Wholesale Supply Data of Antibiotics in Hong Kong

(2014 – 2016)

April 2018

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Background – Antibiotics

▪ Medicines for treatment and prevention of bacterial infections in human and animals, including life-threatening bacterial infections

▪ Also used in food production industry to treat infections in animals to ensure a sustainable food supply

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Background – Examples of antibiotics

▪ Beta-lactam penicillins

▪ e.g. amoxicillin for acute Streptococcal pharyngitis

▪ Macrolides

▪ e.g. erythromycin for atypical pneumonia

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Background – Antimicrobial Resistance (AMR)

▪ AMR occurs when bacteria change in ways that render the medications used to cure the infections they cause ineffective

▪ AMR is a natural process, but overuse and misuse of antibiotics (such as using antibiotics to treat viral infections) is accelerating the development of AMR

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Background – Threats of AMR (1)

▪ AMR is one of the biggest threats to global health, food security, and sustainable development

▪ Infections caused by resistant bacteria:

▪ Often last longer

▪ Can cause more severe illness

▪ Require more doctor visits or longer hospital stays

▪ Involve medication that is more expensive and with more side effects

▪ Can cause more death

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Background – Threats of AMR (2)

▪ AMR leads to about 700,000 deaths each year globally

▪ If no effective strategies are put in place, this death toll will exceed 10 million each year by 2050, i.e. one person every 3 seconds

Source: O’Neill J. Tackling drug-resistant infections globally; final report and recommendations. UK: Wellcome Trust and UK Government; 2016.

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Background

▪ HKSAR Government attaches great importance to the threat of AMR and has set out strategic actions in the Hong Kong Strategy and Action Plan on Antimicrobial Resistance to combat the problem

▪ Monitoring antibiotics usage is one of the strategic actions to provide important information

▪ Currently there is no mechanism to obtain territory-wide antibiotics usage data

▪ Indirect indictors such as wholesale supply data of antibiotics may serve as a proxy to reflect the usage

Wholesale Supply Data of Antibiotics

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Wholesale Supply of Antibiotics

▪ Under the law of HK, certain qualified persons are allowed to sell and supply antibiotics:

▪ Registered medical practitioners

▪ Registered dentists

▪ Registered veterinary surgeons

▪ Public and private hospitals

▪ Community pharmacies

▪ Farmers with Antibiotics Permit (to possess only)

▪ Licensed wholesalers with Antibiotics Permit

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Use of Wholesale Supply Data

▪ The Department of Health collected wholesale supply data (2014 – 2016) reported by the licensed wholesalers through standardised questionnaire

▪ Can capture antibiotics supplied to qualified persons in HK that serves as a proxy to reflect the overall antibiotics use in HK

▪ Both imported and local manufactured products were included

▪ Non-registered drugs which are procured and used through name-patient basis could not be captured

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Sectors being Supplied with Antibiotics

Sectors being supplied with antibiotics from the licensed wholesalers were categorised into the following 8 groups:

1. Department of Health

2. Hospital Authority

3. Private hospitals

4. Private doctors (mutually exclusive with private hospitals)

5. Registered Dentists

6. Veterinary surgeons

7. Community pharmacies

8. Farmers

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Classification of Antibiotics

▪ Antibiotics are generally classified according to their chemical properties and therapeutic features

▪ This exercise adopted the Anatomical Therapeutic Chemical Classification System* used by the World Health Organization (WHO) for drug utilisation monitoring and research

*Drugs belonging to Group J01 – Antibacterials for Systemic Use were included

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Classification of Antibiotics

Code Classes of antibiotics J01A Tetracyclines J01B Amphenicols J01C Beta-lactam Antibacterials, Penicillins J01D Other Beta-lactam Antibacterials J01E Sulfonamides and Trimethoprim J01F Macrolides, Lincosamines and Streptogramins J01G Aminoglycoside Antibacterials J01M Quinolone Antibacterials J01R Combinations of Antibacterials* J01X Other Antibacterials Code J01, Antibacterials for Systemic Use, Anatomical Therapeutic Chemical (ATC) Classification System, World Health Organization

* There was no registered product under “Combinations of Antibacterials” (J01R) in HK

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Broad Spectrum Antibiotics

Some locally-important broad spectrum antibiotics

▪ Antibiotics with a broad spectrum of coverage are reserved for treating infections caused by resistant bacteria

▪ Some are even recognised as last resort antibiotics for treating resistant bacterial infections

▪ Examples: carbapenems, colistin

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Examples of Broad Spectrum Antibiotics

Some locally-important broad

spectrum antibiotics

ATC Group

Piperacillin with tazobactam Beta-lactam Antibacterials, Penicillins

(J01C)

Cefepime

Other Beta-lactam Antibacterials

(J01D)

Cefoperazone with sulbactam

Ceftazidime

Imipenem with cilastatin

Meropenem

Colistin

Other Antibacterials (J01X)

Daptomycin

Linezolid

Teicoplanin

Vancomycin

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Quantification of Antibiotic Usage

Defined Daily Dose (DDD)

▪ Defined as the assumed average maintenance dose per day for a drug used for its main indication in adults

