Nana Fosua Clement, EpiC Liberia Project Director, FHI 360

Antimicrobial resistance (AMR) occurs when microorganisms change over time and no longer respond to treatment with antimicrobial medicines, making infections harder to treat and increasing the risk of disease spread, severe illness, and death. According to the World Health Organization (WHO), AMR has become one of the leading public health challenges of the twenty-first century.

The Global Health Security Agenda (GHSA), which launched in 2014, aims to strengthen countries’ capacity to prevent, detect, and respond to emerging public health threats in a manner that aligns with International Health Regulations requirements. During the 2015 Group of Seven (G-7) Summit in Germany, G-7 leaders made a historic commitment to the GHSA, including a commitment to assist the countries of West Africa. Liberia officially committed to the GHSA in 2015 and began to strengthen critical capacities, including addressing, tracking, and managing AMR.

National assessment of antimicrobial stewardship

The Meeting Targets and Maintaining Epidemic Control (EpiC) project, funded by USAID, is partnering with the government of Liberia to strengthen health security capacity at all levels of the health system. In July 2024, EpiC conducted a nationwide needs assessment of AMR and antimicrobial use (AMU) stewardship. Twenty-two One Health laboratories — which conduct test analysis for human, animal, and environmental samples — across 12 counties were assessed. The assessment findings provided information about AMR surveillance capacity to guide policy decision-making and further interventions:

  • Over 60 percent of assessed facilities lack AMR/AMU capacities.
  • Most facilities with AMR/AMU capacities are not reporting data to the national AMR coordinating unit.
  • Stockouts of essential commodities are common.
  • There is an inadequate number of AMR sentinel sites across the country.

These findings call for prompt action to establish and support AMR and antimicrobial stewardship programs. In support of this goal, EpiC is supporting the Ministry of Health (MOH) to build laboratory staff capacity to conduct high-quality and safe detection of AMR and priority pathogens.

Addressing the growing threat of AMR

EpiC is partnering with the government of Liberia to address the growing threat of AMR and to regulate AMU. The project applies a multisectoral One Health approach, which recognizes the interconnection of human, animal, and environmental health. EpiC works collaboratively across sectors to develop and implement effective strategies that promote appropriate AMU, reduce AMR, and preserve the effectiveness of existing antimicrobials. EpiC engages relevant stakeholders including the National Diagnostic Division, National AMR Unit, MOH, National Reference Laboratory, National Public Health Institute of Liberia, and USAID global health security implementing partners working to coordinate health security activities.

Training on operation of the GeneXpert machine, which tests clinical samples for infectious diseases, at GW Harley Hospital. Photo by EpiC Liberia.

EpiC Liberia’s approaches to strengthen capacity for AMR detection, surveillance, reporting, and data sharing include the following:

  • Mentorship and coaching: EpiC strengthened surveillance of pathogens through on-site mentorship and coaching of more than 30 laboratory staff in three county-level clinical laboratories and built their capacity to conduct quality and safe detection and characterization of AMR in priority pathogens at the three county level hospitals across Bong, Lofa and Nimba. Staff were mentored on techniques and procedures for pathogen identification, how to conduct antimicrobial susceptibility testing, generation of AMR data and reporting to the national unit, results validation, and quality control and assurance.
  • Upgrading laboratory facilities: Tellewoyan Hospital Laboratory in Lofa previously reported data to the Global Antimicrobial Surveillance System (GLASS) — a global WHO platform launched in 2015 to foster AMR surveillance and inform strategies to contain AMR — but stopped in 2022 due to lack of regular power supply. To address this gap, EpiC upgraded the solar system and provided training for end-users at the laboratory. With solar power, the facility now has 24-hour electricity and can commence bacteriology testing to detect AMR and will once again report data to GLASS.  
  • Multisectoral coordination: EpiC is convening quarterly review meetings on surveillance of pathogens by the AMR technical working group to share lessons, best practices, challenges, and solutions. EpiC also provides a platform for multisectoral coordination of AMR by offering a dedicated Zoom link and data to the MOH, enabling quarterly multisectoral meetings in which to share experiences and troubleshoot challenges together.
  • Monitoring progress and mobilizing resources: EpiC participated in working sessions with partners, including the government, to finalize the Tripartite AMR Country Self-Assessment Survey (TrACSS) for Liberia. TrACSS is administered annually to monitor implementation of the AMR national action plan. Data from previous TrACSS surveys has further informed the development of key AMR interventions and technical documents such as the National Health Policy (2022-2031), National Antimicrobial Stewardship Guidelines and Toolkits (2021), Integrated AMR Surveillance Strategic Plan (2023), National IPC Strategic Plan (2023) and the National WASH in Healthcare Facility Roadmap (2018-2024). The TrACSS process also facilitates advocacy and resource mobilization from partners and the government to support AMR interventions.
  • Addressing stockouts of essential commodities: EpiC is working with in-country stakeholders to address stockouts of essential laboratory commodities identified through the nationwide assessment. EpiC Liberia will procure and preposition these needed commodities for three county referral labs. Furthermore, EpiC will facilitate certification of a biosafety cabinet to protect personnel against biohazardous or infectious agents across three counties (Bong, Lofa and Nimba); certification is required annually.
  • Expanding bacteriology testing: EpiC is also expanding bacteriology testing for detection of AMR through strengthening sample referral and transport from district to county labs. EpiC is working with the MOH to develop a sustainability plan that includes training and establishing long-term funding sources.

Next steps and the way forward

While gains have been achieved in combating AMR, EpiC recognizes the need to continue addressing the growing threat of AMR and to regulate AMU. EpiC will continue to support the government to strengthen resource mobilization, coordination and collaboration to enhance capacity for AMR and AMU detection, classification, and surveillance across sectors in the country.

Featured image: Training on bacteriology sample collection, packaging, and transport. Photo by EpiC Liberia.