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Antimicrobial Drugs and Infectious Disease Initiatives: Increasing Drug Access while Containing Drug Resistance MAQ Mini-University May 12, 2003

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Antimicrobial Drugs and Infectious Disease Initiatives: Increasing Drug Access while Containing Drug Resistance MAQ Mini-University May 12, 2003. Burden of Infectious Diseases in Humans: Deaths (14.9 million in 2001). All Others 17%. ARI 27%.

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slide1

Antimicrobial Drugs and Infectious Disease Initiatives:

Increasing Drug Access while Containing Drug Resistance

MAQ Mini-University

May 12, 2003

slide2

Burden of Infectious Diseases in Humans: Deaths (14.9 million in 2001)

All Others

17%

ARI

27%

Which six diseases cause 83% of all infectious disease deaths worldwide?

Measles

5%

Malaria

8%

TB

11%

HIV/AIDS

19%

Diarrheal

Disease

13%

Source: 2002 World Health Report

slide3

Burden of Infectious Diseases in Humans: Deaths (14.9 million in 2001)

Geographic Distribution

Americas, Europe, Eurasia

7%

Why do almost all infectious disease deaths occur in developing countries?

Africa, Middle East,

South/Southeast Asia, Pacific

93%

Source: 2002 World Health Report

slide4

Burden of Infectious Diseases in Humans:

Infections

Implications for disease control and development?

Sources: 2002 World Health Report, 2002 UNAIDS Report, 2002 Global TB Control Report, and other WHO reports

slide5

Lessons Learned from the U.S.

Infectious Disease

Death Rate*

1900-1996+

What lessons apply to the control of infectious diseases worldwide?

  • 75% decrease (1900-1940) before widespread antibiotic, vaccine use.
  •  Need more than tools, technology (e.g. public health, education, etc.)
  • Increase (1980-1996) due to HIV/AIDS and drug-resistant TB.
  •  New tools need to be generated.
slide6
Concern about ID Burden and Availability of Effective Tools has led to Creation of GLOBAL INITIATIVES including:
  • Global Fund to Fight AIDS, TB, and Malaria
  • STOP TB/Global Drug Facility
  • Roll Back Malaria
  • PMTCT
  • A key component of each is increasing access

toantimicrobial drugs for treatment.

slide7

Antimicrobial Drugs

  • Specifically kill or inhibit growth of microbes:
  • Illustrative examples:
    • viruses: HIV, hepatitis
    • bacteria: tuberculosis, some pneumonia and
  • diarrheal disease
    • parasites: malaria
    • fungi: thrush (yeast)
  • Key tools for treating infectious diseases:
  • humans, animals, plants
  • Lose efficacy over time if used inappropriately
other tools and technologies available to control infectious diseases
Other Tools and Technologies Available to Control Infectious Diseases
  • Prevention
      • immunizations
      • hygiene, safe water/food
      • infection control in hospitals
      • insecticide-treated materials and/or insect control
      • condoms
      • other behavior changes
  • Treatment
      • diagnostics
      • antimicrobial drugs

What tools are currently available?

For most of these tools, failure to use properly does not have

any negative consequences on long-term efficacy….

for essential medicines we want to improve access but
For essential medicines, we want to improve ACCESS,but…

we also want to make sure these medicines are USED PROPERLY to avoid the development of drug resistance

  • so that medicines will remain effective to:
    • benefit more people over the long term
    • avoid toxicity, higher cost, complexity of
  • secondary drug regimens.
slide10

Failure to Use Drugs Properly:

Treating P. falciparum Malaria in Thailand

$0.89

Original treatment:

Chloroquine,

$0.10 per patient

Current treatment:

Mefloquine + artesunate,

$3.59 per patient

Higher treatment cost can

limit access

Cure Rate (%)

$0.10

Year

Source: SE Asia J Trop Med Public Health 1999; 30: 68

slide11

Failure to Use Drug Properly:

Treating Drug-Resistant Tuberculosis

1. Treatment 12-18

months (vs. 6

months)

2. Alternative drugs

more toxic

3. Drug costs

>$1,000 (vs. $10)

Prevalence of Drug Resistance in New TB Cases

Source: Anti-tuberculosis Drug Resistance in the World Report No.2. WHO 2000

predictions for hiv aids and potential for drug resistance
Predictions for HIV/AIDS and Potential for Drug Resistance
  • In 2002, 40 million HIV infections (UNAIDS)
  • In 2010, 50-75 million HIV infections predicted for 5 countries: China, Ethiopia, India, Nigeria, and Russia (National Intelligence Council)

“Drug-resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs.“

slide13

Drug Resistance is a Global Phenomenon

12-55%

???

