2015-05-12 11:41:03
A long waited for global action plan against antimicrobial resistance is going to be released in May 2015 by World Health Organization (WHO). A background report on this action plan is published recently (April 2015) where the country situation on antimicrobial response was analyzed with great care and effort. This report includes detail scenario of world situation on response to antimicrobial resistance especially against Bacteria, Tuberculosis, Malaria, Influenza and HIV who are utterly leading and persisting public health threats in the contemporary world. Survey data were collected over a two year period from 2013-2014 and a multi-stage analytical tool was developed to assess the situation at the national level. This report illustrates in-depth analysis of effective practices and structures against antimicrobial resistance in all six WHO regions-
(1) WHO African Region-AFR (Total # of Member States-47, Participated in this survey-8);
(2) WHO Region of the Americas-AMER (Total # of Member States-35, Participated in this survey-26);
(3) WHO Eastern Mediterranean Region-EMR (Total # of Member States-21, Participated in this survey-13);
(4) WHO European Region-EUR (Total # of Member States-53, Participated in this survey-49);
(5) WHO South-East Asia Region-SEAR (Total # of Member States-11, Participated in this survey-11);
(6) WHO Western Pacific Region-WPR (Total # of Member States-27, Participated in this survey-26).
Following major six criteria were selected to analyze in depth country situation on response to antimicrobial resistance:
ü National plans and other strategies,
ü Surveillance and laboratory capacity,
ü Access to quality-assured antimicrobial medicines,
ü Use of antimicrobial medicines,
ü Public awareness and,
ü Infection prevention and control programme
National plans and other strategies
A well-financed national plan with multisectoral input is essential for addressing antimicrobial resistance. Fortunately, the South-East Asia region had the highest proportion of countries with such plans (45%), the European Region followed closely, with 43% while only 2% in the African Region. Surprisingly, no member state from Eastern Mediterranean Region had reported of any such plans. Other national mechanisms, such as national focal point and a central coordination mechanism, were generally more common than plans. Many countries reported having a national policy or strategy, but few had published a progress report within the previous 5 years.
Surveillance and laboratory capacity
Well-equipped laboratories with well-trained staff that report regularly to functioning surveillance systems allow the detection and tracking of antimicrobial-resistant microorganisms and prompt notification to the relevant authorities when an outbreak occurs. Data from surveillance also allow policy-makers to introduce evidence-based standards and regulations and health care managers to make decisions on appropriate care. Antimicrobial resistance among rapidly growing bacteria and Mycobacterium tuberculosis was monitored in all regions, over 60% of respondents in each region reporting this type of surveillance. Regional networks support surveillance in many countries; however, none includes all the countries in its respective region.
Typically, countries cited a lack of laboratories with sufficient competent technical staff, weak infrastructure, poor data management and lack of standards as impediments to effective laboratory surveillance. The highest percentage of countries with national reference laboratories in which organisms are tested for antibiotic sensitivity (96%) was in the Region of the Americas. National reference laboratories existed in 69–82% of countries in the European, South-East Asia and Western Pacific regions. National reference laboratories are often responsible for implementing national external quality assessment schemes, to ensure that the same testing standards and methods are used throughout the country. Although at least one country in each region reported having a national reference laboratory, many did not participate in external quality assessment schemes to ensure that the data on antimicrobial resistance that was collected was of reliable quality.
Access to quality-assured antimicrobial medicines
Ready access to quality-assured antimicrobial medicines is important for preventing the appearance of new antimicrobial-resistant microorganisms. Poor-quality medicines may not contain the correct amount of active ingredient, resulting in sub-optimal dosing. This can be overcome with strong national regulations on medicine production and by strengthening the ability of authorities to regulate the industry. About 15% of AFR Member States answered “Yes” to the existence of national regulatory authority compared to >60% in EUR, SEAR and WPR region each. List of essential drugs is present in ≥60% of member states in all six regions except EMR and AFR.
