«The GARP-Tanzania Working Group Said Aboud, MD, PhD, Chairman Robinson Mdegela, BVSc, PhD, Vice-chairman June 2015 1 GARP TANZANIA WORKING GROUP Said ...»
Antibiotic Use and Resistance in Tanzania
The GARP-Tanzania Working Group
Said Aboud, MD, PhD, Chairman
Robinson Mdegela, BVSc, PhD, Vice-chairman
GARP TANZANIA WORKING GROUP
Said Aboud, MD, PhD, Chairman, Associate Professor of Microbiology and Immunology, Muhimbili
University of Health and Allied Sciences (MUHAS)
Robinson Mdegela, BVSc, PhD, Vice-chairman, Professor of Veterinary Medicine, Sokoine University of Agriculture (SUA) Pastory Dulla, DVM, PGD PM, Vice chairman, Veterinary Council of Tanzania, Chairman Veterinary Pharmaceutical Committee, Ministry of Fisheries and Livestock Development Abdu Hayghaimo, BVSc, MVM, Director of Veterinary Services, Ministry of Livestock and Fisheries Development Dominick Kambarage, BVSc, PhD, Professor of Veterinary Medicine and Vice Chancellor, Julius Nyerere University of Agriculture Rudovick Kazwala, BVSc, PhD, Professor of Veterinary Medicine and Public Health, SUA Jaffary Liana, B.Pharm, Senior technical advisor and local project lead for the Sustainable Drug Seller Initiative (SDSI) program, MSH Siana Mapunjo, B.Pharm, Principal Pharmacist, Ministry of Health and Social Welfare Mary Masanja, B.Pharm, M.Ed, Drug registration, Tanzania Food and Drugs Authority (TFDA) Doreen Mloka, MSc, PhD, Lecturer, Pharmaceutical Microbiology, MUHAS Fausta Mosha, MD, PhD, Director, National Health Laboratory Quality Assurance and Training Centre (NHLQATC) Stephen Mshana, MD, PhD, Associate Professor of Microbiology and Immunology, Catholic University of Health and Allied Sciences Hamisi Nikuli, Cert. Animal Health and Production, MVSc, Coordinator Aquatic Animal and Public Health, Ministry of Livestock and Fisheries Development Balthazar Nyombi, PhD, Senior Laboratory Scientist, Kilimanjaro Christian Medical Centre (KCMC) Eva Ombaka, B.Pharm, PhD, St. John University Meshack Shimwela, MD, MMED, Medical Officer in Charge, Amana Regional Referral Hospital Richard Silumbe, B.Pharm, M.Sc. Pharmaceutical Management, PGD M&E, ADDO Program Coordinator, Pharmacy Council Longinus Tegulirwa, B.Sc, M.Sc. environmental science, Fisheries Health Specialist, Ministry of Livestock and Fisheries Development Edda Vuhahula, DDS, PhD, Senior Lecturer, Department of Pathology, MUHAS i
OTHER CONTRIBUTORSHezron Nonga, PhD, Senior Lecturer, Department of Veterinary Medicine and Public Health, SUA Abdul Katakweba, PhD, Senior Research Scientist, Pest Management Center, SUA
GARP-TANZANIA STAFFKhadija Msami, MD, GARP-Tanzania country coordinator and Medical Officer, Ocean Road Cancer Institute GARP SECRETARIAT: Center for Disease Dynamics, Economics & Policy (CDDEP) Aleefia Somji, GARP- Tanzania Country Coordinator (until August 2013) Hellen Gelband, GARP Global Coordinator, Associate Director, CDDEP
ACKNOWLEDGEMENTSWe would like to acknowledge Dr. Eliudi Eliakimu of the Ministry of Health and Social Welfare Quality Assurance Department for the invaluable information given when consulted. Additional consultation was sought and kindly imparted by Dr. Albert Komba of JHPIEGO and Mr. Jacob Lusekelo of NHLQATC.
Recommended citation: Global Antibiotic Resistance Partnership—Tanzania Working Group. 2015.
