The First National Conference on Antimicrobial Resistance - Promoting Best Antimicrobial Practices in Uganda

By Daisy Winner | 20 Nov, 2016

On November 21st and 22nd in Mbale, Uganda various stakeholders will come together at The First National Conference on Antimicrobial Resistance. The conference will bring together leaders in laboratory sciences, clinical practice, policy makers, veterinary medicine, and pharmacists to examine the problem. Solving antimicrobial resistance will take the collaboration of a multi-disciplinary group of professionals. This conference will focus on finding new and innovative ways to minimize the development of antimicrobial resistance in Uganda.

Birikomawa Mathias and Atyera Jimmy, two first year medical students at Busitema University, will be sharing live updates from the conference over the next two days. Stay tuned!

Attached are the conference schedule and abstract book.

Attached resources:

Replies

 

JIMMY ATYERA Replied at 12:32 AM, 21 Nov 2016

The conference on Antimicrobial resistance taking place in Wash and Wills resort Hotel, MBALE district Uganda has started right now

Zea Rahim Replied at 12:56 AM, 21 Nov 2016

Greetings from Bangladesh. I congratulate the organizers for such a nice initiative.

Best wishes.


Zeaur Rahim M. Phil, DRSU, Ph.D
Mycobacteriology Laboratory
International Centre for Diarrhoeal Disease
Research, Bangladesh
GPO Box 128, Dhaka 1000, Bangladesh
Telephone: 880 2 9840523-32, cell phone: 8801712701920
Fax: 880 2 8812529, 880 2 8812530,
Email: <mailto:>, <mailto:>

JIMMY ATYERA Replied at 1:12 AM, 21 Nov 2016

Moderator; Professor Paul Waako, Dean - Busitema University Faculty of Health Sciences (BUFHS)
Gave an opening remarks and introduced the key speakers

JIMMY ATYERA Replied at 1:57 AM, 21 Nov 2016

Moderator; Professor Paul Ssewankambo, President of Uganda National Academy of Sciences.
Topic; Perspectives of Uganda National Academy of Sciences.
The Uganda National Academy of Sciences(UNAS) is body that has convening power to cause and support meetings of fellows, experts (nationally and internationally) to discuss patent issues for positive Scientific measures.
Sited study that was done in 2013 on antibiotic resistance highlighted the following;
- Many Ugandans are unaware of antibiotic resistance.
-Resistance was more in anaerobic bacteria like S. aureus.
-The expensive antiobitics against which the prevalence of S. aureus resistance is less than 50% are vancomycin, gentamycin, clindamycin, imipenlim and linzolid.
- Very few laboratories in Uganda are capable of culture and sensitivity resting for antimicrobial resistance.
-The incresed resistance is mostly contributed to by freqent dispensation of unprescribed antibiotics by pharmacies.

Jenifer Lasman Replied at 2:01 AM, 21 Nov 2016

Thank you all for participating in this conference. We all must examine this multi sectorial problem to find a source of solution.
Jenifer Lasman MD
Co-Chair of the conference

JIMMY ATYERA Replied at 3:40 AM, 21 Nov 2016

Moderator; Professor Francis omaswa , Executive Director, African centre of Global Health and social Transformation (ACHEST) and Chancellor Busitema University.
Topic; Infectious disease as a neglected dimension to global security.
1. Strengthening Public health as the foundation of health system and first line of defense.
2. Acelerating research and development to encounter the threat of infectious diseases.
3. Strengthening global and regional coordination and capabilities.

JIMMY ATYERA Replied at 4:09 AM, 21 Nov 2016

Moderator; Pontiano Kaleebu, Director MRC/UVRI Uganda Research Unit on AIDS Deputy Director, Uganda Virus Research Institute.
Topic; Progress on National HIV drug Resistance Prevalence surveillance and monitoring program Activities in Uganda.
Pre-ART HIVDR prevalence
overall; 5.6%
pretoria; 1.1%
Kampala; 12.5%
Uganda has a transmitted drug resistance mostly to PIs, NRTIs and NNRTIs of 15%.
There is a high pre- existing Drug Resistance among ( general=10% children on first line; ARV- naive= 8% and ARV-exp.- 80%).

