To help the GRIP members become orientated to Thailand and the developing markets, a number of guest speakers were invited to give their interpretation of current work around antimicrobial resistance and the overall public, prescriber and policy activation plans.
Holding the GRIP meeting in Thailand allowed GRIP members to get a wider perspective of some of the challenges that were happening in different countries around the world, with a view to understanding how future efforts could be directed to maintain focus on this global health priority.
Guest Speaker 1
Burden of AMR and Thailand National Strategic Plan
Dr Direk Limmathurotsakul, MD MSc PhD, Wellcome-Trust Intermediate Fellow for Public Health and Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Thailand
Mortality attributable to antibiotic resistance is as much of an issue in Thailand as it is in many other large countries in the world, said Dr Limmathurotsakul, with estimates of some 19,122 deaths attributable to multidrug-resistant bacterial infection from 2004 to 2010, increasing over time. Comparing the mortality rates with those of the USA (23,000), it is clear to see quite how big an issue this is for Thailand with a population substantively smaller than the USA.
This is the reason why a National Committee has been formed, supported by the Government and the Prime Minister, to investigate the challenges further.
Currently, ambitious goals within the National Strategic Plan for Antimicrobial Resistance 2017 – 2021 in Thailand include:
- 50% reduction in AMR morbidity
- 20% reduction in antimicrobial use in humans
- 30% reduction in antimicrobial use in animals
- 20% in public knowledge and awareness of appropriate use of antimicrobials
- Improvements in the capacity of the national AMR management system
Thinking practically, initial focus would have to be around monitoring and measurement, said Dr Limmathurotsakul, which will inform success in future years based on international monitoring systems such as the WHO Global Antimicrobial Resistance Surveillance System (GLASS), although there has been much debate on collating incidence vs. prevalence data.
When it comes to the reduction in human usage of antibiotics, part of the challenge in Thailand is the free availability of antibiotics over the counter from a pharmacy.
Such easy access poses a challenge because it is difficult to get a clear picture of actual antibiotic use in Thailand in a given year. The same is true for animal usage.
A new taxation system will allow better data collection, however this will not deliver results for the next two to three years. Given the paucity of data, Dr Limmathurotsakul and his teams started to look at a concept called ‘Activity Footprint’.
Working in collaboration with the UK and the USA, the team started to look for cities with a similar footprint – following the impact of a general carbon footprint: “The more you use, the worse you make it for the world but it’s still necessary and you need to use something when you really need it.”
The team are looking at an antibiotic consumption survey to understand more about overall usage figures, including importantly the ex-pat community that resides in Thailand.
Early reads of median data suggest that most people surveyed took an antibiotic within the last six months. As a result, one focus of the messages has been around the fact that antibiotics aren’t required annually.
Recent data on usage in animals is also interesting.
Dr Limmathurotsakul found that in some cases antibiotics are routinely added to feeding systems in small amounts. This is an entirely different issue to address but it is a major focus for the Thai government.
In the areas of awareness and education, Thailand has supported Antibiotic Awareness Week and activations are happening. One particular area is the miswording between ‘antibiotics’ and ‘anti-inflammatories’ which isn’t helping consumer understanding. A further challenge is the availability of antibiotics at no charge from hospitals, and patient demand for the strongest, and therefore what they perceive to be the most effective drugs.
Guest Speaker 2:
Overview of Thai perspective on the challenges of managing upper RTI locally, hospital policy, prescriber behaviors and action plans and key motivators
Associate Professor Dr Paraya Assanasen
Providing an additional perspective on the challenges in Thailand, Associate Professor Dr Paraya Assanasen began by telling GRIP members the challenge for Thai healthcare providers. While respiratory tract infections are well understood and recognized as self-limited conditions that often resolve within two weeks, they do have an impact on patients’ lives, often leading to a reduction in overall productivity. As a result, patients frequently presented with these respiratory infections in the hospital where Dr Assanasen worked, he said. “They are common, acute infections, for which antibiotics are prescribed, even though these are available without a prescription at a low cost over the counter from pharmacies.”
Nonetheless the majority of antibiotics in Thailand are bought by the patients, followed by those that come from seeing a doctor through the universal coverage scheme, or privately.
Data from a study in 2008 showed that the most commonly prescribed antibiotic in the case of fever was amoxicillin.
Presence of a fever was a key indicator for prescription of an antibiotics. This data was also replicated in a recent study from 2016, with Thai nationals most often being given an antibiotic to treat fever.
Looking back historically, from 2000 onwards, Thailand has data that there was relatively high penicillin resistance to Streptococcus pneumoniae but at that time it was still sensitive to amoxycillin and clavulanic acid. Looking at the hospital where Dr Assanasen works, data suggests that from 2010 to 2016 there was a decrease in sensitivity of Streptococcus pneumoniae in the hospital, and resistance increased from 64% to 67%.
