At the last 67th World Health Assembly in May 2014, WHO Member States agreed to a Global Action Plan (GAP) to tackle the escalating antimicrobial resistance, including antibiotic resistance, global public health emergency. Despite having undergone two rounds of consultation with the global health community prior to its tabling at the WHO Executive Board meeting in January 2015, the draft GAP gives no indication on how developing and less developed countries, with limited or even non-existent technical resources and capacities, will design and implement their own national plans
Antibiotic Resistance - Beginning of the End?
by Shila Kaur
Coordinator Health Action International Asia Pacific (HAIAP)
We are in a state of crisis, yet most people don’t even know this. Antibiotics of last resort have become useless in treating infections; there is multi-drug resistant TB, malaria and gonorhhea to contend with and the bugs are mutating faster than our ability to find newer treatments.
In Malaysia the alarm bells were first sounded last year when the country encountered its first publicly reported cluster of deaths due to Carbapenem-Resistant Enterobacteriaceae. The Borneo Post reported that up to August 2013, 10 people had died in Sibu Hospital from Carbapenem-Resistant Enterobacteriaceae.
The second tragedy occurred in the first week of October 2013 when four people died and 60 others were hospitalised after eating contaminated chicken at a wedding feast in Yan, in northern state of Kedah. The Health Department said it was most likely due to Salmonella contamination.
These two reports of lethal infections affecting the general public are just the tip of the iceberg. Many more cases are occurring throughout Malaysia, which do not come to public notice. The situation is similar in many developing countries. Antimicrobial or antibiotic resistance (AMR/ABR) is one of the most serious health threats the world faces. Infections from resistant bacteria are now common and some pathogens have even become resistant to multiple types or classes of antibiotics. With the increasing ineffectiveness of drugs of “last resort”, we are on the brink of a public health disaster/crisis. It is a ticking time bomb in our midst which needs to be taken seriously and urgently dealt with.
The threat is in fact global and the rest of the world is waking up to this, admittedly in various states of unpreparedness.
ABR threatens to undermine the effectiveness of modern medicine as increasingly more strains of bacteria become resistant to the limited number of remaining antibiotics. The ramifications will be devastating to both human and animal health because there are no new antibiotics to treat some of the most serious infections. Millions of people have been infected with antibiotic resistant bacteria and hundreds lose their lives each year. Without a radical change in antibiotic usage, ABR will become one of the greatest threats to humankind, to security and to the global economy.
The World Health Organization states that ABR is no longer a prediction for the future but is happening right now, across the world. Standard treatments no longer work; infections are harder or impossible to control; the risk of the spread of infection to others is increased; illness and hospital stays are prolonged, with added economic and social costs; and the risk of death is greater – in some cases, twice that of patients who have infections caused by non-resistant bacteria.
In April 2014 WHO published its first ever comprehensive Global Surveillance Report on ABR, which stated, “The problem is so serious that it threatens the achievements of modern medicine. A post-antibiotic era – in which common infections and minor injuries can kill – is a very real possibility for the 21st century.”
Common bacteria such as Escherichia coli, Klebsiella pneumonia and Staphylococcus aureus which cause common health-care associated and community-acquired infections such as urinary tract infections, wound infections, bloodstream infections and pneumonia, have become resistant to the most potent antibiotics. And there are no newer antibiotics anywhere is sight to battle the bugs.
In 2012, there were about 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB). Extensively drug-resistant tuberculosis (XDR-TB) has been identified in 92 countries.
Resistance to earlier generation antimalarial drugs is widespread in most malaria-endemic countries. According to WHO, further spread or emergence in other regions, of artemisinin-resistant strains of malaria could jeopardize important recent gains in control of the disease.
Ten countries have already reported treatment failures due to resistance to treatments of last resort for gonorrhea. Gonorrhea may soon become untreatable as no vaccines or new drugs are in development.
At the last 67th World Health Assembly in May 2014, WHO Member States agreed to a Global Plan of Action to tackle this global public health emergency. Contained in Resolution EB134.R13 Combating antimicrobial resistance, including antibiotic resistance, the Global Action Plan (GAP) aims to develop or strengthen national plans and strategies and international collaboration for the containment and control of the escalating AMR crisis. Despite having undergone two rounds of consultation with the global health community prior to its tabling at the WHO Executive Board meeting in January 2015,the draft GAP gives no indication on how developing and less developed countries, with limited or even non-existent technical resources and capacities, will design and implement their own national plans. The draft GAP continues to remain weak on critical issues of innovation, access to new antimicrobial medicines, regulation of promotion and marketing and use in animals, of such medicines. The draft GAP fails to recognize that for developing countries the presence of political will alone is not sufficient to enable them to implement policies and measures required to address AMR. For developing countries, access to financial and technical resources for implementing actions to address AMR is critical.
