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PROCEEDINGS

02.06.2020 – 30.06.2020 www.fao.org/fsnforum/activities/discussions/AMR

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Improving communications for Antimicrobial Resistance (AMR) in Africa. How should we move forward?PROCEEDINGS

Improving communications for Antimicrobial Resistance (AMR) in Africa. How should we move forward?

Collection of contributions received

Table of Contents

Topic note4

Contributions received6

1.. Chioma Achi, University of Cambridge, United Kingdom6

2.Irene Ouoba, FAO-RAF, Ghana7


4.James Sakala Siamate, Ministry of Fisheries and Livestock, Zambia8

5.Dolo Yaya, Mali8

6.Chioma Achi, University of Cambridge, United Kingdom9


8.James Sakala Siamate, Ministry of Fisheries and Livestock, Zambia11

9.Samira Sarter, CIRAD, France12

10.Malik Olatunde Oduoye. Antimicrobial Stewardship, Optimum Access and Use in Uganda, Nigeria12

11.Japhta Mokoele, University of Pretoria, South Africa14

12.Abdulkareem Zainab, Federal Ministry of Agriculture and Rural Development, Department of Veterinary and Pest Control Services, Nigeria14

13.Akinlabi Ogunleye, University of Ibadan, Nigeria15

14.Temitope Alao-Sanni, RD, Diet Tech Africa, Nigeria16


16.Manuel Moya, International Pediatric Association. TAG on Nutrition, Spain17


18.Eliza Smith, Kyeema Foudation, Australia18

19.Lal Manavado, Independent analyst/synthesist, Norway18

20.Abiodun E, Nigeria CDC, Nigeria26

21.Adebayo Depo, Togo27

22.Ramatou Moumouni, Ministère de l’agriculture et de l’élevage, Niger29


24.Mabel Aworh-Ajumobi, Federal Ministry of Agriculture and Rural Development, Nigeria31

25.Dooshima Kwange, Tesedona Foundation for Animal Health, Nigeria31

26.Fernand Boumbandjoka Makandjoka, FAO, Gabon32

27.Saad Uakkas, International Federation of Medical Students' Associations IFMSA, Morocco35

28.Scott Newman, FAO, Ghana and facilitator of the online discussion36

29.Kingsley Pereko, University of Cape Coast, Ghana36

30.Lal Manavado, Norway37

31.Michel Sagno, Ministry of Health, Guinea39

32.Yesutor Soku, Ghana43

33.Ernest Molua, Centre for Independent Development Research, Cameroon45

34.Huda Tawir, United States of America45

35.Diana Gahn-Smith, Ministry of Health, Antimicrobial Unit, Liberia46

36.Yinka Somorin, Queen's University Belfast, United Kingdom47

37.Ibrahima Kouma, Service de Contrôle Vétérinaire et de l’Hygiène Alimentaire de Satama-Sokoro, Côte d'Ivoire48

Topic note

Antimicrobial agents, including antibiotics, have saved millions of lives, substantially reduced the burden of diseases in people and animals, improved quality of life, contributed to improved food production and safety, and helped increase life expectancy.

However, the emergence and spread of antimicrobial resistance (AMR) is complicating the management of many infectious diseases. AMR is a major threat to development and the fight against infectious diseases. It endangers animal health and welfare, as well as food production. AMR also adversely affects the functioning of human, animal and plant health systems and economies.

What is Antimicrobial Resistance (AMR)?

AMR happens when microorganisms such as bacteria, fungi, viruses, and parasites change and become resistant to antimicrobial drugs, including antibiotics, to which they were originally susceptible to. This can be due to different factors such as the misuse or overuse of antimicrobials and exposure to counterfeit drugs. Moreover, when antimicrobials are present in the environment at low concentrations, they can accumulate in human populations via long-term exposure to drinking water, food, or consumer goods with unknown health consequences.

The on-going cycle of antibiotic resistance spread between humans, animals and the environment. Source: Centers for Disease Control and Prevention (CDC). 2013. Antibiotic resistance threats in the United States, 2013. Atlanta, USA. Available at: www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf

The sheer magnitude and complexity of the AMR crisis and antimicrobial pollution results in the need for a coordinated and integrated One Health multi-sectoral approach inclusive of the public & animal health sectors, the agricultural production sectors (crops, forestry, fisheries, aquaculture & livestock), and the environment & ecosystem sectors.

At the African regional level, the Tripartite members (Food and Agriculture Organization of the United Nations - FAO, World Organisation for Animal Health - OIE, and World Health Organization - WHO), and the African Union (African Centre for Disease Control and Prevention – Africa CDC, African Union Inter-African Bureau for Animal Resources - AU-IBAR) and Regional Economic Communities (RECs) are working closely to combat AMR in a holistic continental One Health approach.

Communicating AMR in Africa

As Africa accelerates its AMR interventions, communication has been a key priority in the agenda. The first regional World Antibiotic Awareness Week 2019 was held in Kenya, bringing all the regional AMR stakeholders together in Nairobi creating dialogue from grass-root to policy levels.

In order to better communicate the risks of excessive or inappropriate use of antimicrobials and the importance of proactive participation from all levels of stakeholders, FAO Africa is pleased to welcome you to participate in this online forum to exchange ideas and discuss how to improve AMR communications in the region. Please find the following questions for your consideration and we look forward to receiving your inputs, suggestions and ideas.

1. What is the biggest communication challenge related to AMR and inappropriate antimicrobial usage (AMU) in Africa?

2. What is the best approach to communicate about other antimicrobials (antifungal, antiparasitic, antiviral, pesticides), and not only antibiotics? As viruses, fungi and parasites can also be resistant to medicines commonly used to treat them, and impacting health and food systems, how do we communicate about these issues in addition to antibiotic resistant bacteria?

3. How can we get the topic of AMR included more often in the media? How do we ensure the visibility of AMR amongst other “hot topics”?

4. What communication channels, methods or mechanisms are more suitable and will have the greatest impact at field level in African countries?

5. Which group of stakeholders do you think should be considered as priority for targeted key messages aiming at raising awareness on excessive AMU and AMR?

6. At national, regional and continental levels, who to do think should take leadership and responsibility for awareness and advocacy activities on AMU and AMR

Outcomes of this discussion will help provide insights to the Africa AMR Communications and Advocacy Strategy that is currently under development by the Regional Tripartite (FAO, OIE, WHO) and the African Union (Africa CDC and AU-IBAR).

We thank you for your valuable contributions and we look forward to incorporating your voices into the regional AMR communication strategy.

Scott Newman

Senior Animal Health and Production Officer and

FAO Secretariat to the Africa Tripartite One Health Regional Coordination Group

FAO Regional Office for Africa

Contributions received

. Chioma Achi, University of Cambridge, United Kingdom

I am pleased to be part of this forum and I look forward to discussing with you all and learning from your contributions. It is my first time here, so pardon me if I do not exactly follow the format, I will learn as time progresses.

Early this year, we organized a public engagement program with farmers in Nigeria and we had some good interaction. We conducted one-on-one interviews with farmers upon arrival. This was to enable us to gauge prior knowledge of AMR. About half of the farmers that attended the program said they had not heard about antimicrobial resistance while some who had previously heard of the term AMR but did not completely get the message. My take on the questions raised for this discussion are:

1. The message on AMR is often presented as an abstract term and gives the impression of an impending threat (e.g. 10 million people will die by the year 2050 from AMR infections).

There is a need to make communications on AMR relatable to the “ordinary person” in order to drive the message home and make it easier to understand. The threat of AMR needs to be strongly emphasized and communicated as a problem that is already with us.

In our previous programs, we noticed more engagement when real-life experiences of the impact that AMR has on human health, livestock productivity, and food safety were shared. We also noticed increased interest when we analyzed the economic cost of using antimicrobials versus increased productivity in relation to prevention strategies of infections, improved biosecurity measures, and sanitation. Farmers want to hear how they can save costs whilst improving productivity.

Key stakeholders in the fight against AMR such as farmers who directly use antimicrobials are somewhat ignored in communications regarding AMR and inappropriate AMU in Africa. It is not enough to place posters in strategic places and share pamphlets on AMR without appropriate engagement. We do not need to assume that people will assume what the posters say. Often times, passing a message on behavioral change does not directly translate to change in behavior. Other strategies like active engagement need to be put in place to enable people to understand the meaning behind the message.

