controlling drug resistance in developing countries usaid antimicrobial resistance (amr) working...
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Controlling Drug Resistance
in Developing CountriesUSAID
Antimicrobial Resistance (AMR)Working Group*
ANE/E+E SOTA, October 2002*Includes: Neal Brandes, Tony Boni, Andrew Clements, Ruth Frischer, Marni Sommer, Cheri Vincent
Highlight the complexity of the drug resistance problem and its impact on controlling infectiousdiseases and USAID PHN programs.
Provide information on country-level approachesto control drug resistance and what assistance is available from USAID/W.
Objectives of Presentation
Antimicrobial Drugs
Specifically kill or inhibit growth of microbes: viruses, bacteria, fungi, parasites
Key tools for treating infectious diseases: humans, animals, plants
Lose efficacy over time if used inappropriately
Burden of Infectious Diseases in Humans and Need for Antimicrobial Drugs
Estimated number of infections:• TB -- 2 billion total (9 million new cases per year)• Malaria -- 300-500 million new cases per year• HIV/AIDS -- 40 million total (5 million new cases per year)
Sources: 2001 World Health Report, 2002 UNAIDS Report, 2002 Global TB Control Report, and other WHO reports
0
0.5
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1.5
2
2.5
3
3.5
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ARI HIV-AIDS DIARR.DISEASE
TB MALARIA
Millionsof deathsin 2000
Total infectious disease deaths: 14.4 million each year
Ideal Response to Infectious Diseases
Prevention• immunizations• hygiene, safe water/food• infection control in hospitals• insecticide-treated materials and/or vector control• condoms• other behavior changes
Treatment• rational use of high-quality antimicrobial drugs
Public Sector
Private Sectorand NGOs
Global Initiativese.g. RBM, GDF,
GFATM, Trachoma
Ideal Treatment of Infectious Diseases with Antimicrobial Drugs
Infected patient
Cured patient
1. Trained health provider consulted
2. Specific diagnosis made
3. Correct drug prescribed in correct dose
4. High-quality drug and treatment
information obtained
5. Treatment regimen followed
Treatment failure or drug resistance
indicate a problemBUT
Treatment failuredoesn’t always mean
drug resistance
Challenges to Treating Infectious Diseases with Correct Dose of Appropriate Drug
Poor drug use Poor drug quality
Fake Artesunate in Southeast Asia
Lancet, Vol. 357, June 16, 2001
Shops in Burma, Cambodia, Laos, Thailand, Vietnam:
38% of artesunate samples contained no drug
Private sectorFills in where reach of public sector is limited
Producing/exporting antimicrobial drugs
The Treatment vs. Drug Resistance Dilemma
Health Provider Priority
Client: patient (individual)
Objective: cure disease fast
Possible consequence: more poor drug use
Public Health Priority
Client: MoH (society)
Objective: cure, limit AMR
Possible consequence: limited access to drugs
Evidence that Treatment of Infectious Diseases Needs to be Improved
Sources: 2001 World Health Report and WHO reports
Total : 11,754,000
Outbreaks of Typhoid Fever (Salmonella typhi)
Year(s) ofOutbreak
Location Resistance Type
1989 Pakistan ACSSuTTm
1990-95 India ACSSuTTm
1990-95 Arabian Gulf ACSSuTTm
1990-93 Kuala Lumpur ACSSuTTm
1991 UK CSTTm1991 S. Africa ACSSuT1991-92 Egypt ACSSuTTm
1992-94 Vietnam ACSSuTTm
1993-94 Philippines CKSSuTTm1994 Bangladesh ACSSuTTm
1994-95 Pakistan ACSSuTTm1996-97 Tajikistan ACSuCi
A=Ampicillin; C=Chloramphenicol; S=Streptomycin; Su=Sulphonamide; T=Tetracycline; Tm=Trimethoprim. Reference: Rowe et al. Clin Infect Dis 1997, 24(Suppl 1):S106-9.
Since 1960:
• 6-fold increase in global trade
• 17-fold increase in number of people travelling in airplanes
Since 1980:
• 9-fold increase in number of refugees/displaced people
Spread of Chloroquine-Resistant Malariafrom Cambodia (1960s)Spread of Chloroquine-Resistant
Pf Malaria from Cambodia
National Institutes of Health
HEALTH & FITNESS Tuesday May 7, 2002
Section F, Page 5, Column 1
New Resistant Gonorrhea Migrating to Mainland U.S.
