A surge in antimicrobial resistance reported by WHO

The constant increase in the incidence of antimicrobial resistant infections is now becoming a major concern for the WHO. According to their recent report on 'Antimicrobial Resistance' this is a very real threat to global public health.
In recent decades the world has been aware of the rise in antibiotic resistant bacteria and has been trying to promote responsible use of antibiotic treatment in an effort to counteract this rise. But it is the first time that the WHO has warned of a much more serious problem since antimicrobial resistance covers a much broader spectrum of microbes (eg. parasites, fungi, and viruses).

If such a resistance is seen the world over, effective treatment of even common infection may be difficult or impossible. According to the report;

Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness, higher health care expenditures, and a greater risk of death.
As an example, the death rate for patients with serious infections caused by common bacteria treated in hospitals can be about twice that of patients with infections caused by the same non-resistant bacteria. For example, people with MRSA (methicillin-resistant Staphylococcus aureus, another common source of severe infections in the community and in hospitals) are estimated to be 64% more likely to die than people with a non-resistant form of the infection.


Although this kind of resistance to antimicrobial is being seen more around the world. Unfortunately not only do many of these cases go unreported, but often the infections last longer, leaving the patients infectious for a much longer time period , thus increasing the risk of further spreading the infection to others.

The report also highlights another consequence of AMR (Antimicrobial resistance), when infections fail to respond to first line of drugs, doctors have to resort to more aggressive therapies which are far more expensive, patients need medical supervision for a longer duration and hospital stays are also prolonged. All together these factors significantly increase the health care costs.

According to the report, the economic outcome can be damaging;

The growth of global trade and travel allows resistant microorganisms to be spread rapidly to distant countries and continents through humans and food. Estimates show that AMR may give rise to losses in Gross Domestic Product of more than 1% and that the indirect costs affecting society may be more than 3 times the direct health care expenditures. It affects developing economies proportionally more than developed ones. 

Some of the noteworthy resistances being seen globally are:

Resistance in Bacteria

WHO’s 2014 report on global surveillance of antimicrobial resistance reveals that antibiotic resistance is no longer a prediction for the future; it is happening right now, across the world, and is putting at risk the ability to treat common infections in the community and hospitals. Without urgent, coordinated action, the world is heading towards a post-antibiotic era, in which common infections and minor injuries, which have been treatable for decades, can once again kill.

Resistance in Tuberculosis

Globally, 6% of new TB cases and 20% of previously treated TB cases are estimated to have MDR-TB, with substantial differences in the frequency of MDR-TB among countries. Extensively drug-resistant TB (XDR-TB, defined as MDR-TB plus resistance to any fluoroquinolone and any second-line injectable drug) has been identified in 92 countries, in all regions of the world.

Resistance in Malaria

The emergence of P. falciparum resistance to artemisinin in the Greater Mekong subregion is an urgent public health concern that is threatening the ongoing global effort to reduce the burden of malaria. Routine monitoring of therapeutic efficacy is essential to guide and adjust treatment policies. It can also help to detect early changes in P. falciparum sensitivity to antimalarial drugs.

Resistance in HIV

At the end of 2011, more than 8 million people were receiving antiretroviral therapy in low- and middle-income countries to treat HIV. Although it can be minimized through good programme practices, some amount of resistance to the medications used to treat HIV is expected to emerge. 

There is no clear evidence of increasing levels of resistance to other classes of HIV drugs. Of 72 surveys of transmitted HIV drug resistance conducted between 2004 and 2010, 20 (28%) were classified as having moderate (between 5% and 15%) prevalence of resistance.

Resistance in Influenza

Several countries have developed national guidance on their use and have stockpiled the drugs for pandemic preparedness. The constantly evolving nature of influenza means that resistance to antiviral drugs is continuously emerging.
By 2012, virtually all influenza A viruses circulating in humans were resistant to drugs frequently used for the prevention of influenza (amantadine and rimantadine). However, the frequency of resistance to the neuraminidase inhibitor oseltamivir remains low (1-2%). Antiviral susceptibility is constantly monitored through the WHO Global Surveillance and Response System.


