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Antimicrobial resistance

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Title: Antimicrobial resistance


1
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
2
Content of presentation
  • Introduction
  • Global trends in antimicrobial resistance
  • Infectious diseases
  • Other areas of concern
  • Essential medicines and antimicrobial resistance
  • Irrational use
  • Access
  • Quality

3
Content of presentation
  • Regional situation
  • Status of antimicrobial resistance (AMR)
  • Assessment of economic impact
  • Policy options
  • Recommendations

4
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

5
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)

6
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

7
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

8
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

9
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)

10
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

11
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

12
Medicines Access
  • Multitude of problems
  • Drug pipeline
  • Focus on large markets

13
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
14
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

15
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

16
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.

17
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
18
Regional trends Economic implications Cost of
ARI, diarrhoea, tuberculosis and malaria treatment
19
Regional trends Economic implications Cost of
tuberculosis treatment
TB morbidity
First line
Second line
Third line
20
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

21
  • 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

22
  • 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

23
  • Target audiencePatients and the general
    community
  • Health education
  • Appropriate use of antimicrobials
  • Disease prevention (immunization, vector control)
  • Hygiene

24
  • 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

25
  • 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

26
  • Target audiencePharmaceutical industry
  • Promotional activities
  • Control and monitor promotion for medicines(WHO
    ethical criteria)
  • Quality
  • Good Manufacturing Practice (GMP) of
    pharmaceuticals and diagnostics

27
  • 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

28
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

29
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

30
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

31
Thank you
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