Download Controlling Drug Resistance in Developing Countries

Controlling
Drug Resistance
in Developing Countries
USAID
Antimicrobial Resistance (AMR)
Working Group*
ANE/E+E SOTA, October 2002
*Includes: Neal Brandes, Tony Boni, Andrew Clements, Ruth Frischer, Marni Sommer, Cheri Vincent
Objectives of Presentation
Highlight the complexity of the drug resistance
problem and its impact on controlling infectious
diseases and USAID PHN programs.
Provide information on country-level approaches
to control drug resistance and what assistance is
available from USAID/W.
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
4
Total infectious disease deaths:
14.4 million each year
3.5
3
Millions
of deaths
in 2000
2.5
2
1.5
1
0.5
0
ARI
HIV-AIDS
DIARR.
DISEASE
TB
MALARIA
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
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 Sector
and NGOs
Global Initiatives
e.g. RBM, GDF,
GFATM, Trachoma
Ideal Treatment of Infectious Diseases with
Antimicrobial Drugs
Infected patient
1. Trained health provider consulted
Treatment failure
or drug resistance
2. Specific diagnosis made
3. Correct drug prescribed in correct dose indicate a problem
BUT
4. High-quality drug and treatment
Treatment failure
information obtained
doesn’t always mean
5. Treatment regimen followed
drug resistance
Cured patient
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 sector
Fills in where reach of public sector is limited
Producing/exporting antimicrobial drugs
The Treatment vs. Drug Resistance Dilemma
Health Provider Priority
Public Health Priority
Client: patient (individual)
Client: MoH (society)
Objective: cure disease fast
Objective: cure, limit AMR
Possible consequence:
more poor drug use
Possible consequence:
limited access to drugs
Evidence that Treatment of Infectious Diseases
Needs to be Improved
Total :
11,754,000
Sources: 2001 World Health Report and WHO reports
Outbreaks of Typhoid Fever (Salmonella typhi)
Year(s) of
Outbreak
1989
1990-95
1990-95
1990-93
1991
1991
1991-92
1992-94
1993-94
1994
1994-95
1996-97
Location
Resistance Type
Pakistan
India
Arabian Gulf
Kuala Lumpur
UK
S. Africa
Egypt
Vietnam
Philippines
Bangladesh
Pakistan
Tajikistan
ACSSuTTm
ACSSuTTm
ACSSuTTm
ACSSuTTm
CSTTm
ACSSuT
ACSSuTTm
ACSSuTTm
CKSSuTTm
ACSSuTTm
ACSSuTTm
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.
Drug Resistance: Everyone’sSpread
Problem
Eventually
of Chloroquine-Resistant Malaria
from
Cambodia (1960s)
Spread of
Chloroquine-Resistant
Pf Malaria from Cambodia
HEALTH & FITNESS
Tuesday May 7, 2002
Section F, Page 5, Column 1
Since 1960:
New
Resistant
• 6-fold
increaseGonorrhea
in global trade
Migrating to Mainland U.S.
National Institutes of Health
• 17-fold increase in number of people travelling in airplanes
Since 1980:
Volume 334:933-938, Number 15
April 11, 1996
• 9-fold increase in number of refugees/displaced
Transmissionpeople
of MultidrugResistant Mycobacterium
tuberculosis during a Long
Airplane Flight
Common Approach to Drug Resistance:
Switch Drugs and Ignore Contributing Factors
Cure Rate %
120
Treating P. falciparum malaria in Thailand
$0.89
100
Mefloquine
Current treatment:
Mefloquine + artesunate
80
Quinine
60
40
Sulphadoxine-
Cost: $ 3.59 per patient
Total Pf cases: 62,000
Pyrimethamine
20
$0.10
0
Chloroquine
1975 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994
Year
Year
Source: SE Asia J Trop Med Public Health 1999; 30: 68
Total M/A treatment cost:
$222,000 (34X greater than CQ)
Consequences of not Addressing Contributing
Factors: Drug-Resistant TB
MDR-TB
SIERRA LEONE 1997
Any drug resistance
other than MDR
Susceptible
THAILAND 1997
RUSSIA (Tomsk Oblast) 1999
1. Treatment 12-18
months (vs. 6
months)
2. Alternative drugs
more toxic
LATVIA 1998
3. Drug costs
>$1,000 (vs. $10)
RUSSIA (Ivanovo Oblast)1998
CHINA (Henan Province)1996
ESTONIA 1999
0%
20%
40%
60%
80%
100%
Prevalence of Drug Resistance in New TB Cases
Source: Anti-tuberculosis Drug Resistance in the World Report No.2. WHO 2000
Consequences of not Addressing
Contributing Factors: Cost of TB Drugs
Country
Treatment
(MDR rate in of:
new cases)
India
(3.4%)
Russia
(6.0%)
Notified
SS+ cases
70% of
estimated
SS+ cases
Notified
SS+ cases
70% of
estimated
SS+ cases
No
With
Increased cost
MDR-TB MDR-TB due to MDR-TB
$3.5
million
$5.8
million
$15.3
million
$25.4
million
$11.8 million
$0.3
million
$0.6
million
$1.8
million
$4.2
million
$1.5 million
Source of data: 2002 WHO Global Tuberculosis Control Report
$19.6 million
$3.6 million
What Can Be Done to Address Drug Resistance
in Developing Countries?
WHO Strategy (http://www.who.int/emc/amr.html)
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
USAID
AMR
Activities
What Can Be Done to Improve Treatment in
Developing Countries?
• 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
Improved Procurement of TB Drugs: Example
from Kazakhstan
Types of TB drugs procured
in 1998
non-DOTS
73%
DOTS
27%
Types of TB drugs procured after
1999 tender with RPM assistance
DOTS+
(MDR)
17%
DOTS
83%
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
USAID AMR Partners Include...
• 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
Accessible
to missions
through
existing GH
agreements
USG Interagency Task Force on
Antimicrobial Resistance
Agency for Healthcare
Research and Quality
Centers for Medicare
and Medicaid Services
Health Resources and
Services
Administration
Agency for International
Development
Department of
Defense
Department of
Agriculture
Environmental
Protection
Agency
Department of
Veterans Affairs
Things to Remember about Drug Resistance
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.