3. To get AMR into the news and list of hot topics, countries need to invest in recording and communicating the number of lives lost per year due to AMR, quantifying AMR in terms of economic losses and magnitude of the threat. Proactive key stakeholders involvement is important and it might be needful to have in-country ambassadors for AMR, these could be highly respected people in the society who will be committed to this cause.

4. Properly coordinated, clear and concise messages on AMR in various dialects can be passed through local radio and television networks as well as national stations. Grassroot engagements often in collaboration with various associations could also be useful. Disseminating this information across board will also prompt consumer awareness in demanding for antimicrobial-free (organic) products.

5. Farmers are critical stakeholders and should be given priority. They do need to understand the need for responsible AMU if there has to be behavior change in terms of administering antimicrobials only when needed, not putting pressure on Veterinarians or extension workers for antimicrobials, and taking ownership to ensure the health of the nation in terms of food safety. There is a need to also involve Veterinarians, Lab diagnosticians, government bodies and the media.

6. The National Communication Commissions, National CDCs, various ministries of Health, Agriculture, and Animal Health should be involved at national level while the African Union, African CDC, AU-IBAR need to take a strong stand in leading continental advocacy activities and awareness on AMR and AMU. FAO and WHO regional offices are already doing excellent work in this area and should continue with this.

Irene Ouoba, FAO-RAF, Ghana

Good morning to everyone and thanks to Chioma for the very elaborated and valuable contribution.

1. One challenge is the difficulty to translate technical words into simple statements that can be understood easily by people especially those who have "little" academic education. Explaining what a drug is, is easy, but explaining what a microorganism (microbe) or multi-resistant bacteria or superbug is, in a local language can be challenging. In this case, trying to differentiate technically between the different types of microorganisms (bacteria, viruses, etc.) would not be useful. One solution could be to discuss with local/ traditional therapist/healers to find adequate words to qualify disease-causing agents.

2. Keep the messages simple and just refer to ANTIMICROBIAL resistance. Most people including highly educated people but not in the field of e.g. microbiology, medicine (Vet, human, plant), public health, etc. do not differentiate between types of microorganisms and I doubt are interested in making a difference. When talking about ANTIBIOTICS, most people include everything. This is not appropriate indeed, but they cannot be not blamed if there are not in the field. Thus, an emphasis should be put on using consistently ANTIMICROBIAL and AMR as opposed to ANTIBIOTICS and ABR.

For the general public, one approach is to explain by difference in types of diseases that require different types of drugs for treatment. Also, emphasize that a drug for a specific disease may not be efficient in curing another type of disease because the causing agent is different, thus people should seek medical advice and not self-medicate.

For technical people, research, and academia, technical words for the different types of microorganisms should be used and awareness/ advocacy campaigns should be technical.

5. Adding on to what Chioma mentioned, feed producers should also be also priority targets as many feed


2. Elaborating further what I mentioned in my previous post on the issue raised in question 2, the use of the word ANTIMICROBIAL should be consistent especially for big AMR campaigns. For example it is more appropriate to refer to WAAW as World ANTIMICROBIAL Awareness Week than World ANTIBIOTIC Awareness Week. People will gradually get used to it.

Thanks

James Sakala Siamate, Ministry of Fisheries and Livestock, Zambia

Hello colleagues,

The biggest challenge related to AMR & inappropriate AMU in Africa is; in my own opinion countries in Africa share almost same style of practicing farming especially the small scale farmers market,

The technocrats usually are not there to communicate to communities that ate in the farming groups so as to sensitize on the correct use of antibiotics instead untrained personnel are employed to serve the community on the use of antibiotics they don't advise on the proper usage of the drugs.

The other challenge is that most products are in languages that the locals may not be able to understand they will use it indiscriminately like the way oxytetracyclin is being used no one take time to go and monitor its use.

The other challenge antibiotics are sold on counter without prescription hence no professional takes it up to educate on the abuse of antibiotics.

Communication challenge in AMR & AMU in Africa is that since the marketing democracy every person understands the use of antibiotics in his or her own way. It has become difficult to communicate to the society on the prudence use of antibiotics.

Since this has a long term effect on human health, animal health as well as plant health people tend to ignore advises rendered on the danger of abuse of antibiotics.

Therefore one health approach needs to be adopted to overcome this communication challenge on AMR & AMU.

Regards

Dolo Yaya, Mali

Original contribution in French

Bonjour,

La problématique de la résistance aux antibiotiques occupe de plus en plus nos pensées compte tenu de la position assez préoccupante de la question dans nos pays africains.

Pour trouver un début de solution à ce problème, les efforts doivent être faits à plusieurs niveaux :

- strict respect des textes sur la commercialisation des médicaments vétérinaires.

Dans la plupart des pays africains, la vente du médicament n'est pas soumise à la présentation d'une ordonnance vétérinaire. Donc, la vente est libre.

Les états doivent appliquer les textes afin de permettre aux seuls professionnels de s'approvisionner auprès des structures de vente

- améliorer le niveau de formation et d'information des vétérinaires sur la question de la résistance aux antibiotiques.

Beaucoup de vétérinaires sur le terrain n'ont pas toutes les informations sur la question et cela constitue une grande insuffisance.

- renforcer les services chargés du contrôle des denrées alimentaires : agences nationales de sécurité sanitaire des aliments ,etc ..

- sensibilisation des éleveurs sur les méfaits de cette résistance.

En Afrique, il n'y a pas que la résistance aux antibiotiques. Il y'a de plus en plus une résistance aux acaricides qui se développe, surtout à l' amitraz.

Meilleures salutations

Dr Dolo Yaya

Vétérinaire privé

Bamako, Mali

English translation

Hello,

The issue of antibiotic resistance is occupying our thoughts more and more given the rather worrying state of the issue in our African countries.

To find the beginning of a solution to this problem, efforts must be made on several levels:

- strict compliance with the legislation on the marketing of veterinary medicinal products.

In most African countries, the sale of the drug is not subject to the presentation of a veterinary prescription. So the sale is free.

States must apply the rules in order to allow only professionals to obtain supplies from sales structures

- improve the level of training and information for veterinarians on the issue of antibiotic resistance.

Many veterinarians in the field do not have all the information on the matter and this is a big shortcoming.

- strengthen the services responsible for controlling foodstuffs: national food safety agencies, etc.

- raising farmers' awareness of the harmful effects of this resistance.

In Africa, it's not just antibiotic resistance. There is more and more resistance to acaricides which is developing, especially to Amitraz.

Best regards

Dr Dolo Yaya

Private veterinarian

Bamako, Mali

Chioma Achi, University of Cambridge, United Kingdom

Thanks, Irene and James.

With regards to the best approach of communicating resistance in other microbes, I do agree that the collective term "antimicrobials" should be used in all campaigns. The emphasis has always been on antibiotics and bacteria and not much on the other bugs (except for scientists and researchers who are working specifically in these areas). The message should be clear that any medicine that is used for whatever type of infection or disease should be used only when absolutely needed in order to prevent bacteria from developing resistance to them.

One thing I also found interesting from my engagement with farmers is the use of the "cocktail" of drugs. Here, you have a sachet of medicine labeled "anti-stressor" or "multivitamin" but which in actual fact has a certain amount of antimicrobials incorporated into it. Some farmers would innocently use these without knowing the full content. The cocktails are often administered as growth promoters hence exposing bacteria to minute amounts of the antimicrobials that lead to resistance.

As Irene said, feed producers should be included in the list of priority stakeholders. I do understand that in a bid to compete for the market, producers are somewhat under pressure to ensure that farmers get optimum productivity when they use their products and hence might be compelled to incorporate certain levels of antimicrobials in the feeds. This again is the reason we need serious engagement. The people need to understand the consequences of their actions and take responsibility for propagating and doing right when it comes to AMR stewardship.

The message should also be very clear on AMU, "the intent is not to stop complete use of antimicrobials because they are essential and do save lives but to use them only when absolutely necessary so we do not run out of them".

Even though we need technocrats and people in other sectors to pass on the right message, from my experience of working with farmers, they are more likely to do the right thing when they understand the implications of their actions and when you present to them alternatives. For instance, if you say they shouldn't use antimicrobials, then one must be willing to invest in training them on good biosecurity and husbandry measures and other prevention strategies. As long as this new alternative results in increased profit, less cost and improved productivity, they will most likely go with it.



Merci Dr Dolo.