Volume 334:933-938, Number 15April 11, 1996
Transmission of Multidrug-Resistant Mycobacterium
tuberculosis during a Long Airplane Flight
Drug Resistance: Everyone’s Problem Eventually
Common Approach to Drug Resistance: Switch Drugs and Ignore Contributing Factors
Source: SE Asia J Trop Med Public Health 1999; 30: 68
Treating P. falciparum malaria in Thailand
Year
Cu
re R
ate
(%
)
$0.10
$0.89 Current treatment:Mefloquine + artesunate
Cost: $ 3.59 per patient
Total Pf cases: 62,000
Total M/A treatment cost:$222,000 (34X greater than CQ)
0% 20% 40% 60% 80% 100%
ESTONIA 1999
CHINA (Henan Province)1996
RUSSIA (Ivanovo Oblast)1998
LATVIA 1998
RUSSIA (Tomsk Oblast) 1999
THAILAND 1997
SIERRA LEONE 1997 MDR-TB
Any drug resistanceother than MDRSusceptible
Consequences of not Addressing Contributing Factors: Drug-Resistant TB
Source: Anti-tuberculosis Drug Resistance in the World Report No.2. WHO 2000
1. Treatment 12-18 months (vs. 6 months)
2. Alternative drugs more toxic
3. Drug costs >$1,000 (vs. $10)
Prevalence of Drug Resistance in New TB Cases
Consequences of not Addressing Contributing Factors: Cost of TB Drugs
Source of data: 2002 WHO Global Tuberculosis Control Report
Country(MDR rate innew cases)
Treatmentof:
NoMDR-TB
WithMDR-TB
Increased costdue to MDR-TB
NotifiedSS+ cases
$3.5million
$15.3million
$11.8 millionIndia(3.4%)
70% ofestimatedSS+ cases
$5.8million
$25.4million
$19.6 million
NotifiedSS+ cases
$0.3million
$1.8million
$1.5 millionRussia(6.0%)
70% ofestimatedSS+ cases
$0.6million
$4.2million
$3.6 million
WHO Strategy
1. Support prevention programs to reduce the need for antimicrobial drugs
2. Improve treatment of infectious diseases to reduce emergence of drug resistance
Approach:• promote rational use of drugs • assure good-quality drugs are available when and where needed
What Can Be Done to Address Drug Resistance in Developing Countries?
USAIDAMR
Activities
(http://www.who.int/emc/amr.html)
• Promote rational drug use through strategies such as IMCI and DOTS
• Monitor drug resistance, drug-use practices, drug quality to assess PHN program performance and follow trends
• Support advocacy/communications to mobilize resources and coordinate efforts
• Develop/target interventions based on monitoring data to: -- train health and lab staff: drug use and quality, infection
control, surveillance (see above) -- educate consumers: care-seeking, treatment compliance -- improve drug policy/regulation/management: use, quality, access
What Can Be Done to Improve Treatment in Developing Countries?
Improved Procurement of TB Drugs: Example from Kazakhstan
Types of TB drugs procuredin 1998
Types of TB drugs procured after1999 tender with RPM assistance
Integrated Response to Drug Resistance:An Example from Cambodia
Malaria prevention and treatment for at-risk populations:• Bednets• Rapid diagnostics• Pre-packaged combination therapy (public and private sector)• Surveillance of drug resistance, drug quality, drug-use practices• Patient/provider education (bednets, therapy, drug quality)
Partnerships:• Funded by GH, ANE Bureau, Cambodia mission, EU, Japan• Implemented by WHO/Cambodia, National Malaria Centre• Additional training, technical assistance from WHO/WPRO, ACTMalaria, CDC, RPMPlus, USPDQI
Note: some parallel activities in Thailand, other Mekong countries
USAID/GH Support for a Country-Level Pilot Program to Contain Drug Resistance
Objective: Develop and implement a rational, prioritized, and coordinated action plan to control drug resistance in developing countries
Proposed approach (GH to fund pilot in 1-2 countries):• Assess resistance problem, available resources/partners/capacity• Prioritize areas for action (diseases, PHC, hospitals, consumers, providers, public sector/private sector)
• Monitor and evaluate interventions• Disseminate findings
Other Illustrative USAID Activities(Global/Regional/Country)
Advocacy and communication:• Development of WHO Global AMR Strategy• Increasing awareness of drug resistance problem, impact of new global initiatives (e.g. GFATM)
Surveillance:• Improving monitoring of resistance, drug quality, and drug use
Drug management/use/quality/etc.:• Training on rational drug use, drug procurement• Collecting information on drug quality in ANE region
Research:• Improving drug-use behaviors, drug regimens• Developing new tools for monitoring drug quality, drug use
For more details see: http://www.usaid.gov/pop_health/id/amr/publications/docs/amrstrategies.doc
• Academy for Educational Development
• Alliance for the Prudent Use of Antibiotics
• Boston University
• Centers for Disease Control and Prevention
• ICDDR,B
• International Clinical Epidemiology Network
• Johns Hopkins University
• Management Sciences for Health
• U.S. Pharmacopeia
• World Health Organization
• Other global/regional/national/local organizations
USAID AMR Partners Include...
Accessibleto missionsthroughexisting GHagreements
USG Interagency Task Force on
Antimicrobial Resistance
Department ofDefense
Environmental Protection
AgencyAgency for Healthcare Research and Quality
Centers for Medicare and Medicaid Services
Health Resources and Services
Administration Department ofAgriculture
Department ofVeterans AffairsAgency for International
Development
1. Drug resistance will be a constant threat as long as infectious diseases are present and treated with antimicrobial drugs. Rate of emergence will be faster with poor drug use/ quality.
2. Monitoring drug resistance, drug use practices, and drug quality through existing disease-treatment programs provides valuable feedback on program performance.
3. USAID/W is available to provide technical assistance (and some funding) to support missions in addressing drug resistance.
Things to Remember about Drug Resistance