Osaretin Christabel Okonji

BACKGROUND: A critical and persistent challenge to global health and modern health care is the threat of antimicrobial resistance (AMR). Previous studies have reported a disproportionate burden of AMR in low-income and middle-income countries, but there remains an urgent need for more in-depth analyses across Africa. This study presents one of the most comprehensive sets of regional and country-level estimates of bacterial AMR burden in the WHO African region to date. METHODS: We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen-drug combinations for countries in the WHO African region in 2019. Our methodological approach consisted of five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths attributable to AMR (considering an alternative scenario where infections with resistant pathogens are replaced with susceptible ones) and deaths associated with AMR (considering an alternative scenario where drug-resistant infections would not occur at all). We obtained data from research hospitals, surveillance networks, and infection databases maintained by private laboratories and medical technology companies. We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. FINDINGS: In the WHO African region in 2019, there were an estimated 1·05 million deaths (95% UI 829 000-1 316 000) associated with bacterial AMR and 250 000 deaths (192 000-325 000) attributable to bacterial AMR. The largest fatal AMR burden was attributed to lower respiratory and thorax infections (119 000 deaths [92 000-151 000], or 48% of all estimated bacterial pathogen AMR deaths), bloodstream infections (56 000 deaths [37 000-82 000], or 22%), intra-abdominal infections (26 000 deaths [17 000-39 000], or 10%), and tuberculosis (18 000 deaths [3850-39 000], or 7%). Seven leading pathogens were collectively responsible for 821 000 deaths (636 000-1 051 000) associated with resistance in this region, with four pathogens exceeding 100 000 deaths each: Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus. Third-generation cephalosporin-resistant K pneumoniae and meticillin-resistant S aureus were shown to be the leading pathogen-drug combinations in 25 and 16 countries, respectively (53% and 34% of the whole region, comprising 47 countries) for deaths attributable to AMR. INTERPRETATION: This study reveals a high level of AMR burden for several bacterial pathogens and pathogen-drug combinations in the WHO African region. The high mortality rates associated with these pathogens demonstrate an urgent need to address the burden of AMR in Africa. These estimates also show that quality and access to health care and safe water and sanitation are correlated with AMR mortality, with a higher fatal burden found in lower resource settings. Our cross-country analyses within this region can help local governments to leverage domestic and global funding to create stewardship policies that target the leading pathogen-drug combinations. FUNDING: Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.

Background: Access to safe, effective, affordable, and quality medicines is an essential component of the right to health and is also one of the targets in the global development agenda. In this review article, we extensively discuss the challenges and issues surrounding access to medicines in the African region as well as provides recommendations for ensuring medicines security on the continent. Methods: We conducted narrative review with the use of data reported in published literature, reports, and grey literature available in African countries on topics pertaining access to medicines. The authors also snowballed further data to gather information for this review and narrative synthesis was conducted. Results: Africa faces a double burden of infectious and non-communicable diseases and the need for effective universal access to medicines cannot be deemphasized. However, access to medicines on the continent is not without issues and challenges. Some of which are the high burden of infectious diseases and non-infectious diseases, limited pharmaceutical industries and high costs of raw materials, overdependence on countries abroad for medicines, poor supply chain systems, lack of government investment in the pharmaceutical sector, unfavourable manufacturing conditions, limited health workforce, lack of sustainable health financing mechanisms, lack of infrastructures and technical know-how, low investment on research and development, and circulation of fake and counterfeit medicines among others. Conclusion: This review reifies that access to medicines in Africa faces numerous challenges and it emphasizes the urgent need to address these issues as the continent geared towards strengthening its health systems for universal health coverage.

The SARS-CoV-2 infection, which causes the COVID-19 disease, has impacted every nation on the globe, albeit disproportionately. African countries have seen lower infection and mortality rates than most countries in the Americas Europe and Asia. In this commentary, we explore some of the factors purported to be responsible for the low COVID-19 infection and case fatality rates in Africa: low testing rate, poor documentation of cause of death, younger age population, good vitamin D status as a result of exposure to sunlight, cross-immunity from other viruses including coronaviruses, and lessons learnt from other infectious diseases such as HIV and Ebola. With the advent of a new variant of COVID-19 and inadequate roll-out of vaccines, an innovative and efficient response is needed to ramp up testing, contact tracing and accurate reporting of infection rates and cause of death in order to mitigate the spread of the infection.