Absolument, que cela soit en Afrique ou ailleurs, il n'y a pas que la résistance aux antibiotiques, mais aussi à d'autres antimicrobiens.

C’est la raison pour laquelle la 2 question du Forum est comment mettre aussi en exergue les autres types de résistance. Et j’ai répondu en anglais disant qu'il est très important maintenant de parler d'antimicrobiens et résistance aux antimicrobiens que de mettre souvent en exergue la résistance aux antibiotiques. Si l’on veut même considérer la définition originale d'un antibiotique (produit à partir d’un microorganisme contre un autre microorganisme, ex: la pénicilline), beaucoup de molécules considérer ajourd'hui comme antibiotiques parce qu’utiliser pour traiter des infections bactériennes ne sont pas vraiment des antibiotiques mais des antimicrobiens car synthétiques ou semi-synthétiques. Sans oublier qu'un petit nombre d’antibiotiques est efficaces contre certains parasites microscopiques. Donc il est plus nécessaire de vraiment de parler d'antimicrobiens, surtout dans les campagnes de sensibilisation générales. Maintenant, pour la sensibilisation de personnels techniques et d’experts dans le domaine de la santé, la recherche scientifique et l’éducation, on peut faire la différentiation claire avec les termes techniques.

English translation

Thank you Dr Dolo.

Absolutely, whether in Africa or elsewhere, there is not only resistance to antibiotics, but also to other antimicrobials.

This is the reason why the 2nd question of the Forum is how to also highlight other types of resistance. And I replied in English saying that it is very important now to talk about antimicrobials and antimicrobial resistance rather than to only highlight antibiotic resistance. If we even want to consider the original definition of an antibiotic (produced from a microorganism against another microorganism, ex: penicillin), many molecules considered today as antibiotics because they are used to treat infections bacteria, are not really antibiotics but synthetic or semi-synthetic antimicrobials. Not to mention that a small number of antibiotics are effective against certain microscopic parasites. So, there is more need to really talk about antimicrobials, especially in general awareness campaigns. Now, for the sensitization of technical personnel and experts in the field of health, scientific research and education, we can make a clear differentiation with the technical terms.

James Sakala Siamate, Ministry of Fisheries and Livestock, Zambia

Hello intellectuals

Good morning to you all. Allow me once more to contribute to our hot topic on AMR & AMU this has really impacted a lot of communities. The use of antibiotics has become the order of the day,use of antibiotics as growth promoters for instance in my country most people are in small scale or back yard garden poultry rearing in most antibiotics are used to survive in the day to day life through selling the chickens.

Therefore in my observation I feel the group of stake holders to be considered as a priority are small scale farmers who need to be educated on the prudent use of antibiotics. The awareness needs to to be emphasized on these group of people. The other group of stakeholders are the big farmers and some company's dealing in livestock rearing in feedlots the AMR & AMU are mostly common due to sustain their business and to meet the demand.

The other stakeholders are the consumers who need a lot of sensitization on the use of antibiotics by the farmers they buy livestock and livestock products. There is need to air programs on dangers of AMR & AMU on local radio stations to run a program that will raise awareness on this topic then we will win the battle.

The academia also needs to be targeted to raise awareness, in primary schools and secondary schools the message needs to be communicated to so as to create awareness to pupils who will eventually educate others on the same, we the food safety people we need to go round the farms and monitor the use of antibiotics on the animal and environment, since this is the source of these antibiotics use.

Booklets or small pamphlets can be printed in all local language's so as to raise awareness. Also holding of public symposiums to engage the community to participate and asses their level of understanding on AMR & AMU then will be able to asses how much knowledge is on the same topic.

For now let me end here.

Kind regards

James

Samira Sarter, CIRAD, France

Dear colleagues,

I propose that institutions update a new chart related to the "on-going cycle of AMR spread between human, animals and the envrionnement" mentioned on this page by adding the fish, as aquaculture contributes to the pool of genes of resistance shared with the others activities. it is important for raising awarness regarding AMR in aquaculture as well.

Please find here an article : https://doi.org/10.1038/s41467-020-15735-6

Kind regards

Samira Sarter

Malik Olatunde Oduoye. Antimicrobial Stewardship, Optimum Access and Use in Uganda, Nigeria

Overview

First of all, I will like to commend the efforts of the Tripartite members responsible for AMR control in African Region, including the African Union (African Centre for Disease Control and Prevention – Africa CDC, African Union Inter-African Bureau for Animal Resources - AU-IBAR) and Regional Economic Communities (RECs) for their collaborative efforts towards the combat against Antimicrobial Resistance in African communities in a holistic continental One Health approach.

Talking about Antimicrobial Resistance (AMR) and inappropriate Antimicrobial Usage (AMU) in Africa, I think the biggest communication challenge poor individual understanding of antimicrobial usage at the grass-roots. Most individuals do not have the forehand knowledge of antimicrobial usage.

Hence, tackling antimicrobial resistance in African communities requires multi-sectoral approach and strategic measures. To achieve maximal, improve in communication for AMR, below are my views and opinions.

Firstly, I think the best approach to communicate about other antimicrobials in addition to antibiotic resistant bacteria is through a very strong Advocacy and Campaigns about these antimicrobial agents through reaching out to:

Each household in the African Communities, by communicating with them about the dangers of AMR in their local languages. Through this, there will be proper understanding about AMU and AMR. As we all know that ‘Charity begins at home’

The community and Religious leaders in all African Communities. I believe these set of human beings can also talk and preach to the community members about AMU and AMR especially during community meetings and religious gatherings. Africans listen well to their community leaders and Religious Leader.

Among the African Schools, that is, elementary, basic, high, and tertiary institutions. AMU and AMR should be included in the academic curriculum. Also, seminars on AMU and AMR should be held at regular intervals for the student s and also the teachers. This will give more room for better understanding about antimicrobials.

Government and Non-Governmental agencies in all African States. These are key bodies in policy and advocacy making. I believe they can regulate the dispensing of antimicrobials in all the African States, towns and Villages across the various health care facilities and inter-professionals that is, the physicians, pharmacists, veterinary doctors, agriculturists, nurses etc. Also, these policy makers should give a strict law on irrational dispensing of antimicrobials by all the aforementioned health care professionals and placing punishments on whoever break the law. Also, use of Over The Counter Drugs (OTCs) should be minimized.

Still on the government and non-governmental bodies. The Tripartite members responsible for AMR control in African Region should advocate for more sophisticated and modernized and a well-organized, equipped health care centers to be constructed in all African communities with more health care workers. This will increase the willingness of a common and average man to seek appropriate health care, with optimal health care access and will also reduce the abuse of drugs especially antimicrobials.

Inter-professional health organizations and collaborations should be encouraged among all African States in order to achieve ONE HEALTH approach in solving AMR. It is sad and obvious that most African Health Organizations do not practice proper and organized Inter-professional health care especially in the management of patients.

Strong considerations of Animal Health. Majority of African States, for example, Nigeria, do not really much efforts and priorities in good and proper care of the Animals. Most Animals are left untreated each time they are infected with a disease, and by so doing, human beings could be infected, and prompting him or her to the abuse of antimicrobials.

In addition to my first answers, the ways I think we could get the topic of AMR included more often in the media with more visibility of AMR amongst other “hot topics” include the following:

Creating an accessible social media application for all the African Community members. For example, “AMR- APP FOR ALL”. This this social media can be installed on our phones, laptops. Making AMR and AMU discussions to be easily taught among the African

All African Health Students should also be incorporative in the media strategic measures and campaigns for AMR amongst other “hot topics”. They will also benefit from the Media APP also.

However, more suitable communication channels, methods and mechanisms that I think will have the greatest impact at the field in African Communities include:

Religion Channels

Youth Organizations and Forums

Family meetings and discussions

Social Media Networks especially WhatsApp, Facebook, Instagram, and twitter.

Note: All kind of method, ideas, mechanisms should also be interpreted to most common African languages e.g. Swahili, French, Hausa, Yoruba, Igbo, etc. As this will improve proper and better communication for AMR.

Speaking about the group of Stakeholders to be considered as the priority for targeted key messages, aiming at raising awareness on excessive Antimicrobial Use (AMU) and Antimicrobial Resistance (AMR), I think it is necessary to include the community and religious leaders, primary and high school teachers, university students especially those studying health related courses, including the lecturers among the stakeholders in combating AMR. As this will go along way in reducing the excessive AMU and AMR.

