Global perspective

My name is Dr. Lillian Musila, a principal scientist at the Kenya Medical Research Institute. I’m privileged today to interview Professor Samuel Kariuki, a renowned scientist in AMR in Kenya. You’ve had a very long career in AMR in Kenya. Can you briefly introduce yourself and the work that you have done and what you’re currently doing in the field of AMR today? Hi. My name is Professor Sam Kariuki. I’m currently director of research and development at the Kenya Medical Research Institute. But apart from the work on administration, I am very, very pertinent about research on antimicrobial resistance in Kenya and the region.

And to a large extent, my major works have been in the area of enterics, but also trying to understand in general the epidemiology of AMR and how we can utilise our resources, our knowledge to control antimicrobial resistance in Kenya and the region. I think to a large extent, our major problems with AMR in Kenya, as in any other low and middle-income country facing the same problems is one, of course, one of awareness, where really the general population may not be aware about the extent to which antimicrobial resistance affects them on a daily basis. Secondly, I think there is a big, big issue with aspects of enforcement of already existing legislation.

We know, for instance, that buying antibiotics over the counter without prescription is illegal. We have laws against that, and we are not able to effectively carry out our mandates to enforce them. So there’s a lot of misuse and abuse of antibiotics in that context. The other issue, of course, that we are facing today is the fact that we don’t have enough data sometimes to convince policy makers regarding the big issue of antimicrobial resistance. For instance, we really don’t have data in some of the places that antibiotic resistance poses the gravest danger. Hospital or health care-associated infections, for example, we have patchy data here and there out of sentinel surveillance.

But we don’t have a national surveillance programme that consistently collects data to the point that it can be useful for policy change. So we have a number of gaps that we must be able to fill to be able to effectively advise governments on why antimicrobial resistance is such a big issue. Usage is also another area. We know farmers use a lot of antibiotics. But to what extent do they use antibiotics for, say, prophylaxis or for treatment. Those are things we need to document properly. We have some little data, but not enough sometimes to convince a policymaker to change things. But I’m glad that a few things are happening which may address some of these shortcomings.

Do you want to speak about some of those developments? Some of these developments include, for example, in the last three years, our government, through the Ministry of Livestock, Agriculture, and Fisheries now effectively have outlawed addition of antimicrobials to food for animal feeds. That means, of course, it’s illegal now to add antibiotics to animal feeds, which then actually closes a big gap where we used to use a lot of antibiotics feeding animals. And that, as you know, because we are dealing with a One Health issue, would effectively affect human health. The other one, of course, is the fact that Kenya as a government has adopted the National Action Plan that emanated from the Global Action Plan.

And if we’re able to fully implement the five major objectives of the National Action Plan, then definitely we’ll be able to tackle antimicrobial resistance. And that’s where we need to start and provide all our efforts towards accomplishment of those five objectives of the National Action Plan. Prof, it’s interesting what you’ve said. What are the particular challenges that you face in relation to tackling AMR in Kenya? I think in Africa and Kenya very specifically, we’re facing challenges in both animal health and human health, and also in development.

I mean, in the One Health project where we really are not coordinating with each other because I may be in my own silo doing a little work on human health and documenting work that is ongoing, maybe in issues to do with the health care-associated infections, of surveillance or community-acquired infections. But how about industry? How about pharmaceutical industry? How about the livestock industry and other industries that directly contribute to antimicrobial resistance in their involvement, in animal husbandry? We really need to work as a team, and that’s synergy. At the moment, it’s not well defined. I think secondly, we need to put our money where our mouth is.

As government, if you are very, very concerned that antimicrobial resistance will cost so many lives in 10, 20 years, if we don’t tackle it, then we need to put money in that aspect to be able to tackle that. Lastly, I think it is very, very crucial that we raise awareness among all stakeholders. It’s not enough to do just one week of awareness during the annual World Antibiotic Awareness Week. We need to do this consistently. And we must do it at all different levels. We start right from the level of young children, going to primary school, secondary school, universities, and professionals, so that everybody has a message or gets a message about antimicrobial resistance.

It’s dangerous and what we need to do at all different levels to be able to tackle that problem. And I believe each of us has a stick and something we can do to be able to combat and contain antimicrobial resistance. How is your research helping us understand these problems better? My own research really concerns understanding the epidemiology of antimicrobial resistance at different interfaces. Be it human health or animal health, and particularly, of course, utilising technology, such as whole genome sequencing, viral genetics, and informatics to be able to explain how resistance emerges, how resistance is transmitted, either between humans and humans, or between humans and livestock and so forth.

