Between 2017 and 2019, cholera and typhoid swept through Zimbabwe, infecting thousands. Unlike in decades past, however, frontline antibiotics were not a treatment option because the pathogens had grown resistant to them. 

Now, with thirteen new confirmed cases of cholera as of March 18, fears of another outbreak in the country are mounting given the possibility of further resistant strains that are even more difficult to address. 

Antimicrobial resistant pathogens killed at least 1.27 million people globally in 2019, according to the U.S. Centers for Disease Control and Prevention. 

A recent multicountry study measured the local effectiveness of antibiotics and evaluated the extent to which they were used or consumed. A drug resistance index of 25 percent indicates that antimicrobial resistance is under control. According to the study, which was conducted by the Mapping Antimicrobial Resistance and Antimicrobial Use Partnership, led by the African Society for Laboratory Medicine, Zimbabwe scored 66 percent, which indicates a high risk of antimicrobial resistant pathogens.  

The data "conclusively demonstrate the very real threat of antimicrobial resistance in Africa," says Tapiwanashe Kujinga, the director of the Pan-African Treatment Access Movement, an organization spearheading awareness campaigns on antimicrobial resistance in Zimbabwe. 

Kujinga says that the growing drug resistance is attributable to people's misusing medications obtained in unregulated sales or failing to complete full courses of prescribed medications.  

Edwin Muguti, a surgeon and Zimbabwe's former deputy health minister, says that general practitioners and pharmacists who inappropriately prescribe and dispense medications to maximize profits also contribute significantly to drug resistance. For example, clinicians may provide inadequate courses of antibiotics for Helicobacter pylori, a common cause of stomach ulcers, and the shortened treatments contribute to drug resistance.  

The same principles apply to cholera, typhoid, and other bacterial infections, he said, including sexually transmitted infections and tuberculosis. Access to clean water and effective sanitation are the most important ways to prevent these waterborne diseases. 

"Antibiotics are secondary," he stressed, "because they only come into play after failure of primary prevention." 

Researchers nonetheless say that the strains of cholera and typhoid present in outbreaks in Zimbabwe between 2017 and 2019 showed growing evidence of antimicrobial resistance and were more difficult to contain using the usual antibiotics. 

An outbreak of typhoid in 2017 and 2018 that is believed to have sickened more than three thousand people was caused by an antibiotic resistant strain. The firstline drug, ciprofloxacin, used to treat typhoid, was no longer effective.  

According to a recent study by a team by the Zimbabwe Ministry of Health, a cholera outbreak in 2018 and 2019 was multidrug resistant and infected more than ten thousand people, killing sixty-eight. 

As an adjunct to rehydration therapy, antibiotic drugs such as tetracyclines, macrolides, and fluoroquinolones are commonly used to shorten the duration and volume of diarrhea. They thereby limit bacterial transmission in moderate to severe cases of cholera, according to the study, but in this case the drugs could not be used to their full potential. 

"We emphasize," the authors wrote, "the need for the cross-border collaboration and continued laboratory of surveillance to stem this highly drug resistance cholera strain in Africa." 

Zimbabwe is among a group of African countries supported by the United Kingdom's Fleming Fund to develop and implement a National Antimicrobial Resistance Action Plan. The effort entails, among other things, strengthening surveillance and quantifying the burden of drug resistance pathogens in the country. 

Kujinga suggests various ways of addressing antimicrobial resistance in Zimbabwe. Health centers should embrace enhanced infection prevention control. Society should broaden access to clean potable water, raise awareness about antimicrobial resistance, promote preventive actions such as good hand-washing practices, scale up research, and enhance laboratory capacity.  

"Minimizing the consumption of antimicrobials, especially antibiotics, in the human and animal sector, as well as scaling up on the availability and accessibility of resistance testing," he says, will be critical.