WHO's Alarm Bells: Antibiotic Resistance Now a 'Major Threat to Public Health'

The world's leading health organization is sounding serious alarm bells about the problem of antibiotic resistance.

In its first report on the issue ever, the World Health Organization (WHO) is sounding alarms about the issue of antibiotic resistance and the global public health threats it poses to our increasingly interconnected world.

"The problem is so serious that it threatens the achievements of modern medicine. A post-antibiotic era—in which common infections and minor injuries can kill—is a very real possibility for the 21st century," the report states.

Antibiotic resistance occurs when bacteria no longer die when treated with antibiotics. As a result, doctors have to use stronger, more potent antibiotics, and the more those are used, the more resistance bacteria develop to those as well. The WHO is warning that we're reaching a point in which the strongest antibiotics doctors have in their arsenal, the "treatment of last resort" drugs as they're called, no longer work.

And in fact, it's no longer just bacteria that are becoming resistant. The WHO has stopped referring to the problem as "antibiotic resistance" and now calls it "antimicrobial resistance," to encompass other organisms, such as viruses and parasites, that no longer respond to the drugs of choice. Namely, treating the viruses tuberculosis and HIV, and malaria (a parasite), has become harder as these diseases become resistant to medications. Even H1N1, the so-called "swine flu" that reached pandemic levels in 2009, has begun developing resistance to potent antiviral drugs.

Resistance Is a Worldwide Problem

One of the major points of the report is that diseases that used to be restricted to certain locales are now spreading internationally:

Among their key findings:
• Resistance to the treatment of last resort for life-threatening infections caused by a common intestinal bacteria, Klebsiella pneumonia—carbapenem antibiotics—has spread to all regions of the world. K. pneumoniae is a major cause of hospital-acquired infections such as pneumonia, bloodstream infections, infections in newborns and intensive-care unit patients. In some countries, because of resistance, carbapenem antibiotics would not work in more than half of people treated for K. pneumoniae infections.

• Treatment failure to the last resort of treatment for gonorrhea—third generation cephalosporins—has been confirmed in Austria, Australia, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden and the United Kingdom. More than 1 million people are infected with gonorrhoea around the world every day.

• People with MRSA (methicillin-resistant Staphylococcus aureus) are estimated to be 64 percent more likely to die than people with a non-resistant form of the infection. MRSA, which can cause septic bloodstream infections when exposed to broken skin, is one of the most common "community-acquired" resistant infections, meaning you're likely to pick it up anywhere other people are—your gym, place of worship, a nearby park or even at schools. In the Americas, as many as 90 percent of staph infections are reported to be MRSA.

• There hasn't been a new class of antibiotics developed since the late 1980s.

We Can't Track What We Don't Know

The WHO is calling on countries all over the world to step up their surveillance of these deadly infections, something that happens rarely, if at all. An investigative report, "Hunting the Nightmare Bacteria," that ran on the PBS program Frontline in October 2013 revealed that public health officials in the U.S. have little to no data on the extent of antimicrobial resistance in this country. Healthcare facilities aren't required to report outbreaks, the report found, and many don't because they don't want to scare people or have to deal with bad PR.

“It is frankly embarrassing that we as a country do not know where resistance is occurring, how bad the problem is for various organisms or who’s using what antibiotics when,” Brad Spellberg, MD, an infectious disease doctor at Harbor-UCLA Medical Center, said in the documentary.

The Centers for Disease Control and Prevention has estimated that antimicrobial resistant infections hit two million people a year and kill at least 23,000. But the WHO notes that in most countries around the world, including the U.S., often only the most severe infections are documented and minor community-acquired infections (which can get passed along repeatedly and wind up as a severe infection) go unreported.

Clean Up the Food Supply!

For quite possibly the first time, the WHO also called out the food industry for its contribution to antimicrobial resistance. " The use of antibiotics in animal husbandry—including in livestock, poultry and fish farming—are leading to increasing recognition that urgent action is needed to avoid inappropriate use, and to reduce antibiotic usage in animal husbandry and aquaculture, as well as in humans," the report states. In the U.S., 80 percent of antibiotics sold go into animal feed to prevent infections in healthy animals or to speed growth. And we're not alone. "In many countries, the total amount of antibiotics used in animals (both food-producing and companion animals), measured as gross weight, exceeds the quantity used in the treatment of disease in humans," the authors found.

