Antibiotic Resistance in Southeast Asia
In September 2016, the United Nations General Assembly (UNGA) declared antimicrobial resistance (AMR) a major health threat for nations in every part of the world. AMR comes about when bacteria evolve to resist antibiotics used for the treatment of many infectious diseases such as pneumonia, tuberculosis and salmonellosis. According to the Center for Disease Control and Prevention (CDC), AMR can bring harm to people of all types and agriculture, health care and veterinary industries. Antibiotic resistance in Southeast Asia is of particular concern. 

Antibiotics have been essential to curing infections ever since Alexander Fleming discovered the first form of antibiotics, penicillin, in 1928. In the developing countries of Southeast Asia, antibiotics often do not have regulation and are available for purchase without a prescription from a physician, which exacerbates the phenomenon of AMR and causes major concern. This is an example of how poverty in Southeast Asia contributes to the antibiotic resistance crisis.

Contributions to Antimicrobial Resistance

AMR is a natural process. With or without the use of antibiotics, bacteria will always evolve to fight for survival by strengthening their resistance or by multiplying. Despite this, humans make AMR worse. A plethora of unnatural issues exaggerates AMR, but there are two that are cause for the greatest concern: unregulated sale of antibiotics and the use of antibiotics not as medicine for humans but as growth promoters and disease treatments in livestock. 

Unregulated Antibiotics and Self Medication in Southeast Asia

The World Health Organization Southeast Asia Region (WHO SEAR) includes the countries of Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. These countries are notorious for selling antibiotics as an unregulated product to the public, a reality of many developing countries around the world. In developing countries, the prevalence of infectious deadly diseases is higher than in more developed nations, making the likelihood of death from these issues higher.

Many consider the countries in Southeast Asia listed above to be hotspots for the spread of AMR. Here, the cost of antibiotics bought over the counter is lower than the cost to visit a physician or health professional. As a result, many self-medicate, making it the leading cause of AMR. Self-medication refers to the use of medication to treat ailments, diseases or infections without the guidance of a medical professional. Without curbing this habit practiced in WHO SEAR, bacteria quickly mutate to resist treatment, leading to more intense illnesses, increased medication prices and death. 

The Use of Antibiotics for Livestock in Southeast Asia

In this region, the use of antibiotics in livestock outweighs the use of antibiotics in humans. To keep livestock in countries around the world healthy, farmers commonly use antimicrobials to treat and prevent diseases and decrease mortality in livestock. Though people widely practice this, the countries of WHO SEAR use this technique excessively due to poverty. With weak regulatory laws to govern or survey the effects this has on the AMR crisis, AMR is aggressively growing. 

Where previously people ignored it when considering the causes of AMR, livestock antibiotic use has recently become a growing concern across the globe. With recognition came complication: in developing countries, farmers rely on the use of antibiotics to prevent illness or death of their animals so they can continue to make a profit. In Southeast Asia especially, the hard reality is that these issues layer and mix with other issues, such as poverty and food security. Policies regarding antimicrobial consumption in livestock that work for developed nations often do not work in underdeveloped nations, due to the complex differences of cultural differences and locations. It is for these reasons that poverty contributes to antibiotic resistance in Southeast Asia.

Efforts to Slow Antibiotic Resistance in Southeast Asia

Given that this crisis is on a global scale and affecting every nation, some are making efforts to control AMR. Unfortunately, there is no way to stop it completely. There are, however, the WHO’s action plans that can bring light to this topic. WHO has laid out five strategic goals: to increase recognition and understanding of AMR, to increase global monitoring and research, to decrease the prevalence of infectious diseases requiring antibiotic treatment, to improve the use of antibiotic treatment and to create a case for sustainable investment that includes all nations, no matter location or level of development

An example of raising awareness is World Antibiotic Awareness Week. Every year brings the annual World Antibiotic Awareness Week, created by the WHO in 2015. This week in November sets goals to increase awareness and encourage health care providers, policymakers and the public to practice healthy and sustainable techniques to slow the spread of antibiotic resistance in Southeast Asia.

– Anna Giffels
Photo: Flickr

One Health, Antibiotic Resistance
Generally, the One Health Approach is a collaborative method to address the three cornerstones of health outcomes: humans, vectors/wildlife and the environment. There is a growing concern for antibiotic resistance — the 2018 World Economic Forum estimates that for that there were 100,000 antibiotic-resistance-related deaths in U.S. hospitals and 80,000 in China last year.

One Health Approach to Antibiotic Resistance

Alongside the human toll is an economic burden of an estimated global GDP drag of between 1.1 and 3.8 percentage points between now and 2050. The major issue is that the resistance is spreading and the key drivers of antimicrobial resistance include the use and abuse of drugs in humans, animals and agricultural practices. Many of the antibiotics administered to humans are also being utilized to treat food pens for livestock.

There is a crucial link between humans, animals and the environment, which is why the One Health approach calls for action from all three fronts including measures that would limit and eliminate inappropriate drug use and thus infection for animals. The primary concerns in the animal-health and agriculture sectors are the massive scales in which medication is being used. Some are critical for humans — cephalosporins like Penicillin and other common antibiotics, for instance, prevent protein synthesis in bacteria, and fluoroquinolones commonly treat urinary tract infections.

