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December 31, 2014

by Buddha Basnyat 

In Nepal, as in so much of the world, people think nothing of popping antibiotics for coughs and sniffles, “just in case.” It seems harmless enough and may do some good. In fact, because the most likely culprit is a virus, it won’t do the patient any good and does the whole population bad by promoting antibiotic resistance.  This is the extent of what people think of (if they think of anything) as irrational antibiotic use—a mismatch between disease and treatment. But the roots of antibiotic resistance are deeper and broader.

The Global Antibiotic Resistance Partnership-Nepal (GARP-Nepal) working group, based at the Nepal Public Health Foundation, released the first fully documented situation analysis of antibiotic resistance and related factors in Nepal on December 15 in Kathmandu.  The working group consists of Nepali experts in medicine, veterinary science, pharmacology, microbiology, economics and other fields.

The situation analysis revealed to the assembled dignitaries (including the Minister of Health and Population), clinicians, veterinarians, microbiologists, and others that the problem in Nepal is not just something to worry about in the future—it is here already and getting worse.

However, the seriousness of the situation may not be the most important lesson from the situation analysis or the meeting. More important is expanding the definition of the drivers of antibiotic resistance and the remedies. Hardly anyone in Nepal, including healthcare workers, would equate better vaccination coverage with saving antibiotics. Yet once pointed out, the connection is crystal clear: a child who doesn’t get sick is not given antibiotics (this includes both necessary and irrational prescribing). Perhaps the antibiotic angle is overlooked because we don’t need a rationale for vaccines besides their primary purpose of preventing disease. Similarly, clean water and sewerage can dramatically reduce infection, especially diarrhea in children.  And again, saving antibiotics is not the primary motivation to support these improvements, but it should be registered as an added benefit.

Another example:  infection control measures in hospitals (the best example is hand washing or using alcohol hand sanitizer).  It is well known that hospitals are dangerous places, where patients can get infected with a host of bacteria from other sick patients.  Unfortunately, the “vectors” of many of these infections are the doctors and nurses who move from patient to patient. Hand washing or hand sanitizer between patients definitively cuts down on transmission and therefore the need for antibiotics.
Additionally, few are aware that farm animals are given large doses of antibiotics throughout their lives, and this creates a reservoir of antibiotic-resistant bacteria.  Just as with people, there are ways to cut down this use, through better farm sanitation and vaccines.
Rational use of antibiotics is certainly one of the important pillars for decreasing antibiotic resistance.  On this everyone is clear. But the more comprehensive understanding of the forces leading to antibiotic resistance had not previously been grasped by many attending the meeting and the many more we will be reaching with this message in the next phase of GARP-Nepal.
In the situation analysis and at the meeting, the importance of antibiotic access was brought home—and this, too, had not been clearly grasped by many healthcare professionals.  In the hills and mountains of Nepal, many lack access to doctors and proper antibiotics.  In these parts certain antibiotics may need to be available without prescription, and making a blanket national rule of access to antibiotics only with prescriptions could be detrimental.
With the situation analysis in hand, we are moving ahead to widen our circle of experts and the public, monitor antibiotic resistance in hospitals, develop curriculum for healthcare workers (including veterinarians), support new research and recommend the way forward, with a clear evidence base.  We are planning Antibiotic Awareness Week-Nepal which will coincide with similar efforts all over the world, including GARP partners, in November 2015.
Buddha Basnyat is the chair of the Global Antibiotic Resistance Partnership (GARP)-Nepal working group.
Photo courtesy of the Nepal Public Health Foundation.
 

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