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Asian Tribune is published by E-LANKA MEDIA(PVT)Ltd. Vol. 20 No. 106

Health security is central to "sustainable societies" - Is AMR a threat?

By Manjari Peiris from Sri Lanka

Accelerating research and development for new diagnostics, treatments and vaccines etc. needs more attention since the world is losing effective drugs that are no longer working due to drug resistance. Anti-Microbial Resistance (AMR) is threatening to push us back to the pre-antibiotic era. Today the world is slipping more towards the risk of dealing with 'superbugs' that are virtually untreatable, including drug resistant gonorrhea.

Growing threat of Anti-Microbial Resistance in animal and human world is proving to be a big bottleneck in efforts for elimination of diseases such as TB, malaria, etc. Eliminating TB and malaria are among the targets of the UN Sustainable Development Goals (SDGs) which 193 countries have promised to deliver by 2030.

Addressing a webinar on Anti-Microbial Resistance (AMR) organized by the Citizens News Service (CNS) collecting opinions of experts on the subject by CNS Editor Shoba Shukla, Dr. Soumya Swaminathan, Senior Scientist, Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, expressed her views; " One very important element recently used was implementation of infection prevention and control in health care settings starting from primary health care settings to hospitals, having guidelines for the use of antibiotics, so that all health care workers follow standard guidelines whether they are in private sector or in public sector and reserve the use of latest antibiotics for where it really needed. "

She stressed that veterinary and agriculture use of antibiotics really needs to be stopped in terms of using them as crop promoters or even for prevention of disease and use them only for treatment where it’s needed.

"Further, it is essential to reserve the use of certain antibiotics. WHO has the classification of antibiotics in three categories and the last category are the ones that will be what’s called the aware classification of antibiotics. So the ones that are in the reserved category should not really be used for animal use and should be reserved for humans alone. Lastly the environmental aspects which is really the production facilities and disposal of antibiotics so that they are not contaminating water and soil and so on and spreading their resistance mutations to bacteria which are in the environment."

She stated that TB off course was something that has been monitored for much before the AMR really became of global importance and data is available from 70’s and 80’s. "In TB the drug resistance is of two kinds, one is primary if one gets TB from somebody who has drug resistant TB and thus he gets those bacteria and get infected. And primary drug resistance is increasing. Secondary drug resistance is acquired when one is a patient of TB and he/she is on the wrong combination of drugs or he/she is not taking the right doses or one is irregular than one develops resistance.

Currently WHO is addressing and making guidelines to develop resistance to address sensitive bacteria and says that everyone who has suspected TB, must get molecular diagnostic test or a test for drug resistance right in the beginning. So that the person gets the right combination of drugs and secondly now there are two new drugs, Bedaquiline and Delamanid, that have been developed in last few years.

She revealed that the WHO has come out with the guidelines very recently. "There’s a rapid communication that’s been put out about the use of these new drugs. But I think it is very important that patients have the right diagnosis name and appropriate treatment given and the support for that patient to stay on treatment. We know that treatment for TB is for six months and for drug resistant TB is even longer and can be anything from 18 or 24 months. So patient support, counseling, peer support and if they need nutrition and other kinds of social support are absolutely critical to ensure that we do not go on amplifying this development of drug resistance.

Dr. Saumya was hopeful that in future they would be able to have more drugs developed. "It is after 40 years we have seen a new drug for TB and I think it's very important to use the drug, and to preserve their efficacy for as long as possible. TB bacteria are capable of developing mutation just like other bacteria if they are exposed to the drugs in the wrong dose or for insufficient time. So it’s really very important to use them properly in the correct doses in the correct time duration in which they need to be given."

The guidelines that have been put out by WHO are very clear about the use of these drugs and also they have to be used with right companion drugs. So TB is one organism which can never be treated with a single drug or even with two drugs. You need a combination of three to four highly effective drugs. That’s why it’s so important to know the resistance profile of the bacteria before starting treatment. While on one hand we need to safeguard these drugs to make sure that they are effective at least for the next couple of decades. At the same time, it should not be so restrictive that people who need them are not getting them.

"So we have to be strike the right balance and make this drug accessible to every patient who needs it now. That’s why the new guidelines today really talk about replacing injectable with Bed aquiline, because we know that a lot of patients become deaf because of the use of injectable for prolonged periods. So again I want to emphasize that the patient-centered care is very important."

"While it is a public health program we need a public health approach as well. Every patient is important and within the public health program we need to ensure that we are able to stay with every patient to track them, to monitor them and to make sure that they complete the full course of treatment and without developing the too many side effects. If you are able to do that we can really protect these drugs for a long time to come,” she affirmed.

At the forthcoming UN General Assembly over 45 heads of states would speak on TB. This is the first time ever at the UN general assembly when the heads of state will actually commit, make statements of commitments. So already we are seeing the accountability and we have also the outcome document proposed that there be a national accountability mechanism which means that every head of state is going to commit and be accountable for progress on TB. So this is unprecedented.

Secondly we hope that this will also help to mobilize more funding both for TB programs and for TB research and innovation desperately need new diagnostics, better diagnostics, shorter and better treatment regimens and hopefully a vaccine that would prevent TB in the long run. This would ensure more investment on TB research and innovation particularly from middle income countries and from the high TB burden countries. Similarly, more domestic resources for TB programs there should be a commitment and thirdly we will have a huge amount of awareness that this event will create bringing together the civil society patient voices, political commitment as well as the experts on TB and it’s going to propose that follow up report be submitted to the UN General Assembly in 2020 and then in 2023. Commitments have been made as to the numbers of patients being treated off, number of patients being put on preventive treatment at the global level, but this will also be translated for each country into what does each country will have to do in order for the global goals to be achieved.

Dr. Kamini Walia, Senior Scientist, Division of Epidemiology, ICMR, which is a research organization under the Ministry of Health and Family Welfare, said that the reason that ICMR network focuses on pathogenic groups is that there is no other national program which is looking at these infections. Drug resistant infections caused by bugs which cause large number of drug resistant infections in hospitals and in the communities. The ICMR gathers data from 20 hospitals in their network which is a good mix of government as well as the private hospitals. This data is being used to guide treatment interventions and treatment policies in these hospitals. The ICMR brought out hospital infection control program, policy as well as treatment guidelines which is based on ICMR data. Now as the surveillance network has been going on for the last 4 years, we are moving for the next phase of the surveillance which will focus on looking at the mechanisms of resistance, the locality and the transmission dynamics as well as working with all those hospitals that are part of ICMR network to improve the diagnostics stewardship as well as infection prevention stewardship and the antimicrobial stewardship.

We do understand that unless we reduce the number of infections in our hospitals, we will not be able to achieve much on the antimicrobial resistance reduction because this is the large denominator of drug resistance infections in the hospitals which actually give rise to the drug resistant infections.

Dr. Iresh Jayaweera, MBBS, PG Dip. in MD in Venereology, of Sri Lanka, said, AMR is a long needed one as it is good that you have everything in relation to illnesses and other important components in the past are recorded in one place. But measures should be taken to assure confidentiality and data security and such system with up to date statistics help in planning out prevention and ending communicable diseases to become SDGs a reality. I being a medical officer in relation to sexual health, believe that we have to be careful when handling sensitive and very personal information, so that the information cannot be shared in public AMR. Our information is available on "Need to know basis", even among healthcare workers to ensure prevention of stigma and discrimination and other social family problems. Thus our work should be isolated from general networks. "My personal view is AMR is a good thing."

- Asian Tribune -

Health security is central to "sustainable societies" - Is AMR a threat?
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