91Â鶹ÌìÃÀ

This article was originally published in May 2024 and has been updated for inclusion in the Fall 2024 issue of Microcosm.

It’s true what they say about strength in numbers, and in the fight against antimicrobial resistance (AMR) in Tanzania, laboratories and health systems are finding strength in the form of numerical data.

Through the support of the , 91Â鶹ÌìÃÀ is working alongside public health experts in Tanzania to implement the country’s National AMR Surveillance Framework. This initiative focuses on enhancing laboratory capabilities to produce high-quality data on local resistance patterns for patient treatment and streamlining surveillance activities across both human and animal populations.

"It's not just about ensuring that the data are collected, but also that they are quality-assured and have been validated," said Wes Kim, Ph.D., Director of 91Â鶹ÌìÃÀ’s Global Public Health Programs (GPHP). This emphasis on data-gathering positions Tanzania as a beacon of progress in the battle against this global health threat. “Tanzania is part of a global network of countries that are supporting the fight against AMR,” Kim said.

---

Interested in learning more about 91Â鶹ÌìÃÀ’s Global Public Health Programs?

---

The Mission Behind the Work

Amid surveillance challenges in the region, 91Â鶹ÌìÃÀ’s work in Tanzania emphasizes strategic collaborations, capacity-building and sustained investment to fortify the region’s defenses against AMR.

In partnership with the Fleming Fund, 91Â鶹ÌìÃÀ has supported a significant overhaul, from refurbishing 8 laboratories, to equipping labs with critical instruments like Vitek MS Maldi Tof, (for reliable microbial identification (ID) and antibiotic susceptibility testing (AST)) and BD BacTec FX Top 200 (automated blood culture analyzer) machines.

The Department of Health and Social Care (DHSC)'s Fleming Fund is a United Kingdom (U.K.) aid program supporting up to 25 countries across Africa and Asia to tackle AMR. The Fleming Fund invests in strengthening AMR surveillance systems through a portfolio of country grants, regional grants and fellowships managed by and global projects managed by DHSC. Since 2019, 91Â鶹ÌìÃÀ's Tanzania program has been a country grantee of the Fleming Fund’s investment, bolstering in-country capacity for sustained AMR surveillance and response.

Central to the approach of 91Â鶹ÌìÃÀ's Tanzania program, supported by the Fleming Fund, is a commitment to building lasting capacity within the country that is sustainable and country-owned. By teaming up with local entities, such as the and the , the program (during phase I) led targeted trainings for existing laboratory staff to catalyze sustained, quality-assured data collection and analysis processes across 7 human health surveillance sites and 5 animal health sites, including the national reference laboratories.

AMR Surveillance in Action: Monitoring Dairy Cattle in Tanzania

With one of the , Tanzania is a major source of dairy and beef production. Considering , 91Â鶹ÌìÃÀ’s Fleming Fund Tanzania program launched a pilot program in 2023 (October-November) aimed at surveilling AMR in regions with high livestock density.

“This work helps veterinarians and livestock farmers understand the pattern of resistance,” said Ade Olarewaju, M.S., 91Â鶹ÌìÃÀ’s GPHP Program Officer and Program Lead. “It also helps farmers understand the impact of treating their livestock with antibiotics.”

Olarewaju explained that by characterizing resistance patterns, stakeholders can collaborate to raise awareness and educate livestock operators about the implications of antibiotic use in animal treatment, especially inadvertent transmission of antibiotics to humans through the animal products they consume, like milk.

While results from this pilot program are not yet finalized, the surveillance laboratory was able to conduct a phenotypic test to assess the impact of AMR among a sample of dairy cattle. “The plan is to conduct genetic/molecular characterization of the isolates obtained from the active surveillance. This will help to better understand transmission dynamics and how this relates to pathogens and the resistance patterns,” Olarewaju explained.

Of the more than 600 cows tested, approximately 86% were California Mastitis Test (CMT) positive. And, of the sub-clinical mastitis cows that the team identified, 360 milk samples were procured across several farms. Staphylococcus aureus, Enterococci and E. coli were present in over half of these samples. Further AST revealed multiple resistance patterns for at least 3 pathogens.

This included Enterococcus spp. (resistance to ciprofloxacin, erythromycin, ampicillin, trimethoprim and sulfamethoxazole), which overall had a higher level of multidrug resistance compared to other pathogens, Staphylococcus aureus (resistance to trimethoprim, sulfamethoxazole, ciprofloxacin and erythromycin) and E. coli (resistance to tigecycline, ampicillin and ceftazidime).