The threat has also been recognized by policy makers at the highest global levels such as the G-7; it is listed topmost on the Global Health Security Agenda initiated by the United States.
National level action is therefore paramount and international cooperation essential in managing this crisis.
One driver of ABR is the unnecessarily reckless use of antibiotics in food animals for industrial meat production. Most of this is largely to spur growth – not to treat disease. The more antibiotics are used and interact with bacteria, the faster resistance to antibiotics develops.
While the EU countries are far ahead with regards to regulations and control on the use of antibiotics in food animals, many countries lag far behind. In Malaysia, despite the existence of the Animal Feed Act 2009 , use of antibiotics in animal feeds continues unabated.
A preliminary study of AMR in food-producing animals and foods, carried out by the Department of Veterinary Services (DVS) in 2012 found multi-drug resistant strains of Salmonella in live chickens in SALT - supervised and certified farms* in central Malaysia. Alarmingly, tests on mutton, beef and chicken food samples showed that more that 60% of Salmonella was isolated from imported beef and chicken.
Furthermore, live chickens sold at wet markets tested positive for Campylobacter. More than a third of bacteria samples showed multidrug resistance. Frozen burger patties taken from supermarkets and retail shops showed the presence of multidrug-resistant strains of Listeria monocytogenes; the most common forms of resistance involved tetracycline followed by erythromycin.
According to Institute for Medical Research (IMR) data from 37 hospitals throughout Malaysia, resistance to one or more antibiotics had increased from 2011 to 2012; the most potent antibiotics were becoming increasingly ineffective against some of the micro-organisms surveyed. The actual state of AMR in the country is however unknown as IMR data is partial and does not cover all hospitals from both the public and private sectors. A preliminary survey by Health Action International Asia Pacific (HAIAP) of countries in the region revealed weaknesses in health information systems in the public health sector. Countries lack capacities for data collection and analysis in the public health sector while the private sector remains largely unregulated.
Another driver of antibiotic resistance is the misuse of antibiotics through inappropriate prescribing practices by doctors and inappropriate use by patients. Doctors are known to prescribe antibiotics for prevention or prophylaxis of bacterial infections in cases where the problem is viral and use of antibiotics is, in fact unnecessary. The use of broad spectrum antibiotics where narrower spectrum ones would suffice is another common practice.
On the other hand are patients who, used to being treated with antibiotics for common self-limiting infections, continue to demand antibiotics for ailments where none are needed.
It is a dilemma. And rather than waste time pointing fingers at who created the demand – doctors or patients? - it is time for both to take professional and personal responsibility.
Citizens of the world must collectively wake up to the unassailable facts that there are no more antibiotics left to treat common infections and that health care providers and facilities cannot replace personal hygiene, good sanitation practices and rational use of medicines.
Unless we do so, that apocalyptic scenario of zombie-like creatures with decaying limbs and torsos wandering around hopelessly, may not be so far-fetched after all.
* The DVS awards the SALT certificate and logo to farms that meet the criteria of Good Animal Husbandry Practices (GAHP), animal health management, bio-security, good infrastructure and prudent use of drugs. The certification scheme covers all types of livestock: beef cattle, dairy cattle, broiler chicken, layer chicken, breeder chicken, deer, goat, sheep and pig.
Health Action International Asia Pacific (HAIAP) aims to promote rational use of medicines and equitable health for all, with particular emphasis on the poorest of the poor. It is a network of more than 60 individuals and organizations ranging from powerful consumer organizations and development action groups and small grass roots organizations. Individuals who work with HAIAP consist mainly of health professionals comprised of doctors, pharmacists and academics. As the Coordinator of HAIAP, Shila Kaur responsibilities entail keeping members informed of network activities through HAI News and regular news mailings and emails; coordinating meetings/seminars/conferences; advocacy and lobbying; representation at meetings; coordinating research; fundraising and writing and publishing reports and publications.