How can this surge be slowed down?

According to the WHO report, this rise in AMR is the result of a multiple factors. 
Here are some suggestions it provides in the report:

People

• using antibiotics only when they are prescribed by a certified health professional;
• completing the full treatment course, even if they feel better;
• never sharing antibiotics with others or using leftover prescriptions.

Health Care Workers And Pharmacists

• enhancing infection prevention and control;
• prescribing and dispensing antibiotics only when they are truly needed;
• prescribing and dispensing the right antibiotic(s) to treat the illness.

Policymakers 

• strengthening resistance tracking and laboratory capacity;
• strengthening infection control and prevention;
• regulating and promoting appropriate use of medicines;
• promoting cooperation and information sharing among all stakeholders.

Policymakers, Scientists and Industry

• fostering innovation and research and development of new vaccines, diagnostics, infection treatment options and other tools. 

In the end what is the WHO doing to counteract AMR? 
 
In 2014, WHO published its first global report on surveillance of antimicrobial resistance, with data provided by 114 countries.
WHO is guiding the response to AMR by:

• bringing all stakeholders together to agree on and work towards a coordinated response;
• strengthening national stewardship and plans to tackle AMR;
• generating policy guidance and providing technical support for Member States;
• actively encouraging innovation, research and development.

 

















References:
WHO Report on Antimicrobial Resistance (Updated April 2014)
Detect and Protect Against Antibiotic Resistance Budget Initiative (CDC)

WHO report: Antibiotic resistance happening right now all over the world (The Independent-April 30, 2014)

Millions living with leprosy in spite of being curable

On January 26th The World Day of Leprosy, I saw a video on The Guardian global development news page by Maria Zupello  titled Leprosy in Brazil: Uncovering a hidden disease. Realizing that leprosy is still around was rather disturbing, especially because this is a curable disease and therefore there should be no such thing as living with leprosy in these times, but after doing some research it became apparent that is not the case.

WHO: Leprosy Statistics:

According to the World Health Organization's latest stats on leprosy in the world, there are still around 200,000 reported new cases of leprosy every year in the world. Also known as Hansen's Disease, leprosy is endemic in 91 countries around the world. The highest concentration of reported new cases (at the start of 2012) being in South East Asia (117,147). The majority of which are in India. The second highest incidence is in the Americas (34,801),  of these reported new cases the majority are from Brazil. But because of its long incubation period and the lack of tools to allow early detection leading to late diagnosis, the exact prevalence of Hansen's disease is not clear.

India:
Although the Indian Government declared it has eliminated leprosy in 2005. It has since then become clear that the claim was premature. Of the total leprosy cases in the world 55% are in India, and about 127,000 new cases were reported between 2010-2011. Besides lack of access to basic healthcare services, leprosy patients also suffer socioeconomic isolation as a result of the stigma and discrimination that still exists in India.

Brazil: 
Leprosy is more prevalent in Brazil than in any other country except India. More than 30,000 new cases are diagnosed each year. Despite economic development, expansion of public healthcare, and efforts of the leprosy control program in the past 30 years, this disease has not been eliminated, and new cases are still being detected. The leprosy control program in Brazil distributes free drugs as part of the World Health Organization multidrug regimen for treatment of leprosy. Unfortunately health care services are not available in rural parts of the country. The amazon region of Brazil where leprosy has been endemic for more than a century is almost deprived of such health services.

Leprosy is particularly prevalent among the poorest and most marginalised communities due to their lack of access to healthcare, poor sanitation and congested living spaces. - See more at: http://www.tlmindia.org/index.php/about-leprosy/facts#sthash.zlOMnaBW.dpuf

Government statistics under estimate the extent of leprosy according to research organisations, NGOs and some medical personnel who argue that leprosy cases are on the rise - See more at: http://www.tlmindia.org/index.php/about-leprosy/facts#sthash.zlOMnaBW.dpuf

Government statistics under estimate the extent of leprosy according to research organisations, NGOs and some medical personnel who argue that leprosy cases are on the rise - See more at: http://www.tlmindia.org/index.php/about-leprosy/facts#sthash.zlOMnaBW.dpuf

Government statistics under estimate the extent of leprosy according to research organisations, NGOs and some medical personnel who argue that leprosy cases are on the rise - See more at: http://www.tlmindia.org/index.php/about-leprosy/facts#sthash.zlOMnaBW.dpuf

To understand why the stigmatization, socioeconomic isolation, discrimination leading to leprosy communities in countries like India and Brazil is so wrong, here are some basic facts about Leprosy( Hansen's Disease);

What is Leprosy?