Uganda is still way below the WHO/UNSAIDS target which emphasizes low transmitted drug resistance <5%.

JIMMY ATYERA Replied at 4:31 AM, 21 Nov 2016

Moderator; Dr. Jennifer Lasman, Lecturer, Busitema University, Mbale Regional Referral Hospital.
Topic;The face of antimicrobial Resistance
Presented a case of Rheumatic heart disease caused by pseudomonas which was resistant to cefriaxone, ampicillin, gentamycin ciprofloxacin and it was sensitive to only imipenlin which too expensive for the patient to afford.
The resistance is attributable to irrational antibiotic use.

JIMMY ATYERA Replied at 5:44 AM, 21 Nov 2016

Speech by the guest of Honor, Dr. Moriku joyce,Minister of state for primary healthcare.
Commended the organizers of the conference.
1.Emphasized that the recommendations from this conference will be taken up by the Uganda ministry of health.
2. Emphasized the high prevalence of antimicrobial resistance in Uganda.
3. Requested all the health workers and the general public to have a positive attitude toward cabbing the high prevalence of antimicrobial resistance.
4. Recommended that all the recommendations from this conference should be widely disseminated in order to ensure implementation.
5. Assured organizers and the participants of the government willingness to implement the various recommendations from this conference.

JIMMY ATYERA Replied at 9:10 AM, 21 Nov 2016

Break out 1 Session
Topic; HIV/ TB.
Moderator; Dr. Hanna Kibuuka, Executive Director, Makerere University Water Reed Project.
Topic; Snap shot into HIV viral load among pregnant mothers in Uganda.
Presentation by Ms. Agnes Napyo Kaseda, Busitema University faculty of health Sciences.
1. Turn around time for the dry blood sample is so long because only 7 out 8 high volume health facilities act as collection centers for the samples but with inadequate human resource.
2. Many of the midwives in Uganda do not know how to collect dry blood samples for viral Load.
3. Sample collections are only done in the laboratories but not in the mother- baby care centers, creating inaccessibility to many mothers.

Topic; Invitro evaluation of anti- tubercluosis activities of some plants against multi-drug resistance mycobacterium tubercluosis.
Presenter; Kevin Komakech, Makerere University.
Study was carried out on Cassia Nigricans and E. amplexicaulis and the extracts of the two plants exhibited anti- mycobacterial activity. However, the total crude extract of E. amplexicaulis had the highest activity with MIC of 0.78mg/ml for MDR, H37RV and M. bovis as compared to the totalcrude methanolextract of C. nigricans with MIC of 12.5, 6.25 and3.13mg/ml for the three strains respectively. For the aqeous extract, E. amplexicaulis extract,was the most active against H37Rv (MIC=25mg/ml) as compared to C. nigricans extact (MIC=50mg/ml). However, both extracts did not show activity on MDR and M. bovis. Terpenoids, alkaloids, tannins and saopnins were present in both extracts fromboth plants except flavonoids.

JIMMY ATYERA Replied at 9:37 AM, 21 Nov 2016

Continuation of break out 1.
Topic; A situational analysis of multi-drug Resistance among clinical isolates of staphylococcus aureus in Mbale Regional Referral Hospital.
Presenter; J. Iramoit and J. Lasman, Busitema University.
The study revealed hihest resistance in Trimethoprim/sulfamethoxazole, Ampicillin, Erythromycin and Penicillin G (75, 67, and 51 )% respectively. Linezolid, Imipenem and Vancomycin had existence patterns below five percent.
the prevalence of MRSA was 30% where as that of Inducible Clindamycin resistance was 14.5% of Staphylococcus were multi drug resistant.

JIMMY ATYERA Replied at 9:54 AM, 21 Nov 2016

Topic; Antimicrobial Resistance surveillance In Uganda; Barriers and Recommendations.
Presenter; Nsubuga G. A.
37.5% of health facilities reported the ability to identify and perform susceptibility testing on some priority WHO antimicrobial resistance pathogens. Health workers possessed scanty knowledge on antimicrobial resistance and how the respective data could be generated.
The study also reveal inadequate and poor record keeping tools making record keeping very challenging.

