The Struggle Against Antimicrobial Resistance in Pakistan

Introduction

Pakistan is currently facing a health crisis in the form of inappropriate use of antimicrobials, a group of agents that curtail the spread of microorganisms like bacteria, viruses, fungi, protozoa, and parasites. Antimicrobial drugs are mostly prescription drugs that must be consumed according to the quantity prescribed by a medical practitioner, if at all.

Both humans, animals, and plants need antimicrobials to contain and prevent diseases and infections. Out of other agents, antibiotics are a commonly known and consumed drug in Pakistan. The first big breakthrough in the development of antibiotics came with the discovery of penicillin in 1929, which cures several bacterial diseases such as pneumonia, gonorrhea, and infections of the ear, throat, and urinary tract, among others. Not only did it improve the condition of patients, but it could also be recycled and used again as it is excreted in the patient’s urine.

As groundbreaking as the discovery of penicillin was, the first case of antibiotic resistance soon followed in 1940. Since then, antimicrobial resistance (AMR) has consistently been observed over decades. However, antimicrobial resistance was not a public threat until a few years ago. According to the World Health Organization, the resistance was responsible for the deaths of around 5 million people, with a direct relation to the deaths of 1.27 million in 2019. In Pakistan, the resistance caused the deaths of around 300,000 people, directly and indirectly.

What Causes Antimicrobial Resistance?

The increase in antimicrobial resistance is due to a combination of factors, with the most reported one being the overuse of antimicrobials, especially antibiotics. Evidence suggests a direct linkage between the consumption of antibiotics and the development of antimicrobial-resistant bacteria. It means that the consumption of antimicrobials, even if it’s to treat infections or for infection prevention, creates room for restraint bacteria, let alone overconsumption.

Overconsumption is a global issue, with reports showing India, China, and the USA as the largest consumers. However, in Pakistan, the situation is no less alarming, where most antimicrobials, especially antibiotics, are sold over the counter, which means that anyone could buy antibiotics without a prescription and misuse them.

This is problematic not only for health reasons but also because the national drug policy of Pakistan discourages the selling of antibiotics without a prescription. A study confirmed the presence of 80,000 retail pharmacies within the Pakistani healthcare system, and these pharmacies are responsible for 80% of the drug distribution in the country. This means that the attitude and practices of pharmacies significantly contribute to the overconsumption of antibiotics, and, therefore, the increasing the number of people resistant to drugs and different treatment options.

Antimicrobial resistance in humans also develops through animal consumption. This is because farmers use antimicrobials on animals to improve farm yield, and since Pakistan is one of the largest dairy-consuming countries, the antibiotics from the animals are transferred to humans, therefore adding to overconsumption and increasing the number of restraint bacteria.

Another factor is self-medication, which is a common practice in Pakistani households, with reports suggesting that 52% of Pakistanis consume antibiotics without consulting a doctor. The lack of medical facilities, medicines, and affordability of medical experts is a concern for many Pakistanis, who may resort to self-diagnosis of illness (which will most likely be inaccurate) and treat it with antibiotics after minimal consultation from a nearby pharmacist or by consuming leftovers at home.

The Consequences of Antimicrobial Resistance in Pakistan

A direct consequence of antimicrobial resistance is increasing antibacterial-resistant infections and death rates. Globally, around 700,000 deaths are attributed to antibacterial-resistant infections every year. In Pakistan, notwithstanding the subpar healthcare system, antimicrobial resistance has emerged as the third leading cause of death.

One of the reasons for this is that Pakistan is reliant upon broad-spectrum antibiotics, with no capacity to afford and include narrow-spectrum antibiotics within the healthcare system. Countries reliant on broad-spectrum antibiotics report more mortality, whereas high-income countries that can afford new antibiotics report lower mortality rates.

In addition to increasing mortality rates, antimicrobial resistance overburdens the already-burdened healthcare system of Pakistan, as well as overall healthcare costs for patients. Bacterial diseases such as typhoid, malaria, tuberculosis, certain skin diseases, and blood diseases are already prevalent in Pakistan, and more resistance to antimicrobials means these diseases would become increasingly difficult to treat, leading to prolonged illnesses, burden on hospitals, and additional costs for the patients and their families.

Additional individual expenditure on hospitals and treatments will likely increase poverty in a low-income country like Pakistan. In addition, due to inefficient antibiotics, organ transplants become difficult to perform as bacterial infections are common after transplantation, which will not be cured due to resistance. Similar is the case with cancer treatments, which expose patients to infections.

Pakistan’s National Action Plan

The WHO has been taking notice of antimicrobial resistance since 1998 when the 51st World Health Assembly (WHA) adopted the WHA Resolution 1998/76. Since then, multiple instruments have been adopted; however, global concerns about resistance have only increased in the last decade, and hence, the seriousness of measures has increased.