Reflecting on the action plan from the Thai Government, Dr Assanasen said much work was being done to engage prescribers, including work looking at databases to audit and access compliance. The primary focus was on reducing unnecessary antibiotic use in common diseases such as upper respiratory tract infection and acute ear infection. Work was happening to create de-centralised, collaborative networks between national and local stakeholders, to deliver a national policy on antibiotic prescribing in the context of AMR. This included prescriber education and managing patient expectations.
One such focus was designed to reduce the number of patients who receive antibiotics by 20%. By implementing effective education, the team were able to show real impact on prescribing trends, alongside an improvement in patients’ health perceptions.
Concluding his presentation, Dr Assanasen said data have shown that it was possible to deliver a large decrease in inappropriate prescribing for antibiotic prescriptions through education initiatives. It is vital however to address educational initiatives at the pharmacy based on the free availability of these products without a prescription. Mentoring is critical in this context.
"If you provide more knowledge to the doctor, they can understand and they can prescribe less antibiotic."
Guest Speaker 3
Dr Devendra Soni, ENT Specialist, Prime Healthcare Group, Dubai
Antibiotics are an important front-line instrument in the ﬁght against various infectious diseases in the Middle East, however, the irrational use and prophylactic use of antibiotics is big problem in the region.
Part of the issue is that many patients seek out antibiotics around the second or third day of symptoms. Citing a study conducted in 2010 done in Kuwait, Dr Soni said out of 270 patients, 50% were prescribed antibiotics for upper respiratory tract infections.
To tackle the misuse of antibiotics, authorities in the region are looking at six priorities.
- Reduce use of antibiotics by improved water, sanitation and immunization.
- Educate health care professionals, policy makers and the public on sustainable antibiotic use.
- Improve hospital infection control and antibiotic management.
- Reduce the sub therapeutic use of antibiotics in agriculture.
- Change incentives that encourage antibiotic misuse and overuse.
- Ensure political commitment to meet the threat of antibiotic resistance.
One of the key challenges is that in many Middle Eastern countries antibiotics can easily be obtained over the counter. Issues are also complicated by use in animals, which then makes its way into the food chain. Guidelines may also be important in reducing inappropriate use over the counter.
The affluence of different countries in the Middle East region also impacts on access, said Dr Soni. People have easy access to specialists, so there is an opportunity for more patient demand, and there is no shortage of pharmacies, so populations from higher socio-economic groups can afford to pay for treatment and will likely not have issues getting access to antibiotics, said Dr Soni.
Looking at the importance of public awareness and the need for broader education, pharmacists can play a significant role in promoting prescriber change through education, decision support and treatment recommendation, audit and feedback mechanism, said Dr Soni. “Studies have shown that provider education efforts are most effective when they are viewed as assistance rather than restriction,” he concluded. “Education directed toward small groups appears to be most beneficial, when compared with mass mailing.”
Summing up, Dr Soni said political commitment is critical. Until there are policies in place, it’s difficult to implement successful action plans: this means a co-ordinated effort from doctors, pharmaceutical companies and big pharmaceutical chains to define the appropriate measures to control antibiotic misuse.
Guest Speaker 4
Dr Atif Rizvi, Regional Medical Marketing Manager, RB
Dr Atif Rizvi, who co-ordinates professional marketing efforts for RB across the developing markets, was also asked to provide GRIP members with an overview of the scenario in some of the other markets.
Looking at the challenges and commonalities in the developing markets, Dr Atif began by explaining that in RB terms the developing market included all of Asia, Africa and Latin America. Some 78% of the world’s population is the developing market, and discussions about antimicrobial resistance really matter here. Approximately 25% of the deaths in these regions are caused by infections and diseases relevant to this discussion. This figure rises to around 98% of deaths in children.
In the Philippines, the usage of antibiotics is similar to Thailand, where some 1500 different preparations are available.
Approximately every two out of three purchases are not on prescription. Like Thailand again, the Philippines has started a campaign to educate the people about not using antibiotics where they are not required.
Across all these markets, there is a common availability challenge with two components. Antibiotics are in scarce supply, such as in parts of Africa, or antibiotics have become commodities and are freely available from pharmacies. The third type of market reflects those like Japan and Hong Kong where regulations control access more effectively.
The single biggest area where impact can be made in these regions, said Dr Atif, was through education of healthcare professional and patients. Citing an example where GRIP member Dr Martin Duerden had visited Saudi Arabia, Dr Atif said these efforts created impact, with more than 20 meetings (covering 400 doctors) and some 22 pharmacy education programmes. This triggered a further cascade of activities.
A similar activation programme was seen in Dubai. Further in Dubai some 35,000 leaflets were distributed to patients.
In terms of evaluating impact around 93% of healthcare professionals engaged in these activities reported they had made it clear on when to prescribe and not to prescribe antibiotics.
Summing up the challenges for the developing markets, Dr Atif encouraged the GRIP members to do more to help keep conversations alive at a government level, continuing to influence medical societies and medical opinions through the use of things like protocols, and ensuring that the public continued to be educated in the field of AMR.