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Nigeria Centre for Disease ControlProtecting the health of Nigerians

An analysis of antibiotic consumption in Nigeria and its potential contribution to rising antimicrobial resistance

Abiodun Egwuenu1, J. Obasanya1, A. Ogunniyi1, I.N. Okeke2, A.O. Aboderin3, A. Olayinka4, M. Aworh5, K. Jinadu1, E. Mbadiwe6, L. Omoniyei6, D. Kwange5, F. Abba1, O.

Hamzat7, C. Ogar8, A. Aremu9, F. Kudla9, M. Niyang10, Patrick Nguku4, AMR-TWG11, C. Ihekweazu1

1Nigeria Centre for Disease Control, 2Global Antibiotic Resistance Partnership/University of Ibadan, 3Obafemi Awolowo University/Obafemi Awolowo

University Teaching Hospitals Complex, Ile-Ife, 4Nigeria Field Epidemiology and Laboratory Training Programme, 5Federal Ministry of Agriculture and

Rural Development, 6Global Antibiotic Resistance Partnership/Ducit Blue Solutions, 7World Health Organisation-Nigeria, 8National Agency for Food

and Drug Administration and Control, 9Federal Ministry of Environment, 10University of Maryland Baltimore, 11Antimicrobial Resistance Technical

Working Group

2

Nothing to disclose

Nothing to disclose

Nothing to disclose

Nothing to disclose

Nothing to disclose

Conflict of interest

Introduction

3

• “Time may come when penicillin (antibiotics) can be bought by anyone…exposing microbes to non-lethal quantities may make them resistant…I hope this evil can be averted”

- Alexander Fleming (1945)*

• Antibiotic exposure => risk of resistant infection

Response to AMR threat: Nigeria

4

2015• An integrated global programme for surveillance of antimicrobial

resistance (AMR) adopted by the 68th World Health Assembly

2016• Nigeria committed to establishing a national AMR surveillance system,

in conformity with the global action plan

2016• AMR Coordinating Body established at Nigeria Centre Disease Control

by Honourable Minister for Health

2017• One Health AMR Technical Working Group inaugurated, to conduct an

analysis of the AMR and antibiotic consumption situation in Nigeria

Objectives

5

• Describe legislations guiding antimicrobial use

• Describe existing workforce and framework for antimicrobial distribution

• Characterize antibiotic use in humans and animals

• Elucidate factors related to antimicrobial consumption and its potential contribution to antimicrobial resistance

Conceptual framework: Antibiotic access and use

6

• Rational use of medicines‒ appropriate to clinical needs

‒ In doses that meet individual requirements

‒ An adequate period

‒ At lowest cost

Data collection process

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• January to April 2017

• Review of national reports, policy documents, programmatic data

• Stakeholder interviews:‒ Federal Ministries of Health and

Agriculture

‒ National Agency for Food and Drug Administration and Control

‒ Pharmacists Council of Nigeria (PCN),

‒ Pharmaceutical Manufacturers Group

‒ Academia

‒ Health professional regulatory agencies

Data collation and analysis

8

• Systematic review on antibiotic use in humans• Type: observational studies, 2000-2017

• Databases: Medline, Pubmed, Google Scholar, Embase, AJOL

• Protocol: PRISMA

• Primary data on antimicrobial consumption in animals• National database on antibiotics used in animals, 2014-2015

• Data collation• Entered into purpose-built word and excel templates

• Data analysis• Numeric data: frequencies and proportions calculated

• Thematic synthesis: text responses

Laws and regulations guiding antimicrobial use, Nigeria - 2016

9

Regulations Examples

Humans

5 Regulatory agencies1993: National Agency for food and Drugs Administration and Control (drug access)

8 Healthcare policies1990: National Drug Policy (drug use)2008: Standard Treatment Guidelines

Animals

2 Regulatory agencies1966: Federal Ministry of Agriculture (surveillance)2004: Veterinary Surgeons (practice)

3Medicine use policies

1968: Meat Law (abattoirs)2007: Veterinary Formulary (medicines)

5Medicine use policies (both)

1976: Food and Drugs Act (manufacture)?? NCDC

Antimicrobial production in Nigeria, 2016

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Characteristic Value

Local manufacturers

% Capacity used for local manufacturing 40%

% Market share local medicine production 25%

% Audited local manufacturers 58%

Amount antibiotics manufactured 16 billion grams

Number drug procurement companies 1,304

Procurement of veterinary antimicrobials Mainly imports

Workforce and medicine distribution framework, Nigeria - 2016

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HW/100,000 pop• Medical doctors: 38• Pharmacist: 12• Veterinarians: 3

Registered medicines(n=45,552)

• 6833 (15%) Antibiotics

Regulatory workforce2/100,000 pop

15

1

Retail medicine stores

Registered OTC premises(n=66974)

*OTC: Over-the counter premises

Antimicrobials sold or used in animals and humans in Nigeria

12

Antibiotic use in humans, Nigeria 2000 - 2017

Characteristic Median %

Persons using antibiotics without prescription

46.8

Patient drug encounters with antibiotic prescribed

49.1

0

80

160

Tonne

Antimicrobial class

20142015

Antimicrobials used/sold in animals, Nigeria 2014-2015

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Nwolisaet al -2004

Akandeet al -2007

Sadoh etal - 2009

Ekwochiet al -2012

Rasaq etal - 2013

Sanya etal - 2013

Sanya etal - 2013

Sanya etal - 2013

Ekwochiet al -2014

Fadare etal - 2015

Perc

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Year-Author

Antibiotics used or prescribed to humans in Nigeria, 2000-2017

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Themes related to antimicrobial consumption in Nigeria

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WeakRegulation

Inadequate funding

Human-resource limited

Low staff retention

Fragmented Procurement

Counterfeit/Poor quality control

Access to medicated feeds

Over-reliance on importation

Multi-molecule antibiotics

Stock-outs

Chaotic Distribution

Over-counter sales

Unlicensed persons or premises

Poor public-private network

Urban-rural disparity

Non-adherence to guidelines

Consumer demand

Low awareness

Poor access to health insurance

Unrestricted access

Demand for antibiotics

Fragmented surveillance: resistant bugs, antibiotic use

Conclusion, actions taken and next steps

15

• Large volumes of antibiotics used in agriculture

• Access to antibiotics is poorly regulated

• Actions taken‒ National Action Plan developed to address gaps

‒ Policies reviewed: National Standard Treatment Guidelines, National Drug Policy

‒ National AMR surveillance data collection (2017)

‒ National Antibiotic Awareness Campaign established: Nov - 2017, 2018

• Next steps‒ NCDC and National AMR TWG support antimicrobial

stewardship in hospitals: consumption, PPS

‒ “Hub and spoke” model: pharmacies and OTC premises

References

16

• Penicillin's finder assays its future. Sir Alexander Fleming. 1945. New York Times

• Van Boeckel TP et. al, 2000-2010

• Cizman et. al 1998

• CNN vital signs 2016: Antimicrobial Resistance -https://edition.cnn.com/2016/09/21/health/what-is-antimicrobial-resistance-amr/index.html

Further information:

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• https://ncdc.gov.ng/themes/common/docs/protocols/56_1510840387.pdf

• https://ncdc.gov.ng/themes/common/docs/protocols/77_1511368219.pdf

Thank you

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• Prof. Iruka Okeke

• Prof Dipo Aboderin

• Prof. Adebola Olayinka

• Ministries

• Academia

• Private sector

• National AMR technical working group