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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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Antimicrobial Drugs and Infectious Disease Initiatives:

Increasing Drug Access while Containing Drug Resistance

MAQ Mini-University

May 12, 2003

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

All Others




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












Source: 2002 World Health Report

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

Geographic Distribution

Americas, Europe, Eurasia


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

Africa, Middle East,

South/Southeast Asia, Pacific


Source: 2002 World Health Report

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Burden of Infectious Diseases in Humans:


Implications for disease control and development?

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

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Lessons Learned from the U.S.

Infectious Disease

Death Rate*


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.

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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


  • A key component of each is increasing access

    toantimicrobial drugs for treatment.

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Antimicrobial Drugs has led to Creation of

  • 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

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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….

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    For essential medicines, we want to improve ACCESS, Diseasesbut…

    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.

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    Failure to Use Drugs Properly: Diseases

    Treating P. falciparum Malaria in Thailand


    Original treatment:


    $0.10 per patient

    Current treatment:

    Mefloquine + artesunate,

    $3.59 per patient

    Higher treatment cost can

    limit access

    Cure Rate (%)



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

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    Failure to Use Drug Properly: Diseases

    Treating Drug-Resistant Tuberculosis

    1. Treatment 12-18

    months (vs. 6


    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

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    Predictions for HIV/AIDS and Potential for Drug Resistance Diseases

    • 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.“

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    Drug Resistance is a Global Phenomenon Diseases






    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

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    Here Today, There Tomorrow Diseases


    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

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    Increasing access Diseases to drugs while preventing resistance requires a

    balancing act between:

    Patient Good:


    Access to


    Public Health:



    To Preserve

    Drug Efficacy

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

    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?

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    Why is appropriate use of antimicrobial drugs Diseases

    such a challenge in developing countries?

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    Treating Malaria in Southeast Asia Diseases

    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

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    So when increasing access to drugs to treat infectious diseases

    Also need to consider….

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    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


    5. Monitoring drug resistance to ensure only

    efficacious drugs recommended for treatment.





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    Increasing the availability of an efficacious drug is Increased Access of MedicinesNOT the whole answer to controlling infectious diseases

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    Programmatic Effectiveness, Burkina Faso, 1994 Increased Access of Medicines

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

    • 1. Patient seeks help at clinic


    • 2. Complete history taken


    • 3. Physical exam done


    • 4. Correct drug at correct dose recommended


    • 5. Correct drug at correct dose bought by patient


    • 6. Complete dose taken by patient


    • 7. Efficacy of drug


    Overall programmatic effectiveness = 3%

    Krause & Sauerborn, Annals Trop Paeds, 2000

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    Distribution Increased Access of Medicines











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


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    Things to Remember about Access to Increased Access of Medicines

    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