Antibiotic use and resistance in emerging economies: a situation analysis for Viet Nam

Kinh Van Nguyen 4 Nga Thuy Thi Do 0 Arjun Chandna 0 Trung Vu Nguyen 4 6 Ca Van Pham 4 Phuong Mai Doan 2 An Quoc Nguyen 7 Chuc Kim Thi Nguyen 6 Mattias Larsson 0 Socorro Escalante 5 Babatunde Olowokure 5 Ramanan Laxminarayan 5 Hellen Gelband 5 Peter Horby 0 1 Ha Bich Thi Ngo 9 Mai Thanh Hoang 8 Jeremy Farrar 0 Tran Tinh Hien 0 3 Heiman FL Wertheim 0 1 0 Oxford University Clinical Research Unit , Hanoi , Viet Nam 1 Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford , Oxford , UK 2 Bach Mai Hospital , Hanoi , Viet Nam 3 Hospital of Tropical Diseases , Ho Chi Minh City , Viet Nam 4 National Hospital of Tropical Diseases , Hanoi , Viet Nam 5 World Health Organization , Country Office, Hanoi , Viet Nam 6 Hanoi Medical University , Hanoi , Viet Nam 7 Ministry of Agriculture and Rural Development , Hanoi , Viet Nam 8 Drug Administration of Viet Nam, Ministry of Health , Hanoi , Viet Nam 9 Medical Service Administration, Ministry of Health , Hanoi , Viet Nam Background: Antimicrobial resistance is a major contemporary public health threat. Strategies to contain antimicrobial resistance have been comprehensively set forth, however in developing countries where the need for effective antimicrobials is greatest implementation has proved problematic. A better understanding of patterns and determinants of antibiotic use and resistance in emerging economies may permit more appropriately targeted interventions. Viet Nam, with a large population, high burden of infectious disease and relatively unrestricted access to medication, is an excellent case study of the difficulties faced by emerging economies in controlling antimicrobial resistance. Methods: Our working group conducted a situation analysis of the current patterns and determinants of antibiotic use and resistance in Viet Nam. International publications and local reports published between 1-1-1990 and 31-8-2012 were reviewed. All stakeholders analyzed the findings at a policy workshop and feasible recommendations were suggested to improve antibiotic use in Viet Nam. Here we report the results of our situation analysis focusing on: the healthcare system, drug regulation and supply; antibiotic resistance and infection control; and agricultural antibiotic use. Results: Market reforms have improved healthcare access in Viet Nam and contributed to better health outcomes. However, increased accessibility has been accompanied by injudicious antibiotic use in hospitals and the community, with predictable escalation in bacterial resistance. Prescribing practices are poor and self-medication is common - often being the most affordable way to access healthcare. Many policies exist to regulate antibiotic use but enforcement is insufficient or lacking. Pneumococcal penicillin-resistance rates are the highest in Asia and carbapenem-resistant bacteria (notably NDM-1) have recently emerged. Hospital acquired infections, predominantly with multi-drug resistant Gram-negative organisms, place additional strain on limited resources. Widespread agricultural antibiotic use further propagates antimicrobial resistance. Conclusions: Future legislation regarding antibiotic access must alter incentives for purchasers and providers and ensure effective enforcement. The Ministry of Health recently initiated a national action plan and approved a multicenter health improvement project to strengthen national capacity for antimicrobial stewardship in Viet Nam. This analysis provided important input to these initiatives. Our methodologies and findings may be of use to others across the world tackling the growing threat of antibiotic resistance. - Background Antimicrobial resistance is a global concern and a particularly pressing issue in resource-limited countries. Respiratory, diarrheal, sexually-transmitted and nosocomial infections are leading causes of death in the developing world [1] and their management is critically compromised by the appearance and rapid spread of resistance. Antibiotic drug pressure is a key driver of resistance. Whilst it is an unavoidable consequence of antibiotic use both rational and irrational unnecessary antibiotic pressure can and must be reduced. The World Health Organization (WHO) published comprehensive recommendations designed to restrict the emergence and spread of antimicrobial resistant organisms, promoting prudent use of antimicrobials in humans, foodproducing animals and aquaculture [2]. With a population exceeding 91 million, Viet Nam is the worlds 13th most populous country (Table 1) and has a rapidly developing economy [3,4]. In 1986 a series of economic reforms, termed the i Mi, facilitated the transition to a more market-driven economy. One of the consequences of economic liberalization has been a relatively unregulated access to antimicrobials and this, coupled with the high burden of infectious disease, has made Viet Nam a potential hotspot for the emergence of drug resistance. Our paper presents a situation analysis that addresses the current patterns and determinants of antibiotic use and resistance in Viet Nam. It suggests how the information gained during this process can be used to develop effective interventions to improve antibiotic Table 1 Key health and development indicators in Viet Nam Population growth rate (%) Urbanization rate (%) Life expectancy (male/female) GDP per capita (PPP) (US$) Infant mortality rate (per 1000) Maternal mortality ratio (per 100,000 live births) Poverty rate (% < 1.25USD/day) Access to improved drinking water sources (%) Access to improved sanitation facilities (%) Adult literacy rate (%) Sources: World Health Organization (http://apps.who.int/gho/data/view. country.21300, date accessed: 09/10/2013). United Nations (http://data.un.org/CountryProfile.aspx?crName=Viet%20Nam, date accessed: 09/10/2013). CIA World Factbook (https://www.cia.gov/library/publications/the-worldfactbook/geos/vm.html, date accessed: 09/10/2013). stewardship in Viet Nam, whilst taking care not to diminish access to these life-saving drugs. Formulating policy to improve antibiotic stewardship is best accomplished by beginning with a broad analysis of a country and its health system. The first iteration of such an analysis was produced for Viet Nam in 2009, when it became one of the first countries to join the Global Antibiotic Resistance Partnership [5]. This paper considers policy recommendations made in light of that analysis and highlights existing challenges. Methods We established a working-group, which included key representatives from across Viet Nam. The working-group organized a stakeholder meeting in Hanoi (September, 2009) attended by the Vietnamese Ministry of Health (MoH), WHO, hospital directors, universities, research organizations and local and international experts in public health, agriculture, microbiology, pharmacy, and clinical infectious diseases. During this and subsequent meetings, a framework for the situation analysis was o (...truncated)