The Threat of Antimicrobial Resistance in Infectious Disease Prevention and Control in Somaliland

1.        Introduction
Antimicrobial resistance (AMR) is the development of resistance (microbes not responding to the administered drugs) in microorganisms—bacteria, viruses, fungi and parasites—to an antimicrobial medicine to which it was previously sensitive (WHO, 2015). AMR in a wide range of infectious agents is a growing public health threat of huge concern to countries and to many sectors. 

Especially alarming is the rapid global spread of multi-resistant bacteria that cause common infections and that resist treatment with existing antimicrobial medicines. There were 39.5 million deaths in the developing world where 4.123 Billion (78%) of the world population lived in 1992 and 9.2 million of the deaths were estimated to have been caused by infectious and parasitic disease (Murray & Lopez, 1997).

Although the discovery of first antimicrobials against bacteria (Antibiotics) in 1930s was a major breakthrough in the prevention and treatment of killer infections, warnings from the development of potential resistance to the new antibiotics surfaced. For instance, Alexander Fleming (the founder of penicillin) said in his Nobel prize acceptance speech 

“it is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them…there is the danger that the ignorant man may easily under-dose himself and, by exposing his microbes to nonlethal quantities of the drug, make them resistant” (Fleming, 1945).

Our ability to develop and mass-produce over 25 classes of antimicrobials in seventy years may seem monumental—indeed, many hailed the new antibiotic era as the end of infectious diseases. But, truth is, Microbes have infinitely more opportunities to gain resistance genes than we have to create new antimicrobials (Laxmanirayan, 2013). The speed of emergence of multi drug resistant pathogens globally outmatches the pace of discovery of new antimicrobials.

 There have been no successful discoveries of new classes of antibiotics since 1987 (Patel & Banomo, 2013). For example, just three years after Fleming’s warning, 38% of Staphylococcus aureus strains in one London hospital were penicillin-resistant ( Barber & Rozwadowska-Dowzenko, 1948) and roughly 90% of strains in the UK ( Johnson, et al., 2012) and nearly all of those in the US, while in some communities more than 50% of strains are resistant to methicillin (Klevens, 2007). 

The burden of AMR is very high in developing countries though due to the lack of sufficient body of research available as well as rudimentary healthcare systems with limited surveillance strategies/ programs on antimicrobial resistance which makes exact quantifications of the extent of AMR difficult as in the case in Somaliland.For instance, For example, in Matlab and Dhaka, Bangladesh, over 95% of Shigella dysenteriae isolates were resistant to multiple first line drugs (Hussain & Rahman, et. al., 1998).

 In Somalia in a cholera epidemic in 1985-6, there was a case fatality rate of 13% because the initially sensitive V cholerae quickly acquired plasmid encoded resistance to ampicillin, kanamycin, streptomycin, sulphonamides, and tetracycline (Coppo, et. al., 1995).
Therefore, considering facts presented here, multiple stakeholder cooperation is needed at national (as in Somaliland) as well as international level to fight against this serious threat facing the mankind.
2.                 Burden of Antimicrobial Resistance
a)                 Impact on Health Outcomes
Deaths from acute respiratory infections, diarrheal diseases, measles, AIDS, malaria and tuberculosis account for more than 85% of the mortality from infection worldwide (WHO,1999) and resistance to first-line drugs in the pathogens causing these diseases ranges from zero to almost 100% ( WHO,2001).
 Resistance frequently leads to a delay in the administration of microbiologically effective therapy, which may be associated with adverse outcomes (Kollef, Sherman, Ward & Fraser, 1999).

The impact on particularly vulnerable patients is most obvious, resulting in prolonged illness and increased mortality (Who, 2014). Infections caused by antibiotic-resistant bacteria are believed to result in higher mortality rates, longer durations of hospital stays, and higher health care costs compared to those that result from infections with their antibiotic-susceptible counterparts (Holmberg, et. al., 1987). 

According to Carmeli, et. al., (1999), there is an association between antibiotic resistance and adverse outcomes on the order of a 1.3–2-fold increase in mortality, morbidity, and cost for patients with resistant versus susceptible infections.
          