JIMMY ATYERA Replied at 10:26 AM, 21 Nov 2016

Topic; Microbial Colonization of Ugandan Women in Lobor.
Presenter; Josephine Tumuhamye.
Study result; 81 pregnant womwn were enrolled for the study; 25% primegravida, 98% vaginal delivery,74% completed primary education and 83% were married/co-habiting. 78 were recovered from 81 of the enrolled women.
Potntially pthogenic strains isolated were K. pneumoniae(8), S.aureus(4), Group B Streptococcus(1), and Group A streptococcus (GAS) (1). Other microbes isolated include Candida spp(38), coagulase negative Staphalococcus (13), Bacillus (4), Lactobacillus (2), Corynebacteria (2), Acinebacter (1), Citrobacter (1) and Micrococcus (1).
The study is still ongoing.

JIMMY ATYERA Replied at 12:47 AM, 22 Nov 2016

We welcome everyone to day two of the first national conference on antimicrobial resistance conference
Theme - Promoting the beat antimicrobial use in Uganda.We continue to ask for your active participation, this last day of the conference.
We are currently having a recap of yesterday's sessions.

Jenifer Lasman Replied at 1:16 AM, 22 Nov 2016

We are now on day 2. We just had a wonderful summation of day one. Please see the attached file for a nice review of the first day's talks.
Thank you
Jenifer Lasman

Attached resource:

JIMMY ATYERA Replied at 1:24 AM, 22 Nov 2016

Moderator; Nicholas Kauta.
Topic; Agriculture and veterinary practices contributing to AMR.
There is currently high use of antibiotics in animals and poultry in Uganda.
These antibiotics are used for therapeutic, prophyatic and non-therpeutic purposes eg for stimulating growth in animals and birds.
This misuse of these antibiotics are also linked to development of antimicrobial resistance in humans.
In Uganda, farmers rear large number of livestock which they treat with a single antibiotic everytime.

JIMMY ATYERA Replied at 1:40 AM, 22 Nov 2016

Moderator; Donna Kusemererwa, Executive Director, National Drug Authority.
Topic; Policy, Regulaation and AMR.
Highlighted the the roles of National Drug Authority which included;
1. Clinical trial review.
2. Drug assessment.
3. Monitoring and evaluation of drugs in Ugandan market.

Also highlighted of the presence of the Uganda National Policy and authority Act.
There is a national medicines policy on AMR, 2015.
3/4 of Ugandans still seek medical care from herbalist who used drugs that are not screened.

JIMMY ATYERA Replied at 2:02 AM, 22 Nov 2016

Moderator; Henry Kajumbula, Chair, MOH Task Force on AMR- Surveillance.
Topic; Surveillance of Antimicrobial Resistance in Uganda.
Highlighted that one of the major roles of the task force is to collect data, characterize and monitor Resistance to antimicrobials.
Informed members that the force is working in line with the strategic objectives of the global Action Plan.
South happens to be best in disease surveillance in Africa.

Strategies of Ministry of Heath task force on Antimicrobial Resistance .
1.Leadership and coordination.
2.UNHLS (CPHL) to act as National Referral Laboratories.
3.Selecting surveillance sites which will provide reliable representative data.
4.Surveillance methods - lab based surveillance.
-supplementary.
5. Strengthening of lab capacities.
6. Providing diagnostic stewardship at the sites.

JIMMY ATYERA Replied at 2:31 AM, 22 Nov 2016

Questions and comments.
1.What is the National Drug Authority doing towards regulation of herbal medicines in Uganda?
2. Ugandan health practitioners should endeavor to fully educate their clients about the different antibiotics they are prescribing
3. Many Ugandans seek medical care from Private facility rather than government facilities including the health worker themselves.
4. What is the National Drug Authority doing towards regulating over- the counter (unprescribed) antibiotics.
5. The conference attendants expressed fear about the absence of clear regulations regarding the operation of private pharmacies in the country.
6.How do the herbal medicines get into the Ugandan market?
7. How can the general public access the data collected by the surveillance task force since it is not readily available even to the health practitioners.
8. Pharmacists who legally registered the different private Pharmacies are always not in these pharmacies and drugs are being sold and issued by dispensers who do not know the dosages.