Leprosy is a chronic bacterial disease caused by Mycobacterium leprae and Mycobacterium lepromatosis. This infection primarily affects the skin, peripheral nerves and upper airway. It is well known that leprosy is not spread through casual contact. 

About 95% of human beings are naturally immune making leprosy the 'least contagious communicable disease'. The World Health Organization suggests that it is transmitted through moisture from the nose and mouth during frequent and close contact with an untreated leprosy-affected person. It might also happen if you are exposed to other nasal fluids (also known as secretions). Droplets and other secretions can contain the bacteria that cause Hansen’s disease. If you breathe these in, you can become sick with the disease.

According to the CDC,  as incubation period of the bacteria is long , it may take up to 2-10 years for signs and symptoms to appear. The disease mainly affects the skin, nerves and the mucous membranes. Common signs and symptoms include; disfiguring skin sores, lumps, or bumps that do not go away after several weeks or months. The skin sores are pale-colored. Nerve damage can lead to loss of feeling in arms and legs and muscle weakness. Without treatment, leprosy can permanently damage your skin, nerves, arms, legs, feet, and eyes.

Treatment of Leprosy

Leprosy can be cured. In the last two decades, more than 14 million people with leprosy have been cured. The World Health Organization provides free treatment for all people with leprosy.

Treatment depends on the type of leprosy that you have. It is treated with a combination of antibiotics. The treatment may last anywhere from 6 months to 2 years. People with severe leprosy may need to take antibiotics longer. Antibiotics cannot treat the nerve damage.

Anti-inflammatory drugs are used to control swelling related to leprosy. This may include steroids, such as prednisone.

Patients with leprosy may also be given thalidomide, a potent medication that suppresses the body's immune system. It helps treat leprosy skin nodules. Thalidomide is known to cause severe, life-threatening birth defects and should never be taken by pregnant women.

According to the WHO 'Access to information, diagnosis and treatment with multidrug therapy (MDT) remain key elements in the strategy to eliminate the disease as a public health problem, defined as reaching a prevalence of less than 1 leprosy case per 10,000 population. Only a couple of endemic countries have still to achieve this goal at the national level; most are now applying the same elimination strategy at regional, district and sub-district levels. MDT treatment has been made available by WHO free of charge to all patients worldwide since 1995, and provides a simple yet highly effective cure for all types of leprosy.

Most countries that were previously highly endemic for leprosy have achieved elimination at the national level and are intensifying their efforts at regional and district levels.'

Information campaigns about leprosy in high risk areas are crucial so that patients and their families, who were historically ostracized from their communities, are encouraged to come forward and receive treatment. The most effective way of preventing disabilities in leprosy, as well as preventing further transmission of the disease, lies in early diagnosis and treatment with MDT. (WHO)

P.S: 
The Leprosy Mission India 
The Leprosy Mission Canada  
Hansen's Disease (CDC) 
Leprosy (WebMD)
Leprosy Today (WHO) 
National Hansen's Disease Program (HRSA) 
Watch Video: Leprosy in Brazil: Uncovering a hidden disease (The Guardian)

Watch Video: Battling leprosy in Brazil(BBC World)

Watch Video: Leprosy: India's Hidden Disease (The Guardian)

Photo Gallery: Colonia Antonio Alexio - Leprosy community in Manaus, Brazil (Photojournalist: Sharon Steinmann)

High Incidence of Diseases Endemic to the Amazon Region of Brazil, 2001–2006 (CDC)

 

The rise of the drug-resistant infections

For many decades after the discovery of the first antibiotic, we have been able to root out and beat bacterial infections after bacterial infections. But when the medical professionals celebrated this invincibility with the widespread use of antibiotics, most of them forgot the fact that bacteria like any other life form know how to evolve. And thus after being victorious against even the most aggressive and deadly infections for almost a century, we are now facing a new breed of bacteria that have learned to survive even the strongest drugs in our antibiotic arsenal.