Figure 1: Global attributable mortality to AMR

Projections of the future deaths due to AMR based on the current trends are described in the following figure 2.

b)                Impact on Economy
Antimicrobial resistance affects all areas of health, involves many sectors and has an impact on the whole of society. Antimicrobial resistance is a drain on the global economy with economic losses due to reduced productivity caused by sickness and higher costs of treatment (WHO, 2015). Antibiotic resistance has a significant health and economic implications, increasing national investment spending and reducing global GDP by 0.4 to 1.6 % (World Economic Forum, 2013). The annual societal cost-of-illness for AMR is considered to be roughly $55 billion for the US alone (Smith & Coast, 2013).

In an American study in 2008 of attributable medical costs for antibiotic resistant infections, it was estimated that infections in 188 patients from a single healthcare institution cost between $13.35 and $18.75 million dollars (Roberts, et. al., 2009). 

3.     Factors associated with occurrence of AMR
                   i.           Patient factors: self-medication of antimicrobials, patient’s level of education and awareness about safe use of antibiotics, poor adherence to prescribed medications (these factors are all highly prevalent in Somaliland).
                 ii.           Irrational use of antimicrobials including lack of standard antimicrobial prescribing policies/guidelines
               iii.           Advertising and promotions: allows pharmaceutical companies to advertise drugs directly to public.
               iv.           Economic factors: people may buy cheap and low quality medicines due to out-of- pocket situations
                 v.           The burden of substandard and counterfeit medicines worldwide: these may contain quantities less than required for effective antimicrobial activity (above MICs/MBCs), thereby exposing low concentrations to pathogens and promoting resistance.
               vi.           Lack of public health policies towards the containment of antimicrobial resistance nationwide as well regulations for promotion of rational use of antimicrobials.
             vii.           Lack/poor surveillance of the burden as well as trends of antimicrobial resistance (e.g. routine such surveillance is lacking in Somaliland).

4.     Impact Of AMR On Public Health Efforts To Control And Prevent Communicable Diseases
AMR resistance has substantially decreased our ability in controlling several important diseases, leading not only to economic losses, but also to social damages in the Public Health field (Munir and Xagoraraki, 2011; Wiesch et al., 2011).

The effect of AMR on public health summarized:
a)     It hinders the ability of public health measures to control the burden of infectious diseases as infections due to resistant pathogens prevail ( e.g. the challenges posed by MDR-TB associated with longer treatment periods, higher costs of therapies by using expensive second line drugs, reduced cure rates- decline from 80-90% in non-MDR cases to less than 50% in cases due to MDR-T.B; this is a global challenge as well as to the the Somaliland national TB program ,in particular, with rising prevalence of MDR-T.B.).

b)     It is associated with increased spending in healthcare and burden on national and institutional health budgets.

c)     It is associated with increased morbidity and mortality attributed to infectious diseases (e.g. Nosocomial infections and the challenge of MRSA/VRSA).

d)    If not contained from the current trend, the world may live similar era when a simple infection such as typhoid or plague had caused widespread epidemics/pandemics.

5.     Recommendations, Way Forward

•  AMR is a major threat to public health and coordinated efforts are needed nationally as well as globally to lessen and reverse its burden by Strengthen interdisciplinary cooperation and developing holistic strategies and action plans ( Somaliland can take an active role in for instance, WHO endorsed global strategy for containment of AMR). 
• Routine antimicrobial resistance surveillance is vital and urgently required to fight against AMR.( Somaliland should cooperate with international partners engaged in surveillance programs for this problem; e.g. WHO international surveillance program for AMR). 
• Improving regulatory frameworks based on internationally agreed principles and standards (Codex, OIE) 
• Reducing the need for antimicrobials in animal husbandry, by improving animal health disease prevention and good practices along the chain  
• Public health education and raising awareness (among veterinarians, value chain actors including producers and the public) about AMR 
• Developing appropriate policies/guidance on the prudent and responsible use of antimicrobials in animal husbandry  
• Rational prescribing and use of antimicrobials is a golden strategy to fight the AMR threat.( self medication as well as the use of antibiotics for conditions not requiring so is highly prevalent in Somaliland and the government must act to address this problem) 
• Supporting research to generate data on the prevalence and trends in AMR, as well as supporting risk assessment, risk management and risk communication in the AMR area . The research data available on the magnitude as well as the health and economic implications of AMR through quality studies employing sound and standardized methodologies is limited globally and lacking in regard to Somaliland and shows the underestimation/lack of required attention to this problem.

References
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By: Saed Ahmed

Medical logistician & Chief Pharmacist at MAS children Hospital,