▪ Commonly used across many overseas health authorities for comparison of drug usage

DDD per 1,000 inhabitants per day (DID)

▪ A standardised unit used internationally to measure antibiotic use among population

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Results – Total Wholesale Supply

▪ The wholesale supply of antibiotics in 2014 – 2016 (human use only) were:

▪ The trend is increasing with an increase by 1.8% (0.39 DID) from 2014 to 2015 and 4.9% (1.11 DID) from 2015 to 2016

Year 2014 2015 2016

Total Wholesale Supply of antibiotics (DID) 22.24 22.63 23.74

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Results – by Classes of Antibiotics (1)

▪ The top 3 classes of antibiotics with highest volume of wholesale supply in 2014 – 2016 were: “beta-lactam penicillins” (11.1 – 11.9 DID); “macrolides, lincosamines and streptogramins” (2.9 – 3.3 DID) and “other beta-lactam antibacterials” (2.9 – 3.0 DID)

▪ They accounted for 76 – 77% of the overall antibiotics being supplied to human in HK in 2014 – 2016

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Results – by Classes of Antibiotics (2)

* There was no registered product under “Combinations of Antibacterials” (J01R) in HK Wholesale supply data of antibiotics to farmers and veterinary surgeons were excluded.

Total wholesale supply of antibiotics in HK by classes of antibiotics (2014 – 2016)

ATC Group

Total amount of supply (DID)

2014 2015 2016

DID % DID % DID %

J01A Tetracyclines 2.1 9.6 2.0 9.0 2.1 8.7

J01B Amphenicols <0.05 <0.05 <0.05 <0.05 <0.05 <0.05

J01C Beta-lactam antibacterials, penicillins 11.1 49.9 11.4 50.2 11.9 50.2

J01D Other beta-lactam antibacterials 2.9 12.9 3.0 13.5 3.0 12.8

J01E Sulfonamides and trimethoprim 0.2 1.1 0.2 1.0 0.2 0.9

J01F Macrolides, lincosamides and streptogramins 2.9 13.2 2.9 12.9 3.3 14.0

J01G Aminoglycoside antibacterials <0.05 0.2 <0.05 0.2 <0.05 0.2

J01M Quinolone antibacterials 2.2 9.8 2.3 10.1 2.4 10.2

J01R Combinations of antibacterials* - - - - - -

J01X Other antibacterials 0.7 3.3 0.7 3.1 0.7 3.0

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Results – Supply of Broad Spectrum Antibiotics (1)

▪ The 11 locally-important broad spectrum antibiotics only accounted for 0.94 – 1.11% of the total wholesale supply in 2014 – 2016

▪ Most (99.2 – 99.4%) were supplied to hospitals

▪ The top 3 locally-important broad spectrum antibiotics with highest volume of wholesale supply were piperacillin with tazobactam (0.0891 – 0.1138 DID), meropenem (0.0521 – 0.0698 DID) and vancomycin (0.0285 – 0.0354 DID)

▪ These 3 accounted for less than 1% (0.76 – 0.92%) of the total wholesale supply in 2014 – 2016 only

▪ The rest accounted for less than 0.2% of total wholesale supply in 2014 – 2016

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Results – Supply of Broad Spectrum Antibiotics (2)

▪ Among top 3 locally-important broad spectrum antibiotics with highest volume of wholesale supply, there were increasing trend of supply from 2014 to 2016

Top 3 locally-important broad spectrum antibiotics

Change in Wholesale Supply 2014 – 15 2015 – 16

Piperacillin and Tazobactam 0.0163 DID (18.3%) 0.0084 DID (7.9%) Meropenem 0.0073 DID (14.0%) 0.0104 DID (17.5%) Vancomycin -0.0003 DID (-1.2%) 0.0073 DID (26.0%)

Private Doctors 51.9%

Hospital Authority

21.4%

Farmer 0.0%

Dentists 1.6%

Community Pharmacies

18.2%

Veterinary surgeons

1.1%

Private Hospitals

4.8% Department of Health

1.0%

2014 59.5M DDD

Private Doctors 51.5%

Hospital Authority

20.8%

Farmer 0.0%

Dentists 1.8%

Community Pharmacies

18.6%

Veterinary surgeons

1.2%

Private Hospitals

5.3% Department of Health

1.0%

2015 61.1M DDD

Private Doctors 51.4%

Hospital Authority

21.0%

Farmer 0.0%

Dentists 2.0%

Community Pharmacies

18.3%

Veterinary surgeons

1.1%

Private Hospitals

5.3%

Department of Health

0.9%

2016 64.7M DDD

Wholesale data cannot tell the appropriateness of antimicrobial use (AMU) by different sectors as there is no information on the casemix and load they have encountered.

