Antimicrobial resistance in Nepal reaching alarming levels, say experts

 Ampicillin, a medication used to treat typhoid fever caused by the bacterium Salmonella Typhi, has been ineffective as an antibiotic for a long time now.

This prompted doctors to switch to ciprofloxacin, another antibiotic, but this too proved weak in the fight against the disease.

They now prescribe amoxicillin (yet another antibiotic) to typhoid patients. But even the new drug’s effectiveness against the disease has dropped to 15 percent now, according to the National Public Health Laboratory, which regularly carries out sensitivity testing of antibiotics.

Antimicrobial resistance is an issue not only in the treatment of typhoid fever, but in many other health conditions. The irrational use of antimicrobials in humans, animals and plants is leading to a ‘silent pandemic’, public health experts in Nepal have warned.

“Antimicrobials, without which the lives of many people will be at risk, could soon be completely ineffective due to the growing resistance rate,” said Dr Madan Upadhyay, chief of Policy Planning and Monitoring Division at the Ministry of Health and Population. “Even though we say this is a silent pandemic, it is no longer silent and has been causing serious problems in the country.”

The World Health Organisation said antimicrobial resistance happens when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of their spread to others.

Antibiotics, despite being prescription drugs, can be easily purchased over the counter in Nepal. Many people buy them without telling the pharmacists their exact problem. Pharmacists too do not bother to inquire and in most cases fail to emphasise the importance of completing the course of medicine, which is among the main reasons for the growing rate of antimicrobial resistance, according to experts.

Second, most of the time doctors prescribe antibiotics on the basis of clinical diagnosis, even before they get laboratory test reports. Experts say antibiotics do not work if the underlying infection is caused by a virus.

According to a 2021 study of the Nepal Health Research Council (NHRC), only 32 percent of the doctors and health workers have access to laboratories for antibiotic susceptibility testing. Among them, only 49 percent recommend antibiotic susceptibility testing before prescribing antibiotics. This means that only 16 percent of doctors recommend antibiotics after susceptibility testing.

“There is a significant reason for influencing rational prescriptions of antibiotics,” the report stated.

The study also shows that more than one-third—37.8 percent—of prescribed medicines were antibiotics, which is higher than the World Health Organisation’s standards.

The study shows about one-fourth (22 percent) of the outpatients did not consume a full course of antibiotics. Similarly, about 10 percent of the outpatients consume antibiotics as prophylaxis while eight percent take double-dose antibiotics for a quick recovery.

Around 22 percent of them save residual antibiotics for the treatment of similar symptoms in the future. Additionally, around 28 percent of outpatients said they buy antibiotics without doctors’ or health workers’ prescriptions.

The report shows that a significant number of patients do not know that a course of antibiotics must be completed and if they stop halfway, the same antibiotic may not work the next time.

“Every one of us has been affected by the antimicrobial resistance in one way or another,” said Dr Ranjan Bhatta, director at the NPHL. “The problem has become so serious that it has raised both morbidity and mortality rates, not only in our country but throughout the globe.”

While human antibiotic use contributes to antibiotic resistance, the widespread use of antibiotics in agricultural applications—most notably livestock and poultry production—is also a potential driver.

Doctors say agricultural antibiotics contribute to the presence of resistant bacteria in meat and poultry products; in addition, resistant organisms are released from farms into soil, groundwater, and surface waterways, leading to contamination of water sources used for crop irrigation and domestic purposes.

“Farmers often bring samples of dead or sick animals to our labs for tests only after using two-three antibiotics,” said Dr Prerana Sedhain Bhattarai, deputy director general at Animal Quarantine Division. “Use of multiple antibiotics on animals, without actually understanding the disease, is among the chief culprits for antimicrobial resistance.”

The NHRC study showed around 70 percent of farmers used progressively higher doses of antibiotics and more frequently for faster recovery of sick animals or fowls.

The study identified big shortcomings in awareness and availability of national guidelines for prescribing antibiotics and infrastructures for recommending antibiotic susceptibility tests among both human and animal health professionals. 

Mental health experts in Nepal have warned of potential exacerbation of mental health problems in the areas hit hard by Friday night’s earthquake that killed at least 153 in Jajarkot and West Rukum districts.

Experts—psychologists and psychiatrists—have alerted the authorities concerned to the risks and called for timely measures to address them.

“The rise of mental health problems in the aftermath of disasters is an obvious occurrence, not only in Nepal but everywhere,” said Dr Basudev Karki, a consultant psychiatrist at Nepal Mental Hospital. “So the agencies concerned should prepare for it.”

Mental health issues were discussed extensively in the aftermath of the 2015 earthquake that killed around 9,000 people, injured thousands, and displaced hundreds of thousands.

According to a study carried out in the aftermath of the Gorkha earthquake, there was a 34 percent rise in anxiety and depression in the major quake-hit districts—Kathmandu, Gorkha and Sindhupalchok. Similarly, the study found a 20 percent increase in alcohol use and an 11 percent increase in suicidal thoughts among the displaced.

Anger that was out of control was reported by around 34 percent of the respondents. Over five percent of people had elevated rates of posttraumatic stress disorder. The report shows that 42 percent of people reported that ‘distress’ was a serious problem in their community.

“Mental health issues should not be underestimated, especially in the disaster-hit areas, as they can have long-term consequences,” said Karki. “Our own experience shows that mental health problems get worse after disasters—be it after the 2015 earthquake, the Covid pandemic, or the recent Jajarkot earthquake.”

Easing access to counselling services, timely detection of mental health problems, imparting life skills to people, and creating general awareness are some ways to address mental health problems, according to experts.

Health workers serving in quake-hit districts say that coming days will be more challenging, as there will be high risk of an outbreak of communicable diseases, as well as of an increase in non-communicable diseases including mental health problems and respiratory illnesses.

“Even if we are yet to witness serious problems, they are bound to arise in the coming days,” said Pratiksha Bharati, a health worker serving at Health Office Jajarkot. “Many people are in trauma and it will take time for them to recover.”

Doctors say an outbreak of communicable diseases—cold-related ailments and waterborne diseases—is likely in the coming days due to falling temperatures and damaged infrastructure.

Along with houses, toilets were also destroyed in Friday’s earthquake. Officials say the destruction of toilets increases open defecation, which risks contamination of water sources. The risk of spread of vector-borne diseases—malaria, dengue, kala-azar and scrub typhus among others—also increases, according to experts.

Nepal saw a surge in scrub typhus cases after the 2015 earthquakes, which killed nearly 9,000 people. Three months after the twin earthquakes, the BP Koirala Institute of Health Sciences, Dharan had alerted the Epidemiology and Disease Control Division on six cases of children with unusual fever and severe respiratory problems.

Over 4,000 people have been infected with scrub typhus since January this year.

Meanwhile, the Health Ministry officials say that they are aware of possible public health challenges, which could arise in the quake-hit areas in the coming days.

“We have been working to send psycho-social counsellors to affected districts,” said Dr Roshan Pokhrel, secretary at the Health Ministry. “We are also aware of the risk of outbreaks of communicable diseases there.”

 

Arjun Poudel

kathmandupost