Little progress in containing AMR

Antimicrobial resistance (AMR) is becoming a major hurdle in controlling infectious diseases, and the steps taken so far to combat this health crisis have proved to be inadequate.

AMR occurs when germs like bacteria, viruses, fungi and parasites change over time and no longer respond to medicines. This makes infections harder to treat and increases the risk of a disease spreading rapidly, ultimately leading to severe illnesses and even death.

Because of AMR, antibiotics and other antimicrobial drugs become ineffective for treating both humans and animals in general.

"We are yet to make any big leap [to resolve the problem], because all factors responsible for this health crisis are still there despite all efforts," said Prof Zakir Hossain Habib, who has been leading the laboratory-based AMR surveillance activity in 11 hospitals nationwide.

According to experts, indiscriminate use of antimicrobials, poor medicine quality, and inappropriate antimicrobial waste management are the main factors behind the proliferation of germs that have AMR.

Government studies have found that important and widely used antibiotics have lost half their effectiveness due to their increasingly irrational use.

In 2019, the High Court directed authorities to take steps to reign in over-the-counter sale of antibiotics. In response, the Directorate General of Drug Administration (DGDA) said it has incorporated a provision in the proposed drug act to penalise pharmacies for selling antibiotics without a prescription from a registered doctor.

As per DGDA's decision, sales of antibiotics have started in red packages from November 30.

The act, however, has not been passed in parliament yet.

The preventive steps, so far, have been limited to discussions on preparing national plans and policies by the Directorate General of Health Services (DGHS), with no field-level activities. DGHS has no budgetary allocation to contain AMR.

A 15-point to-do list made at a meeting in the health ministry on October 4 highlighted that all the plans to control AMR have been waiting to be implemented for three years.

On November 13, the "National Technical Committee on AMR Containment", led by DGHS, had a meeting with no new agenda.

The only notable decision was about forwarding the "National AMR Strategy and Action Plan 2022-26" to the National AMR Steering Committee in the ministry -- that too after about 10 months since the technical committee approved the document.

According to DGHS officials, the delay for implementation was because the approved plan did not have the budgetary proposal for executing the tasks. The 2022-2026 plan now has a proposal for allocating around Tk 900 crore, according to DGHS officials.

NOT ENOUGH DOCTORS

The proposed drug act has a provision of fining Tk 20,000 for selling antibiotics and antimicrobials without receiving a prescription from a Bangladesh Medical and Dental Council (BMDC) registered doctor.

However, due to a massive shortage of doctors, the majority of the population go to quacks or the nearest drug store for healthcare advice, experts said.

There are around 1,04,644 registered doctors, according to the recently published Human Resources for Health datasheet of 2022. Of them, around 25,000 work at public hospitals, according to DGHS.

A 2011 study in Cox's Bazar found that  67 percent of patients in Chakaria upazila went to quacks for their first line of care.

The survey calculated that 250 registered doctors are needed to serve Chakaria. Currently, there are 13 doctors at Chakaria Upazila Health Complex.

"Containing AMR requires an all-out and multifaceted approach. All community clinics should have at least an assistant doctor," said Prof MA Faiz, former director general of the DGHS.

NO LABS, PHARMACISTS IN HOSPITALS

Faiz said not having designated microbiology laboratories is a big weakness of public hospitals.

"At least all medical college hospitals [117] should have a well-equipped microbiology laboratory with the capacity to meet patients' diagnosis needs," Faiz said.

Echoing the same, Zakir said the existing microbiology labs at medical colleges cannot provide round-the-clock service.

Hospitals, moreover, lack antibiotic waste-management and good pharmacy practices, according to health officials.

Besides, there are no graduate pharmacists for counselling patients and auditing prescriptions.

The issue of medicine quality has not received proper attention during discussions on AMR, said experts.

"If the quality of medicines is not ensured and medicine wastes are not managed properly, only stopping irrational use will not be fruitful in containing AMR," Mehedi Hasan, technical officer at the US Pharmacopeial Convention, Bangladesh, told The Daily Star.

Over the last three years, Fleming Fund Country Grant has supported the refurbishing of 12 microbiology labs in different hospitals and livestock research centres.

"Everything should be integrated into the system. Otherwise, nothing will make a difference," Prof Nitish Debnath, team lead of the Fleming Fund programme in Bangladesh, told The Daily Star.

Prof Ahmedul Kabir, additional director general (administration) at the DGHS and co-chair of the national technical committee, said, "Fragmentation will not solve the problem. This is an entire system we need to work on collectively."