Crucially Important Health Recommendations

It is critical to reduce over-prescribing and over-utilizing antimicrobials, and instead improve sanitation and infection control. There is inadequate conversation about the pollution from industrial, residential and farm waste; thus, the One Health approach calls for improvements in antimicrobial use regulation and policy, surveillance, stewardship, infection control, sanitation, animal husbandry and alternatives to antimicrobials.

The World Health Organization (WHO) recently launched updated guidelines on how people ought to view and use medically important antimicrobials in food-producing animals, recommending that farmers and the food industry stop using antimicrobials routinely to promote growth and prevent disease in healthy animals. By reducing our reliance on these antibiotics in animals, its effectiveness as human medicine can be preserved, if not, prolonged.

Every Action Counts

Small yet uniform individual steps can result in a larger collective impact. These steps from the One Health approach calls for humans to act preventatively, first and foremost. That is, to routinely practice strong hygiene practices which, in turn, can assist in the early detection of infection. Users of antibiotics must remember to not overuse, but rather to use it completely and for the entire treatment period so latent bacteria and fungus cannot mutate and grow resistant.

Vaccination is a key preventative measure as is remaining mindful that pets also share germs with its human owners. From the stance of animals, we must keep in mind that we share the planet with many wildlife species that may be playing its role as disease reservoirs, hosts or vectors, so it is crucial to wear tick spray and protective gear, and to treat these wildlife species with caution and care.

Lastly, on the environmental front, humans must change the current reliance on antibiotics in agriculture practices. Whether preventing crops from getting deterred by pests or encouraging and artificially accelerating growth of hens and pigs, the environment is being damaged and it’s important for populations to remain mindful of this sobering fact.

A Holistic Approach to Antibiotic Resistance

The WHO explains the critical importance of a holistic approach to antibiotic resistance since human use of antibiotics does not tend to recognize “geographic, human, or animal” borders. In general, the main takeaway from the One Health Approach is for all three actors and elements above to collaboratively prevent the spread of these diseases by corroborating with each other.

– Quy Mai 
Photo: Flickr

Antibiotic resistance poses one of the greatest threats to global health and so-called “superbug” infections continue to grow. The latest World Health Organization (WHO) survey shows widespread confusion surrounding antibiotic resistance in developing countries.

The WHO reveals that those most affected by and at risk for antibiotic-resistant infections are confused about them. This poses a challenge to the treatment and eradication of antibiotic-resistant infections, which are propagating all over the world.

“Antibiotic resistance is occurring everywhere in the world, compromising the treatment of infectious diseases and undermining many other advances in health and medicine,” says the WHO.

According to the Alliance for the Prudent Use of Antibiotics, bacteria become resistant either by a genetic mutation or by acquiring resistance from another bacterium.

The survey, carried out in September and October 2015, covered 12 countries including Barbados, China, Egypt and India. The statistics cover the countries’ use of antibiotics and knowledge of antibiotics and antibiotic resistance.

The results were below expectations. Although respondents acknowledged that antibiotic resistance is a threat to them and their families, they did not fully understand how it affects them or what they can do to protect themselves.

According to the findings, “64 percent of respondents believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses.”

Almost one-third of respondents believe they should stop taking antibiotics when they feel better, rather than for the full course of the prescription, which is also incorrect.

This uncertainty is occurring at a time when the threat of antibiotic resistance is reaching a peak. Deaths caused by antibiotic-resistant infections, known as “superbugs,” are growing faster than we are able to respond to them. The death rate for patients with infections caused by common but resistant bacteria treated in hospitals can be about twice that of patients with infections caused by the same non-resistant bacteria, says the WHO.

With results as pronounced as these, the WHO has started a new campaign to increase global awareness and improve understanding of the problem of antibiotic resistance.

Ashley Tressel

Sources: WHO 1, WHO 2, WHO 3, TUFTS
Photo: Joint Programming Initiative on Antimicrobial Resistance

Overuse of antibiotics throughout the world has led to a growing problem of antibiotic resistance that could lead to the total ineffectiveness of these often life-saving drugs. In the developing world, the problem is especially acute.

According to an article in the journal Nature, some studies have suggested that in Nigeria, as many as 88 percent of Staphylococcus aureus infections cannot be treated with methicillin — once a potent weapon against the microbe.

Antibiotic resistance is also a significant issue in the emerging economies known as the ‘BRIC’ states: Brazil, Russia, India and China, the article says, as well as in India and Pakistan.

The problem is especially worrisome to public health officials due to the lack of new antibiotic compounds introduced into medical practice.

But last January, researchers at Northeastern University and NovoBiotic Pharmaceuticals announced they had developed a new potential antibiotic, called Teixobactin, that has some exciting new properties.

In addition to proving itself effective in the treatment of MRSA, Streptococcus pneumoniae, and M. Tuberculosis in animal efficacy trials, the compound has the potential to become resistance-proof.

