August 24, 2011
South Africa is a country of stark contrasts. It’s middle-income, with high health expenditures, but its health statistics are often grim. Life expectancy is low (53/55 (male/female)), while child mortality is high (104 deaths per 1,000 live births). The country also faces a quadruple burden of disease, with HIV/AIDS, other infectious diseases, injuries, and non-communicable diseases. It has the highest number of HIV-infected people in the world, with an estimated 5.6 of its 50 million people living with the disease (2009).
The issue of antibiotic resistance understandably usually takes a back seat to other major health challenges in the country, but the burden of bacterial infections is substantial and intensified by the prevalence of HIV. The Global Antibiotic Resistance Partnership recently wrapped up its Situation Analysis: Antibiotic Use and Resistance in South Africa report, published in conjunction with the South African Medical Journal. Here are a few of the key findings and recommendations:
Resistance in context
With striking economic inequalities, South Africa represents a paradox of antibiotic management that we’ve seen in other developing countries the simultaneous presence of both overuse and underuse (resulting from lack of access) of antibiotics. Antibiotic resistance exacerbates the problem of access: the more expensive second-line treatments are even more unaffordable to the poorest in the population.
A full breakdown of resistant pathogens in South Africa, based on the information available, can be found in Part 4 of the report. But it’s worth mentioning the particular concern in South Africa regarding resistance to treatment for STIs, especially Neisseria gonorrhoeae. Gonorrhea rates in South Africa are among the highest in the world, and these infections are linked with HIV, as the presence of gonorrhea increases the risk of contracting HIV.
Revised treatment guidelines in 2008 were designed to account for high rates of quinolone-resistant N. gonorrheae, found in 42% of samples from Durban in 2005. But, the recent global emergence of cephalosporin-resistant, and multi-drug resistant, strains of gonorrhea is cause for concern in South Africa. To date, there is no sign of cephalosporin resistance in the country.
Surveillance systems for bacterial infections
Surveillance is a critical component of successful antimicrobial resistance (AMR) interventions knowing the scope of the problem is essential to tackle it. The foundation for surveillance in the South African context is substantial the National Antibiotic Surveillance Forum (now the South African Society for Clinical Microbiology), the Group for Enteric, Respiratory, and Meningeal disease surveillance (GERMS), and their partners perform surveillance that is nationwide, long-term, and focused on clinically relevant pathogens and antibiotics.
But there are gaps. As surveillance is laboratory-based, it’s not possible to correlate resistant pathogens with clinical outcomes. Measurement of resistance in the community is virtually nonexistent. Collection practices aren’t uniform and there are concerns about comprehensiveness, as participation is voluntary and limited to large university health centers.
Still, surveillance of AMR in South Africa is the best on the continent.
Interventions for the South African Context
GARP’s mandate is to propose actionable policy solutions that fit within a local context. Interventions range from creating a more accurate picture of antibiotic resistance in the country to limiting spread of resistant infections through vaccination and infection control practices in hospitals.
As mentioned, South Africa has a valuable start on surveillance, but gaps must be addressed. Additionally, data from this surveillance must be translated into the already existing mechanisms for regulating medicines, including the Essential Drugs List (EDL) and Standard Treatment Guidelines (STGs). There has been little research to evaluate the impact of the EDL and STGs thus far.
Increasing vaccine coverage is another area deserving attention. The South African Expanded Programme on Immunization introduced vaccines for six major diseases in 1995, and since then has grown to include others such as Hepatitis B and the pneumococcal vaccine (PCV-7). Vaccines not only reduce disease incidence, they also cut down on the demand for antimicrobial therapy, limiting the selection pressure on drugs and curtailing resistance. Vaccines are a best buy investment, even though South Africa is not a GAVI-sponsored country.
Finally, data suggests that infection control programs in South Africa are understaffed and overburdened. Expanded IPC specialist coverage in the public healthcare sector, which serves 85% of the population, should be a priority. This intervention will likely be hindered by severe human resources challenges facing South Africa, where physicians and nurses are .77 and 4.08 per 1,000 population, respectively (compare to 2.3 and 12.12 per 1,000 in the UK).
Read the full report here, or on the SAMJ website. Its findings will be discussed in detail at the 1st Global Forum on Bacterial Infections.
image credit: iStock photo