“The high prevalence of sub-clinical mastitis among lactating cows (86.3%) indicates a significant health issue within the cattle population. This condition can impact milk quality and animal welfare, affecting both production and animal health,” Olarewaju said. “Continuous surveillance and monitoring of AMR in cattle populations are crucial to track trends, identify emerging resistance patterns and implement targeted interventions to preserve the effectiveness of available antimicrobials and safeguard animal and public health.

"Addressing these implications requires a multifaceted approach involving prudent antimicrobial use in veterinary practices, enhanced surveillance, research into alternative treatments and education about responsible antibiotic usage in livestock,” Olarewaju said. The Directorate of Veterinary Services (DVS) plays a pivotal role in these efforts, coordinating the implementation of strategies, providing guidance on best practices, ensuring compliance with regulatory frameworks and overseeing various initiatives aimed at combating AMR as it relates to animal health.

Olarewaju also noted the findings presented in this report are based on a specific study conducted in a particular region and may not be generalizable to other regions in-country or other settings.

How Data Informs Policy

Data collected from surveillance efforts often fuel major policy moves, especially when it comes to public health decisions. “Data are the cornerstone of evidence-based policy making,” Olarewaju said. “If you don't have data, everything will be [based on] an opinion, and it can be dangerous to create policies based on opinion alone.”

For example, blood samples collected from patients and tested for drug-resistant bacteria enable detection of resistance to front-line antibiotics. This can indicate to policymakers that the typical course of action for prescribing antimicrobials would only further contribute to AMR. These data are most compelling to health and agriculture officials.

Antibiograms developed by surveillance sites are used to inform antibiotic prescription practices and the preparation of hospital formularies. Tanzania is proactively reviewing the National Standard Treatment Guideline ahead of schedule, prompted by significant findings from 4 years of AMR data generated through Fleming Fund support. Furthermore, Fleming Fund’s support was instrumental in the development of Tanzania’s AMR National Action Plan (NAP) 2023-2028. And, ultimately, when put into action, new policies can empower health care providers to treat patients based on local resistance patterns.

“After all those data are collected, we may need to implement better stewardship policies, for example, so patients are not just going to a pharmacy and picking up antibiotics when [their ailment] may be a viral infection, rather than bacterial,” Kim said.

Surveillance Challenges in Tanzania

The burden of AMR has disproportionately impacted Africa, including Tanzania. Limited access to diagnostic services and quality-assured microbiology laboratories severely hampers surveillance capabilities that are critical for properly treating patients and fortifying defenses against AMR. In 2019, . This number outranked deaths associated with tuberculosis, malaria, HIV/AIDS and other adverse health conditions in the region.

Among the 50,000 medical laboratories networked across 14 participating countries in the project (a program supported by the Fleming Fund and led by the ), 1.3% engage in bacteriology testing to identify what kind of bacteria might be causing an infection, highlighting a critical gap in diagnostic infrastructure. Compounding this challenge is a limited workforce, Africa.

is a program that works toward strengthening laboratory systems. Despite this program’s efforts, to standards. The accreditation provides assurances of quality testing to patients and the broader community.

91Â鶹ÌìÃÀ, in partnership with Fleming Fund, hopes to address these surveillance challenges in Tanzania.

Key Milestones in Tanzania

A key output of phase I included establishing Technical Working Groups (TWGs) and strengthening the functionality of the Multi-sectoral Coordinating Committee for One Health alignment. The formation of TWGs has greatly enhanced critical components of AMR surveillance, including the development and review of guidelines, tools and protocols. Continued support through regular meetings and the implementation of surveillance activities in alignment with the NAP enabled smooth operation of national AMR governance. Through these collaborative efforts, the work has led to improved surveillance mechanisms, the development of standardized documentation and the production of quality-assured data, thereby fostering a robust framework for sustained progress in combating AMR.

In addition, with Fleming Fund’s support, 91Â鶹ÌìÃÀ prioritized modernizing laboratories by refurbishing 3 human health and 4 animal health laboratories, while updating 12 others with microbiology equipment and supplies. 91Â鶹ÌìÃÀ also facilitated the establishment of a robust nationwide framework for AMR data aggregation, management and reporting across the 12 sites. This enabled training and mentorship of more than 200 laboratory personnel on biosafety measures and advanced AMR laboratory techniques.