Use of antimicrobial medicines
Both overuse and misuse of antimicrobial medicines accelerate the emergence of resistant microorganisms. Misuse can be due to:
ü poor prescribing practice, including prescribing antimicrobial medicines when not required, incorrect choice of medicine, or at an incorrect dosage;
ü self-medication in countries in which antimicrobial medicines are freely available;
ü failure to finish a course of antimicrobial medicines or taking them for too long;
ü lack of regulations or standards for health care workers (WHO, 2011); and
ü misuse and overuse in animal husbandry and agriculture.
Survey report confirms us that Antimicrobial medicines are freely available in all the regions and monitoring activities in the last five years are as low as 6% and 9% in the Member States of African and South-East Asian Regions respectively while it is 66% in the European regions.
Public awareness
At the time of the survey, public awareness appeared to be low in all regions which seems around 80% in WHO European Region, approximately 45% in South-East Asian Region and as expected WHO African Region is in the bottom of this list (<5%). This situation is alarming, particularly in countries where antimicrobial medicines are readily available without a prescription. In the analysis of the level of awareness about antimicrobial resistance in health care, politics, the media and academia, academics were generally more aware of the problem than others, including health care workers. The general lack of awareness in those sectors would indicate that antimicrobial resistance is likely to spread further. Infection prevention and control programmes (IPC)
Resistant microorganisms can spread rapidly across countries, regions and the world, facilitated by global trade, travel and tourism. Poor infection control in any setting can greatly increase the spread of drug-resistant infections, especially during outbreaks of disease. IPC programmes are thus essential to curb the movement of antimicrobial-resistant organisms, starting with good basic hygiene, which limits the spread of all infections, including those that are resistant to antimicrobial medicines.
At least half the Member States in the European, South-East Asia and Western Pacific regions reported having such a programme; fewer stated that all tertiary hospitals in the country had one. Only 4 Member States of African Region answered “Yes” in response to IPC existence which accounts for only 8%. No other evidence is required to explain why controlling recent “Ebola” epidemic in this region is so challenging.
South-East Asia: Recognizes antimicrobial resistance as a serious threat to public health
WHO South-East Asia region consists of 11 Member States including Bangladesh. In this region, 26% of the total world population resides. All Member States committed themselves to concerted action by adopting the Jaipur Declaration on Antimicrobial Resistance in 2011 to best defend the region against this pressure. The country situation of this region had been further analyzed based on above mentioned SIX major criteria.
As said earlier, national plan and other strategies are the most important factor to combat resistance, this region was able to develop national plan in 5 Member States, National coordinating mechanism was available in 7 countries, 4 have National focal point, 6 have Policies or strategies in place and all 11 countries have produced progress report in the last 5 years. Although, about half of the Member States of this region requires to enact their own National plan and other strategies yet.
Next to national plan, surveillance and laboratory capacity had been developed to this region (Fig 2). All member states reported that they had conducted Bacterial and Tuberculosis surveillance while 1-2 member states had not develop same type of surveillance and laboratory diagnosis facility for Malaria, Influenza and HIV infection. Nine countries (82%) had national reference laboratories for testing sensitivity to antibiotics and six (53%) participated in external quality assessment which is still an area to improve.
Additionally, a National Regulatory Authority existed in nine (82%) countries and six (55%) had quality standards; seven (64%) reported that they could enforce the quality standards. Counterfeit medicines were a significant problem in this region. However, all 11 member states had a list of essential drugs.
However, access and use of Antimicrobial medicines were possible without a prescription in 64% (Table 1) of countries even though some of them had a national regulatory body to control the misuse of medicines.
To increase public awareness, the WHO Regional Office has been distributing material to Member States in this region since World Health Day in 2011. At the time of the survey, five countries (45%) reported having conducted a public information campaign on antimicrobial use in the previous 2 years. Further progress has been made, with campaigns now being undertaken in almost all countries.
Last but not least, Infection control and prevention (IPC) programmes address all types of infection and are especially important in slowing the transmission of antimicrobial-resistant organisms. Nine of the Region’s Member States reported a national IPC programme, and seven reported that all their tertiary hospitals had such a programme.
Summarizing the information of this first country situation analysis data provided by WHO, it can be said that there are clear gaps seen in the existing structure and policies. This survey report will help to fill the gaps and can be a good platform for possible antimicrobial resistance solution all over the six WHO regions through the Global Action Plan to be published this month.