The same classes of antibiotics used on these animals are the same as those given to humans. In particular, fluoroquinolones, antibiotics used widely in the poultry industry, are increasingly ineffective against urinary tract infections caused by drug-resistant E. coli bacteria, which have been detected on all forms of supermarket meat, and against MRSA soft-tissue and skin infections.

Numerous groups in the U.S. have sued the Food and Drug Administration to revoke its approvals in animals for antibiotics that are valuable for humans. The agency's only response has been to set voluntary guidelines for the industry.

What You Can Do

Despite the damage factory farming has done to antibiotic effectiveness, the WHO and other public health officials insist that the first line of defense in controlling the problem of antimicrobial resistance is the healthcare setting: Stopping doctors from giving patients antibiotics for conditions they aren't designed to treat, for instance, when you're given antibiotics for a cold that's caused by a virus, not bacteria.

• Don't automatically ask for antibiotics when you feel sick and visit a doctor.

• If your doctor prescribes an antibiotic, ask if there's an alternative before just accepting the advice. Some doctors feel compelled to offer the drugs to make people feel better, but asking for an alternative can open up a dialogue about other options.

• When you do need an antibiotic, take the full course, even if you're feeling better.

• Wash your hands frequently to protect yourself from community-acquired infections, and keep your hands away from your nose, eyes and mouth, where infections can enter.

Contributed by  By EMILY MAIN

 


Alarm bells over antibiotic resistance 

The World Health Organisation’s most comprehensive report to date sounds a warning that we are entering a world where antibiotics have little effect.

THE World Health Organisation (WHO) has sounded a warning that many types of disease-causing bacteria can no longer be treated with the usual antibiotics and the benefits of modern medicine are increasingly being eroded.

The comprehensive 232-page report on anti-microbial resistance with data from 114 countries shows how this threat is happening now in every region of the world and can affect anyone in any country.

Antibiotic resistance – when bacteria evolve so that antibiotics no longer work to treat infections – is described by the report as “a problem so serious that it threatens the achievements of modern medicine”.

“A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century,” said Dr Keiji Fukuda, WHO assistant director-general who coordinates its work on anti-microbial resistance.

“Without urgent, coordinated action, the world is headed for a post-antibiotic era in which common infections and minor injuries which have been treatable for decades can once again kill.

“Effective antibiotics have been one of the pillars allowing us to live longer, live healthier, and benefit from modern medicine.

“Unless we take significant actions to improve efforts to prevent infections and also change how we produce, prescribe and use antibiotics, the world will lose more and more of these global public health goods and the implications will be devastating.”

The report, “Antimicrobial Resistance: Global Report on Surveillance”, shows that resistance is occurring in many bacteria causing different infections.

It focuses on antibiotic resistance in seven bacteria responsible for common, serious diseases, such as bloodstream infections (sepsis), diarrhoea, pneumonia, urinary tract infections and gonorrhoea.

What is especially alarming is that the bacteria’s resistance has also breached “last resort” antibiotics, which are the most powerful medicines that doctors resort to when the usual ones do not work.

When patients do not respond to the usual medicines (known as first-line or first-generation medicines), doctors prescribe newer (second line medicines) which also usually also cost more.

When these also don’t work, newer and often more powerful (but sometimes with also more side effects) antibiotics are used, and they are even more expensive.

If these third-line or “last resort” medicines are not available or too costly for the patient, or if they don’t work on a patient because of antibiotic resistance, the patient remains ill or dies if the infection is a serious one.

New antibiotics have been discovered in the past to treat infections when the old ones became useless due to resistance.

But these discoveries dried up in the past 25 years.

The last completely new classes of anti-bacterial drugs were discovered in the 1980s.

Pathogens that are becoming increasingly resistant including to the more powerful antibiotics include E. coli, K. pneumonia, S. aureus, S. pneumonia, salmonelia, shigella and n. gonorrhoeae.

Key findings from the report include:

> Resistance to the treatment of last resort for life-threatening infections caused by a common intestinal bacteria, K. pneumonia — carbapenem antibiotics — has spread worldwide.

K. pneumoniae is a major cause of hospital-acquired infections such as pneumonia, bloodstream infections, infections in newborns and intensive-care unit patients.

In some countries, because of resistance, carbapenem antibiotics would not work in more than half of people treated for K. pneumoniae infections;

> Resistance to one of the most widely used antibacterial medicines for the treatment of urinary tract infections caused by E. coli – fluoroquinolones – is very widespread.

In the 1980s, when these drugs were first introduced, resistance was virtually zero.

