Every year, out of 7.7 million deaths that are associated with bacterial infections globally, nearly 5 million deaths are attributable to a rapidly emerging public health threat called antimicrobial resistance (AMR). Among these deaths, almost 1.3 million deaths are caused by bacterial pathogens that are resistant to the effects of antibiotics currently available to treat them.
AMR occurs when microbes such as bacteria, viruses or fungi evolve mechanisms that protect themselves from the effects of antimicrobial medicines. Increases in drug-resistant infections have a direct and adverse effect on incidence and death rates associated with infectious diseases, as they limit the benefits of antimicrobial drugs and force the use of stronger, last-resort drugs. Along with increases in healthcare expenses, this also results in longer hospital stays, prolonged illnesses, and disability.
A recently published series of papers in the highly cited journal Lancet highlighted that AMR has been on the rise globally in recent decades and estimates from some countries show that resistance to last-resort antibiotics could more than double in 2035 as compared to 2005. This is a dire scenario wherein even the strongest antimicrobial drugs available are unable to treat the infection. The Lancet series also underlines the fact that the impact of rising AMR is not felt uniformly across the globe – low- and middle-income countries bear the biggest brunt. South Asia, for instance, accounts for 77 AMR-associated deaths in a population of 100,000.
Nepal has not been spared the effects of this public health phenomenon. In 2019, over 23,000 deaths were associated with AMR while 6,400 of those deaths were directly attributable to AMR. Deaths associated with AMR in Nepal are already more in number than those due to diabetes, neoplasms, and maternal and neonatal disorders. The pathogens that have been found to have developed resistance against antimicrobial drugs in Nepal are responsible for a plethora of diseases.
Given that there is no specific target population at heightened risk of AMR (all ages are at risk), it is imperative that governments and populations move swiftly and take actions to contain the spread of AMR. Research shows that vaccines have the potential to play a vital role in mitigating AMR. Effective and comprehensive vaccination campaigns reduce the incidence of diseases in the population, thereby lowering the prescription and consumption of antimicrobial drugs, and eventually slowing down the emergence and spread of drug resistance.
For instance, diarrhea is very common among young children in Nepal – children are estimated to contract diarrhea at least thrice before they turn two, and a high proportion of these cases are treated with antibiotics. One common cause of diarrhea is the microbe rotavirus, which spreads through hand-to-mouth contact. Antibiotics are useless against viruses, yet those continue to be used widely for diarrheal cases around Nepal. Modeling estimates show that over half of the antibiotic-treated cases of diarrhea that are caused by rotaviruses are preventable by the rotavirus vaccine. In other words, an effective coverage of the rotavirus vaccine in Nepal has the potential to avert a large proportion of diarrhea cases that are treated with antibiotics, bringing down both the incidence of diarrhea in the population as well as the consumption of antibiotics.
Therefore, it is critical for national health policies to account for the role of vaccines in the fight against AMR, and to bolster existing immunization programs in the country. The Global Antibiotic Resistance Partnership (GARP) – a network of 15 countries in Asia and Africa – is one of many global efforts involved in this endeavor. In 2015 – when little was known about AMR and its effects in South Asia – GARP’s Nepal chapter brought out a situational analysis report describing antibiotic use and resistance in the country, going into details of health systems and the economic context of Nepal, drug regulations relevant to AMR, supply chain management and access to antibiotics, and even AMR in livestock, fisheries and agriculture. GARP is still an active network in Nepal working toward mitigating the challenges posed by AMR, under the banner of Nepal Public Health Foundation and supported by the One Health Trust. In addition to making priority vaccines more easily available to the population, other interventions can also have a direct and significant impact on the spread of AMR, especially in low- and middle-income countries. The Lancet series finds that improving healthcare facility, infection prevention and control standards, and improving access to clean water, sanitation and hygiene are some such ways. Even indirect ways like improving awareness on AMR both among the public and healthcare providers can go a long way in fighting this public health threat.
While the government has already taken multiple steps to address the spread of AMR in the country, much more must be done both in terms of policy and action. An immediate, yet long discussed issue is that of access versus excess, which is directly linked to equity. While excess antibiotic is a serious concern, so is lack of access to this life-saving medication for many in remote parts of the country. Similarly, more robust surveillance incorporating all medical institutions, veterinary institutions has been recommended by experts in the country. This requires education and awareness campaigns at a larger scale, targeting user as well as provider groups. Further, Nepal has made immense progress in the area of routine immunization, thereby leading to reduction in incidences of major infectious diseases and also deaths caused by those in the population over the years. Yet, challenges remain, especially as the country transitions into provincial and local government setup. Continued achievements of the immunization program will be a critical factor in the fight against AMR pathogens. AMR is a complex issue involving multiple sectors, thus a holistic approach is required rather than efforts conducted in silos. Such an integrated approach is still not fully implemented in Nepal, and the government should play a stronger proactive role toward ensuring that all relevant stakeholders are equally involved in this important cause.
(Dixit is Director at Global Antibiotic Resistance Partnership (GARP) Nepal and Bhagawati Senior Research Analyst with One Health Trust)