5-95%

2-39%

30-50%

Up to 98%

Total : 11,604,000

Sources: 2002 World Health Report and WHO reports

  • Indicates that:
  • appropriate use of antimicrobial drugs is a challenge;
  • containment of drug resistance is difficult
slide14

Here Today, There Tomorrow

HEALTH & FITNESS

Tuesday May 7, 2002

Section F, Page 5, Column 1

New Resistant Gonorrhea Migrating to Mainland U.S.

Spread of Chloroquine-Resistant Pf Malaria from Cambodia

National Institutes of Health

Volume 334:933-938, Number 15

April 11, 1996

Transmission of Multidrug-Resistant Mycobacterium tuberculosis during a Long Airplane Flight

slide15

Increasing access to drugs while preventing resistance requires a

balancing act between:

Patient Good:

Increasing

Access to

Cure/Treat

Public Health:

Containing

Resistance

To Preserve

Drug Efficacy

slide16

Are we trying to save lives, save drugs, or both?

How many deaths are we willing to accept in order to prevent resistance?

How much future drug resistance (and future deaths) are we willing to risk in order to prevent deaths now?

What are the implications of finding ourselves in some middle ground?

slide17

Why is appropriate use of antimicrobial drugs

such a challenge in developing countries?

slide18

Treating Malaria in Southeast Asia

Conditions: Consequences:

Malaria common in poor, rural, border Care seeking mostly in private sector,

areas (government services limited) households paying for most services

Substantial population movement Limited access to health care, limited

driven by conflict ability to follow up to ensure cure

Poorly regulated sales of antimalarial Incorrect drug or dosing contribute

drugs in private sector to drug resistance

Self-medication and poor patient Incorrect drug or dosing contribute

compliance with treatment regimen to drug resistance

Poor regulation and quality of locally- Incorrect dosing contributes to drug

produced antimalarial drugs resistance

Note: most of these conditions also affect other countries and infectious diseases

slide20

Other Essential Investments in Health Systems to Complement Increased Access of Medicines

1. Patient education to improve care seeking

behavior and treatment compliance.

2. Provider education to improve diagnosis

and prescription of correct drug in correct

dose and follow up to confirm cure.

3. Drug management and regulation to ensure

high-quality drugs and treatment information

available to both providers and patients.

4. Public health measures to prevent disease

transmission.

5. Monitoring drug resistance to ensure only

efficacious drugs recommended for treatment.

Infected

patient

Cured

patient

slide21
Increasing the availability of an efficacious drug is NOT the whole answer to controlling infectious diseases
slide22

Programmatic Effectiveness, Burkina Faso, 1994

7 steps for fully “effective” case management of malaria:

  • 1. Patient seeks help at clinic

21%

  • 2. Complete history taken

31%

  • 3. Physical exam done

69%

  • 4. Correct drug at correct dose recommended

81%

  • 5. Correct drug at correct dose bought by patient

91%

  • 6. Complete dose taken by patient

68%

  • 7. Efficacy of drug

85%

Overall programmatic effectiveness = 3%

Krause & Sauerborn, Annals Trop Paeds, 2000

slide23

Distribution

challenges

Drug

resistance

Wastage

Drug

toxicity

Provider

misuse

Patient

misuse

What are some potential negative consequences of increasing the amount of drugs without simultaneously strengthening the health system?

Illustrative

slide24

Things to Remember about Access to

Antimicrobial Drugs and Drug Resistance

1. Drug resistance a constant threat as long as infectious

diseases present and treated with antimicrobial drugs.

2. Rate of emergence of drug resistance faster in places

where volume of drug use is greater and where drug

use/quality are poor. Spread of drug resistance to other

countries/regions will follow.

3.Increased access to antimicrobial drugs needs to be

complemented by other programmatic interventions,

e.g. monitoring drug resistance, drug use practices, and drug

quality, use of tools for prevention of disease

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