As for the leadership and responsibility roles, I think the key health care professionals, that is the Medical Doctors, Pharmacists, Veterinary Physicians, including other prominent health care personnels should be appointed for the awareness and advocacy activities on AMR and AMR at national, regional and continental levels. As this create more strong and effective combat against AMR.

Japhta Mokoele, University of Pretoria, South Africa

Dear colleagues

My name is Japhta Mokoele based at the University of Pretoria, Department of Production Animal Studies.

I am involved with the survey of Antimicrobial use and resistance in the pig farms in Gauteng. what I see is that the pig farmers want to solve all the problems with drugs and that is not how it should be.

We need do more veterinary extension work to help train farmers on the role of antimicrobials and when and how they need to be used. This need to be a coordinated work for all the professions within animal agriculture.

What is the biggest communication challenge related to AMR and inappropriate antimicrobial usage (AMU) in Africa?

In South Africa, we have two acts controlling AMR, mainly Fertilizers, Farm Feeds, Agricultural Remedies and Stock Remedies Act, 1947 (Act No. 36 of 1947) controlled the Department of Agriculture and The prescription only medicines in South Africa, is controlled by a second drug control act, known as the Medicines and Related Substances Control Act, 1965 (Act No. 101 of 1965), administered by the Department of Health (DOH) i.e. the major difference between the Medicines Act and the Stock Remedies are restricted to veterinary prescription, while stock remedies are typically over-the-counter drugs.

The challenge is that most of these drugs (tetracyclines, sulphurs) are registered under act 36 and that is the challenge because this drug is sold by big cooperatives that are manned by people with less know how about the drugs.

My view is that we need to have this place employing para-vets or working with the veterinarians to assist with this important messaging on dosages, withdrawal periods and the best way of storing and usage of drugs at farm level.

Abdulkareem Zainab, Federal Ministry of Agriculture and Rural Development, Department of Veterinary and Pest Control Services, Nigeria

Good day colleagues,

The challenges of communication on AMR is not far from the issue of addressing multiple/ different stakeholder groups in the animal health sector unlike the human health sector. Here the one-cap fits-all does not work, hence the need to utilize different strategies of communication to capture different groups of stakeholders.

In communicating resistance of other antimicrobials, we can use same approach, same opportunity as communicating on antibiotics however my suggestion is to allow farmers consume messages on AMR on antibiotics before gradually introducing other antimicrobials.

Frequent engagement of media personnel (journalists), getting them to understand what AMR is, providing them with the right information on AMR will enable them amplify and pass the messages correctly. This will also enhance wider coverage of stakeholders and AMR will be a hot topic on print, electronic and social media platforms

In my opinion the best approach for reaching out to target groups is focus group discussion. That way you can pass your messages to them, get their perception and possibly opinions, faster way of getting feedback for you to possibly modify your messages or approach. It also offers opportunity for them to seek clarification to further enhance message consumption. Radio programs such as jingles and phone-in programmes on AMR is also a very good approach.

The group of stakeholders to prioritize for raising awareness on AMR and AMU in my opinion are livestock farmers, feed millers and Veterinary drug retailers because they are the greatest users of antibiotics. Feed millers use quantities of antibiotics to prevent feed contamination and for growth promotion of animals.

Thank you

Zainab Abdulkareem

Akinlabi Ogunleye, University of Ibadan, Nigeria

One of the biggest problems in the communication about AMU and AMR in Africa has to do with difficulties in using African contextualized scientific facts on the subject to successfully educate the stakeholders to the level of achieving the anticipated necessary changes towards attainment of good stewardship. A number of factors such as the level of awareness, knowledge, attitude, emotional undertone behind the current practices and behavioral tendencies associated with the subject are often undermined or sometimes ignored during the attempt to communicate to the stakeholder. One more fundamental challenge has to do with the need for consensus definitions of some important concepts and terms regarding AMR and AMU based on African realities. For example, could the term: prudent/ judicious use of a particular antibiotic mean exactly the same thing in terms of specific details as applicable for example in USA, Europe as well as in Africa? This is open to discussion in our African context. Correct answers to some of these issues will go a long way in helping us to overcome our challenges communicating about AMU and AMR in Africa.

In an attempt to communicate about other antimicrobials (antifungal, antiparasitic, antiviral and pesticide), we must take into consideration the complex nature of the subject and approach it with the application of one health concept. Necessary information about them can be communicated based on African contextualized integrated research findings, education on the subjects and extension programmes. And just as mentioned for antibacterial agents, the correct assessment of the prior knowledge, awareness, attitudes, emotional undertone that inform the stakeholders current positions must be given a priority. Connection with the targeted stakeholders this way may help them to accept the new concept and information that may result into the actualization of the desired outcome.

In order to get topics of AMR and AMU more included in the media among hot topics: we must present it to the public as a one health problem that requires multidisciplinary approach to be handled.

Every stakeholder such as Veterinarians, medical doctors, environmentalist, Agriculturist must work together as a team by honestly acknowledging the contribution from their respective sectors to AMU and AMR problems as well as their contribution to the desired solution. The general public and media will be interested in the dissemination of such information.

Communication through extension service team comprising necessary stakeholders well equipped with the required knowledge about AMU and AMR to the targeted stakeholders will be very practicable and effective in the African context.

Based on the one health nature of AMU and AMR the following stakeholders should be targeted as priority group with the key messages about raising awareness on excessive AMU and AMR:

Animal Agriculturists, Veterinarians, medical doctors, environmentalists and general public.

At the national, regional and continental levels: Veterinarians, medical doctors, relevant scientists/ researchers should take leadership and responsibilities for awareness and advocacy activities on AMU and AMR.

Temitope Alao-Sanni, RD, Diet Tech Africa, Nigeria


As it was highlighted in this article, Antibiotics have been used for healthcare purposes in Africa for years, and the efficacy is somewhat undeniable, this is where I believe the challenge lies. The biggest communicable challenge will be that people don't believe what is being communicated because they know that antibiotics indeed works for some illnesses and conditions.


For me, the best approach is to channel just as much energy into these other areas as well. Specific dates should be set out to create awareness about antifungal resistance, antiviral resistance, etc.


I would say, more people should be encouraged to tell their stories about their AMR journey so people can see practical examples.


The media. Social networks through a systematic approach. Let us engage more professionals outside of the healthcare space with discussions that center around AMR.


Healthcare workers (pertinent to one health) are a priority group, but owners of local drug stores where people are very likely to get these antibiotics from should be considered as priority too. Pharmaceutical companies responsible for the manufacturing and distribution of these drugs should also be encouraged to include a caveat on the packaging of antibiotics.


Everyone that identifies with the one health system in the country, including organizations like the food and drug administration, ministry of health etc.


We need to break the silo mentality and start to work together as a unit, therefore practicing one health system to the later. That is basically taking responsibility.

Manuel Moya, International Pediatric Association. TAG on Nutrition, Spain

This comment will be focused mainly on human antimicrobial resistance (AMR). This can be a small contribution to the general problem but as it has been deeply studied in clinical ground, some issues merit to be considered. Antibiotics have reduced mortality in LMIC, but their misuse has contributed to the present problem, clearly expressed in the Spread cycle appearing in the Topic introduction. Specific rules for antibiotics uses are beyond this comment.

One of the starting points to consider is primary care for non-severe infections such as the common upper respiratory tract infections (URTIs) and acute diarrhea especially in children and youths. Only a minority of URTIs are of bacterial origin, despite this they frequently attract antibiotic prescription which can lead to a more severe and difficult to treat situation (1). Acute diarrhea is another generalized condition that frequently still receives antibiotics despite proven inefficacy (2, 3). It is important to spread the concept that acute fever rarely requires antibiotic administration. This knowledge should be enrooted both in the population and in primary care providers. Also basic information on adequate nutrition is most likely to be the best preventive circumstance at any age but especially in the first year of life by promoting a more generalized breast feeding, it should be taken into account that bovine lactoferrin does not prevent infections in early life (4). As important as this is the hand-hygiene. Additionally, providing information about antibiotic use risks (allergies, hardly recovery of microbiota…) whenever possible would be helpful. Development of ‘Antimicrobial stewardship’ programs (5) by (human and veterinary) Health Departments could be the first step for improving the use of this important tool so easily misused.