JIMMY ATYERA Replied at 4:20 AM, 22 Nov 2016

Breakout Session 6.
Topic; Hospital Acquired Infections.

Topic ; Baby gel Pilot: A pilot cluster randomized trial of the provision of alcohol hand gel to postpartum mothers to prevent neonatal infective morbidity in the home.
Presenter; Dr. Ditai James.
The research was carried out in Mbale Regional Referral Hospital on 103 women (55 in intervention and 48control clusters).
Almost all, 99% participants who had live births were followed up until day 90.
Many health workers were not able to complete the WHO screening tool, especially taking vitals like respiratory rate, pulse.
Of the 98 live babies, 54 had evidence of infection. However, only 30 screened positive for the sepsis, 16 hadnclinically diagnosed infection, and 44 women mothers reported their babies as having been infected.
In total, 21 babies received antibiotics for suspected infections without screening.
There were 5 confirmed bacterial infections by positive culture and sensitivity.
The primary outcome of this study was problematic as many babies received antibiotics without the WHO IMCI Screening tool for sepsis.

JIMMY ATYERA Replied at 4:35 AM, 22 Nov 2016

Topic: Joint Medical Stores (JMS) Contribution in the fight against AMR.
1. Ensure quality of products in the market.
2. Rational/Appropriate use.
3.Consistent supply of medicines.
4. Advocacy for policies.
5.Physio-chemical screening.
6.Pedigree checks and pharmacovigilance.
7. Capacity building and advisory services.

Questions and comments.
1. Are there any current data JMS available on AMR in Uganda ?
Answer: Yes they but only that people do not bother to search for it.
2.Are diagnostics evaluted by higher authorities like NDA?
Only some are evaluated but others are not.

JIMMY ATYERA Replied at 5:16 AM, 22 Nov 2016

Moderator: Dr. Ambrose Otau Talisuna, WHO/CPI/WHO Regional Officer for Africa, Medical Officer.
Topic: Global Health Security and International Health Regulations-What we need to collectively make Africa safe.
There are 100 public health events annually of which 80% are infectious, 17% are disaster , 3% are chemical.
Uganda has one of the best response towards epidemics but despite that, no country is safe.
The 3clear objectives of the WHO regional strategies.
1. to Prevent epidemics.
2. To promptly detect epidemics.
3. To restore.

Al least 80% of the member states have developed joint internal evaluation committees.
The WHO has also developed a combined approaches with 4components.
1. Annual reporting.
2.After action Review.
3.Exercises.
4.Joint external evaluation.

Birikomawa Mathias Replied at 6:49 AM, 22 Nov 2016

Round Table Discussion.
Panelists.
1. Nicolas Kauta, Director Animal Resources, Ministry of Agriculture Animal Industry and Fisheries.
2. Patric Tusiime, Commissioner National Disease Control, Ministry of Health.
3. Donna Kusemererwa, Executive Director, National Drug Authority.
4.Nelso Sewankambo, President of Uganda National Academy of Sciences.
5.Henry Kajumbula, Chair, Ministry of Health Task Force on AMR-Surveillance.
6. Mohammed Lamorade, Principal Investigator, IDI-GHSP Project.
7.Bildard Baguma, Executive Director, Joint Medical Stores.

Discussion question: What and how each of these sectors may contribution to promoting best antimicrobial Practices in Uganda.
Some highlighted points.
1. Having the coordinating Partners and all appropriate contributors work together.
2. Influencing political support as well as support from the ministry of health.
3.Health workers' collaboration in promoting best antimicrobial practices.
4. Adopting the world Health approach.
5. Ensuring better remuneration to the health workers to enure motivation and availability in the health facilities.
6. Improving medical training to ensure that the Medical workers acquire quality knowledge and skills for effective practices.
7. Improving research and development within the country.
8. Stream lining surveillance on best antimicrobial practices.
9. Promoting intersectorial collaboration key to cabbing AMR.
10. Behavioral change in medical field.
11. Enhance community sensitization on antimicrobial use.

