Essay – Draft

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Public Health Issue: Increasing Antimicrobial Resistance Challenge in the UK and Nigeria

Introduction

The essay proposes to critically analyse the public health issue from a national context
and global health perspective. The chosen health issue is the increased antimicrobial resistance
and associated challenges. Antimicrobial resistance emerged as a concerning alarm because of
unrestrained use of these in man and animals prompted us towards their resistance. The
controversies are found in the long-term risk of using antimicrobial agents for medical care and
in the agriculture sector. This is so because the consistent use disrupted the bactericidal effects of
antibiotics since bacteria evolved over time in their genus and species (Wise et al., 1998). The
present discussion, therefore, shed light on this public health challenge and describes the national
and global health measures against the issue. The government and regulatory framework for
assessment, risk management and health promotion strategies have also been discussed. Finally,
a case of an emerging public health issue has been detailed with implemented changes.

Public Health Issue

Antimicrobial resistance (AMR) is narrated as a multifaceted phenomenon across the
globe. The issue has affected both the health and economy of the world. Antibacterial resistance
(ABR) emerged as the most significant concern with the large spread of communicable diseases
caused by bacterial infections. Global health was greatly compromised as the Center for Disease
Control and Prevention (CDC) in the US reported that about two million incidental cases are
caused by microbial infections, and > 20,000 mortalities in the states are reported (Prestinaci,
Pezzotti and Pantosti, 2015). In Europe, multidrug-resistant bacteria are the main cause of
mortality (Prestinaci et al., 2015). One of the drastic effects of AMR is its relatable harms
irrespective of the country's income and developmental level. For example, the issue is highly
prevailing at all developmental levels, including the US, Europe, Africa, and Southeast Asia. The
surveillance report by World Health Organisation (WHO) from Nigeria, 2014 demonstrated a
high level of gram-negative bacterial resistance towards common and frequently used antibiotics
in the region (Tadesse et al., 2017). However, the present patterns of incidence and management
show differences in the European and African countries and therefore, the comparison is carried
out between countries in these two regions.
 In the United Kingdom, the significant mortality caused by the outbreak of beta-lactam E.
coli and Klebsiella pneumonia extended the suffering of the population and caused the public a
major health cost (Webster et al., 2011). On the other hand, in Nigeria, the increase in multidrug-
resistant bacteria causing typhoid fever is currently posing a serious challenge. The African
countries contribute greatly to the world death statistics associated with typhoid fever. The lack
of sanitation, extensive urbanisation, overcrowdedness, and ineffective healthcare delivery
system is the reason for such severity (Akinyemi et al., 2018). The management in both countries
differs in their status of development. The AMR-gram negative bacterial incidence is frequently
reported in Nigeria. The current management practices in Nigeria include the daily prescriptions
of medicines and less practice of antibiotic stewardships (Babatola et al., 2021). However, the
prescribing practices are still underdeveloped. On the other hand, practices in the UK suggested
reducing prescribing of antibiotics. The national policy in the UK guided the NHS staff to
perform hygienic practices such as standardised care, knowledge skills, and prevention and
control. The nurses and midwives follow the antibiotic stewardship strategy to tackle the
challenges through diagnosis, prevention, and person-centered care (RCN, 2022).

In addition, no specific management approach from Nigeria is reported. However,

research conducted surveys to analyse the use of antibacterial agents that would facilitate the
development of a strategic plan (Awogbemi, Adeyeye and Akinkunmi, 2018). Unlike in the UK,
risk assessment practices have been developed. The national policy imposed the emergency risk
management practice (ERMP), which is a five-step procedure and ensures that the risk profile for
AMR epidemics is generated and registered and use in case of emergency management of the
incidence (Dominey-Howes et al., 2015). There may be different risks of incidence and
management of the public health issue in a global and national context, and therefore a
comparative approach for public health measures is the most effective method to critically
analyse each healthcare system of two countries without criticizing any one of them (Lovett-
Scott and Prather, 2014). A comparative healthcare system in the context of chosen public health
issue is reflected in the next section with a discussion about primary, secondary, and tertiary care
in Nigeria and UK and a discussion about national and global health measures.
 National and Global Health Measures

The public health measures and actions are developed by the national and international
bodies that are aimed at preventing the spread of infectious diseases. AMR has become an
important concern of the global health agenda since the rising voice of national parties from
different countries. The global health measures for AMR rest on collaborative practices and
public-private partnerships between organisations to tackle the challenges at national and
international levels (Wernli et al., 2017). For example, the Prime Minister of the UK, David
Cameron, proposed a review to address the challenges of AMR and recommended effective
solutions that can be implemented on a global scale (O'Neill, 2016). Both in UK and Nigeria, the
national and global health measures would be individually discussed to analyse the effectiveness
of national and global efforts to reduce AMR in the two countries.

