By Azrul Mohd Khalib. Published in The Malay Mail Online 26 September 2016

SEPTEMBER 26 — With all the attention placed on Zika infections these past couple of months, it is tempting to think that that virus is the most pressing public health threat currently facing the country.

Viewing images of babies born with congenital microcephaly, a severe birth condition where they have abnormally small heads and underdeveloped brains, to mothers infected with Zika can be particularly emotional even if you are not pregnant. Testing positive for this mosquito-borne virus can be devastating knowing the risk it poses in a pregnancy.

In adults, Zika infections have been linked to causing Guillain-Barré syndrome, a rare neurological disorder where the body’s immune system attacks part of the nervous system.

With hundreds of cases now reported in neighbouring Thailand and Singapore, increasingly numbers of suspected infections in Malaysia and the looming inevitability of local Zika virus transmission, it is not surprising that all hands are on deck to prevent its spread, manage infected cases and deal with the socioeconomic consequences of the epidemic.

However, Zika, actually discovered in 1947, arguably is not as big a threat as the lurking menace which exists in the very places where we seek medical assistance such as in hospitals, clinics and in communities namely the overuse and indiscriminate application of antibiotics for treatment.

The risk of antibiotic resistance has been around since Alexander Fleming scrapped off a sample of that mold he found growing in his petri dish back in 1928. It occurs in nature and is an excellent example of evolutionary biology at work.

Fleming actually recognised this threat during his acceptance of the 1945 Nobel Prize in Physiology or Medicine when he said that “there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

Well, that danger is here. Effective antibiotics have allowed us to live longer, healthier, and benefit from modern medicine. Today, there is an emerging crisis of waves of new strains of antimicrobial resistant bacteria which render existing antibiotics ineffective and useless. Infections have become increasingly irresponsive, or becoming less susceptible to normal treatments, resulting in prolonged illness and greater risk of death.

The approach to disease management has increasingly been forced to use more sophisticated and toxic classes of antibiotics.

The worldwide emergence of methicillin-resistant Staphylococcus aureus (MRSA) back in the 1960s, was certainly a warning shot for what was to come. The increasing incidence and prevalence of MRSA in healthcare and community settings in almost every country in the world since then gives an idea as to the enormity of the task at hand. MRSA is no longer resistant to just methicillin but has become multidrug resistant (MDR) to a wide range of antibiotics, severely limiting treatment options.

People with MRSA are estimated to be 64% more likely to die than people with a non-resistant form of the infection.

The World Health Organisation has already stated its fear of a “post-antibiotic era in which common infections and minor injuries, which have been treatable for decades, can once again kill”. It is sobering to hear from WHO that even a common disease like gonorrhea may become untreatable.

Antibiotic resistance is a growing public health burden where worldwide, drug-resistant infections kill an estimated 700,000 people annually. More people are expected to die each year from drug-resistant infections and related complications. These numbers will certainly outnumber those of Zika, which is non-fatal and with only one in five infected actually becoming sick.

The cost of healthcare will certainly increase as more expensive and stronger classes of antibiotic treatments are required, lengthier hospitalisation and longer-term and more intensive care is needed.

The cause and proliferation of this threat directly related to the rate of antibiotic use in the community can best be understood within the Malaysian context. This country is fast becoming one of the frontlines of this global struggle.

With a culture of prescribing this type of drug for medical conditions remotely linked to a cold or fever coupled with private clinics also acting as dispensaries, problems of excessive, inappropriate and indiscriminate use of broad-spectrum antibiotics are common in Malaysia. Coupled with the proliferate use of antibiotics in livestock production, the environment here is ripe for the spread of this problem.

The result has not only been a steady increase in incidences of antibiotic resistance but also an explosion of diversity in the types being detected.

The National Surveillance on Antibiotic Resistance has indicated that we have almost every variety of antibiotic resistance thus far documented including some which have not yet made an appearance in other parts of the world.

A recent finding by the European Molecular Biology Laboratory detected the presence of a gene (MCR-1) which confers resistance to colistin, an antibiotic known as the drug of “last resort”, in bacterial samples from Malaysia. First discovered among animals, the resistance has already made the interspecies leap to humans. Despite its toxicity, doctors are forced to resort to using colistin as resistance continues to mount. One day, even this drug might no longer be an option.

Unfortunately, there are few new effective antibiotics in the pipeline after colistin. The arsenal of treatment options is steadily depleting, particularly with pharmaceutical companies limiting or stopping their investments in antibiotic innovation.

Recently, news broke of a Malaysian researcher at Melbourne University whose approach to the problem went outside the box. Though years away from commercialisation and public use, her research has the potential of creating a new classification of antimicrobial drugs which could be an alternative to antibiotics.

This is the kind of innovation in cutting edge medical research and development which is desperately needed and should be encouraged and supported.

Malaysia has not been a shrinking violet in participating in crucial clinical trials for new and innovative approaches to disease prevention and management. The government has introduced policies intended to make the country a preferred clinical research destination.

However, what we need to do better is to make available those same innovations once they have been cleared for release and public use. What is the point in participating in clinical trials for innovative and cutting edge drugs and treatment approaches but later deny their use and availability for Malaysian patients?

It is sobering to realise that in the case of antibiotic resistance, the time for us to act was actually yesterday.


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