Answers to questions:

1: To reach individuals

2: Same way as antibiotics, but explaining that presently their resistance is not so widespread.

3: -

4: Ministry of Health and specific section/ persons dealing with health care providers (Med and Vet)

5: Ex-aequo Simple legislation and Primary Care Delivering local organization.

6: Ex-aequo Ministries of Health and the Regional Tripartite (FAO, OIE, WHO)

Harris C, Mills R, Seager E et al. Pediatric Deaths in Tertiary Government Hospital Setting, Malawi. Paediatr Int Child Health 2019; 39(4): 240-8.

Reiner RC and Local Burden of Disease Diarrhoea Collaborators. Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries 2000-2017: analysis for the Global Burden of Disease Study 2017. Lancet 2020; 395: 1779-801.

Florez ID, Veroniki AA, Al-Khalifah R. et al. Comparative effectiveness and safety of Interventions for acute diarrhea and gastroenteritis in children: A systematic review and network meta-analysis. PLoS ONE Dec 5 2018, doi: 10.1371/journal.pone.0207701.

Doyle L, Cheong J. Does bovine lactoferrin prevent late-onset neonatal sepsis? Lancet 2019; 393: 382-4

Septimus EJ. Antimicrobial Resistance: An Antimicrobial/Diagnostic Stewardship and Infection Prevention Approach. Med Clin North Am 2018; 102(5): 819-29.

Manuel Moya MD

University Miguel Hernández. Campus de S. Juan. Alicante. Spain


We need to have social scientist to be part of the research on AMR. We also need to collaborate more with everyone in the media space, coaches and speakers to make this message easier to the public to understand. Sometime scientist deliver message in way that common people find it difficult to connect with.

We need to get public figures also to be involved as ambassadors of the antimicrobial use and resistance programme and we need to also highlight the importance stewardship.

The communication tools mainly in the rural areas still dependant on the tradition way of doing things, including the traditional or tribal offices, meetings with the local farmers through the local agricultural advisors or state veterinary office. However, in towns and cities people are able to access and communicate effective using social media platform (Facebook, twitter and Instagram) etc . We will need to explore these platforms more to reach the younger generation.

Eliza Smith, Kyeema Foudation, Australia

3. Target social media, particularly for example on agricultural marketing platforms with large numbers of engaged followers. For example - we are looking at trialling informational series on www.mkulimayoung.com blog shared on the social media platform with over 170,000 followers. Partner with stakeholder groups to deliver accurate messages.

Lal Manavado, Independent analyst/synthesist, Norway

Why Should Someone Learn about and Understand Resistance to Antimicrobials?

Before we begin, it is reasonable to ask ourselves the question embodied in the title of this contribution. One might respond by saying, the purpose of communicating information on resistance to antimicrobials is to enable the public to understand the phenomenon. But, why should they do so?

Everybody seems to think the answer to this question is so obvious; therefore, one may dismiss it as trivial. However, let us consider the commonest response to it, i.e., “everybody should learn about and understand it in order to address the problem.” Here, we run into several difficulties. One of the most important among them is who exactly is able to address it and precisely how. Let us deal with these two questions in turn.

We cannot determine which public group could do something practical about resistance to antimicrobials unless we know what to do about it. We have looked at many a learned suggestion, but none seem to have troubled to distinguish between these two logically linked categories before they were put forward. We cannot think of communication without making sure that each group is informed of what exactly it ought to do to resolve the current problem. Otherwise it would be a vain endeavour.

In order to place the discussion in the real world, let us first look at public behaviour associated with the use of antimicrobials. Most of them use today has been prescribed by authorised medical or veterinary professionals to lay people. In most countries, should the latter try to discuss the prudence of a prescription with the professional, one can nearly always expect a less than cordial response. This type of real life data is not within the domain of either ‘the big data’ or ‘research.’ So, even if the lay people should know about and understand resistence to antimicrobials, it does not seem to have a practical significance.

Even in affluent countries where the relationship between the professional and the seeker of help is cordial, wider implications of a prescribed treatment hardly enters the exchanges between them. Belief that one needs medical or veterinary help often precludes one from taking a wider view. It would be unrealistic to expect anything else. Worried people are very different from the theoretical ones, and hardly anybody remains coldly objective when one believes that one requires medical or veterinary help.

It is true that in some countries antimicrobials are available over the counter. Likewise the free trade in adulterated antimicrobials is a promoter of resistance to antimicrobials as well as serious ill health. Unfortunately, it is unrealistic to believe better information on the consequences of their dubious practise would have much influence on the public behaviour where these occur.

We may be charged being too pessimistic about the efficacy of better communications about the problem. This would be quite wrong; what we question here is the wisdom of directing one’s efforts at an enormous, vague target group hoping for the best. En passant, we should like to underline those efforts if appropriately targeted, would prove very useful, and they would be of universal applicability.

In his contribution, Prof. Moya has taken an important step in the right direction when he chooses health personnel as an appropriate target for the proposed communications strategy. However, this would entail a non-stop cycle of communication as new batches of health personnel are employed. We find this approach a partial solution at best.

We were personally involved in basic research on resistance to antimicrobials in early 1970’ies, albeit in a modest capacity. At that time, the problem was clearly understood by the medical microbiologists and they were investigating the extent of inter- and intra species plasmid transfer of such resistance. Quite a number of pharmacologists were collaborating with microbiologists, and the problem has been communicated to surgeons and clinicians via many a medical journal.

At this point, the perceptive reader would ask, “why wasn’t anything done then? Weren’t the health ministries informed of this?” The answer to both questions is the age-old one. First, word of a person investigating the basic principals is often ignored because it is not ‘glamorous’ as that of technologists who make use of basic research to make ‘novel’ inventions. Secondly, it is very rare for a health ministry to be headed by a medical professional or it to have officials with relevant medical competence in its higher echelons. This defect is universal, and now it seems to be worse.

We shall take Prof. Moya’s proposal a step further; the authorities should make teaching of appropriate use of antimicrobials a compulsory part of medical and veterinary syllabi. Once this is in place, effective communications may be directed at the established health personnel. It must be noted that the first part is the responsibility of the national authorities in consultation with competent medical microbiologists, pharmacologists, surgeons and clinicians.

One may now ask, “Shouldn’t the public be informed of this serious problem?” The answer to this depends on what one wishes to achieve by informing the general public. If it should cause undue alarm, then the answer is a firm “no!” On the other hand, if the purpose is to encourage the public to compel the authorities to take rapid, appropriate action, then the answer is a resounding “yes!”

Assuming our mythical reader has persisted in reading this far, he may now ask, “well, do you propose to communicate anything more to the authorities, and what would you like to say to the general public?” This indeed is the challenge, and its resolution is complex. We will look at what to say to the authorities first, and then direct our attention to the general public.

The authorities should require the relevant syllabi to embody the appropriate use of antimicrobials. What is appropriate use of antimicrobials? This seems to be easy as it is concerned with medical appropriateness. Hence, it would be appropriate to use antimicrobials when it is clinically indicated. This applies with equal force to human and animal patients as well as to the crops.

We are sceptical about blanket recommendations based on case numbers, for we hold that each living entity of a given species has a certain degree of singularity which can also vary with circumstances. This somatic variability makes statistical recommendations on antimicrobial use nothing short of being mischievous. Hence it should be left to the surgeon or the clinician to determine the appropriate treatment on a case by case basis.

But this recommendation is too general, for it does not indicate how one may determine medical appropriateness. Once again, this would have to be determined by the competent professionals in medical microbiology, pharmacology, clinical practice, etc., which would have to be supplemented by the experience to be acquired by every newly qualified practitioner. This then is what the authorities should be made to understand and take steps to implement.

Up to this point, the task may seem feasible given the seriousness of the current situation with respect to the antimicrobials. Unfortunately however, there are already in our environment a vast number of pathogenic organisms that are resistant to a variety of antimicrobials. Even scrupulous personal hygiene is no guarantee against them. For instance, all it takes is an unforeseen minor accident out of doors leading to an injury that might be infected by an organism resistant to some common antimicrobials. This also applies to domestic animals and crops

Thus, nothing short of creating some fictional gnotobiotic environment where people, can live raising domestic animals and crops, there is no way to totally safeguard ourselves and our food sources from microbes resistant to antimicrobials. It must be noted that higher the population density around one’s residence, greater the one’s chances of being threatened by such microbial pathogens. Birth control is necessary to diminish this problem, but efforts to achieve this objective have shown meagre results.