In the UK, primary care focuses on antimicrobial stewardship as per the guidelines of
WHO, which suggests that microbial resistance is caused by microbial potential against
medications. Therefore, a stewardship approach guides the prescribing patterns for the effective
management of microbial infections without the risk of developing resistance (GOV.UK, 2019).
The national care program focused on raising awareness and changing prescribing behaviours,
and implementing prevention and control in both primary and secondary care management. The
dispensing and administering of antibiotics are difficult to process in both care settings, and
therefore National Health Service (NHS) made efforts with Public Health England (PHE) to
tackle the challenges (NHS) (DH, 2013). However, the development of national action remains
ineffective without global significance. The UK, Netherlands and Sweden developed an action
called AMR Package supported by global health security agenda started by WHO. The global
effort proved effective for tertiary or specialised care treatment in the UK with education and
good prescription practice. Antibiotic prescribing was reduced, and public health professionals
received training in the specialist curricula (Hopkins, 2016).

On the other hand, Nigeria's traditional healthcare services provide care in both the public
and private sectors. However, 85% are only covered by primary care services, and the rests are
from secondary and tertiary care. Nigeria faced an increased burden of communicable diseases
such as malaria, respiratory infections, and tuberculosis, accounting for > 60% of total morbidity
(NCDC, 2017). The impulsive patterns of AMR prescribing and use are highly reported from the
local regions in the state. The bacteria causing UTI (urinary tract infection) showed greater
resistance. The governing policies aimed to form collaboration and use a comprehensive
approach at all healthcare levels to address the issues. In November 2016, the government took
action to develop a tripartite structure based on federal developmental bodies whose purpose was
to use the 'One Health' approach against AMR (NCDC, 2017). The 'One Health' approach is
conceptualised by the World Health Assembly, adapting this global action plan in collaboration
with member states. The action plan ensured effective disease surveillance and safe medicine use
in countries facing the threats of AMR. The WHO demonstrated the significance of the One
Health approach in Nigeria because of ineffective surveillance and lack of specialised care
practices. This was the most effective global health measure that was implied in the national
context to overcome the disturbing situation in the country (NCDC, 2019). In addition, the
national efforts are reflected in the development of Nigeria's AMR coordinating national body,
which carried out the situational analysis on public awareness, disease surveillance, one health
coordination, and practice of antimicrobial stewardship (NCDC, 2019). However, these actions
still require practical reality to tackle the outbreaks of public health issues.

The policy and regulations significantly emerged over time in both countries. The
practices such as risk assessment and emergency management for AMR evolved to impact the
outcomes of public health issues. As proposed earlier, the global and national health measures
were the adaptations of policy developments. In a UK study, Carter and colleagues conducted a
risk assessment for PAN-drug resistance (gram-negative bacteria resistance), which collected
data from surveillance systems and responses of experts. The research was based on a
quantitative approach and concluded that AMR-associated death rates are increasing in the UK,
subjecting to the need for national policy and regulations (Carter et al., 2017). The national
efforts also focused on harnessing the action plan for emergency response against AMR. The
country speeds up its rapid diagnostic testing, especially in the present situation of pandemics
(Martínez, 2020).

In Nigeria, NESREA, the environmental regulatory agency, directed the field farmers to
carry out a risk assessment for environmental management against the AMR. It supported the
country's preventive practices in the agricultural sector. The efforts to reduce the infectious
spread in food products would safeguard the health of individuals from infectious incidences
(WHO, 2018). Other types of approaches are the national investments into the governance of the
One Health approach to ensure antimicrobial stewardship and fostering communities to
participate at the local level in the management of AMR within society (Achi et al., 2021). These
approaches reflect some assessment and management actions that can result in positive health
outcomes in the population.

Healthcare systems of both countries for health promotion – transnational bodies (WHO,
UN, UNICEF) can be included as well – 700

Justified case with system changes – 500

Conclusion – 200

Critically appraise work that has contributed to the assessment of risk, incident management,
emergency planning and/or legal and regulatory governance which may impact on Antimicrobial
resistance.

Many organizations in UK and Nigeria are conducting research and research based surveys for
risk assessment of antimicrobial resistance.

Antimicrobial resistance is a global problem that is affecting the life and economy of our
country. To overcome this problem world is working together and many transitional bodies are
also playing their role to manage this global issue of Antimicrobial resistance. On May 2017
Nigeria submitted national action plan to WHO for antimicrobial resistance. This national action
plan was developed according to “One health” approach. Nigeria also participated in WHO
GLASS surveillance program. Nigeria is also strengthening stewardship on antimicrobial use in
humans and food animals(1) . In contrast to Nigeria, UK is also working hard to manage this
global issue.UK develop their 2019–2024 national action plan to tackle AMR within and beyond
their borders. This national action plan put forward three ways for tackling Antimicrobial drug
resistance: minimization of unintentional exposure to antimicrobial, optimization in the use of
antimicrobials and by investing in innovation, supply and access.(2)

Legal and regulatory bodies are also working in UK and Nigeria in collaboration with
transitional bodies like WHO, UN, UNICEF. In both countries legal and regulatory bodies have
made legislation and passed the law according to which no one can buy antimicrobial agents
without prescription, limited time is prescribed for the consumption of antimicrobial agents and
no one can consume them for a longer period.

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