The program’s engagement in national antimicrobial consumption (AMC) and use (AMU) data compilation and submission to the underscores a commitment to global health. Across the human health sector, the work also catalyzed a significant surge in human blood and urine sample collection and AMR testing, soaring from 9,690 samples collected and analyzed in 2020 to 42,682 in 2022.

The number of priority bacteria (S. aureus, Klebsiella pneumoniae, E. coli and Acinetobacter baumannii) reported to the GLASS showed a steady increase from 895 in 2020 to 3,352 in 2021 and, most recently, 4,289 in 2022. Analysis of the 2020-2022 AMR surveillance data showed persistent high resistance rates to first-line antibiotics, which highlights the need for robust antimicrobial stewardship programs and updated treatment guidelines tailored to local findings.

At the site/facility level, 91Â鶹ÌìÃÀ trained 6 hospitals to conduct Point Prevalence Surveys (PPS), which assist health care professionals to monitor antimicrobial efficacy and best practices for prescribing pharmaceuticals vital for effective treatment. Nationally, data is being used to update scientific guidelines for conditions such as UTIs and sepsis. Health systems also tapped into this countrywide AMR stewardship effort. Moving forward, efforts are focused on ensuring data quality and utilizing it for policy change and a more streamlined sample flow to laboratories for efficient surveillance.

Given the small percentage of veterinary labs engaged in bacteriology testing, 91Â鶹ÌìÃÀ established the Central Veterinary Laboratory and collaboratively facilitated ISO 17025: 2017 accreditation for 4 tests by SADCAS (Rose Bengal Plate Test for Brucellosis, Indirect ELISA Brucella, Competitive ELISA CBPP (Contagious bovine Pleuropneumonia), Real Time PCR Brucella).

Data on veterinary drug importation and AMC gathered from Tanzania Medicines and Medical Devices Authority (TMDA) over a period of 2 years (2021-2022) through the Fleming Fund’s support revealed common antimicrobial groups used in Tanzanian animals, which includes tetracycline, sulfonamides, penicillin, macrolides and antiprotozoals.

Possible reasons for their use include frequent bacterial and parasitic diseases, low vaccination rates and over-the-counter use as prophylactics due to inadequate biosecurity. All antibiotic classes showed an increase in quantity except beta-lactams, which may possibly have decreased due to resistance development, based on key findings from passive AMR data. Further research is needed to confirm these hypotheses.

Quantities (kg) of Most Consumed Classes of Antibiotics in Tanzania by Veterinarians During 2021-2022

Scroll right to see full table.

The program in Tanzania ultimately leverages in-country expertise with local subject matter experts (SMEs) serving as consultants. This work has garnered support from the Tanzania Ministry of Health and Ministry of Livestock and Fisheries, which not only amplifies its efficacy, but also fosters a sense of ownership and sustainability.

Through mentorship and strategic alliances, 91Â鶹ÌìÃÀ has helped transform laboratory capacities and lay a strong foundation for the implementation of evidence-based antimicrobial stewardship strategies in alignment with Tanzania’s National Action Plan on AMR.

Creating a Lasting Impact

Now, with the foundational investments in place, sustaining Tanzania’s AMR surveillance and stewardship efforts will be the prime focus for phase II of the Fleming Fund investment, for which 91Â鶹ÌìÃÀ has been recently awarded a 2-year, £3 million continuation country grant.

“Tanzania is now one of the leading countries in the region [for AMR surveillance] and in the implementation of the ,” said Patrick Mubangizi, FCCA, Regional Director of Africa for the Fleming Fund. "This plan outlines infection prevention control from farms to hospitals,” he explained.

In the second iteration of the program, 91Â鶹ÌìÃÀ will further expand quality data collection and analysis for both human and animal health sectors, while also furthering engagement with the government of Tanzania toward sustainable investments at national and global levels to counter AMR. This includes publishing and promoting outputs of surveillance efforts to inform policies and institutionalize surveillance governance and leadership.

91Â鶹ÌìÃÀ will facilitate the development of a national stewardship strategy, including updating national human and veterinary treatment guidelines, hospital formularies and adopting at select sites. At the end of phase II of the Fleming Fund grant, Tanzania will have costed strategies and plans for the country’s AMR response, thereby characterizing the level of sustainable government investments required beyond this.

"Advocating and educating people around what AMR is and its impact will be critical for assuring government’s continual commitment to combat drug-resistance," Kim said.

---