In May 2015, the WHA Resolution WHA68.7 set the course for Resolution WHA A68/20 Corr.1, which introduced the Global Action Plan (GAP), a comprehensive manual to combat antimicrobial resistance. The Food & Agriculture Organization of the United Nations and the World Organization for Animal Health also contributed to the GAP. Accordingly, in WHA Resolution WHA68.7, member states were required to implement the objectives of GAP through exclusive national action plans, strategically designed according to the needs of that country.

Subsequently, Pakistan developed the Antimicrobial Resistance National Action Plan (NAP). At the core of the NAP is the “One Health” approach, advocated by the WHO, a global initiative of making collective efforts towards a unified approach to optimizing the health of all stakeholders of the ecosystem, i.e. humans, animals, plants, and the environment, through intergovernmental coordination, and partnership with international bodies.

The national action plan takes the objectives of the GAP into account. The GAP focuses on improving awareness, developing strong surveillance and research systems on antimicrobial resistance, controlling the spread of infections, optimizing antimicrobial agents, and, more importantly, rationalizing the economic means required to sustain the plan. To attain these objectives, an intra-sectoral core committee was tasked with:

• Assessing the situation of antimicrobial resistance
• Outlining the areas where measures were needed
• Identifying policy-makers, pharmaceutical owners, and experts in infections and animal health
• Recommending public engagement and awareness tools
• Developing provincial action plans

Subsequently, key stakeholders from across the relevant sectors were identified and the National Strategic Framework for Containment of Antimicrobial Resistance was designed in 2016. The following year, a national consultative workshop in coordination with the WHO was conducted to include important stakeholders and ensure their commitment to the NAP.

Across all provinces of Pakistan, all health-related policies and mandates are enforced and undertaken by the Ministry of National Health Services, Regulations and Coordination. Accordingly, to implement the International Health Regulation, and the Global Health Security Agenda, the ministry constituted a multi-sectoral national task force, and made the Health Planning, System Strengthening, and Information Analysis (HPSIA) Unit as the focal point to ensure collaboration across all relevant federal and provincial authorities.

Implementation and Challenges

The most important objective of the NAP that has to be strategically executed is spreading awareness about antimicrobial resistance through proper channels. This is particularly important in the Pakistani context since there are no post-graduate training programs for physicians, pharmacists, and nurses who are directly involved in a dialogue with patients. There is a dire need for such programs to develop professionalism in medical practitioners and pharmacists so that basic knowledge about antimicrobials can be imparted to patients who consult them.

Accordingly, awareness campaigns are being conducted across the federal and provincial levels, with the most momentum observed in Islamabad and Punjab. Medical practitioners and farmers are being educated at seminars and symposiums. Moreover, to combat foodborne antimicrobial resistance, i.e., resistance spreading from food made from animals, special Training of Trainers (ToT) workshops are conducted to reach as many key players in the food and agriculture industry as possible, at a grass-roots level.

The Government of Pakistan is also monitoring and tackling unprofessional medical practitioners, or quacks, across provinces. These quacks are mostly found in rural areas and prescribe medicines for cheap without considering the efficacy of their prescription.

However, concerning other objectives—such as surveillance, infection control and prevention (IPC), optimizing antimicrobial agents, and sustainable investments—making progress has been difficult and slow, primarily due to a lack of infrastructure and funds. Taking the case of surveillance, Pakistan does not have many standardized laboratories that could accumulate credible data, and in the absence of such laboratories, the existing data is questionable.

IPC is also unsatisfactory, particularly for vaccine-controlled infections such as polio, and even though multiple guidelines for polio have been made, the problem persists. Similarly, sustainable investment cannot be achieved if the key stakeholders across health sectors do not monitor the prices of antimicrobials and coordinate with the government to control them.

Pakistan needs dedicated infrastructural changes to accomplish the objective of NAP and conform to its international obligations. Dedicated efforts by the federal and provincial governments are required for the implementation of the NAP. Standardized laboratories, trained medical professionals, committed multi-sectoral stakeholders of hospitals and pharmaceuticals, consistent governmental intervention and monitoring, and rigorous awareness campaigns for the general public, farmers, and medical practitioners are few of the many but important steps that have to be taken for the containment of antimicrobial resistance.

It is important to remember that Pakistan was able to contain the spread of COVID-19 by introducing laboratory training programs, public-private partnerships, selling antibiotics at reasonable prices, and engaging the general public. With equal, or more dedication from all sectors, Pakistan can reduce the impact of antimicrobial resistance as well.

Conclusion

Antimicrobial resistance is a serious public health threat in Pakistan. Responsible for an alarming number of deaths in recent years, the resistance needs strategic tackling and consistent policies, and their implementation thereafter. The governments, both federal and provincial, need to pay genuine attention to the issues that hinder the progress of NAP and collaborate with key multi-sectoral players and stakeholders to ensure the containment of the resistance before it becomes an impossibility.

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