Background: Tuberculosis is the leading cause of death from a single infectious agent among the HIV-negative population and ranks first among the HIV-positive population. However, few studies have assessed tuberculosis trends in Brazil, Russia, India, China and South Africa (BRICS) or with an emphasis on HIV status. This study assesses the time trends of tuberculosis mortality across the BRICS with an emphasis on HIV status from 1990 to 2019. Methods: We obtained tuberculosis data from the Global Burden of Disease 2019 study (GBD 2019). We calculated the relative proportion of tuberculosis to all communicable, maternal, neonatal, and nutritional diseases by HIV status across the BRICS. We used age-period-cohort modelling to estimate cohort and period effects in tuberculosis from 1990 to 2019, and calculated net drift (overall annual percentage change), local drift (annual percentage change in each age group), longitudinal age curves (expected longitudinal age-specific rate), and period (cohort) relative risks. Findings: There were 549,522 tuberculosis deaths across the BRICS in 2019, accounting for 39.3% of global deaths. Among HIV-negative populations, the age-standardised mortality rate (ASMR) of tuberculosis in BRICS remained far higher than that of high-income Asia Pacific countries, especially in India (36.1 per 100 000 in 2019, 95% UI [30.7, 42.6]) and South Africa (40.1 per 100 000 in 2019, 95% UI [36.8, 43.7]). China had the fastest ASMR reduction across the BRICS, while India maintained the largest tuberculosis death numbers with an annual decrease much slower than China's (-4.1 vs -8.0%). Among HIV-positive populations, the ASMR in BRICS surged from 0.24 per 100 000 in 1990 to 5.63 per 100 000 in 2005, and then dropped quickly to 1.70 per 100 000 in 2019. Brazil was the first country to reverse the upward trend of HIV/AIDS-tuberculosis (HIV-TB) mortality in 1995, and achieved the most significant reduction (-3.32% per year). The HIV-TB mortality in South Africa has realised much progress since 2006, but still has the heaviest HIV-TB burden across the BRICS (ASMR: 70.0 per 100 000 in 2019). We also found unfavourable trends among HIV-negative middle-aged (35-55) adults of India, men over 50 in the HIV-negative population and whole HIV-positive population of South Africa, and women aged 45-55 years of Russia. China had little progress in its HIV-positive population with worsening period risks from 2010 to 2019, and higher risks in the younger cohorts born after 1980. Interpretation: BRICS' actions on controlling tuberculosis achieved positive results, but the overall improvements were less than those in high-income Asia Pacific countries. BRICS and other high-burden countries should strengthen specified public health approaches and policies targeted at different priority groups in each country. Funding: National Natural Science Foundation of China (82073573; 72074009), Peking University Global Health and Infectious Diseases Group.

In August 2021, the Marburg virus disease (MVD) outbreak was confirmed amid the coronavirus disease 2019 (COVID-19) pandemic in the Republic of Guinea. This is the first time it is detected in Guinea and West Africa. Marburg virus is one of the world's most threatening diseases, causing severe haemorrhagic fever, with a case fatality rate of 90%. Currently, there are no vaccines and specific antiviral drugs for MVD. Technical teams and community health care workers that were set up as part of the recent Ebola virus disease (EVD) outbreak that was declared over on June 19, 2021, are now redeployed to support governments response activities of the MVD outbreak in the country. The MVD is an added burden to the fragile healthcare systems that are already overburdened with multiple reoccurring epidemics and the COVID-19 pandemic. Previous epidermic strategies are needed to contain the spread of the disease, amid the COVID-19 pandemic, so the health care systems are not overwhelmed. This commentary discusses the available evidence regarding the epidemic of MVD in Guinea amid the COVID-19 pandemic, and highlights the efforts, challenges to be prioritized, and provides evidence-based recommendations.