According to the CDC Antibiotic Resistant Threats 2013 Report;
Each year in the United States, at least 2 million people acquire serious infections with bacteria that are resistant to one or more of the antibiotics designed to treat those infections. At least 23,000 people die each year as a direct result of these antibiotic-resistant infections. Many more die from other conditions that were complicated by an antibiotic-resistant infection.
In addition, almost 250,000 people each year require hospital care for Clostridium difficile (C. difficile) infections.In most of these infections, the use of antibiotics was a major contributing factor leading to the illness. At least 14,000 people die each year in the United States from C. difficile infections. Many of these infections could have been prevented.
The most aggressive and lethal drug resistant infections are caused by gram-negative bacteria, which are mostly seen in healthcare settings, but other forms of bacteria are also showing presence of drug-resistant strains. As to who is more likely to be at high risk, according to the report, it is often individuals with suppressed, weak or damaged immunity. But many innovative treatments require effective treatment of any infection, as a result it is becoming very difficult to offer such options to individuals with other pre-existing conditions, such as diabetes, rheumatoid arthritis, and asthma.
Some of the common medical situations in which doctors are faced with this dilemma are;

1. Cancer Chemotherapy
2. Complex Surgeries (eg. Joint replacement, Cardiac Bypass)
3. Rheumatoid Arthritis
4. Dialysis for End-Stage Renal Disease
5. Organ and Bone Marrow Transplants

What makes these new infections worrisome it the fact these can happen anywhere. Data has shown that majority of these happen in the general population but the antibiotic resistance mostly develops in a healthcare setting such as a hospital or nursing home.


The CDC also classifies these drug-resistant superbugs by threat levels: 
Urgent:

These are high-consequence antibiotic-resistant threats because of significant risks identified across several criteria. These threats may not be currently widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission.

Serious:

These are significant antibiotic-resistant threats. For varying reasons (eg.,low or declining domestic incidence or reasonable availability of therapeutic agents), they are not considered urgent, but these threats will worsen and may become urgent without ongoing public health monitoring and prevention activities.

Concerning: 

These are bacteria for which the threat of antibiotic resistance is low, and/ or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness. Threats in this category require monitoring and in some cases rapid incident or outbreak response.

The report in the end points to the lack of certain measures that might help, as a result, these are some of the suggested steps, that might allow healthcare professionals everywhere, better understand and cope with this serious growing medical problem, include;

 An efficient capacity to detect and respond to urgent and emerging antibiotic resistance threats at national, state and federal levels.
-A collaborative systematic international surveillance of antibiotic resistance threats.
-Systematically collect data on antibiotic use in human healthcare and agriculture.
-More widely use programs to improve antibiotic prescribing practices in the United States.
-Promote the use of advanced technologies that can identify threats much faster then current practices.

P.S: 
CDC Antibiotic Resistant Threats 2013 Report
CDC sets threat levels for drug-resistant 'superbugs' (CNN News)

What are the real benefits of antibacterial soaps, if any?

Probably because of my medical background I have always worried about the indiscriminate use of antibiotics, which can consequently create antibiotic-resistant bacteria called 'Super Bacteria'. Treating the infections caused by these super bacteria can be a nightmare, often leading to disastrous outcomes, even death.

It is in the same vein, I have always been a bit skeptical of the antibacterial soaps sold to consumers. Since antibacterial soaps are supposed to be killing everyday bacteria we end up collecting on our hands, they are also indirectly creating super bacteria. And besides that these antibacterial soaps are also killing off the normal bacterial flora on our hands. 

What is normal bacterial flora on our hands?