Richard Novick, a microbiologist at New York University’s Langone Medical Center has called it “a major breakthrough because it is virtually certain to be effective for the multi-resistant strains that are now all but impossible to treat.”

Doctors are eager for new medicines to treat infectious diseases. In the past, most antibiotics were developed through screening soil samples for microorganisms. But soil samples eventually gave way to millions of dollars fruitlessly spent on synthetic attempts to produce antibiotics.

The team from Northeastern and Novobiotic decided to turn back to mining soil-based uncultured bacteria by using a new technology called Ichip. In this approach, soil samples are diluted with agar, allowing a single bacterial cell to be isolated. Researchers are able to isolate up to 96 cells in individual “chambers” in each Ichip device. Teixobactin was discovered from a soil sample from Maine.

Seventy years of antimicrobial use and overuse have given bacteria ample time to genetically fortify themselves for a new wave of infectious disease. Now, the CDC estimates that antibiotic-resistant bacteria will infect two million people and among those two million, 23,000 will die from those infections.

The techniques used to extract Teixobactin from the Maine soil sample have opened up millions of microorganisms for future study. Ichip allows researchers to harness this biodiversity in traditionally rich environments such as forest soil and even marsh water.

“This biodiversity is also hiding a lot of chemical diversity that may include new, other antibiotics,” wrote Gerard Wright, director of the Institute for Infectious Disease Research in Canada.

Emma Betuel

Sources: The Scientist, Nature 1, The Lancet, Nature 2, ACS, CDC, Popsci
Photo: medicaldaily

overuse of antibiotics
Prescriptions, particularly antibiotics, are alarmingly easy to get a hold of these days. Antibiotics are usually used to treat bacterial infections and not viruses, though recently doctors have begun prescribing them more liberally. The New England Healthcare Institute (NEHI) says that physicians often resort to prescribing antibiotics because “determining if an infection is viral or bacterial is expensive and time-consuming,” so the seemingly “safe” solution is to provide the drugs. Additionally, doctors want to avoid issues of malpractice, which could arise if an actual bacterial infection goes untreated.

Patient influence also has some weight in a physician’s decision on whether to prescribe antibiotics or not. NEHI states “patients may pressure providers to prescribe antibiotics for conditions for which they are inappropriate…or inappropriately save antibiotics for later use.” These ostensibly commonplace habits may seem harmless, but they have unfortunately led to a rise in antibiotic resistance.

The CDC claims that instead of resorting to antibiotics as a quick fix for clearing up viruses, “symptom relief might be the best treatment option.” Overuse of antibiotics for viruses, such as colds or other respiratory issues, could lead to the drug losing its effectiveness against bacterial infections. Bacterial infections like MRSA and C-difficile are drug-resistant and have been a major cause of concern in the past decade due to their high mortality rates.

According to the Tufts University Alliance for the Prudent Use of Antibiotics (APUA), antibiotics resistance happens when “an antibiotic has lost its ability to effectively control or kill bacterial growth.” Antibiotic resistance also occurs naturally. During the use of an antibiotic, some bacteria can resist being killed, which can increase future survival of even more of that “resistant strain” of bacteria. The overuse of antibiotics can exacerbate this process. Genetic mutation of bacteria and “acquired resistance” from other bacteria can also breed more resistant bacterium.

Preventing disease in the first place by practicing good hygiene is the first suggestion that Tufts gives to combat antibiotic resistance. Additionally, they suggest that overall, antibiotics must be used less frequently. Patients who are prescribed antibiotics should complete the course of their antibiotics, even if they are feeling better partway through, and not save antibiotics for future unsupervised use.

This issue not only exists in the first world, where antibiotics are clearly incredibly accessible, but this problem also plagues developing countries. According to Nature: International Weekly Journal of Science, “around the globe, overuse of these drugs has created resistant strains of deadly bacteria.”

In developing nations like India and Pakistan, as high as 95 percent of adults “carry bacteria that are resistant to β-lactam antibiotics,” whereas only 10 percent of adults in Queens, N.Y. are carriers, says Timothy Walsh of Cardiff University in an interview with Nature. This could be attributed to poor sanitation in developing countries. Due to a lack of restrictions on hygiene, bacteria are spread more easily. Additionally, training of pharmacists must be improved so that the incorrect use of antibiotics decreases.

Potential solutions to this crisis have been broached. Developing new antibiotics can be incredibly expensive, “requiring approximately 10 years and $300 million” according to Tufts. However, scientists have considered strengthening existing antibiotics or using “decoy molecules” to trick bacteria into attacking the decoy instead of the antibiotic. Additionally, it has been suggested that antibiotics be altered to combat “the mechanisms that promote resistance,” rather than solely focus on destroying the bacteria itself.

While these solutions are certainly credible, decreased use of antibiotics and more strict regulations are the primary step toward eliminating the antibiotic resistance epidemic.

  — Bridget Tobin

Sources: New England Healthcare InstituteCenter for Disease ControlTufts (1)Tufts (2)Nature
Photo: Nature