Another great stumbling block is our unwillingness to take sufficient responsibility for our own good health. An impartial pharmacologist would recommend intake of smaller doses of antimicrobials at shorter intervals. Indeed, this has been the case previously. But, patients’ reluctance to wake up at night and take one’s medicine made them skip a dose, which results in the development of resistance to antimicrobials. Sadly, nobody dares to talk of prudence among the patients.

In order to deal with this patient lethargy, a dubious change in treatment regimen was undertaken. It simply involved oral administration of higher doses of antimicrobials at longer intervals. So, previous 6 hourly smaller doses were ‘revised’ to 8 hourly high doses, and even to 12 hourly massive doses. We know of some northern holiday makers who visited the ‘sunny south’ armed with such prescriptions for potential tourist diarrhoea and use them. They found that the resultant extermination of gut flora gave them greater discomfort and required treatment.

Therefore, we think it is important to communicate to the professionals and the public that the optimal dose should be taken at proper intervals and this should override their reluctance to be responsible for their own health. Their ease must not prevail over medical appropriateness. This should be impressed on the general public. In affluent countries with adequate primary and specialist care this is difficult enough, but how about the situation elsewhere.

It is precisely in countries where even primary health care is either absent in most areas or when available, a service of indifferent quality, one encounters hawking of adulterated antimicrobials and their over the counter sales respectively. It is unlikely that public communications would deter those unscrupulous sellers or their helpless victims from continuing these practices. When one has what one believes to be a health problem and when there are no really competent people to help them, they will resort to any means supposed to offer relief.

A survey of the distribution of indifferent primary health care and its absence will show a remarkable one to one correspondence between those two and the two problems just discussed. Do consider now how many ‘patent medicines’ and useless ‘health supplements’ are sold even in the most affluent countries where the authorities proudly claim high levels of public education and health care. The plain fact is that one knowing something does not necessarily mean one is going to act in accordance with what one knows.

Therefore, we think that rapid improvements in the quality and the availability of primary health care combined with stricter control of the antimicrobial sales are necessary. So, communications should encourage the public to demand the authorities to do so while simultaneously requesting powers that be to undertake those actions. Judging by the evident laxity in personal hygiene noticeable everywhere, we think a vigorous global advocacy to counter this challenge is long overdue.

We have identified two target groups for a communications strategy viz., authorities and the public as well as two types of content, each specific for a target group. Further, we have recommended a global action to promote better personal hygiene everywhere as an adjunct to reduce the risk of infection and infestations. At this point, every competent biologist would raise an objection which has been blissfully ignored by various fraternities of experts on resistance to antimicrobials.

It is an elementary fact of biology viz., viruses and all other things identified as living tend to adapt to adverse variations in their environment. Those who fail to do so become extinct like the dinosaurs and the mammoth. We have failed to take into account the consequences of this primeval biological tendency. We would happily defer to what competent professionals know about whether the Trematodes (liver flukes) and Cestodes (tape worms) have developed resistance to drugs used against them. These are considerable health problems in South East Asia and Africa respectively.

Going over to protozoan pathogens, it is well known that Plasmodium sp., (Malaria), Trypanasoma sp., (Sleeping sickness) etc., have developed resistance to some of the commonest substances used against them. Further, Leishmania sp., have been difficult and expensive to treat while global warming has triggered its entry into previously cooler northern areas like Southern Europe and the upper regions of the United States. These and several more pathogens will remain, and we cannot ignore the threat they pose.

Bacterial pathogens resistant to antimicrobials are legion, and need no elaboration. A large number of them for instance, Staph. Aureus, Esch. Coli, Psd. Aëruginosa, Kleb. Aërogenes, Proteus sp., Vibrio cholarae etc., can live in a moist ambience outside the human body. And they will multiply outside as long as sufficient nutrients are available to them. Human and animal waste is quite adequate for this purpose.

Thus, while the protozoans resistant to antimicrobials will remain and multiply at a relatively slow rate, similar bacteria will not only multiply more quickly, but will continue to spread owing to international travel and trade. We maintain that every rational and practical effort to deal with the problem should take this into account, and the communicators should bear this in mind.

Now a few facts which may ruffle quite a few feathers soon. As any competent medical microbiologist with an adequate knowledge of basic facts would testify, a bacterium exposed to anything equal or lesser than the so-called minimal inhibitory concentration of an antimicrobial may develop a resistance to it. This amount is very small, no more than a few micrograms of it per millilitre. At the same time, any competent pharmacologist would tell one most antimicrobials are excreted in urine and faeces whether the patient follows the most prudent regimen of treatment or not. Since the use of Penicillin became wide-spread, antimicrobials have been in use for over 70 years.

Now even in the most affluent countries, sewage including domestic waste has been discharged into the sea and rivers in its raw state even as late as in the 1980’ies. This included a considerable quantity of human excretion products containing antimicrobials at low concentrations in an environment containing many a potential pathogen.

This provided those microbes a nutrient environment where they could develop resistance to the antimicrobials involved. One does not need further elaboration of the point to grasp the simple fact that this has done much to spread microbes resistant to antimicrobials.

True, it has been done unwittingly, but it makes placing the onus of responsibility for the current situation entirely on physicians unjust and contrary to basic biological facts. Furthermore, in the sewage mentioned here, the microbes that have developed resistance to an antimicrobial could transfer it not only to others of the same species, but also to some others through plasmid transfer of such resistance.

Moreover, according to statistics from the UN, 2 billions of people in the world do not have access to a sanitary latrine. It is unlikely that none among them have been on an antimicrobial therapy when they relived themselves out of doors. This provides the faecal bacterial flora an ideal opportunity to develop antimicrobial resistance and remain in nature. In this case, ‘prudent’ use of an antimicrobial by a physician or a patient becomes academic with no practical significance.

The perceptive reader who has persisted in reading this far, would have now realised that this applies with equal force to the veterinary use of antimicrobials. There are no provisions in animal husbandry to prevent the development of resistance to antimicrobials in waste from animals on them. Further, Tetracycline derivative has been used as a ‘growth accelerator’ for many years, and this has rendered it almost useless owing to many species of bacteria developing resistance to it. These bacteria remain with us.

As the space at our disposal is limited, we have not dealt in depth with the subject. However, a clear thinking person with no vested interests will freely admit to points; the balance sheet is grim indeed and the experts have overlooked the importance of human and animal waste disposal as a major cause of the problem which could not have been avoided by the so-called prudent use of antimicrobials. Nor yet can we expect microbes not to evolve a counter strategy to deal with antimicrobials.

Both the competent medical microbiologists and the pharmacologists understood this when they observed the emergence of the so-called L-forms of bacteria in response to Penicillin and its derivatives. As Penicillins act by interfering with bacterial cell wall synthesis prior to cell division, the bacterial simply evolved into a cell wall-less organisms known as L-forms, making Penicillins useless against them.

Pathogenic fungi like Candida sp., Cryptococcus sp., etc also have developed resistance to several antimicrobials used against them. Nor have we tried here to give a complete list of protozoan, fungal, bacterial and viral pathogens that have already developed resistance to the medicines commonly used to deal with them. What is important here is to understand clearly the influence of the following biological and social facts on resistance to antimicrobials.:

· There is a considerable load of protozoan, fungal, bacterial and viral pathogens that already possess resistance to antimicrobials used against them. Their number will continue to increase and spread as global temperatures rise, international trade and travel continues and population density increases in inhabited areas.

· Defective and non-existing human waste disposal will continue to introduce into the environment pathogens resistant to antimicrobials.

· The types of pathogens we have discussed will continue to develop strategies to meet the threat antimicrobials pose to them.

· In view of the foregoing, over the counter sale of antimicrobials and hawking of their adulterated variant only play a limited role.

· The highly publicised ‘prudent use’ of antimicrobials has no effect whatsoever on the first three influences listed above.

One may now ask, “Do you maintain that what has been done so far is futile? Do you say that all the recognised experts who have been working on the problem are incompetent?” And it is a short step from such question to the well-known ploy, “ah, you think you are the only one who knows what to do!” Perhaps, such candid statements will remain unspoken.

We would like the impartial reader to consider the three facts listed above. Their factual soundness is obvious to anyone versed in biology, medical microbiology and social conditions in less affluent countries. True, lack of proper latrines and their biological consequences may be beneath the dignity of academic debate, but it is nevertheless a real world problem.

