Developing countries in East and Southeast Asia have been stepping up their efforts to address the growing global public health threat of the overuse and misuse of antibiotics that health experts say will increase deaths, strain health systems, and impose huge economic costs in the years to come.
The inappropriate use of antibiotics to clear up viral infections such as the flu in humans and to promote physical growth in livestock and plants can cause resistance to drugs over time, making treatments for future infections useless or less effective.
The emergence of superbugs — drug-resistant bacteria and infections that have developed the ability to withstand medicines that should stop them — is “not a theoretical issue,” said Keiji Fukuda, who is in charge of antimicrobial resistance (AMR) at the World Health Organization (WHO).
“This is not something that we’re waiting to have happen,” he told reporters during a briefing at the Social Good Summit in New York in September. “This is something which has begun, so right now we are estimating that there are several hundreds of thousands of people who die on an annual basis because the antibiotics don’t work.”
The problem is so serious that the United Nations General Assembly adopted a political declaration in September aimed at combating the global threat posed by AMR — only the fourth time in its history that the body has taken action on a health issue.
Developing countries, where infectious diseases thrive, will feel the effects of AMR more acutely than developed ones that have the resources available to address the issue, health experts said. For instance, nations in the Greater Mekong Subregion — Vietnam, Cambodia, Laos, Myanmar, and Thailand — are already experiencing greater threats from drug-resistant malaria strains.
“Many countries in Asia may also be highly impacted due to a host of factors such as adequacy of healthcare, affordability and access to antibiotics, antibiotic resistance patterns, practices and preferences in treatment, and health system pressures,” said Dr. Sujith J. Chandy, head of ReAct Asia Pacific, a global network of antibiotic resistance experts.
A report commissioned by the United Kingdom and issued in May warned that if policies do not change, superbug-related deaths will skyrocket to 10 million worldwide by 2050 from the current 700,000 deaths and cause a loss of U.S. $100.2 trillion in global economic output.
The report also estimated that 4.73 million people in Asia will die annually by 2050 because of AMR.
A World Bank report issued in September forecast that in a high-case scenario for AMR, low-income countries could lose more than five percent of their gross domestic product. It also said the crisis could plunge up to 28 million people, mostly in developing countries, into poverty by 2050.
“Many governments are not equipped to contain the rapid emergence and spread of drug-resistant diseases,” said David Newby, coordinator of emergency medical teams at the WHO and an associate professor of pharmacology at the University of Newcastle in Australia, about developing countries in East and Southeast Asia.
Getting out the word
One of the main concerns of health professionals is getting out the word to the public that AMR is an issue that must be dealt with now. The WHO launched World Antibiotic Awareness Week last year in response to growing antibiotic resistance globally for countries to conduct campaigns to educate people about using antibiotics responsibly.
“Many countries have plans for World Antibiotic Awareness Week,” said Chandy, referring to this year’s event on Nov. 14-20. “These include programs which aim to increase awareness, improve use of antibiotics, and try to prevent infections through better hygiene.”
In China, one of the world’s top consumers of antibiotics, the WHO and the government’s National Health and Family Planning Commission held an educational campaign on Tuesday at Peking University First Hospital in Beijing to increase public awareness about the risks of misuse of antibiotics, said Martin Taylor, coordinator for health systems and health security at WHO’s China office.
WHO, along with the Chinese government and the U.N.’s Food and Agricultural Organization (FAO), also produced a video about the behaviors that lead to antibiotic resistance, why ordinary people should care about the issue, and what they can do to help, he said via email.
Vietnam is continuing a campaign to get 1 million signatures of people who pledge to use antibiotics responsibly, launching an antibiotic use surveillance center, and offering a session on AMR at a lecture series on health and development. Health officials have also set up a Facebook page dedicated to World Antibiotic Awareness Week to reach the many people who exchange news primarily through social media given the country’s press restrictions.
Cambodia's awareness campaign includes a competition to design a comedy on the dangers of AMR, a poster design competition on the responsive dispensing of antibiotics, and a tuk-tuk and bike rally on AMR.