Situation Analysis and Recommendations: Antibiotic Use and Resistance in Tanzania. Washington, DC and New Delhi: Center for Disease Dynamics, Economics & Policy.
ii Table of Contents Page PREFACE
CHAPTER 1: EXECUTIVE SUMMARY
Burden of Bacterial infections and their resistance rates
factors affecting antiBiotic resistance and remedial measures
current activities with relevance to antiBiotic resistance and use
CHAPTER 2: POPULATION AND HEALTH BACKGROUND
availability of and accESS to ESSEntial mEdicinES
GovErnmEnt PolicES and tHE rEGulatory EnvironmEnt
food animal contribution to tHE Economy
GovErnmEnt PoliciES and rEGulatory EnvironmEnt
CHAPTER 3: BURDEN OF DISEASE AND ANTIBIOTIC RESISTANCE INHUMANS
national burdEn of diSEaSE
Bacterial Diseases in Humans anD tHeir resistance rates
SurvEillancE for bactErial infEctionS
CHAPTER 4: BURDEN OF DISEASE AND ANTIBIOTIC RESISTANCE INFOOD ANIMALS
national disease Burden
Bacterial Disease in FarmeD animals
animal disease surveillance
CHAPTER 5: ANTIBIOTIC USE AND SUPPLY CHAIN MANAGEMENT
antiBiotic use in Human HealtH
antiBiotic supply cHain
antiBiotic use in animals
antiBiotic supply cHain
iii Preface Antibiotics and other antimicrobial agents are invaluable life savers, particularly in resource-limited countries where infectious diseases are abundant. Both uncomplicated and severe infections are potentially curable as long as the aetiological agents are susceptible to the antimicrobial drugs. The rapid rate with which antimicrobial agents are becoming ineffective due to resistance acquired as a result of unchecked overuse and misuse threatens to undo the benefit of controlling infections. The evidence for resistant microorganisms, many times to more than a single antimicrobial agent, has been observed globally. In Tanzania, there is evidence in the form of few scattered studies conducted in different parts of the country in a multitude of settings including health care facilities, the community, domesticated animals and wild animals. The (multi-) resistant organisms observed in animals and animal products are passed on to even antibiotic naïve individuals through consumption of meat, milk and other animal products. This contributes to the steep decline towards ineffective antibiotics, a situation that can be likened to a siren that is getting progressively louder.
Conversely, access to high quality, life-saving antibiotics has remained a challenge and the need to institute control to conserve the power of antibiotics must not be misconstrued as an obstacle to access. We need to reach a balance where on one hand antibiotics are optimally available versus limiting access to unwarranted use on the other hand.
Several initiatives are part of an international response to the global health threat of AMR, which are having a ripple effect in low-and middle-income countries. This situation analysis is a locally generated report with proposed recommendations for immediate and long-term action plans. Prior to its development, the evidence had never been consolidated to give a summary picture of what is known of the entire country’s antibiotic use and resistance status, both in the humans and animals. With the policy recommendations and areas of focus discussed, there is an urgent call for a coordinated response. Changing the status quo on irrational use of antibiotics among humans and their animal counterparts is a tangible road map towards the judicious use of antibiotics in Tanzania.
Some of the recommended changes may cause upheavals in what are accepted standard procedures and may be met with resistance. Hospital managers may not appreciate the added constraints on the budget that antibiotic stewardship may entail during the start-up of such a program. Some antagonism may be felt from drug outlets that profit from dispensing prescription-only as over-the-counter drugs. Patients may also offer some resistance due to the belief that treatment is incomplete without an antibiotic prescription. Farmers may be highly opposed to reducing antibiotics use in their livestock.
These anticipated reactions result from a prevailing lack of knowledge—which this report should start to remedy—and reluctance of those who should know better. With this report and further work, policies that will fill the current gaps can be developed and enforced. The GARP-Tanzania working group will continue to champion this noble cause by allocating technical and other expertise in meeting various milestones to mitigate the current AMR problem. We welcome ideas, comments and collaboration in this effort.
Said Aboud, MD, PhD Associate Professor and Chairman, GARP Tanzania Working Group iv
Executive Summary Antibiotics are the ‘miracle drugs’ of the 20th century. They made possible great progress in turning many bacterial infections into illnesses rather than death sentences. Along with vaccines, they have transformed death in infancy and childhood from an ever-present danger into a rare event. Remarkably, Alexander Fleming, who discovered penicillin, warned of resistance in the 1930s. He made what may have been the first plea for antibiotic stewardship—use penicillin only when necessary and do not ‘under-dose’.
