Increasing antibiotic resistance

While research tries to find the treatment for antibiotic resistance, so far prevention by controlling the over prescription and overuse of the ‘wonder drug’ among humans and food animals is the only cure available in Pakistan.

By 2050, an estimated 10 million deaths per year globally will be attributable to antimicrobial resistance (AMR), with a cumulative economic cost of $100 trillion. The Netherlands-based Access to Medicine Foundation says that AMR causes over 700,000 deaths annually worldwide. In Europe, an estimated 25,000 people a year die from antibiotic-resistant bacteria. In the US, at least two million illnesses and 23,000 deaths a year can be attributed to antibiotic resistance, according to the foundation’s report.

The situation is much more severe in low and middle-income countries like Pakistan which are still struggling to extend healthcare coverage to all. Now the Pakistan government has to take utmost care that its coverage of population with medicine access should not be affected by AMR.

AMR is the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, anti-virals, and anti-malarials) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others. The World Health Organization (WHO) warns that massive overconsumption of existing antibiotics, along with a shortage of new ones, has hastened the emergence of highly resistant bacteria – or ‘superbugs.’

Antibiotic-resistant infections are already spreading in all parts of the world. If urgent action is not taken, we could face a future where simple cuts and scrapes would once again kill.

When the first antibiotics were introduced in the 1940s, they were hailed as ‘wonder drugs’, the miracles of modern medicine. No significant new class of antibiotics has been discovered since 1987, and too few antibacterial agents are in development to meet the challenge of multidrug resistance.

Antibiotic resistance is rising to dangerously high levels in all parts of the world. New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases. A growing list of infections – such as pneumonia, tuberculosis, blood poisoning, gonorrhoea, and food-borne diseases – are becoming harder, and sometimes impossible, to treat as antibiotics become less effective.

The primary objective of Pakistan’s AMR National Action Plan is to ensure that current antimicrobials remain effective as long as possible for all those who need them while minimising the expense associated with indiscriminate use. In Pakistan, where antibiotics can be bought for human or animal use without a prescription, the emergence and spread of resistance is made worse. Similarly, without standard treatment guidelines, antibiotics are often over-prescribed by health workers and veterinarians and overused by the public.

Pakistan’s 2017 National Action Plan that was evolved by the Ministry of National Health Services Regulations & Coordination (NHSR&C) is based on the ‘National Strategic Framework for Containment of AMR’ which was developed as a follow up of the Global Action Plan to tackle AMR. The action plan was endorsed in the 68th session of the World Health Assembly (WHA) in Geneva in May 2015 by all countries including Pakistan.

Pakistan’s action plan has the participation of the health, veterinary, agriculture and other sectors at the federal, provincial and regional levels in the WHO recommended ‘One Health Approach’. The ambitious plan talks of awareness-raising and behavioural change strategy; establishment of a surveillance system (human, animal usage and resistance monitoring); improved prevention and control of infections in healthcare; enforcement of improved regulations; phasing out use of antimicrobials as growth promoters and providing appropriate alternatives (such as prebiotics, probiotics); integration of AMR in all public health research agendas including research on vaccines; and, estimation of the health and economic burden of AMR for decision-making.

There has been a 65 percent increase in Pakistan in the use of antibiotics over 16 years. The challenge is to introduce effective AMR regulations in over 13,000 public-sector health facilities, and sensitize around 400,000 healthcare providers. The size of the private-sector health facilities is much larger.

Not only in human medicine but antibiotic use in veterinary medicine and agriculture too has been linked to the rise of antibiotic resistance globally since transmission of animal-origin resistant bacteria to humans is possible through the environment and food chain and to agricultural workers by direct contact.

Misuse of antibiotics in food animals is a major driver of resistance. Farm animals consume around two-thirds of the world’s antibiotics, with much of this added to feed or water to make animals grow faster or to counter unsanitary conditions. Between 2010 and 2030, it is predicted that antibiotic use in food animal production will increase by two-thirds.

Pakistan’s action plan notes that in low- and middle-income countries there is a huge and unprecedented growth in demand for animal protein. The global consumption of antimicrobials in animal food production estimated at 63,151 tons in 2010 is projected to rise by 67 percent to 105,596 tons by 2030.

Pakistan is one of the top ten producers of livestock and poultry in the world. Meat production in Pakistan is 4.3 million tons, which includes poultry meat production of 1.40 million tons. In several parts of the world, more than 50 percent in tonnage of all antimicrobial production is used in food-producing animals. Besides, veterinarians in some countries earn at least 40 percent of their income from the sale of drugs, creating a strong disincentive to limit their use. The problem arises when drugs used for food production are medically important for human health, as evidence shows that pathogens that have developed resistance to drugs in animals can be transmitted to humans. Standards developed by the World Organization for Animal Health (OIE) and Codex Alimentarius need to be adapted.

A few decades back, it was believed that the war against infectious diseases had been won. Pharma companies saw a more profitable future in chronic diseases. Heart conditions, stroke and Type 2 diabetes were and are the big killers today, worsening as obesity levels rise. Moreover, unlike infectious diseases, where people take a one-off course of drugs and are hopefully cured, those with chronic diseases could be on these drugs for life.

Infectious disease products may broadly be broken down into three categories: vaccines, diagnostics, and antimicrobial medicines. The global market for such products reached $108.4 billion in 2015, and is forecast to reach $183.2 billion in 2021.

The Access to Medicine Foundation estimates that the antibiotic market is expected to grow from $27.1 billion in 2015 to $35.6 billion in 2022, in step with growing demand for generic antibiotics from emerging markets.

Between 2002 and 2010, global consumption of antibiotics increased by 36 percent, and three quarters of this increase was accounted for by Brazil, Russia, India, China and South Africa (BRICS). Growing demand coupled with poor surveillance and stewardship is likely to drive the emergence of resistant strains, particularly in high-burden areas.

To counter, the Access to Medicine Foundation has developed an AMR Benchmark, which systematically evaluates how a cross-section of the pharmaceutical industry is responding to the AMR threat. The benchmark found that almost all companies are taking some action to limit AMR. There are good practices in most areas, although there is also much more to be done.

Pakistan’s $2.2 billion pharmaceutical industry, with 600 registered pharmaceutical manufacturing units, also has 21 multinationals. Many of the multinationals working in Pakistan are also reflected in the benchmark. It is pertinent that the benefits of the research to counter AMR should also be accrued to Pakistan.

It’s been over two years now that the Pakistan government has finalised a national action plan for the containment of AMR, but its implementation remains muted, slow and ineffective.

The writer is a freelancecontributor.

Email: nadympak@hotmail.com