▪ The top 3 sectors supplied with the largest proportion of overall antibiotics in 2014 – 2016 were private doctors (51.4 – 51.9%), Hospital Authority (20.8 – 21.4%) and community pharmacies (18.2 – 18.6%)

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Results – Among Different Sectors (1)

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Results – Among Different Sectors (2)

▪ Excluding those supplied to veterinary surgeons and farmers, antibiotics supplied to various sectors for human use is as follow:-

Sectors Wholesale Supply of Antibiotics (DID)

2014 2015 2016 Private Doctors 11.68 11.79 12.34 Community Pharmacies 4.09 4.25 4.39 Dentists 0.35 0.40 0.49 Department of Health 0.23 0.22 0.21

Sub-total (a) 16.35 16.67 17.42 Hospital Authority 4.81 4.76 5.04 Private Hospitals 1.08 1.20 1.28

Sub-total (b) 5.90 5.96 6.32 (a) This figure only largely reflects the antibiotics supplied to the community setting as the antibiotics supplied to the

clinics of hospitals should also be counted as used in the community setting but is not reflected here. (b) Since this figure includes antibiotics supplied to clinics of public and private hospitals, which should be included as

for community setting, this is likely to be an overestimation.

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Summary (1)

▪ The total wholesale supply of antibiotics in HK has increased slightly from 2014 to 2016

▪ Comparison of data with overseas countries would be difficult as they use different methodologies to collect antibiotics usage or supply information

▪ Direct comparison of data among different countries should be interpreted with caution or it can be misleading

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Summary (2)

▪ The top 3 most supplied antibiotics were: i) beta-lactam penicillins; ii) macrolides, lincosamines and streptogramins and iii) other beta-lactam antibacterial. They are:

▪ For treating common bacterial infections & usually prescribed as first-line treatment if bacterial infections are suspected

▪ Used in both community and hospitals

▪ Wholesale supply of the 11 locally-important broad spectrum antibiotics only accounted for a very small proportion (0.94 – 1.11%) of the total supply in HK

▪ Majority of them were supplied to Hospital Authority and private hospitals

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Summary (3)

▪ Private doctors, Hospital Authority and community pharmacies were the 3 sectors supplied with the highest volume of antibiotics in HK in 2014 – 2016

▪ As private doctors and Hospital Authority are the major sectors providing health services in the community and hospital settings in HK respectively, they were supplied with the largest amount of antibiotics. This observation is not unexpected

▪ There was about 18% of total antibiotics supplied to community pharmacies. The Department of Health has been closely monitoring the situation

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Limitations

▪ Wholesale supply data only provides indirect information to reflect antibiotics use but it is never equal to dispensing or consumption data

▪ Whether the use of antibiotics is appropriate depends on the clinical situation. Wholesale supply data contains no information to reflect the appropriateness of the use

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Follow-up Actions

▪ Health education and promotion

▪ Enforcement and regulations

▪ Surveillance

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Health education and promotion (1)

Public Education

▪ The Department of Health has launched a series of publicity campaigns to advocate appropriate use of antibiotics through different media

More information can be accessed at the Centre for Health Protection webpage: https://www.chp.gov.hk/en/index.html

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Health education and promotion (2)

Standards and Guidelines

▪ The Interhospital Multi-disciplinary Programme on Antimicrobial Chemotherapy (IMPACT) has been updated to promote proper use of antibiotics in hospitals

▪ The Department of Health has launched the Antibiotic Stewardship Programme in Primary Care to promote prudent use of antibiotics in the community

More information can be accessed at the Centre for Health Protection webpage: https://www.chp.gov.hk/en/index.html

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Enforcement and Regulations

▪ In HK, sale and supply of antibiotics are regulated under Antibiotics Ordinance, and Pharmacy and Poisons Ordinance

▪ Community pharmacies can only sell antibiotics to customers with a valid prescription

▪ Illegal sale of antibiotics is a criminal offence. The maximum penalty is a fine of $30,000 and 12 months of imprisonment

▪ The Department of Health has reminded community pharmacies regarding compliance with the law, and stepped up enforcement actions against illegal sales of antibiotics

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Surveillance

▪ Wholesale data can provide part of the information of overall AMR situation in HK only

▪ In joint effort with other government departments and organisations, the Department of Health will initiate other surveillance activities to provide a more comprehensive picture on the overall AMR situation in HK

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Advices to Public

▪ Do not purchase antibiotics without a prescription

▪ Do not request antibiotics from your doctor

▪ Follow your doctor’s advice when taking antibiotics

▪ To prevent AMR, maintaining personal hygiene and receiving up-to-date vaccination are equally important

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Advices to Community Pharmacies

▪ Only supply antibiotics in accordance with the law

▪ Illegal sale of antibiotics is a criminal offence

▪ e.g. supply of prescription antibiotics to the general public without the authorisation of a prescription

▪ The maximum penalty is a fine of $30,000 and 12 months of imprisonment

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Advices to Healthcare Workers

▪ Antibiotics are precious resources against infections. Healthcare workers play an essential role in preserving them:

▪ Continue to prescribe antibiotics in accordance with therapeutic guidelines in consideration of clinical situations

▪ Discuss with your patients about the importance of appropriate antibiotic use and the dangers of AMR

▪ Apply best practice of infection prevention and control

▪ Educate patients about how to prevent infections and their spread

▪ e.g. vaccination, maintain personal hygiene and hand hygiene

THE END