Unfortunately, the world has used penicillin and the rest of the available antibiotics, developed mainly in the 1940s and 1950s, at an ever-increasing rate, both when they are needed and when they are not, in human beings and other animals. The result is that today many antibiotics have lost their effectiveness against common bacterial infections and antibiotic resistance continues to increase in most countries before it has even been recognized as a major problem.
Antibiotic resistance is no longer a concern for the distant future but is a pressing issue, both globally and in Tanzania. Data on antibiotic resistance in Tanzania is scarce, but even in the 1990s, resistance to antibiotics in common use, such as ampicillin, tetracycline and trimethoprim-sulfamethoxazole, was significant. As part of global effort to preserve the effectiveness of antibiotics, the Global Antibiotic Resistance Partnership (GARP)-Tanzania aims to develop policy recommendations to govern prudent use of antibiotics. This situation analysis is a first step, creating a baseline for what is known and identifying the important information gaps to be addressed in order to create responsible and effective recommendations for policymakers to consider.
The aim is not to withhold antibiotics when they can save lives and health. Ample evidence—in the form of infant and child deaths from pneumonia—warns that many people have no access. The aim is to eliminate as much inappropriate use as possible and increase access where it is inadequate.
About GARP Antibiotic resistance is a shared global concern, but the problems and solutions have strong local components. Progress against the problem is best made when national experts collaborate to understand all aspects of antibiotic access, use and resistance within their own country context, and then work to craft policy solutions tailored to meet their own needs. With the press of other health issues capturing most global attention—HIV/AIDS, tuberculosis, malaria, malnutrition and epidemics—few low- and middleincome countries had yet recognized antibiotic resistance, though certain scientists, clinicians and public health specialists in every country were aware of and concerned about it.
This was the reason for establishing the GARP, which is a project of the Center for Disease Dynamics, Economics & Policy (CDDEP), a non-profit research and policy organization with offices in Washington, DC and New Delhi. GARP is funded by the Bill & Melinda Gates Foundation. GARP creates conditions that enable local experts to occupy the multidisciplinary space to understand local conditions and identify policy opportunities related to antibiotics, especially (but not limited to) those affecting antibiotic resistance.
GARP began in 2008, in Kenya, India, South Africa and Vietnam, where working groups continue to develop a deeper understanding of antibiotic issues and have become trusted sources of information for all sectors. Those groups have become largely independent of CDDEP for financial support, but continue to collaborate and form a brain trust for the newer partners. After a successful 3-year phase, culminating with a major international conference, the 1st Global Forum on Bacterial Infections, held in New Delhi in October 2011, the Gates Foundation supported establishing GARP in a second group of countries: in addition to Tanzania, Nepal, Mozambique, and Uganda.
1Burden of Bacterial Infections and their Resistance Rates
HUMANS HIV/AIDS, malaria, lower respiratory infections (pneumonia) and diarrheal diseases are the top four diseases contributing to illness and death in Tanzania (Institute for Health Metrics and Evaluation, 2012).
Of these four, bacterial pneumonia and a minority of diarrheal infections are the only ones requiring antibiotics for treatment, yet antibiotics are often prescribed (both by healthcare workers and by patients themselves) for all of them. This indicates an opportunity for reducing antibiotic use by both reducing the burden of infections and by sensitizing healthcare workers and the public about when antibiotics are needed and when they are not.
These top four categories of disease, along with bloodstream infections (including typhoid, sepsis, meningitis and bacteremia), urinary tract infections, sexually transmitted infections (gonorrhea and other bacterial infections), and healthcare-associated infections (such as methicillin-resistant Staphylococcus aureus or MRSA) are important in not only understanding the range of bacterial infections, but also for understanding contexts in which antibiotics are prescribed.
Tuberculosis is also a major infection that contributes to the growth of antibiotic resistance (via multidrug resistant tuberculosis, MDR-TB, and rarely, extensively drug resistant tuberculosis, XDR-TB); however, Tanzania has managed to maintain low prevalence rates for MDR-TB. For TB cases in general, the average rate of increase was 2 percent in the 2000s, a dramatic improvement from the average 10 percent increase in the 1990s. These rates indicate that efforts from the national TB control program have possibly helped maintain such low prevalence for both TB and MDR-TB (NTLP manual sixth edition, 2013).