“The problem of AMR in [middle-income countries like] China, Vietnam, Thailand, Indonesia, and Malaysia is known to be large,” said Direk Limmathurotsakul, head of microbiology at the Mahidol-Oxford Tropical Medicine Research Unit at Mahidol University in Bangkok.
The AMR problem is growing in Laos, Cambodia, and Myanmar, he said, “but the size or nature of the problem may be different than what we’ve observed in middle-income countries” in the region, possibly because broad-spectrum antibiotics such as carbapenem are not used in hospitals there.
The carbapenem class of antibiotics is used to treat infections known or suspected to be caused by multidrug-resistant bacteria mainly in people who have been hospitalized.
“However, many patients in Laos, Cambodia, and Myanmar might still die of AMR against other commonly used drugs that those countries can afford such as the penicillin and cephalosporin drug group,” Limmathurotsakul said.
National action plans
Three United Nations agencies — the WHO, FAO, and World Organisation for Animal Health (OIE) — are working together to help countries in Asia to coordinate AMR surveillance, document the use of antibiotics, and take corrective action, said Kundhavi Kadiresan, assistant director-general of FAO regional representative for Asia and the Pacific, in a statement issued on Monday for World Antibiotic Awareness Week.
Besides the awareness campaigns this week, countries in the Asia-Pacific region, where a majority of the world’s population lives, have been developing national action plans (NAPs) to contain AMR. China, Vietnam, Cambodia, Thailand, and the Philippines have already issued plans covering the years 2016 to 2020. Laos is holding a workshop to develop its NAP on Nov. 17-18, Newby said.
In addition to the NAPs, the countries are implementing OIE international standards on the prudent use of antimicrobial agents in animals.
“Cooperation between human health, animal health, and environmental health sectors is of critical importance to address AMR,” said Dr. Poonam Khetrapal Singh, the WHO's regional director for Southeast Asia in the statement issued on Monday. "This mechanism should be established both within countries and between countries, as we strive to protect the health of people in our countries, regions, and at the global level.”
Health experts lament that efforts to spread the word about AMR have been overshadowed by news of other major health concerns such as the outbreak of the Zika virus this year in Thailand, Singapore, Myanmar, and Cambodia.
About 450 cases have been reported in Singapore, more than 680 cases in Thailand, including 33 news cases this week, and one recently confirmed case in a pregnant woman in Myanmar. On Friday, Cambodia confirmed its first case of the Zika virus in Kompong Cham province in the central lowlands of the Mekong River.
The mosquito-borne virus, which is spread through bug bites or sexual contact, is an infectious disease that may cause fever, red eyes, joint pain, headache, and a rash. It can also cause the birth defect microcephaly that results in babies born with smaller-than-usual heads and brains.
“Zika deserves rapid and appropriate reaction,” Limmathurotsakul said. “However, given that close to a million people die annually of AMR globally, the public should urgently demand action on AMR plans.”
Countries must continue to increase their efforts to contain AMR because new antibiotics will not be available on the market in the next five to 10 years, he said.
Even if they are available, they will likely be too expensive or unaffordable for many people in the region and could also be misused so that resistance against them may emerge and spread rapidly, he said.
“We need to support efforts to stop or reduce over-the-counter antibiotic consumption, antibiotic use in animal agriculture, [and] hospital-acquired infection,” Limmathurotsakul said.
While some countries in the region such as Thailand are increasingly using traditional and herbal medicines rather than antibiotics to treat common colds and diarrhea, according to Limmathurotsakul, no nation can afford not to use antibiotics to treat some infections, health experts said.
“Unfortunately, there are very little alternatives to treat bacterial infections except antibiotics,” Chandry said. “What needs to be done is to try and improve rational use of antibiotics by avoiding antibiotics for symptoms suggestive of viral infections and for situations that do not need antibiotics.”
Research for this story was supported by a fellowship from the International Center for Journalists and the United Nations Foundation.