donna kusemererwa
DESCRIPTION
http://www.cddep.org/sites/default/files/donna_kusemererwa.pdfTRANSCRIPT
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Reflections from GARP Phase 1 Kenya
Donna Kusemererwa Executive Director, Ecumenical Pharmaceutical Network
Member, GARP-Kenya Working Group
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Overview
• Background • GARP-Kenya contributions • Recommendations • Challenges
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BACKGROUND
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Antibiotic Resistance Knowledge Base
• Antibiotic overuse in some settings, yet little or no access in others, especially rural and remote places
• No clear picture of the extent of antibiotic resistance: glimpses from occasional hospital-specific studies
• Strong suspicion that patient treatment was being adversely affected by resistance: high treatment failure rates in ICUs and HDUs, prolonged hospitalizations
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Mortality in Kenyan Children Under 5 Years (2000-2003)
Source: World Health Organization. Kenya: Country Health System Fact Sheet 2006,
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Antibiotic Resistance in Kenya
Source: Kenya Situation Analysis
0
10
20
30
40
50
60
70
80
90
100
do
xy
pe
n (
2003
)
co
trim
(20
02-2
003)
co
trim
am
p
ch
lor
co
trim
tet
am
p
co
trim
am
p
co
trim
am
p
co
trim
tet
ch
lor
S. pneumoniae H. influenzae
type b (2003)
Shigella (2003) non-typhoid Salmonella
(2005)
S. Typhi (2008) E. coli (2005)
Resi
sta
nce
(%
)
Antibiotic, by pathogen Source: Kenya Situation Analysis
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Knowledge Gaps • Almost nothing known about antibiotic
resistance in the community • What drives antibiotic prescribing? UNKNOWN! • Antibiotic treatment guidelines: how are they
used and how effective they in patient treatment? UNKNOWN!
• Staff in many hospitals lack access to guidelines, even if they know about their existence
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Comparison of S. aureus isolates that are MRSA in Kenya
(2001, 2006) and other geographical regions (2007)
Sources: Vincent, J.-L., J. Rello, et al. (2009); Kenya Situation Analysis; Andhoga J., et. al (2002).
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Antibiotic Use in Animals
• Lack of information about how and what antibiotics were being used by farmers raising cattle, pigs, chickens.
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Staphylococcus aureus in Milk Samples: Resistance to Antibiotics (2001-2002)
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Penicillin
G
Tetra
cyclin
e
Chlora
mphenic
ol
Eryth
rom
ycin
Multi-
drug
Resi
sta
nce
Ra
te
Antibiotics
Large Farms
Small Farms
Source: Shitandi, A. and A. Sternesjo. (2004)
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GARP-KENYA CONTRIBUTIONS
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Situation Analysis and Recommendations
. Released August 2011
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1. Survey on Perception of Antibiotic Resistance and Use in District Hospitals
• Antibiotic prices, pro!tability to supplier, affordability to patient or consumer
• Volumes of antibiotics purchased by hospitals
• Knowledge and perceptions of health workers in hospitals
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Results
• Antibiotic resistance is a serious national problem…but not in my hospital
• Antibiotic shortages are common, especially outside of Nairobi
• Perception that infection control is adequate: may not equate with reality
• Medicines and therapeutics committees: private and faith-based hospitals have been ‘less enthusiastic’ than have public hospitals
• Treatment guidelines welcome if available
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2. Antiobiotic Use and Resistant Bacteria in Food Animals
Two part pilot study:
• Knowledge, attitude and perceptions of prescribers and users of antimicrobials (livestock farmers, vets): which antibiotics they use, how often and why
• Resistance pro!les for common bacterial pathogens from livestock
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Findings: Interviews • >80% of farmers gave antibiotics without veterinary
supervision • Most frequently used: tetracyclines, sulfonamides,
penicillins, streptomycins • Lack of access to veterinary professionals, especially in
arid and semi-arid regions (cattle raising areas) • Vaccines provided by government reduced antibiotic use
AND antibiotics provided by NGOs increased use • Government rules for antibiotic use had little impact BUT
antibiotic residues better controlled in animals raised for export
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Findings: Laboratory • Signi!cant antibiotic resistance across the three livestock
production systems • 10-15% bacteria from beef cattle and poultry production
systems: resistant to 3 or more of 11 antibiotics tested; 15% pig samples resistant to 4 or more of antibiotics tested
• Most commonly used antibiotic classes also recorded the highest number of resistant bacteria: § tetracyclines, penicillins, sulfonamides and
streptomycins And has led to funding of continuing surveillance by FAO
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Number of bacteria resistant to various classes of antibiotics
0
10
20
30
40
50
60
70
Penic
illins
Stre
ptom
ycins
Sulfo
namid
es
Tetra
cyclin
es
Quinolo
nes
Nu
mb
er
of s
am
ple
s re
sist
an
t (n
)
Class of antibiotics
Pig (n=8)
Beef cattle (n=42)
Chicken (n=20)
Total (n=70)† †Is the sum of intermediately sensitive and resistant samples
Source: Laboratory data
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RECOMMENDATIONS
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General Areas of Focus
• surveillance and monitoring • training and education • vaccination • quality control and supply chain
improvements • veterinary use of antibiotics
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Specific: Critical Paths for Policy Actions
HOSPITAL INFECTION CONTROL • An agenda for the National Infection Prevention
and Control (IPC) Secretariat, within the Ministries of Health § Determine current IPC activities in all hospitals § Collect speci!c information on antibiotic use
regularly
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Critical Paths [2]
VETERINARY • Fast-track Veterinary Poisons and Medicines bill
to provide legal mandate for further action Future steps • Surveillance • Education and training • Supply chain and quality assurance
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Critical Paths [3]
ANTIBIOTIC USE GUIDELINES • Experts and stakeholders
§ Pharmacists, microbiologists and clinical specialists from professional bodies, Ministry of Health regulatory bodies, private sector, consumer society and relevant NGOs.
• Annual production of national antibiotic use guidelines • Antibiotic guideline review in professional medical journal • Pocket guideline distribution to all hospitals • Repeat annually!
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Challenges
• Expanding the GARP circle within Kenya: getting the word out about antibiotic access and resistance
• Sustainability of activities recommended/started (e.g., surveillance): interest and resources
• Conflicting interests among key players in antibiotic procurement, distribution, sale and use
• Taking advantage of GARP as a global partnership
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Acknowledgments
• KEMRI • University of Nairobi • Ministry of Public Health and Sanitation • Global Antibiotic Resistance Partnership