In many countries today, this treatment is ineffective in more than half of patients;

> The sexually transmitted disease, gonorrhoea may soon be untreatable unless there are new drugs. Treatment failure to the last resort of treatment for gonorrhoea – third generation cephalosporins – has been confirmed in several countries; and

> Antibiotic resistance causes people to be sick for longer and increases the risk of death.

For example, people with MRSA (methicillin-resistant Staphylococcus aureus) are estimated to be 64% more likely to die than people with a non-resistant form of the infection.

There are many cases of patients being infected by MRSA in hospitals.

The report also gives useful information on the worrisome building up of resistance in four serious diseases — tuberculosis, malaria, HIV and influenza.

A major factor accelerating resistance is in the animal husbandry sector, where there is a liberal use of antibiotics mainly to promote the growth of the animals used for food, for commercial purposes.

This builds up resistance in the bacteria present in the animals.

These resistant germs are passed on to humans who consume the meat.

The report has a small section on the animal-food chain, which has been identified as a major problem.

The European Union has banned the use of antibiotics as growth promoters in animals, but it is still allowed in other countries.

A WHO press release on the report calls for some actions. These include:

> Setting up basic systems in countries to track and monitor the problem;

> Preventing infections from happening in the first place to reduce the need for antibiotics;

> Only prescribing and dispensing antibiotics when they are truly needed, and prescribing and dispensing the right antibiotic(s) to treat the illness;

> Patients using antibiotics only when prescribed by a doctor and completing the full prescription; and

> Developing new diagnostics, antibiotics and other tools to stay ahead of emerging resistance.

Contributed by Global Trends by Martin Khor

Martin Khor is executive director of the South Centre, a research centre of 51 developing countries, based in Geneva. You can e-mail him at director@southcentre.org. The views expressed are entirely his own.

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Do You need jabs, antibiotics?

OUR population is getting more and more educated and knowledgeable. With the convenience of internet and smart phone, information can be assessed anytime and anywhere.

Facebook and Google have become the source of reference for most people. Many can now be “experts” in many specialised fields, including engineering, law and even medicine.

Nowadays, the medical practitioners enounter some patients who are so-called internet savvy, and refuse antibiotics and vaccines.

This issue arose due to the spread of such information in the internet, claiming antibiotics could lead to “superbug” and are associated with many adverse effects, while vaccines could cause autism or death.

Well, the risks of administration of both drugs are certainly debatable.

What we know for a fact is that since Alexander Flemming discovered penicillin and the pox vaccine, many lives were saved.

Nevertheless, I am not in the position to comment on the good and bad of both antibiotics and vaccines. But, it is more important for the general public to understand more about the need for antibiotics and vaccines.

Antibiotics or more specifically antibacterial, is a medicine indicated to kill (bactericidal) or inhibit the growth (bacteriostatic) of the bacteria.

There are various types of antibiotics with different mode of actions and indications. Strictly speaking, the mechanism of action for antibiotics is rather complicated.

However, it works mainly to counter attack the rapid reproduction of bacterial colonies, so that our immune system has enough time to defeat the illness.

Thus, the usage of antibiotics is strictly limited to the bacterial infection. In common clinical conditions, like acute exudative tonsillitis, abscess formation and urinary tract infection, antibiotics are strongly prescribed.

It must be understood that antibiotics have no role in curing diseases caused by fungus, virus or other parasites.

Therefore, it should not be overprescribed in cases like common cough and cold, flu and fungal infection of skin.

As for vaccines, they are biological preparations that help to boost immunity. Its primary focus is on disease prevention. It is always better to prevent a disease than to treat it.

Vaccines work by introducing the weakened form of “disease germ” into the body. The body will respond by producing antibodies to fight these invaders. At this stage, technically, the immune system is being sensitised. If the actual disease germ attacks the body, more antibodies will be produced to destroy the real enemy.

Vaccines are responsible for the control of many infectious diseases that were once common in this country and around the world, including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), mumps, tetanus, Hepatitis B and Haemophilus influenzae type b (Hib).

Many patients question the need for further vaccination as diseases such as diphtheria, pertussis are very rare these days.

Furthermore, there are people that do not get vaccination, yet able to live healthily until old age. This is the myth behind “herd immunity”.

Herd immunity serves as a preventive barrier as most of the population had been vaccinated, thus, the disease is contained from spreading. If herd immunity is compromised, the widespread of the disease may occur.

A piece of advice to all, a little knowledge is a dangerous thing. Before you start to tell doctors about the negative effects of antibiotics and vaccines, why not, give them a chance to explain to you before you make a decision.

