Will High Court directives pave the way for breaking the stalemate? This is the last instalment of a three-part series
Following reports published in different media outlets, public concerns have been raised over antimicrobial resistant superbugs. The High Court recently issued a rule directing the government to ensure that no antibiotics are sold without prescription across Bangladesh.
Physicians, however, believe that such measures will not be enough to get rid of antimicrobial resistance (AMR), but rather, we need to take sustainable measures to eliminate the problem from the country_ or at least keep it under control.
Health rights activists and researchers have long been saying that the country needs to stop irrational use of antibiotics not only for the safety of its citizens, but also for future generations.
Dr Zafrullah Chowdhury, founder of Gonoshasthaya Kendra Hospital, welcomed the directive, saying that initiatives should have been taken much earlier to prevent the problem becoming deep-rooted in the country.
The AMR problem drew attention in 2015 when scientists from China and Great Britain published a research where they claimed to have found a superbug, a genre of E coli, which is resistant to all antibiotics, including colistin, termed as a last resort antibiotic.
In another report, published by the World Economic Forum, scientists speculated that the post-antibiotic era has already begun.
Experts opined that it appears Bangladesh is yet to make a major move to combat AMR. The World Health Organisation, in a recommendation made in 2014, said every country should have a separate body focusing only on AMR, but Dhaka is yet to form one.
What Bangladesh is doing
Although researchers and physicians suspect that Bangladesh is standing on the brink of an infectious disease outbreak due to the rapid growth of AMR, the country is far from taking measures that could be implemented immediately for improving the situation.
Proceedings of the National Academy of Science of the USA, in a publication in March 2018, titled "Global increase and geographic convergence in antibiotic consumption between 2000 and 2015", identified Bangladesh as an upper-middle antibiotic consumer, as rated per 1,000 people, from 2005 to 2015.
The report findings recommend the need for global surveillance to support policies to reduce antibiotic consumption and resistance, while providing access to the lifesaving drugs.
Meanwhile, Bangladesh included the issue in its seventh five-year plan in 2015 and following that initiative, an action plan was formulated in 2017. The Directorate General of Health Services (DGHS) in January 2017 introduced a program, “Antibiotic resistance containment”, for tackling the situation under its Communicable Disease Control (CDC) wing.
But no visible progress has been made since then. However, DGHS sources said CDC is carrying out the legal and immediate measures part of the program, while the Institute of Epidemiology, Disease Control and Research (IEDCR) has been designated to do the surveillance.
Besides, the Directorate General of Drug Administration (DGDA) has been working for ensuring proper circulation of antibiotics from medicine shops.
What experts say
Mohammad Aminul Islam, associate scientist and head of icddr,b's Enteric and Food Microbiology Laboratory, in his presentation at "Workshop on national action plan on antimicrobial resistance for developing countries", identified five major challenges to controlling AMR.
According to the scientist, lack of communication and coordination among different sectors, including human health, animal health and environment, inadequate surveillance and laboratory capacity, and little logistics support and trained staff development are the major challenges to establishing a reference laboratory for AMR in the country and open access to antimicrobial medicines.
He also cited a weak drug regulatory system and law enforcement, and called for stopping the sale of antibiotics without prescription, infection prevention and control programs, supervision and monitoring of waste management, and ensuring bio-safety and bio-security.
Aminul Islam further said improvements are necessary in three areas of surveillance capacity -- data collection and data sources, data management, analysis and interpretation; information reporting, dissemination, communication and use, and focused and targeted international cooperation.
BSMMU Pharmacology Department Professor Dr Sayedur Rahman said that to improve the situation, three things should be ensured -- surveillance: to monitor ‘how we are doing’; rational antimicrobial use: to reduce the ‘pressure for resistance’ by adopting antimicrobial policy/guideline; and infection control: to reduce the spread of infections in general.
Healso said that though a good policy has been formulated, the follow-up workis facing slow progress.
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"Surveillance should include identification of pathogens/diseases of public health importance, creation of a network of antibiotic susceptibility testing (AST), and finally, but most importantly,a standardised methodology for microbial identification and AST," he said.
Dr Sayedur said the government could ensure proper use of antibiotics by adopting a national or institutional antimicrobialpolicy, implementing formulator restrictions, developing, updating and using standard treatment guides and treatment algorithms, decreasing diagnostic uncertainty by any type of diagnostic tool or decision support, improving preoperative prophylaxis, and promoting short-course, high-dose antibiotic therapy.
According to the professor, the drug policy implementation apex body has to play a more effective role in controlling access to available antibiotics. Besides, the authorities have to increase surveillance and put in place strict monitoring systems.
The government has to play a supportive role in terms of expenditure in healthcare facilities following a comprehensive approach, and if necessary, give subsidy to the services, he said.
Besides, standard microbiological tests in laboratories must be ensured, so that basic possible (disease) patterns can be identified, he added.
Moreover, a DGHS source agreed that there were lacking in the initiatives.
Besides, an action plan has already been formulated, the experts said, adding that a strategy plan has also been finalized, and a revised or new drug law and policyare underway where selling antibiotics without prescriptions from physicians registered with the Bangladesh Medical and Dental Council (BM&DC) would be a punishable offence.
“In the plan, we determined causes of rising resistance and are discussing a national strategy to tackle it,” said Dr Sania Tahmina, head of the program.
Professor Dr Meerjady Sabrina Flora, IEDCR director and also the head of Epidemiology Department at National Institute of Preventive and Social Medicine, said they have already started AMR surveillance in the country.
DGDA Director Ruhul Amin said that DGDA, DGHS, IECDR, and several other departments, along with the Ministry of Health, are working closely so that the AMR problem can be tackled.
“We have instructed the medicine shops not to sell antibiotics without a physician’s prescription. A directive has also been given to the pharmacies to display a notice so that people can be aware of the fact that (taking) antibiotics without prescription would be dangerous for them.”
He also emphasized on strengthening the monitoring system.