According to the 'WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.' and Medical Microbiology. 4th edition :
The bacteria found on our hands can be divided into two types; namely resident and transient. The resident bacteria being the ones normally residing on our hands, these predominantly include Gram-positive organisms (e.g., staphylococci, micrococci, diphtheroids). The resident flora primarily plays a protective role by providing microbial antagonism and the competition for nutrients in the ecosystem. Hence the resident flora rarely causes infections.
The transient bacteria are the one we acquire through contact with infected individuals or surfaces. These can lead to infections and spread from person to person. This transfer of bacteria through direct contact is highest in health care workers. In fact their hands may constantly become colonized by some pathogenic flora such as Staphylococcus Aureus and Gram-negative bacilli.

The main bacteria killing ingredient in majority antibacterial soaps is Triclosan. Although Triclosan is meant to rid our hands of the transient kind of bacteria, over time it indiscriminately also kills the resident kind. 

What is Triclosan?

According to the FDA Consumer Update on Triclosan:

'Triclosan is an ingredient added to many consumer products to reduce or prevent bacterial contamination. It may be found in products such as clothing, kitchenware, furniture, and toys. It also may be added to antibacterial soaps and body washes, toothpastes, and some cosmetics—products regulated by the U.S. Food and Drug Administration (FDA).'

'Triclosan is not currently known to be hazardous to humans. But several scientific studies have come out since the last time FDA reviewed this ingredient that merit further review.

Concerns about Triclosan:

According to the FDA Consumer Update on Triclosan:

'Animal studies have shown that triclosan alters hormone regulation. However, data showing effects in animals don’t always predict effects in humans. Other studies in bacteria have raised the possibility that triclosan contributes to making bacteria resistant to antibiotics.

In light of these studies, FDA is engaged in an ongoing scientific and regulatory review of this ingredient. FDA does not have sufficient safety evidence to recommend changing consumer use of products that contain triclosan at this time.

For some consumer products, there is clear evidence that triclosan provides a benefit. In 1997, FDA reviewed extensive effectiveness data on triclosan in Colgate Total toothpaste. The evidence showed that triclosan in this product was effective in preventing gingivitis. 

For other consumer products, FDA has not received evidence that the triclosan provides an extra benefit to health. At this time, the agency does not have evidence that triclosan in antibacterial soaps and body washes provides any benefit over washing with regular soap and water.

We are engaged in a comprehensive scientific and regulatory review of all the available safety and effectiveness data. This includes data relevant to the emerging safety issues of bacterial resistance and endocrine disruption due to triclosan in FDA-regulated products.'

On December 16  2013, FDA finally came out with the verdict FDA Taking Closer Look at 'Antibacterial' Soap.  Colleen Rogers, Ph.D., a lead microbiologist at FDA stated that "there currently is no evidence that over-the-counter (OTC) antibacterial soap products are any more effective at preventing illness than washing with plain soap and water." She goes on to say "New data suggest that the risks associated with long-term, daily use of antibacterial soaps may outweigh the benefits."

The update states "In light of these data, the agency issued a proposed rule on Dec. 16, 2013 that would require manufacturers to provide more substantial data to demonstrate the safety and effectiveness of antibacterial soaps. The proposed rule covers only those consumer antibacterial soaps and body washes that are used with water. It does not apply to hand sanitizers, hand wipes or antibacterial soaps that are used in health care settings such as hospitals.

According to Rogers, the laboratory tests that have historically been used to evaluate the effectiveness of antibacterial soaps do not directly test the effect of a product on infection rates. That would change with FDA's current proposal, which would require studies that directly test the ability of an antibacterial soap to provide a clinical benefit over washing with non-antibacterial soap, Rogers says."

In the end, it seems to be wise to continue washing our hands with just plain ol' soap and water, and postpone the use of these fancy antibacterial soaps till further notice. 



References:
Dangers of Antibiotic Resistance
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.
Medical Microbiology. 4th edition 
FDA Consumer Update on Triclosan
FDA Taking Closer Look at 'Antibacterial' Soap.