMR and supporting the development of local antibiograms and treatment guidelines.

Drug Resistance to AIDS; Tuberculosis and Malaria in the African Region

With just 10of the world population; sub-Saharan Africa has the highest burden of HIV/AIDS; tuberculosis and malaria in the world. Both access to and adequate utilization of eff ective treatment with quality-assured medicines are crucial for reducing the disease burden. However; eff orts to improve access to treatment are hampered by the development of HIV; TB and malaria drug resistance. This is a result of genetic mutations and is a major threat to control of HIV/AIDS; TB and malaria. HIV drug resistance can be minimized by good antiretroviral treatment (ART) programmes; removal of barriers to continuous access to ART and reduction of HIVtransmission. Recent surveys conducted at antenatal clinics in several countries in the African Region estimated that HIV resistance to all drug classes is less than 5. A global HIV drug resistance network established in 2001 supports countries in capacity building and guidance on standard procedures for monitoring HIV drug resistance. Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) are principally a result of inadequate or poorly administered treatment regimens. The new WHO Stop TB Strategy launched in 2006 identifies management of MDR-TB as a core component of TB control. The magnitude of MDR-TB in the African Region is still unknown. In 2007; 27 countries notifi ed MDR-TB cases; and six reported at least one case of XDR-TB. Following widespread resistance to chloroquine and sulphadoxine-pyrimethamine all malaria-endemic countries except two in the Region have changed the treatment policy to artemisinin-based combination therapy (ACT). The main method of monitoring antimalarial drug resistance is through therapeutic efficacy testing. Todate there has been no confi rmed resistance to ACTs in the African Region. Given the emergence and spread of resistance to HIV; TB and malaria drugs; the purpose of this paper is to describe the issues and challenges and propose a way forward with regard to the prevention and control of such resistance

Increasing antimalarial drug resistance in Uganda and revision of the national drug policy.

Chloroquine (CQ) resistance was first documented in Uganda in 1988. Subsequent surveillance of antimalarial drug resistance, conducted by the Ugandan Ministry of Health and several research organizations, suggests that resistance to CQ is now widespread, reaching critical levels in many areas of the country. In June 2000, the Ministry of Health held a National Consensus Meeting to evaluate the available drug efficacy data and review the national antimalarial drug policy. After extensive debate, the combination of CQ + sulfadoxine-pyrimethamine (SP) was chosen to replace CQ as the first-line treatment of uncomplicated malaria as an interim policy. This review evaluates the in vivo drug efficacy studies conducted in Uganda since 1988 and issues confronted in revision of the drug policy. The Ugandan experience illustrates the challenges faced by sub-Saharan African countries confronted with rising CQ resistance but limited data on potential alternative options. The choice of CQ + SP as a provisional policy in the absence of prerequisite efficacy, safety and cost-effectiveness data reflects the urgency of the malaria treatment problem, and growing pressure to adopt combination therapies. Surveillance of CQ + SP treatment efficacy, collection of additional data on alternative regimens and active consensus building among key partners in the malaria community will be necessary to develop a rational long-term antimalarial treatment policy in Uganda.

Intensity of malaria transmission, antimalarial-drug use and resistance in Uganda: what is the relationship between these three factors?

We studied (in 1998 and 1999) some factors that may be linked to the spread of chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) resistance in 7 discrete communities in Uganda. Exposure to malaria infection was measured by parasitological surveys in children aged 1-9 years, drug use by community surveys and drug resistance by in-vivo tests on children aged 6-59 months with clinical malaria. CQ use was inversely related to parasite prevalence (r = -0.85, P = 0.01). CQ and SP treatment failure rates varied significantly according to parasite prevalence (P = 0.001 and 0.04 respectively). The highest CQ (42.4%, 43.8%) and SP (12.5%, 14.8%) treatment failure rates were observed in sites characterized by high parasite prevalence. Using areas with medium parasite prevalence as reference, the relative risk (RR) for CQ treatment failure was 3.2 (95% CI 1.6-6.4) in high parasite prevalence sites and 3.1 (95% CI 1.2-7.7) in low parasite prevalence sites. The RR for SP treatment failure was also higher in sites with high parasite prevalence but low in those with low parasite prevalence. According to our findings, drug resistance seems to spread faster in higher transmission areas, regardless of drug pressure. In low transmission areas, drug pressure seems to be the critical factor. A decrease in transmission coupled with rational use of drugs may delay the spread of resistance.

Malaria: Current Situation and Way Forward

Malaria remains one of the most serious causes of ill health in the world; affecting people in more than 100 countries (World Health Organisation 1993). WHO estimates that the global incidence is between 300-500 million cares annually and this results in 1.5-2.7 million deaths. Nearly 25of all childhood deaths in Africa and half of the fever episodes in African children are attributable to malaria (WHO/CTD 1996). In Uganda; malaria has remained the leading cause of morbidity and mortality. The proportional morbidity attributable to malaria has been on the increase in Uganda (HMIS reports; unpublished)

Bed occupancy due to HIV/AIDS in an urban hospital medical ward in Uganda.

OBJECTIVE: To determine the proportion of patients with HIV-related illness admitted to a medical ward. DESIGN: A prospective study. SETTING: Rubaga Hospital, the third largest hospital in Kampala, the capital of Uganda. PARTICIPANTS: A total of 449 patients admitted to the medical ward between September and November 1992. RESULTS: Of the 449 patients, 390 (86.8%) agreed to provide a blood sample for HIV serology. Of these, 55.6% (95% confidence interval, 50.7-60.5%) were positive for HIV. Eighty-six (22.2%) of all patients [71 (33%) of the seropositives and six (3.5%) of the seronegatives] met the World Health Organization case definition for AIDS in Africa. The HIV-seropositives had a mortality rate of 17.4%, significantly higher (P = 0.00057) than the 5.8% rate observed in the seronegative group. The overall mortality rate was 13.7% and was significantly associated with HIV infection (P = 0.0005). CONCLUSION: HIV infection is a major contributor to morbidity and mortality in Uganda. Over 50% of the medical admissions were HIV-positive revealing the serious impact of HIV on the health-care system.