Will drug resistance become pandemic?

Jasson Urbach | 05 Apr 2014
Saturday Star
The rising trend of resistance to pharmaceuticals is one of the most important and worrying topics raised at the 16th International Congress on Infectious Diseases (ICID) currently underway in Cape Town. With no sign of any new drugs becoming available, increasing wide-spread resistance to existing drugs has the potential to relegate humanity back to an era not experienced in decades. 

Discussions at the ICID are highlighting such critical threats as the rise of antimicrobial resistance. With repeated exposure, germs develop a resistance to antimicrobials so that they become no longer effective in treating particular illnesses. Resistant organisms, which include bacteria, fungi, viruses and some parasites, are able to withstand attacks by antimicrobial medicines, such as antibiotics, antifungals, antivirals, and antimalarials, so that treatments then prove ineffective and infections persist.

The evolution of resistant strains is a natural process that occurs when microorganisms are exposed to antimicrobial drugs. Misuse of antimicrobial medicines accelerates this phenomenon. Every time a person or animal takes antibiotics, sensitive bacteria are killed, but some resistant germs may survive to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria. Antibiotics should be used to treat bacterial infections only, since they are not effective against viral infections like the common cold and the flu. The prevalence of fake and substandard drugs also raises the probability of resistance emerging to good quality drugs.

It is essential to differentiate between fake and sub-standard drugs. Fake drugs are produced by criminals, often with no attempt whatsoever to include active ingredients. If included, there is usually just enough to pass a basic test. Fake drugs not only fail to cure patients' ailments, but also frequently contain chemicals that cause additional harm to the patient. In contrast, sub-standard drugs, more often than not, while produced by legitimate drug manufacturers, are of poor quality. Sub-standard drugs made with either too little or too much active ingredient often deteriorate before a normal expiry date. Fake drugs may be highly detrimental to patients who consume them, but sub-standard drugs are far more damaging because they increase the probability of resistance emerging to good quality drugs. Sub-standard drugs have the potential to render an entire class of proven drugs useless.

Consider what is happening with anti-malarial treatments. In 2012 the Lancet medical journal published a study conducted by the National Institutes of Health unit which found that 35 per cent of 2,300 malaria drug samples tested in sub-Saharan Africa were of "poor quality" - either fake, expired or badly made. This is devastating because, in the case of anti-malarial treatment, there are few effective drugs remaining.

The once highly successful malaria treatments, chloroquine and sulphadoxine pyrimethamine (SP), are seldom recommended to treat malaria thanks to resistance. One strategy to contain resistance is to combine two treatments. The current best treatment is achieved by combining artemisinin with another anti-malarial drug. Preserving these artemisinin combination therapies, or ACTs, required a halt in the use of artemisinin monotherapies and also careful efforts to ensure high standard ACTs are used, and used appropriately.

In January 2006 the WHO appealed to pharmaceutical manufacturers to cease production of monotherapies. Regrettably many companies continued to produce these drugs and far too many malarial country governments continue to allow their use. According to the WHO's World Malaria Report: 2013, "The number of countries that still allow the marketing of these products decreased from 55 in 2008 to 9 as of November 2013; 6 of those 9 countries are in the African Region. The number of pharmaceutical companies marketing these products dropped from 38 in 2010 to 30 in 2013. Most of the countries that allow marketing of these medicines are in the African Region, whereas most of the manufacturers are in India".

Countries need drug regulators, but far too often these bureaucracies demand that legitimate producers fulfil lengthy and expensive registration processes that they have already undertaken in other countries. If regulators were to harmonise more and accept registrations on a regional basis, it would undoubtedly free up more time and resources to monitor sub-standards and prevent fakes from entering the market. A more efficient process would relieve the 'regulation' pressure on good quality drugs and help us escape the serious threat of wide-scale resistance.

The international community should commit to signing an international treaty on counterfeiting medicines, such as one proposed by Prof Amir Attaran and Dr Roger Bate. Currently medicine counterfeiters are able to use all sorts of legal loopholes to get away with what they are doing. Unlike counterfeit currency, there is no consistency in the laws that deal with producers of fake medicines. A global treaty is needed to close the many loopholes and standardise the legal treatment of criminals whose trade is deadly. Such a treaty concerning counterfeit currency has already existed for decades. It is high time one is adopted for medicines to protect the future of humankind.

A version of this article was first published in the Saturday Star, Apr. 5, 2014