It is in this light we propose to outline a set of strategies to address the problem of resistance to antimicrobials. We do not use the common abbreviation AMr in deference to Standard English grammar and semantic correctness. It will be noted that we do not ignore any one of the above facts and understand the enormous difficulties one would have to overcome to resolve the present problem.

· Discovery/invention of antimicrobials will have to be a continuous endeavour in order to deal with the already resistant pathogens and those that might emerge in the future.

· This will require non-commercial, reliably peer reviewed basic research which is best carried out on an international cooperative basis with a view to developing, rigorously testing, manufacturing and distributing the new antimicrobials.

· Research and development is needed to devise an effective method to rapidly break down the excreted antimicrobials in order to minimise the development of resistance to them.

· Rapid incorporation into medical and veterinary syllabi extensive theoretical and practical instructions on the use of antimicrobials. When appropriate, such may be included in agriculture syllabus.

· International and national efforts to deploy adequate primary health care especially where none exists or the existing units are inadequate.

· Redouble the efforts of the UN to provide adequate latrines to those 2 billions.

· Comprehensive school and public education of the importance of personal hygiene.

· Although difficult, it would repay to halt the global increase in population with a view to reducing it.

· A new approach to animal husbandry is required, for large populations of a single species in a confined area promotes the development of resistance to antimicrobials as well as the emergence of New pathogens.

We do not claim that this list of strategic steps is exhaustive, but they represent the essential practical things we can do to address a problem that has not received the attention it deserves until now. The other virtue of the proposed approach is that it openly admits two biological facts; living pathogens will continue to develop counter measures against the chemicals we use against them and it is impossible to eradicate from the world those pathogens that have succeeded in doing so.

We shall next describe some of the ways and means we may use to implement those strategies. These can be placed in two broad categories. In the first, we have the real world actions various groups should undertake while the second contains the acts of communication that would prod the decision-makers to respond rapidly and appropriately. Moreover, it would inform the public of the seriousness of the problem with a view to inducing it to encourage the authorities to act promptly.

Naturally, the decision to undertake the requisite strategic actions will have to be taken at the cabinet level, and they should seek advice only from the professional groups mentioned below. Authorities should understand the problem in terms of misery that accompanies infectious disease. It would be irresponsible to view the problem primarily in monetary or sociological terms, for it would be putting the cart before the horse. Obviously, potential financial loss or social disruption comes as a consequence of pain, discomfort and dysfunction from infection. So, let us deal with the cause rather than drowning in secondary issues.

A note of caution must be sounded at this point. On implementing the strategies listed here, one requires tactical/field support on an inter-disciplinary basis. But, this coordinated support only involves competent medical microbiologist, pharmacologists, surgeons, physicians and teachers in medical, veterinary and the agriculture schools. In communication, personnel with competence in medical and biological sciences are to be preferred.

We have not gone into the tactical implementation of the strategy suggested here because it has little to do with communication. We have discussed the problem somewhat at length in order to illustrate two important points:

· The purpose of communication is to encourage a target audience to behave in a desirable way. If people just learn about a problem and remain indifferent to it, communication would be pointless.

· But, if we just inform the people that resistance to antimicrobials exists, does that mean that they would know what to do about it?

· We have pointed out that two relevant, basic biological facts, and the social issue of adequate latrines have been overlooked in the current expert debate on the problem.

· We have demonstrated with reference to the real world that it has been unfair to place the onus of responsibility for the problem on the medical profession. We have emphasised that we are dealing with a biological issue, and its correct description does not depend on consensus or a majority of votes.

· So, what are we to communicate and to whom?

· Obviously, we need to communicate to the right target audience what would make them to do one of the two things:

· Implement the proposed strategies;

· Compel those able to implement them to act quickly and appropriately.

· The target audience capable of implementing the strategies are the authorities. As they may not be familiar with the scientific reasoning presented here, the communicators should prepare a simple presentation in consultation with the professional groups described here. Its content should be neither technical nor yet a tabloid type simplification. It must underline the seriousness of the problem as well as its inevitability even if we had taken greater care in the use of antimicrobials.

· Moreover, as it is a universal problem with the potential to cause a great deal of human and animal misery, it must be emphasised that research and development of new antimicrobial should be an international effort anchored in a sense of common decency and good will rather than financial gain from pain and suffering.

· Communicators should encourage the public to demand from their governments the type of research and development described above.

· Likewise the public should be informed of the biological facts and the pointlessness in blaming any group, because we generally do not consider the consequences when we solve a problem. History can provide countless examples of this.

· Communicators should stress the importance of personal hygiene as a very effective way of avoiding infection and parasitic infestation.

· Communicators in countries where primary health care is sketchy and/or poorly distributed and where adequate latrines are the exception, should inform the public of their importance with a view to creating a wide-spread demand for them.

At the outset, we were aware of two critical issues the present forum discussion appears to have overlooked, viz., why one should communicate to the public information on the problem and for what purpose. Unless the public acted on such information in a suitable way that would facilitate its resolution, such communication would serve no purpose. Therefore, it becomes necessary to understand not only the full implications of resistance to antimicrobials, but also what biological and social factors that influences it.

An understanding of those factors is crucial for determining what we need to communicate and to whom it should be directed. In this submission, we were compelled to identify those factors in order to distinguish between our principal target audiences i.e., the decision-makers, relevant advisors and the general public. As their contributions to the resolution of the current problem are very different in kind, information that would motivate them to act appropriately would also differ significantly.

We have given a general description of the information each target group ought to consider carefully. How it may be most effectively disseminated remains a problem. We do not believe that a few disjointed sentences widely publicised will have greater effect than a shrug and an expletive or two. We believe public meetings where articulate speakers who have a thorough understanding of the problem would be of greater use. Their speeches can be followed by the distribution of lucid explanations of the problem adopted for lay readers but not deviating from the facts.

Our approach here has been pragmatic, but we have always kept in mind that it is vital that the decision-makers respond appropriately and speedily while the general public can only demand such action. Every realistic communicator should bear these two things in mind. We can easily deceive ourselves into thinking that we have done a great deal even if we have achieved very little.

Another great danger is the belief that inter-disciplinary action is a panacea for all our ills. Nothing can be farther from the truth. Yes, it is a must, but only when it involves disciplines relevant to the issue under discussion. We do not believe anyone would propose to include a famous literary critic, a well-known novelist, archaeologist, an actor, a barber, or a linguist in a committee to decide on what to say to the public about resistance to antimicrobials. Let us never forget the relevance at all times.

We have not touched on the consequences of not responding to the problem in a timely manner because they are well established. Competent relevant professionals involved have known about them, and have issued many unheeded warnings. We hope the actions stemming from this discussion would make the authorities and the public to shake off their tendency to indulge in masterly inaction.

Best wishes!

Lal Manavado.

Abiodun E, Nigeria CDC, Nigeria


· Behaviour change remains a big challenge, despite the increase in communication related to AMR and AMU. In addition, communicating the role of agriculture and the environment in spreading resistant microorganisms. Also, a lot of the terms related to AMR are technical, translation into local dialects is challenging.


· Resistance to some of the antimicrobial agents e.g. antimalarials, antiretrovirals are being managed as siloed programs. It is best to integrate communication on antibacterial resistance into these programs, since antibacterials are used in conjunction with these medication and these program have well established communication structures.


· The media need to be trained on AMR, what it means and how it impacts the health of the population and the economy. The media can then take responsibility and own the story. Grants could be awarded via a competitive process to media to develop creatives e.g. a documentary, on AMR


· Engagement via social media and mass media remains essential. Using innovative interpersonal communication methods e.g. community drama, children summer camps, could also result in greater impact.


· Health workers, political leaders, religious leads and education institutions should be prioritised.


· At the national level, National Public Health Institutes, Federal Ministries of Health, Agriculture and Environment should take the lead. At the regional level, Regional Centres for Disease Control and regional bodies for agriculture and environment. At the continental level, the African Union arms for public health, agriculture and environment.

Adebayo Depo, Togo


1) En matière de communication, quel est le plus grand défi lié à la RAM et à l'utilisation inappropriée des antimicrobiens (UAM) en Afrique ?

