1 Combating Drug Resistance Syed Khalid Saeed Bukhari

World Health Day 2011 The Regional theme is combating Drug Resistance (DR) The slogan is "COMBAT DRUG RESISTANCE, NO action today, NO cure tomorrow" 2

Pakistan 30% prescription lack a diagnosis/complaint. EDL was present in 19% health facilities. 1 in 6 prescription do not contain any dosage instructions. According to EDSP 2002 report prescription contain 52% antibiotics. 3

Percentage of Encounters with antibiotic Provinces NWFP49.7% Baluchistan49.7% Punjab60.7% Gender Males58.8% Females46.4% Prescribers Doctor53.3% LHV21.4% Dispenser32.4% AGE Child (<15 Years)65.8% Adult (<15 Years) 44.8%

Countries Comparison of Percentage of Antibiotics Pakistan52% Bangladesh25% Nigeria48% Nepal43%

No action today, no cure tomorrow DR kills human lives Challenges care and control of infectious diseases Greatly increases care costs Threatens healthcare gains for individuals and society Can take us back to the pre-antibiotic era Threatens health security and damages trade and economy

Thomas McKeown The role of Medicine: Dream, Mirage, or Nemesis DECLINE OF RESPIRATORY TUBERCULOSIS DECLINE IN CHILDHOOD MEASLES DECLINE IN CHILDHOOD DIPTHERIA Low relative impact of health care in other diseases See the trend in decline of the disease was there even before the advent of modern medicine Modern medicine contributed only a portion of further decline The main decline was due to improved hygiene, sanitation, living conditions, lifestyles, preventive approaches, and these are all important public health practices we teach and advice

WHD 2011: What will we achieve? Goal: To save lives and protect health by keeping precious, life- saving medicines effective and useful to combat diseases Aims: - To raise awareness on what drives DR - To build commitment for effective policies and practices and their implementation to combat DR Objectives: To provide policy guidance to Member States on top priority actions to combat DR To reach and engage key stakeholders through innovative communications, advocacy and events To promote further collaboration across sectors and among stakeholders 9

What is DR? DR arises when Patients do not take their medicine properly and rationally Providers do not prescribe the medicine properly Patients and community do not know proper use of medicine & problem of drug resistance Health authorities do not maintain quality of drugs Hospitals do not adopt infection control measures Health policy makers do not prioritize drug resistance containment There is limited research on new medicine 10

What is DR? TB: 440,000 new multidrug resistance (MDR) TB cases annually; extensively drug resistance (XDR) TB cases reported in 58 countries so far Malaria: Emergence of Artemisin resistance linked to ongoing use of monotherapies HIV: With expanded use of antiretrovirals (ARVs), resistance is a concern 11

What is DR……. Methicillin-resistant Staphylococcus aureus: lethal infections in hospital settings which are becoming increasingly frequent Multi-drug resistant E. coli and K. pneumoniae: infections are on the rise Neisseria gonorrheae and Shigella: are becoming increasingly resistant to drugs 12

What drives DR? Policy Drug resistance plans & resources are not comprehensive Monitoring Surveillance system is weak Quality assurance System to ensure quality and supply of medicine is inadequate 13

What drives DR? Awareness Consumers and communities are not aware of drug resistance Prevention Poor Infection prevention & control R&D Research & development for diagnostics and drugs is insufficient 14

Six Steps to Stop DR 1. Political commitment Committing to a comprehensive, financed national plan with lines of accountability and civil society engagement 2. Monitoring Strengthening surveillance and laboratory capacity 3. Quality control & assurance Ensuring medicines of good quality and regular supply 4. Rational use of medicine Regulating and promoting rational use of medicines, including in agricultural sector, and proper patient care 5. Prevention & stopping the spread Enhancing infection prevention & control 6. R&D Fostering innovations, research & development 15

To address DR, we should know: DR is complex as it involves different diseases, settings and demands well coordinated actions across different sectors DR is also a behavioral issue DR is EVERY BODY’ problem 16

WHO Global strategy In September 2001, WHO launched the first Global Strategy for Containment of Antimicrobial Resistance which aims to encourage the urgent actions needed to reverse or at least curtail trends which have major economic as well as health implications.

WHO Policy & strategy options Addressing antimicrobial resistance requires a comprehensive multisectoral approach Target audience” Intervention area Government (health systems) Patients and the general community Pharmacists Prescribers and dispensers Hospitals Pharmaceutical industry Food production

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

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

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

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

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

WHO's response policy guidance, support for surveillance, technical assistance, knowledge generation and partnerships, including through disease prevention and control programmes; essential medicines quality, supply and rational use; infection prevention and control; patient safety; laboratory quality assurance

Messages on DR Policy makers Ministries of Health, other than Ministry health policy influencers & makers: The threat of DR is real & enormous; needs vigorous response with allocation of proper resources, public awareness campaigns, and the establishment and enforcing of clear policies to prevent the onset and dissemination of DR 25

Messages on DR The public: understand and adopt the appropriate use of, or alternatives to, antimicrobials prevent from and get treatment for infectious diseases; and learn & adopt measures to reduce transmission 26

Messages on DR Practitioners & prescribers understand and appropriately use antimicrobials against TB, malaria and HIV and other diseases learn and adopt disease prevention and infection control measures 27

Messages on DR Media: promote awareness of DR as a real, enormous public health threat encourage actions at policy levels to address DR 28

Messages on DR Pharmaceutical industry promote production of quality drugs foster proper branding, publicity, and marketing measures that favor prevention and containment of DR 29

THANK YOU 30