Contributed by DR H.B. CHEE, Muar, Johor The Star/Asia News Network

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Love your liver! World Hepatitis Day today

A look at one of the most insidious infectious in the world 

Many people are unaware that being diagnosed with hepatitis B and C is a lifelong sentence.

Dr Syed ... Patients diagnosed with hepatitis B and C need to come for their annual check-ups to catch signs of liver damage in the early stages. – LOW LAY PHON/The Star

MANY ancient civilisations rightfully believed that the liver is one of the most crucial organs in our body.

Although their understanding was not based in scientific fact – for example, the Babylonians, Estrucans, Romans and Greeks believed that the liver was the seat of all emotions and the organ closest to divinity, while in traditional Chinese medicine, it purportedly helps to regulate the flow of qi and blood in the body, and governs anger – the liver is indeed vital to our existence.

Like the heart, we cannot function without our liver.

It is one of the most hardworking organs in our body, performing over 500 different functions, including processing and storing nutrients, manufacturing proteins and hormones, neutralising toxins, breaking down drugs and removing waste from our body.

It is the second largest organ in the body after the skin, and the only one that has significant regenerative capabilities, being able to grow back to full size from as little as a quarter of its cells.

However, even this ability cannot overcome the insidious presence of the two hepatitis viruses that cause chronic infection in the liver.

These viruses work silently – often residing in the infected person’s body quietly, slowly damaging the liver without causing any outward signs of illness, until it is too late.

Passed on through bodily fluids, they can be contracted through sex, the sharing or reuse of unsterilised sharp objects like needles, razors, and even earrings, from mother to child in the womb, and basically, any activity that can result in the transference of blood, semen, vaginal fluid and saliva directly from the infected person to someone else.

The virus usually gains access into the body via the bloodstream through minor wounds, like nicks or cuts, that one may not even notice.

But because these viruses rarely cause any specific symptoms during the acute stage, people are unaware that they have been infected, and may go on to infect other people unknowingly.

This is why, according to consultant hepatologist Dr Syed Mohd Redha Syed Nasir, the most important form of transmission is perinatal or early childhood transmission.

He explains: “If someone in the family has hepatitis B, it is likely that someone else will have it too; that’s why we have to screen everyone in the house.”

This is especially in the case of children whose immune systems have not completely matured yet.

As a rule, hepatitis is usually only picked up upon screening, or when patients have already developed complications from the disease.

A chronic problem

Despite being considered a major global health threat – it is one of only four diseases that the World Health Organisation (WHO) considers crucial enough to mark with an international World Day, the awareness of hepatitis is still disturbingly low among the general population.

This infectious disease, which causes inflammation of the liver, is caused by five viruses: hepatitis A, B, C, D and E.

Of these, hepatitis B and C are the most worrisome as they can become chronic infections, which may result in liver cirrhosis (also known in layman’s terms as scarring or hardening) and liver cancer. (See Acute infections for more information on the three other viruses.)

These two viruses are also the main focus of the World Hepatitis Day campaign.

According to the World Hepatitis Alliance website, “The long-term objective of the campaign is to prevent new infections and to deliver real improvements in health outcomes for people living with hepatitis B and C.”

In Malaysia, hepatitis B is an important enough health concern that the vaccine is part of the compulsory national immunisation programme for all babies.

Despite that, Dr Syed says that around 5% of the population still has hepatitis B.

There is no vaccine for hepatitis C; neither is there any local data on the spread of hepatitis C or the three other hepatitis viruses in the country, according to him.

“In our setting, from my experience, we often encounter patients, who are diagnosed to have hepatitis B in particular, many years ago.

“Little do they realise that hepatitis B is a chronic infection that has the potential to cause long-term damage to the liver,” he says.

The doctor, who was previously with the national referral centre for liver diseases at Hospital Selayang and is now in private practice, adds that this often results in the patient being unaware of the importance of long-term follow-up, and creates the tendency for them to skip their annual check-ups.

“For these patients, you can’t be sure whether their infection will become active again, or develop into liver cancer.

“A few years down the road, they will come and you discover they have liver cirrhosis, and it is already a lost battle.”

He says that most patients tend to come in when they already have decompensated liver cirrhosis, which presents with abdominal swelling, with or without accompanying leg swelling, and either vomiting or passing motion with blood.

Some may also come in with a yellowish complexion (jaundice), episodes of losing awareness of their surroundings (hepatic encephalopathy), and other bacterial infections, as the liver is part of the immune system.