JIMMY ATYERA Replied at 7:25 AM, 22 Nov 2016

PLENARY SESSION: 6
MODERATOR: Dr. Crispus Tegu, Department of Head of Paediatrics, Busitema University Faculty Of Health Sciences.
Ongoing.

JIMMY ATYERA Replied at 7:27 AM, 22 Nov 2016

Topic: Artesunate/amiodaquine versus artemether/lumefantrine for treatment of uncomplicated malaria in Uganda: A randomized clinical trial at three sites in Uganda.
Presenter; Adoke Yeka, Makerere University Infectious DIsease Research Collaboration.

Background:
With older therapies limited by widespread drug resistance, standard treatment for uncomplicated
falciparum malaria is now artemisinin-based combination therapy, with nearly all endemic countries
in sub-Saharan Africa recommending either artemether/lumefantrine (AL) or artesunate/amodiaquine
(AS/AQ). In Uganda, AL has shown superior efficacy compared to AS/AQ and is the first-line
regimen. However, recent changes in treatment practices and evidence of shifting drug sensitivities
prompted a reassessment of the relative efficacies of these regimens.

Methods:
We enrolled 602 patients aged 6-59 months from health centers in Apac, Mubende, and Kanungu
Districts in Uganda in 2013-14. Children with uncomplicated falciparum malaria were randomly
assigned treatment with AL or AS/AQ, and 594 (98.7%) of those enrolled were followed for 28
days. Recurrent infections were genotyped to distinguish recrudescence from new infection, and
Plasmodium falciparum resistance-mediating polymorphisms were characterized for all infections.
Results:
The risk of recurrent parasitemia was lower in children treated with AS/AQ, compared to
those treated with AL, at all three sites (overall 28.6% vs. 44.6%, respectively; p <0.001).
Recrudescences were uncommon, but all occurred in the AL treatment arm (0% vs. 2.5%; p =
0.006). Improvement from baseline hemoglobin was greater in the AS/AQ arm (1.73 vs. 1.39 g/
dl, p = 0.04). Both regimens were well tolerated; serious adverse events were uncommon (1.7%
for AS/AQ and 1.0% for AL). Considering new infections after therapy, the two regimens selected
for opposite polymorphisms in pfcrt and pfmdr1, with each drug selecting for polymorphisms
associated with decreased sensitivity to the partner drug. Polymorphisms in the propeller domain of
the K13 gene, which have been associated with artemisinin resistance in Asia, were uncommon and
not associated with recurrent parasitemia.

Conclusion And Recommendations:
Both AL and AS/AQ were highly efficacious, however, overall, AS/AQ showed superior antimalarial
efficacy contrasting with older data and consistent with recent changes in parasite drug sensitivity.
Malaria treatment guidelines should consider multiple or rotating regimens to maintain the efficacies of the leading treatment.

JIMMY ATYERA Replied at 7:34 AM, 22 Nov 2016

Topic; From Antiretroviral Therapy Access to provision of the Third Line regimens: evidence of HIV Drug Resistance Mutations to first and second line regiments among Ugandan adults.
Presenter: Ivan Namakoola, MRCIUVRI Uganda Research Unit on AIDS.

Background:
HIV care programs in resource-limited settings have hitherto concentrated on antiretroviral therapy
(ART) access, but HIV drug resistance is emerging. In a cross-sectional study of HIV positive
adults on ART for ≥6months enrolled into a prospective cohort in Uganda, plasma HIV RNA was
measured and genotyped if ≥ 1000 copies/ml at enrollment. Identified drug resistance mutations
(DRMs) were interpreted using the Stanford database, 2009 WHO list of DRMs and the IAS 2014
update on DRMs, and examined and tabulated by ART drug classes.

