Antimicrobial resistance (AMR) poses a global threat. High levels of AMR to commonly used antibiotics have been reported in East Africa. A situation analysis of AMR in Ethiopia also indicated high resistance levels. To prevent and contain AMR, Ethiopia established a national surveillance network.
This article describes the steps taken to prioritise AMR and establish the National Antimicrobial Resistance Surveillance System in Ethiopia, as well as present the challenges and lessons learned through implementation.
In April 2017, Ethiopia had developed and approved the National AMR Surveillance Plan for laboratory-based AMR surveillance. The World Health Organization recommendations and Ethiopias’s current microbiology capacity were used to prioritise organisms for reporting. The surveillance system is comprised of a network linking the national reference laboratory with surveillance sentinel sites. Roll-out of the AMR surveillance network occurred in three phases in order to ensure successful implementation.
Electronic capture and transmission of data, supply chain for the microbiology laboratory and communication problems were challenges observed after implementation started. Support from Ethiopian Public Health Institute focal persons for data entry, regular scheduled communication establishment and procurement of supplies by the American Society for Microbiology were some of the measures taken to address the challenges.
Ethiopia has demonstrated that setting up AMR surveillance in lower resource settings is possible with strong leadership and stakeholder engagement.
Across the globe, the emergence of antimicrobial resistance (AMR) is threatening the effective and successful treatment of infectious diseases. Drug resistance proliferates due to the improper use of drugs, poor regulation of antibiotics, limited antimicrobial stewardship, poor prescribing habits and non-compliance with prescription.
In 2009, concerned about the increasing prevalence of AMR globally, the Ethiopian Drug Administration and Control Authority, in collaboration with Management Sciences for Health or Strengthening Pharmaceutical System, conducted a situation analysis, the
In addition to increased morbidity and mortality, AMR is an increasing threat to global health security with potential economic, social and political ramifications.
Following the 2009 situation analysis, Ethiopia began to focus its efforts on disseminating information about AMR to the community and establishing a national strategy and action plan to curb the rising resistance. The National Advisory Committee on Antimicrobial Resistance Prevention and Containment, a multi-disciplinary body to govern and oversee the development and implementation of the national strategy, was established in 2011 with representation from both the human and animal health sectors of the government. By August of that year, the
In 2015, with financial and technical support from the United States Centers for Disease Control and Prevention (CDC) through the GHSA, various multi-sector partners collaborated to produce a revised 5-year
The development and implementation of the Ethiopia AMR Surveillance Plan was a national effort led by the Ethiopian Public Health Institute (EPHI) under the Federal Ministry of Health and supported by CDC, the American Society for Microbiology (ASM) as well as Ohio State University’s Global One Health initiative. In August 2016, EPHI held a 3-day workshop to kick off discussions around AMR surveillance to address the need for a ‘surveillance system that captures the emergence of resistance, trends, its spread and utilization of antimicrobial agents in different settings’. The workshop served as an opportunity to both sensitise key stakeholders about the importance of AMR and discuss and agree on priorities and methods for surveillance implementation. Staff from EPHI, stakeholders and other decision-makers used guidance materials from the World Health Organization’s (WHO) Global AMR Surveillance System (GLASS) to inform discussions and decision-making around the selection of sites, organisms and specimens to prioritise for reporting and data management methods.
By April 2017, Ethiopia had developed and approved the
In addition to WHO GLASS recommendations, selection of organisms and specimens to prioritise for reporting took into consideration pathogen prevalence and the current microbiology capacity of laboratories in Ethiopia. Ethiopia chose to focus on surveillance of
Priority surveillance pathogens by specimen for inclusion in Ethiopia AMR surveillance.
Specimen | Basic laboratory case definition | Priority surveillance pathogens |
---|---|---|
Urine | Significant growth in urine specimen | |
Wound | Isolation of pathogen in the presence of pus (Gram smear shows presence of pus with associated organism) | |
Other (any specimen) | Significant growth | Carbapenem-resistant: |
Ethiopia’s surveillance system is structured to connect sentinel surveillance sites to the national reference laboratory at EPHI. Each surveillance site includes a laboratory that is either affiliated with or located within a hospital. Currently, the surveillance network includes a total of 16 sentinel surveillance sites located across four regions and one city administration. Roll-out of the AMR surveillance network is occurring in three phases in order to ensure successful implementation and to effectively prepare sites for sample collection, diagnostic testing, data management and reporting. In order to prioritise sites for roll-out, EPHI, with assistance from ASM, assessed laboratories across Ethiopia in late 2016. A standardised assessment tool was used to better understand the conditions and capacities of potential AMR surveillance sites.