Too late to treat

While treatment is available for both hepatitis B and C, Dr Syed cautions that patients need to be carefully evaluated before the decision to start treatment is made.

This evaluation is to determine the degree of viral activity, as well as the level of liver damage. Both these factors need to be carefully balanced in order for treatment to be fully effective.

“When we give treatment, we must make sure it is indicated, because it is for life. For example, if a patient is 25 years old, he has to take it for the next 40 to 50 years (until he dies),” he says.

The development of resistance to the antiviral medication given for the disease is also another reason why doctors need to make the decision to treat judiciously.

Aside from oral antiviral drugs, patients may also be treated with interferon injections, which are typically given for the period of one year.

Dr Syed explains: “Interferon modulates your immune system, as well as clears the virus, so there is an added effect. After one year, your immune system will be able to clear the virus on its own.”

According to studies, the percentage of patients on interferon in which the virus can no longer be detected increases from 3-5% in the first year to 12% five years after completing their treatment.

However, he adds that this treatment is often not an option for most Malaysian patients, as the damage to the liver is already too advanced by the time they go see the doctor.

Unfortunately, the reality of the situation in Malaysia is that most patients with chronic hepatitis only see the doctor when their condition is so advanced that they are already well on the way to requiring a liver transplant.

- By TAN SHIOW CHIN The Star

Related Notes:

Hepatitis A
Transmitted through the oral-faecal route, usually through water or food that has been contaminated with the faeces of an infected person. Prevalent in places with poor hygiene and sanitation. There are an estimated 1.4 million cases of hepatitis A every year worldwide. Symptoms include fever, malaise, loss of appetite, diarrhoea, nausea, abdomi -nal discomfort, dark-coloured urine and jaundice. There is no treatment, but the immune system is usually able to get rid of the infection by itself. There are a number of vaccines available.

Hepatitis D

Transmitted through bodily fluids, usually through sex, contact with the blood of an infected person, sharing of sharp objects like needles, razors or syringes, and from mother to child in the womb. Requires the presence of the hepatitis B virus to replicate, and as such, is usually found together with hepatitis B as a co-infection or a superinfection. Not usually tested for in a clinical setting. Treatment and vaccination for hepatitis B is equally effective for hepatitis D.

Hepatitis E
Transmitted through the oral-faecal route, usually through contaminated drinking water and eating products from an infected animal. Every year, there are 20 million infections, over three million acute cases, and 57,000 deaths. Over 60% of infections occur in East and South Asia. Symptoms include jaundice, anorexia, an enlarged, tender liver (hepatomega -ly), abdominal pain and tenderness, nausea, vomiting and fever. There is no treatment, but the immune system is usually able to get rid of the infection by itself. However, complica -tions may arise in pregnant women. The first vaccine was registered in 2011 in China, but is not currently available globally.

Sources: WHO, the US Centres for Disease Control and Prevention, and consultant hepatologist Dr Syed Mohd Redha Syed Nasir.

 
There are vaccines available for hepatitis A, B and E, but the vaccine for hepatitis E is only available in China. – AFP

Facts an figures -by the Numbers:

• There are over 400 million cases of  HEPATITIS every year, compared to 34 million cases of  HIV/AIDS cases (IN 2011) and almost 29 million cases of CANCER  (in 2008).
• HEPATITIS B & C infections cause an estismated  57% of liver cirrhosis cases and 78% primary liver cancer. Liver cancer is the SIXTH most common cancer worldwide.
• Around 240 million people have chronic Hepatitis B, with 600,000 dying every year due to complications from the infection.
• The percentage of  those who develop chronic Hepatitis B infections are: 80-90% of infants infected before he age of one, 30-50% of children infected before six and <5% of otherwise healthy adults.
• The Hepatitis B vaccine is administered at ZERO (at birth), one and six months of age in Malaysia. It is 95% effective at preventing infection.
• About 150 million people have chronic Hepatitis C, with over 350,000 dying every year due to complications from the infection.
• Around 80% of peopole do not exhibit any symptoms follwoing initial Hepatitis C infection.
• Around 75-85% of Hepatitis C patients develop chronic infection, of which 60-70% develop chronic liver disease. 2-20% will develop cirrhosis, with 1-5% dying from cirrhosis or liver cancer. Hepatitis C causes 25% of liver cancer cases.
• July 28 was chosen for World Hepatitis Day in honur of the birthday of Nobel Laureate Prof Baruch Samuel Blumberg, who discovered the Hepatitis B virus.