Antimicrobial resistance

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Antimicrobial resistance and rational use of
antimicrobial agents
Agenda item 11 (a) 49th Session of the Regional
Committee for the Eastern MediterraneanCairo,
Egypt30 September 3 October 2002
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Content of presentation

• Introduction
• Global trends in antimicrobial resistance
• Infectious diseases
• Other areas of concern
• Essential medicines and antimicrobial resistance
• Irrational use
• Access
• Quality

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Content of presentation

• Regional situation
• Status of antimicrobial resistance (AMR)
• Assessment of economic impact
• Policy options
• Recommendations

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Introduction

• Antimicrobial resistance is both a natural
  phenomenon and a major global threat to public
  health
• Through replication and conjugation by jumping
  plasmids
• Observed soon after introduction of penicillin

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Introduction

• The link between antimicrobial resistance
  development and inappropriate use of
  antimicrobials in humans and animals is
  acknowledged
• Health Assembly resolution WHA51.17 (1998)
• Regional Taskforce on Antimicrobial Resistance
  (2000)
• WHO Global Strategy for Containment of
  Antimicrobial Resistance (2001)
• Regional Consultative Committee (2002)

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Global trendsInfectious diseases
Infectious diseases still account for 45 of
deaths in low-income countries

• Acute respiratory infections3.5 million killed
  globally (1998)
• Influenza and pneumonia
• Diarrhoea2.2 million killed globally (1998)
• E. coli, shigellosis, cholera
• Lack of testing for antibiotic sensitivity during
  outbreaks

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Global trendsInfectious diseases
Infectious diseases still account for 45 of
deaths in low-income countries

• HIV/AIDS
• Resistance to multidrug therapy
• Malaria
• Chloroquine no longer effective in 81 of 92
  countries
• Tuberculosis
• ? 20 of resistant new tuberculosis cases are
  multidrug resistant
• Cost implications

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Global trendsNosocomial infections

• Intensity of use of antimicrobials in hospitals
• Increasing resistance of highly virulent strains
  (Staphylococcus aureus)
• Hospital acquired infections (mainly drug
  resistant microbes) account for significant death
  rates and numbers
• 40 000 deaths/year in USA

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Global trendsFood production

• About half of all antibiotics produced are used
  for farming
• Reports indicate that 50 of human antimicrobial
  resistance is caused by growth promoters in
  livestock
• Where growth promoters are phased out,
  antimicrobial resistance in livestock drops
  dramatically (Denmark)

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Medicines (ir)rational use

• 2575 of antibiotic prescriptions inappropriate
• Empirical treatment, lack of diagnostic services
• Lack of targeted education
• 5090 bought privately from community pharmacy
  
• half for 1-day treatment
• Only half of 102 countries surveyed regulate drug
  promotion

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Medicines Access

• Between 1975 and 1997
• 1223 new compounds launched
• only 11 for tropical diseases

RD expenditure (US billions)

• New products (number)

• Multitude of problems
• Drug pipeline

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Medicines Access

• Multitude of problems
• Drug pipeline
• Focus on large markets

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Medicines Access
Percentage of population withregular access to
essential drugs

• Multitude of problems
• Drug pipeline
• Focus on large markets
• Geographical inequities
• Financial inequities

More than 100 million people in the Region do not
have regular access to essential drugs Problem
not only found in the low income countries
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Medicines Quality
Quality and safety standards exist, enforcement
varies greatly

• not all countries in the Region have
  well-functioning drug regulatory systems
• 1020 of drugs fail quality testing
• substandard and counterfeit drugs continue to
  kill

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Medicines Quality
Quality and safety standards exist, enforcement
varies greatly

• not all countries in the Region have
  well-functioning drug regulatory systems
• 1020 of drugs fail quality testing
• substandard and counterfeit drugs continue to
  kill

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Regional trends Health implications

• Similarity between the Member States in terms of
  scope and magnitude of the problem
• Link between antimicrobial resistance and
  irrational use of medicines is established in
  various studies
• High levels of drug resistance are found
  throughout the region for medicines used in
  common infectious diseases
• Tuberculosis, acute respiratory infections,
  urinary tract infections, malaria, etc.

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Regional trends Health implications

• Multidrug resistance is commonly found
• Need to underpin treatment choice with
  laboratory tests
• Need for time-series to determine trends

Wide availability of antimicrobials Widespread
use of new generation antimicrobials
Antimicrobial resistance is increasing in the
Region
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Regional trends Economic implications Cost of
ARI, diarrhoea, tuberculosis and malaria treatment
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Regional trends Economic implications Cost of
tuberculosis treatment
TB morbidity
First line
Second line
Third line
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Policy strategy options Addressing
antimicrobial resistance requires a comprehensive
multisectoral approach
Target audience
Intervention area

• Government (health systems)
• Patients and the general community
• Prescribers and dispensers
• Hospitals
• Pharmaceutical industry
• Food production

• Advocacy and intersectoral action
• Regulations
• Policies
• Guidelines and formularies
• Education
• Surveillance
• Infection control
• Diagnostic services

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• Target audienceGovernment (health systems)

• Advocacy and intersectoral action
• Intersectoral task force
• Resources to promote the implementation of
  interventions
• Indicators to monitor and evaluate the impact of
  resistance
• Regulations
• Prescription-only status
• International quality, safety and efficacy
  standards

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• Target audienceGovernment (health systems)

• Policies and guidelines
• National Drug Policy and Essential Drugs List
  (EDL)
• Surveillance
• Designate or develop reference microbiology
  laboratory facilities
• Drug resistance surveillance

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• Target audiencePatients and the general
  community

• Health education
• Appropriate use of antimicrobials
• Disease prevention (immunization, vector control)
• Hygiene

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• Target audiencePrescribers and dispensers

• Education (undergraduate an postgraduate)
• Appropriate use and containment
• Disease prevention and infection control
• Diagnosis and management
• Management, guidelines and formularies
• Prescription audits / prescription limits
• Standard treatment guidelines and prescription
  limits
• Regulation
• Professional registration based on continuing
  education

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• Target audienceHospitals

• Management
• Infection control programmes
• Hospital therapeutic committees
• Monitor antimicrobial usage
• Diagnostic laboratories
• Ensure access to microbiology laboratory services
• Diagnostic and treatment option support

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• Target audiencePharmaceutical industry

• Promotional activities
• Control and monitor promotion for medicines(WHO
  ethical criteria)
• Quality
• Good Manufacturing Practice (GMP) of
  pharmaceuticals and diagnostics

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• Target audienceFood production

• Regulation
• Prescription-only use of antimicrobials for
  disease control
• Phase out use of antimicrobials for growth
  promotion
• Monitor resistance
• Guidelines
• Develop guidelines for veterinarians to reduce
  overuse and misuse

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RecommendationsTo Member States

• National intersectoral task force on
  antimicrobial resistance
• Legislation and regulationprescription-only use
  of antimicrobials
• Hospital therapeutics committees and infection
  control programmes
• Essential drugs concept in educational programmes

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RecommendationsTo WHO

• Continued advocacy with Member States
• Support for surveillance networks
• Support for operational research
• Exploring the possibility of designating regional
  regulatory reference laboratories
• Development of a regional strategy on the
  prevention, control and monitoring of
  antimicrobial drug resistance

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Some final points.

• Antimicrobial resistance control is not an
  option, it is a must
• Health and economic incentive
• Implementation of comprehensive, integrated
  strategies involving all key partners will
• Lead to control of antimicrobial resistance
  development
• Improve the quality of health servicesantimicrob
  ial resistance control as a proxy indicator for
  an effective essential drugs programme

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Thank you