And how we can utilise our technologies to be able to interrupt this transmission. That’s very, very crucial. Because if we have those tools and we have that information, we can be able to persuade policymakers and public health that if we intervene in this way, we can be able to interrupt transmission of antimicrobial resistance. So I worked on various pathogens, including Salmonella, E. coli, cholera, and so forth. And what we have found out is that in certain instances, the persistence of antimicrobial resistance in their environment is usually to do with overuse or abuse of antibiotics in certain communities. And we have shown that. You’ll find that in cities, there is more antimicrobial resistance compared to some of the rural sites.

Why is that? It’s because there is more access in the cities and urban areas compared to elsewhere. So if you can be able to tackle some of these issues using the data that we already have, then we have made some headway. Given the complexity of this AMR problem, if you were omnipotent for a day, you could wave your hand and do anything, what would you do for a start? Yes, I think it’s a very difficult question to be able to put into just one sentence. Because if you recall, the National Action Plan has five key objectives. And all these objectives have to run with each other. None of them is more important than the other.

Because they all are tackling a singular problem that is of major public health importance. And that is combating and trying to prevent antimicrobial resistance. But from my own side point of view, I would say that we need more funding for research and development because we want to understand certain aspects of why there is, for example, human behaviour of people wanting to buy antibiotics over the counter without prescription, using antibiotics that you are buying over the counter to add to a feed for animals, and so forth. I want to know, why do people behave this way? And that kind of study needs to have been done yesterday.

In addition, I think we need to develop new technologies to be able to perform surveillance faster and to gather data much faster on usage in both humans and also in livestock as well. Because this is the kind of data that we require to compel policy makers that we need change, that we need to move from data to action. So without data, they will say, well, we can’t act. And in addition, of course, there are a lot of gaps. There are a lot of gaps in this country that require research and development efforts. Including, for example, how much is used in as far as antibiotics are concerned. We only have a small snippet of what happens.

But then we need data on how much is used in hospitals, in the community, and for what purpose, and how much is misused in livestock or not, and so forth, how much is imported and for what. That level of understanding provides us with data for our government to know that we are probably importing more than we require and probably need to look at the way we distribute our pharmaceuticals. Too much is going in this way, whereas it’s not useful that way. And that kind of data can only be generated through research and development. How do you think that these problems we face in Kenya fits into the international picture? Are there lessons that other countries can learn from us?

I think we can learn from each other. One thing we can do, for example, is I’ll give one example. We have very low levels of MRSA, Methicillin-Resistant Staphylococcus aureus. And there’s a good reason for that. It’s simply because we haven’t probably misused antibiotics for treatment of staphylococcal infections to the extent that other countries in the developing world have done. That we can say, yes, it may have been a coincidence. But we can learn from some of the findings that we have that doing certain things is wrong because of what we’re seeing currently. What approach do you think would yield the best and earliest rewards in tackling AMR in Kenya?

I think, to me, I look at tackling antimicrobial resistance as saving humankind. If you are able to implement the National Action Plan as a team, the five major objectives, and we get our act together to reduce the burden of antimicrobial resistance even by half, I’m sure the quality of life will rise more than 50%. I am sure the standard of living will equally rise. And I’m equally sure that the survival of, say, for example, newborn children will be much, much higher. Because we lose a lot of people due to infections that cannot be treated properly. We lose a lot of people.

We lose a lot of animals because they are wrongly diagnosed for the wrong things, and then the treatment is not appropriate. I think by and large, if we are able to talk about the issue of antimicrobial resistance in Africa, our standards of living will be much, much higher than they are now. And definitely, we will have saved so much money that will go into developing new antimicrobials. And that can be used elsewhere in the economy. I think one thing I would want to add is the fact that in raising awareness, we need to build more capacity in our institutions on antimicrobial resistance.

And of course, these advanced courses are one way of providing capacity for laboratories, both in human health and also in animal health, to be able to perform quality antimicrobial resistance surveillance, as well as genomics to really be able to inform policy on what’s happening on the ground. I think that we will be able to raise a huge number of people in Africa that are able to, qualitatively and in a quality assured manner, provide detail that is compelling enough for policymakers to take it seriously.