In the first phase of implementation, 4 of the 16 sites have been targeted to participate. The national reference laboratory at EPHI is coordinating and overseeing all surveillance activities. Focal persons from EPHI have been assigned to each of the initial four sites to support implementation. Implementation began with personnel training for clinicians and laboratory staff. ASM supported EPHI to train laboratory staff from the initial four surveillance sites in basic microbiology, antibiotic susceptibility testing and data management. A model of laboratory mentorship has been put in place. The four sites have begun receiving hands-on mentorship during which experienced laboratorians from ASM and EPHI work alongside the staff from the respective surveillance sites to ensure procedures are understood, followed and refined. To ensure that quality laboratory data is generated, all sites have been enrolled in an external quality assessment programme to evaluate diagnostic and reporting ability. As the quality of specimens sent for testing also affects laboratory data quality, Ohio State University’s Global One Health initiative conducted training for clinical and laboratory staff on proper methods for clinical specimen collection. In addition, the training aimed at introducing the purpose and goals of AMR surveillance and broadly conveying the importance of stewardship, infection prevention and control in the context of AMR surveillance.
The four sentinel sites receiving hands-on mentorship are currently involved in active surveillance. As part of surveillance, specimens, sent to the sentinel site laboratories, undergo routine culture and antibiotic susceptibility testing (
Diagram of AMR surveillance data flow within the Ethiopia National Antimicrobial Resistance Surveillance System.
Implementation and roll-out of AMR surveillance has started according to plan. After the fourth month of implementation, an early evaluation was conducted with support from CDC subject matter experts. The evaluation identified a number of challenges that EPHI is now taking strides to address. A primary challenge has been the integration of electronic data capture for AMR surveillance into the normal work and laboratory processes at the sentinel surveillance sites. One reason for this is that none of the sites has an established electronic laboratory information management system in use for microbiology and thus staff are not accustomed to inputting data electronically as a regular activity. As an effect of incorporating electronic entry of AMR results into their normal workflow, microbiology staff at some of the sites have reported slower turnaround times for getting laboratory results back to the ordering physicians. Frequent microbiology staff turnover at the sites has also made electronic data entry challenging, as fewer staff are available to run culture and input data.
Laboratory capacity building through on-site mentorship at the surveillance sites and provision of necessary supplies has proved a useful method for ensuring sites are producing quality data. The use of focal persons from EPHI in monitoring progress at each surveillance site has been crucial for identifying problems and supply needs, and for facilitating corrective action on laboratory practices and data reporting. Prior to the evaluation, focal persons from EPHI were visiting sites irregularly and thus creating gaps in communication. Communication between the EPHI focal persons and surveillance sites has since been improved by establishing weekly calls and arranging monthly site visits for the focal persons at EPHI to work on capacity building and quality improvement activities.
Local procurement of quality microbiology supplies is a challenge in Ethiopia. In the meantime, ASM purchased the needed AMR supplies for EPHI and the sentinel surveillance sites. For long-term sustainability, EPHI has begun working with the Pharmaceutical Fund and Supplies Agency, Ethiopia’s central procurement agency, to ensure adequate, quality supplies are available in future.
Ethiopia has committed to join global partners in the detection and prevention of AMR. In a region where AMR data is under-represented and often lacking, Ethiopia has made great strides in the establishment its National Antimicrobial Resistance Surveillance System to properly understand and address the prevailing problem in the country.
The authors would like to acknowledge the United States Centers for Disease Control and Prevention, Atlanta for technical and financial support. We would also like to thank the American Society for Microbiology for technical support.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
The surveillance was funded by the United States Centers for Disease Control and Prevention, Atlanta.
R.A.I. was the surveillance coordinator. A.M.T., S.F.D. and N.A.A. made conceptual contributions and participated in the write-up. A.A.N. contributed to the write-up. F.G.D. made conceptual contributions. E.T.S. contributed to the write-up and revision. A.W.G. made conceptual contributions and W.M.K. contributed to the write-up.