One Health approach for containment of antimicrobial resistance (AMR) in Bangladesh
With the initiation of this new millennium, one big question is arisen; “Are bacteria more powerful than us?” This question is bringing more questions one after another; “Are antimicrobials a blessing or curse to the human race?” or “Are we bringing our own Armageddon by our own hands?” These questions are piling up in the scientific society for nearly a decade just for one reason; “Antimicrobial Resistance’ or also called as AMR. We humans, thought us to be the supreme species in the earth for centuries, are on the brink of extinction just for this phenomenon unless we come forward right now to stop this. And as the whole human race is facing the aftermath caused by AMR, all the tiniest factions of this race should come forward under the umbrella of ‘One Health’ to fight against this ultimate challenge.
According to ‘World Health Organization’ (WHO), One Health is “an approach to design and implement programs, policies, legislation and research in which multiple sectors will communicate and work together to achieve better public health outcomes.” Though it took decades for different sectors of health to understand the importance of ‘One Health’, the forefather of all physicians, ‘Hippocrates’ promoted his concept of dealing human health along with ensuring environmental health. Our environment is consisting of floras, terrestrial animals, aquatic animals, soil and the sky and their components. These essential elements of the planet earth are not only easing the life of human but also have been harboring millions of other species, from diatoms to dinosaurs, for millennia. One health approach was formulated to ensure food safety, targeting zoonoses and fighting against AMR. Among the three areas of work to implement ‘One Health’ approach, AMR has become such a burning issue which in turn creates an importance to address the UN general assembly in 2016. The Director-General of WHO urged the global leaders to come forward to fight against this disaster quoting it as ‘a slow tsunami’. The magnitude of this problem has already been reflected.
According to the report ‘Antibiotic Resistance Threats in the United States, 2013’ published by CDC (authored by Vaughn et al.), depicts that each year AMR causes 23 thousands expiration of human patients. The magnitude of this problem is much more nerve-racking in the developing countries. There is a forecast of death of 10 million people every year by 2050 if effective measures will not be taken (de Kraker et al., 2016). Among these 10 million peoples, about 90% will be from the underdeveloped countries of Asia and Africa (Sugden et al., 2016). The economic impact of AMR will also break the already fragile economy of these countries. In a report published by Shrestha et al., 2018 showed the cost of AMR caused by only five organisms are about 0.5 billion dollars in Thailand only. So, the AMR will not only kill us but also take out our money which will be necessary to fight against it.
From the inception of One Health, it is working hard to minimize the health threats to the human being. It is a big achievement for the people, that the three leaders of One Health, FAO, WHO and OIE, came in a memorandum to combat health threats to both human and animals. These playmakers of the world have realized that, it is impossible to save ourselves without working together. In May 2018, they prioritized AMR as the global health threats and agreed to work on the surveillance, monitoring and evaluation programs to set up a proper action plan against it. The organisms causing similar types of diseases in livestock and human may be the cause of creating superbugs as both are dependent upon same type of antibiotics. The microbes especially bacteria travels from animal to environment and then to human body or directly to human body and vice versa. Because of having a fantastic genetic mechanism, after each cycle a resistant bacterium produce more resistant bacteria and get spread throughout the whole ecosystem. One Health is working on the baseline survey and researches to find out the route of infection and thus minimizing the sources by which microbes can enter into human or animal body. The FAO/WHO expert meeting on food-borne antimicrobial resistance held in Rome highlighted the relationships between agriculture and AMR. Various studies revealed that about 25% crops are contaminated with bacteria being resistant to one or more antimicrobials (Schwaiger et al.,2011).
More than 80% of the antimicrobials are excreted from the feces and urine to the soil. So that, soil borne bacteria, even very low pathogenic organisms, may become resistant to precious antibiotics. Aquaculture has also been playing a hidden role in AMR. To tackle this various suggestions were given from this meeting to reduce the irrational use of antimicrobials in horticulture and aquaculture and strong quality control of the produce worldwide. In 2015, WHO made it 68 member countries to become “committed to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality assured, used in a responsible way and accessible to all who need them with the adoption of the Global action plan on antimicrobial resistance”. And in the year 2016, it has revised its category of antimicrobials for the human medicine. The OIE with the help of WHO, is encouraging the veterinarians to become rationale to use the antimicrobials. In 2016, OIE made a commitment of its 180 member states to follow the WHO global action plan. This global action plan includes ‘improving awareness and understanding’, ‘strengthening knowledge through surveillance and research’, ‘support good governance and capacity building’ and ‘encourage implementation of international standard’. To execute these plans enormous efforts have been taken in different countries including Bangladesh. Seminars, symposiums and workshops are being taken places focusing the threat of AMR. There is a national alliance called ‘Bangladesh AMR Response Alliance’ or BARA has started its journey focusing on training the both human and veterinary clinicians under same roof for better understanding between this group to work together. This alliance is working on setting up the guideline of use of antimicrobials in different species to minimize irrational use. The directorate-general of drug administration is encouraging doctors to reduce antibiotic use along with pharmacists to sell antibiotics only to the prescribed clients. These all approaches are initiated with the utmost encouragements of One Health approach.
Along with the ongoing approaches, newer strategies are required to combat this destructive hazard for the safe living of all living species, except pathogenic organisms. The key sectors, e.g. human health, animal health and production, agriculture and environmentalists should create updated plan to ensure global action plan of WHO. The human doctors can prescribe the antimicrobials in generic form rather than in trade names. The drug administration may set up hospital base pharmacies for the antibiotics of ‘highest priority’ list. Sudden surveillances can be done in the pharmaceuticals factories to ensure the quality of the antibiotics. Illegal import and export of the antibiotics should be stopped. All the animal and fish feed and growth promoters should go through rigorous scanning in the labs to ensure zero residues of antimicrobials. Animal and fish wastes should be treated to minimize the risk of contaminating the greens. The animal wastes can used only in the forage produced for animal feed. The milk of dam, being treated with antimicrobials, can only be given to the calves to stop human consumption. The vegetables and fruits which are eaten raw should not be produced in the vicinity of the animal farms. Extensive trainings should be provided to the farmers and other stakeholders to encourage them to minimize the antibiotic uses. Drug companies should be encouraged for the research of newer antibiotics and alternative drugs. These approaches can be taken all over the world.
Bangladesh, being an over populated country, is in serious threat of AMR. Hopefully the literacy rate is increasing day by day. So, knowledge on one health can be disseminated among the students as they are going to be future leaders. Compulsory courses can be introduced in the MBBS, DVM, BSc in AH and other courses related to agriculture, pharmacy and environmental sciences. The lessons on AMR can be introduced in the primary and high school syllabus. Mass media should be involved to en-light the general people about this issue.
In the eve of world war two, the invention of penicillin; the first antibiotic, saved a lot of people from pre mature death. Now at this 21st century, we all have to come forward to fight a new war against AMR to save our human race from extinction caused by tiny yet powerful superbugs. According to Hellen Keller, ‘Alone we can do so little; together we can do so much.’ This is the penultimate time to work together for the containment of antimicrobial resistance. And to do that, we all have to come under the umbrella of ‘One Health’ and act whole-heartedly.
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