En matière de communication, la cible responsable de l'utilisation inappropriée des antimicrobiens dans le domaine de l'élevage se trouvent dans les milieux ruraux et sont déconnectés des réalités ou des moyens de communications usuels utilisés par les organismes de lutte contre le RAM. Un autre défi est qu'il reste toujours à faire dans la communication, puisque la belle preuve est que même dans la capitale je prends l'exemple de Lomé, très peu sont au courant de la situation de RAM et même dans le secteur agronomique (animal) très peu ont l'information.

2) Quelle est la meilleure approche pour communiquer sur les autres antimicrobiens (antifongiques, antiparasitaires, antiviraux, pesticides), et sans se limiter aux antibiotiques ? Comme les virus, les champignons et les parasites peuvent également résister aux médicaments couramment utilisés pour les traiter, et avoir un impact sur la santé et les systèmes alimentaires, comment communiquer sur ces questions en plus des bactéries résistantes aux antibiotiques?

Il faudrait définir un plan de communication par pays suivant les réalités de chaque. Ce plan doit prendre en compte la segmentation de la cible, le niveau d'alphabétisation (langue locale), les canaux de communication anciens comme nouveaux. Ce plan doit pouvoir faire intervenir la représentation à tous les niveaux et même local pour participer à l'élaboration de ce plan qui prendra en compte l'aspect socio-culturel de la cible. Pour finir, plusieurs canaux doivent être utiliser et la population toute entière doit être informée de ce fléau de résistance qui par la fin cause un probleme de santé.

3) Que pouvons-nous faire pour que le thème de la RAM soit plus souvent abordé dans les médias? Comment assurer la visibilité de la RAM par rapport à d'autres « sujets sensibles »?

Nous devons faire des rencontres, des réunions, inviter les médias et les journaux en ligne à en faire une campagne. La question doit être abordée plusieurs fois dans plusieurs occasions pour susciter une attention particulière.

4) Quels sont les canaux, méthodes ou mécanismes de communication les mieux adaptés et les plus susceptibles d'avoir un impact sur le terrain dans les pays africains?

Les réseaux sociaux pour les agripreneurs, les crieurs pour les agriculteurs, les radios, télévisions pour la population. Les affiches et pancartes aussi s'avèrent aussi influencer comme une #éducationRAM.

5) Quel groupe de parties prenantes devrait, selon vous, être considéré comme prioritaire pour la diffusion de messages clés ciblés visant à sensibiliser à l'utilisation inappropriée des antimicrobiens et à la RAM?

Les étudiants agronomes, les éleveurs, les médias verts, les vétérinaires et même les responsables d'approvisionnement des ces antibiotiques.

6) Aux niveaux national, régional et continental, qui devrait, à votre avis, prendre la direction et la responsabilité des activités de sensibilisation et de plaidoyer sur l'utilisation inappropriée des antimicrobiens et la RAM ?

Les responsables de la santé humaine et animale.

English translation

1) What is the biggest communication challenge related to AMR and inappropriate antimicrobial usage (AMU) in Africa?

In terms of communication, the target responsible for the inappropriate use of antimicrobials in the livestock sector are found in rural areas and are disconnected from the realities or usual means of communication used by AMR organizations. Another challenge is that there is still work to be done in communication, since the good proof is that even in the capitals, I take the example of Lomé, very few are aware of the AMR situation, even in the agronomic sector (livestock).

2) What is the best approach to communicate about other antimicrobials (antifungal, antiparasitic, antiviral, pesticides), and not only antibiotics? As viruses, fungi and parasites can also be resistant to medicines commonly used to treat them, and impacting health and food systems, how do we communicate about these issues in addition to antibiotic resistant bacteria?

A communication plan per country should be defined according to the realities of each. This plan must take into account the segmentation of the target audience, the level of literacy (local language), the old and new communication channels. This plan must be able to involve representation at all levels, including local to participate in the development of this plan, which will take into account the socio-cultural aspect of the target. Finally, several channels must be used and the entire population must be informed of this scourge of resistance which, in the end, causes a health problem.

3) How can we get the topic of AMR included more often in the media? How do we ensure the visibility of AMR amongst other “hot topics”?

We need to meet, convene, invite the media and online newspapers to design campaigns. The issue needs to be addressed multiple times on multiple occasions to gain special attention.

4) What communication channels, methods or mechanisms are more suitable and will have the greatest impact at field level in African countries?

Social networks for agrientrepreneurs, town criers for farmers, radios, televisions for the population. Posters and placards are also proving to be good to raiser awareness on AMR.

5) Which group of stakeholders do you think should be considered as priority for targeted key messages aiming at raising awareness on excessive AMU and AMR?

Agricultural students, breeders, green media, veterinarians and even those responsible for supplying these antibiotics.

6) At national, regional and continental levels, who to do think should take leadership and responsibility for awareness and advocacy activities on AMU and AMR

Human and animal health officials.

Ramatou Moumouni, Ministère de l’agriculture et de l’élevage, Niger


1) En matière de communication, quel est le plus grand défi lié à la RAM et à l'utilisation inappropriée des antimicrobiens (UAM) en Afrique ?

Le plus grand défi lié à la RAM et à l'utilisation inappropriée des antimicrobiens en matière de communication dans le domaine de l’Agriculture et l’Elevage au Niger se trouve être le manque de moyens financiers pour la mise en œuvre du plan d’Action National multisectoriel pour combattre la RAM.

2) Quelle est la meilleure approche pour communiquer sur les autres antimicrobiens (antifongiques, antiparasitaires, antiviraux, pesticides), et sans se limiter aux antibiotiques ? Comme les virus, les champignons et les parasites peuvent également résister aux médicaments couramment utilisés pour les traiter, et avoir un impact sur la santé et les systèmes alimentaires, comment communiquer sur ces questions en plus des bactéries résistantes aux antibiotiques?

Il faudrait prendre en compte l’utilisation des autres antimicrobiens dans l’élaboration et la mise en œuvre de la communication du Plan d’Action National RAM. Ce plan doit prendre en compte la communication interne au sein du Ministère de l’Agriculture et de l’Elevage et aussi l’externe vers les parties prenantes (Agriculteurs, éleveurs, décideurs politiques…) et les acteurs des médias.

3) Que pouvons-nous faire pour que le thème de la RAM soit plus souvent abordé dans les médias? Comment assurer la visibilité de la RAM par rapport à d'autres « sujets sensibles »?

Nous devons faire des rencontres, des réunions, des conférences, des débats radio-télévisés et écrire des articles sur la lutte contre la RAM dans les journaux. La question doit être abordée plusieurs fois dans plusieurs occasions pour susciter une attention particulière et enfin des campagnes de sensibilisation de la lutte contre la RAM.

4) Quels sont les canaux, méthodes ou mécanismes de communication les mieux adaptés et les plus susceptibles d'avoir un impact sur le terrain dans les pays africains?

Les messages radiophoniques en langue locale diffusés par les radios communautaires et la radio nationale, les fora (fêtes locales des agriculteurs et éleveurs) et les crieurs publics. Les affiches et posters s'avèrent aussi nécessaires.

5) Quel groupe de parties prenantes devrait, selon vous, être considéré comme prioritaire pour la diffusion de messages clés ciblés visant à sensibiliser à l'utilisation inappropriée des antimicrobiens et à la RAM?

Les techniciens du développement rural (Direction Générale des Services Vétérinaires (DGSV) à travers la Direction des Pharmacies Vétérinaires Privées et de la Privatisation de la Profession Vétérinaire (DPVP/PV), Direction Générale de la Protection des Végétaux (DGPV) à travers la Direction de la Règlementation Phytosanitaire et du Suivi Environnemental (DRP/SE), les points focaux RAM et les centrales d'approvisionnement des antimicrobiens.

6) Aux niveaux national, régional et continental, qui devrait, à votre avis, prendre la direction et la responsabilité des activités de sensibilisation et de plaidoyer sur l'utilisation inappropriée des antimicrobiens et la RAM ?

Les responsables nationaux de la santé humaine, animale, et végétale,

Au niveau régional : OOAS, UEMOA, CILSS

Au niveau Continental ; alliance tripartite (OIE, FAO, OMS), UA /IBAR.

Contribution de la DGSV/DPV/PV-DGPV/DRP/SE-LABOCEL/Direction Contrôle Qualité/ MAG/EL/Niamey-Niger

English translation

1) What is the biggest communication challenge related to AMR and inappropriate antimicrobial usage (AMU) in Africa?

The biggest challeng

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