Findings:
Between July 2013 and August 2014, 953 individuals were enrolled, 119 (12.5%) had HIVRNA≥
1000 copies/ml and 110 were successfully genotyped; 75 (68.2%) were on first-line and 35 (31.8%)
on second-line ART regimens. The commonest clinically significant major resistance mutations
associated with the highest levels of reduced susceptibility or virological response to the relevant
NRTI were M184V -20.7 %, K65R -8.0%, and thymidine analogue mutations (TAMS); M41L -8%
and K70R -8%, while major NNRTI mutations were K103N -19.0%, G190A - 7.0% and Y181C -
6.0%. A relatively nonpolymorphic accessory mutation A98G - 12.0%, was also common. Seven
of the 35 patients on second line ART had the most common clinically significant PI-resistance
mutations associated with the highest levels of phenotypic resistance and/or with the strongest
clinical evidence for interfering with successful PI therapy. These were V82A - 7.0%, I54V,
M46I, and L33I (all 5.0%). Also common were L10I - 27.0%, L10V -12.0% and L10F-5.0%
accessory PI-selected mutations that either reduce PI susceptibility or increase the replication of
viruses containing PI-resistance mutations. Of the 7 patients with major PI DRMs, five had high
level resistance to boosted Lopinavir and Atazanavir, with Duranavir as the only susceptible PI
tested.

Conclusions:
In resource-limited settings, HIV care programs that have previously concentrated on ART access,
should now consider provision of access to routine HIV viral load monitoring, targeted HIV drug
resistance testing and availability of third-line ART regimens.

JIMMY ATYERA Replied at 7:47 AM, 22 Nov 2016

Topic: Cultural, Ecological and Environmental drivers of AMR.
Presenter: Paul Kyambadde, Ministry of Health.

Environmental factors.
1. Effluent from production sites.
2.Animal manure fro live stock farming.
3.Inappropriate sewage treatment.
4. Inappropriate disposal of pharmaceutical companies.
5. Antibiotic use in both Animals and humans concurrently.

JIMMY ATYERA Replied at 8:22 AM, 22 Nov 2016

Topic: Changes and issues in antibiotic therapy in UCG 2016
Name: Juliet Kitutu, Appropriate Medicine Use Unit, Pharmacy Division, Ministry of Health.

Uganda Clinical Guideline guides the health workers on the optimal management of common conditions.
It is edited every after four years and the current edition id that of 206.

Priciples for antimicrobial usage in Uganda.
1. First line are narrow spectrum antibiotics, oral formulations.
2.Few antibiotics in Primary Health Care which include empirical broad spectrum.
3. Recommended switch to IV within 24hours if necessary.
4. Do culture and sensitivity whenever necessary.

Input/Sources of information.
1.Guidance from microbiology experts.
2.Situation analysis/recommendations by UNAS, 2015.
3.Ministry of Health and WHO Guidelines and and Policy.

General recommendations.
1. Cotrimoxazole NO LONGER recommended except fro prophylaxis against IOs in HIV.
2. Emphasize NO USE OF ANTIBIOTICS to treat nonbacterial infections and/or diseases.
Challenges faced by UCG.
1.Inadequate data on AMR pattern.
2.Lack of diagnostic tests to guide choice.
3.Balancing between rational use, cost containment without negativity.

Future Challenges.
1. Implementation challenges.
2.Health workers' attitude to UCG; ( Cheap, recommendations not the best).
3.Adherence to STGs still Poor (60% of non-pneumonia URTIs get antibiotics).
4.Private sector not well- regulated.
5. Need for community sensitization to complement efforts.

JIMMY ATYERA Replied at 9:04 AM, 22 Nov 2016

Closing remarks.
Dr. Joseph L. Mpagi ,Chairperson organizing committee, Head department of Microbiliogy and Immuniology, Busitema University Faculty of HEALTH sciences.
1. Thanked the participants of the conference.
2. Thanked the sponsors of the conference.
3. Encouraged dissemination of recommendations and resolutions made in this conference.
4. Promised to continually work together with all stakeholders wherever deemed necessary.
. Finally wished all participants safe travel back.