Health Exchange

Drug resistance is a growing problem. Efforts to combat ill-health caused, for example, by malaria, tuberculosis, HIV and AIDS, are being undermined by drug-resistant forms of the diseases. What can be done at community health care facility level to respond to the situation? What type of international response is appropriate?

Emma Back and Eva Ombaka share recent findings about drug resistance, and some possible ways forward.

Let us start with the good news. In recent years, significant investments – of time, effort and money – have been made in fighting infectious diseases and improving access to medicines in developing countries. We are starting to see improvements in access, with growing numbers of HIV patients on antiretroviral therapy, newer antimalarials now widely available, and an increase in treatment success rates for tuberculosis.

But the bad news is that our efforts are being undermined. The efficacy of vital medicines is being eroded, as drug resistant forms of disease emerge and spread.

Drug resistance has already dramatically increased the costs of fighting tuberculosis and malaria. It is reversing or slowing gains against childhood diarrhoea and pneumonia, and now threatens efforts to treat people living with HIV and AIDS effectively. In some cases, resistance is occurring almost as quickly as new drugs appear on the market. Second- and third-line treatments are almost always more costly, harder to use, have worse side effects, and require greater medical oversight.

A snapshot of the problem

We know that drug resistance is on the rise. It is of increasing concern to many organisations working on global health, including the World Health Organization (WHO), ReAct, the Alliance for the Prudent Use of Antibiotics (APUA), the Ecumenical Pharmaceutical Network (EPN) and the US Center for Global Development (CGD). However, we cannot comprehend the full extent of the problem. There is no global system for monitoring and tracking which drugs are losing effectiveness, how fast microbes are evolving, or how resistant forms of disease are spreading; and the burden of ill health linked to drug resistance is rarely quantified.

The data we have are pretty compelling though. We know, for example, that multi-drug resistant Streptococcus pneumoniae is widespread in parts of Asia (i),  as is quinolone-resistant Neisseria gonorrhoeae (ii).  ‘Superbugs’, such as methicillin-resistant Staphylococcus aureas (MRSA) and Clostridium difficile are found globally, often in hospitals but increasingly in the community. In the US, treating a single MRSA patient may cost as much as US$60,000 (iii).

Drug-resistant tuberculosis (TB) is a particularly serious public health problem. About 20 per cent of new TB cases each year are resistant to at least one first-line TB drug and nearly half a million cases are resistant to multiple drugs. Second-line drugs cost an average US$3,500 per course – that is, 175 times more than the average first-line treatment course. http://pdf.usaid.gov/pdf_docs/PNADP643.pdf

Chloroquine effectively treated malaria for decades. But in East and Central Africa, where 110 million people are exposed to malaria, more than half of all cases are thought to be drug resistant. Even artemisinin-based combination therapies, the newest and most effective antimalarials, are beginning to lose efficacy in parts of South-East Asia.

Lives are at risk. Children, who are particularly vulnerable to infectious diseases, are more likely to die or suffer long-term damage if not treated promptly and effectively. The most lethal childhood bacterial infections – pneumonia, other respiratory infections, and diarrhoeal diseases – no longer respond to older antibiotics. However, new and expensive alternatives are often not available in poor countries.

Over the past decade, governments, multilateral agencies, civil society organisations and foundations have worked tirelessly to increase access to medicines in developing countries, particularly for malaria, HIV and TB. But challenges remain in preserving the effectiveness of these drugs. There is a clear need not only to ensure broad access to medicines, but also to ensure lasting drug efficacy.

What can be done?

We need a systematic global response to the challenge of drug resistance.
At community and health care facility level, health workers can take several simple steps to reduce the risk that drug resistant forms of disease will emerge and spread. These include following standard treatment guidelines, using laboratories to confirm diagnosis and inform prescribing, and exercising good infection control (including regular hand-washing). One of the most important things that prescribers and dispensers can do is to take time with each patient to explain how they must take their medicines and to stress the importance of completing their course of treatment. Patient adherence to the prescribed treatment regime is vital, as microbes are more likely to survive and mutate to resistant forms if they are exposed to an insufficient dose of drug therapy.

At the global health policy level, donors and technical agencies must act to protect their investments. They can do this by supporting efforts to strengthen regulation, build laboratory and surveillance capacity, and improve prescribing and dispensing practices. They must also work with academic researchers and biopharmaceutical companies to expand research and development into new medicines – particularly new antibiotics – and into technologies that can help us use drugs more wisely and prolong their efficacy. Such technologies include diagnostics that can screen for many different pathogens simultaneously; tests that health workers can use to ascertain which drugs will work for a particular patient; and technologies that can protect drugs directly (for example, by stopping microbes from destroying them or pumping them out). Indeed, pharmaceutical companies also have important roles to play to ensure medicines are used appropriately and to monitor drug resistance through post-marketing activities.

Ultimately, one of the most effective ways to protect our medicines for the future is to use them more sparingly today. To do this, we must prevent disease – by improving access to clean water and good sanitation, increasing immunisation, and encouraging environmental and personal hygiene, safe sex, and other strategies such as the use of bednets in malarial zones.

If we all act now to ensure we use medicines appropriately, then we can also help to ensure access to effective medicines for future generations. The health of our children and grandchildren depends on it.

Emma Back is an independent consultant and member of the Center for Global Development’s Drug Resistance Working Group.

Eva Ombaka is an independent consultant and the former coordinator of the Ecumenical Pharmaceutical Network.

Resources:

Centre for Global Development
www.cgdev.org/drugresistance

Ecumenical Pharmaceutical Network AMR Campaign
www.epnetwork.org/AMR-Campaign/

ReAct
http://www.reactgroup.org

Alliance for the Prudent Use of Antibiotics
http://www.tufts.edu/med/apua

Filed under: Access to medicine Tagged: | access to medicines, drug resistance, essential medicines, HIV&AIDS