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Lecture 10

HLTB21 lecture 10- Nov. 21.docx

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University of Toronto Scarborough
Health Studies
R Song

HLTB21- Lecture 10- November 21 Drug (Antibiotic) Resistance  Occurs because drugs target very specific bacterial proteins; with such specificity, any mutation in these proteins will interfere with or diminish its microbe destroying effect • Changes in bacteria: 1) spontaneous or induced genetic mutation; or 2) acquisition of resistance genes from other bacterial species (horizontal gene transfer via conjugation, transduction, transformation); can also use enzymes to modify the antibiotic itself (to be less effective)  REMEMBER: exposure to antibiotics will naturally select for the survival of organisms with genes for Resistance Factors in Anti-Microbial Drug Resistance  At population and individual levels  Overuse in different contexts: health care settings, nursing homes, livestock farming, aquaculture, agriculture, home (bactericidal chemicals, cleaners)  Hospital use of broad-spectrum antibiotics while waiting for test results  Poor adherence / compliance (incomplete usage)  Counterfeit drugs (under-dosed, incorrectly dosed)  Prophylactic use (preventative, e.g., pre-surgery)  Misuse for viral infections (e.g., upper respiratory)  Overuse of antibiotics to re-assure patients From 1990-2003, the number of available antibacterial products jumped from 23 to more than 700 (Levy 2003)  leading to drug-resistance  Living in a too-clean environment can be problematic  Ex. children and allergies: there’s an association between kids with allergies and more sterile environments  Malaria in India  Medical Malpractice and the Spread of Malaria  Good example of how drug resistance develops Malaria  Protozoan parasitic infection  Plasmodium falciparum, vivax, ovale, malariae  Transmitted by female Anopheles mosquito  Flu-like symptoms: fever, chills, headache, muscle pains, sweats, tiredness, nausea, diarrhea, anemia, vomiting  No vaccine, only prophylactic drugs: quinine, chloroquine and artemisinin derivatives and preventative measures (bed nets, screens, activity timing, insecticides, reducing water sources)  We just don’t have as many treatments as we used to  Chloroquine: least effective drug • Note: syndemic with other diseases of poverty  Prevalent in Africa, Latin America, Asia (endemic in 100+ countries)  Approx. 219 million affected in 2010, killing 490,000 - 836,000  Majority of malarial deaths: sub-Saharan Africa, mostly kids  Mortality rates have fallen by more than 25% globally since 2000  Up to 5% of malaria episodes are severe, with case-fatality rate for severe episodes in epidemics possibly up to 20% (WHO)  Persistence of malaria is problematic due to changing climates Healthcare Systems and Malaria  Between 60 and 86% of those in need of ambulatory care in both rural and urban areas of India resort to unregulated private health facilities – Why? greater access, convenience of timing, non-availability of alternative source of health care (publicly-funded)  Consequences? Private Health Care in India Challenges: (Kamat 2001)  Irrational therapeutics, overprescription, and unnecessary investigations and surgery  Unscientific disease diagnosis  Inappropriate prescription habits (e.g., poly- prescription/overprescription, sub-optimal dosages, even mistreatment/malpractice) -anti-malarial drug resistance?  Malaria is not bacterial infection- it’s protozoan  Economic interests of private practitioners  Intense pharmaceutical competition  Doctor-patient interactions (blame and misperceptions)  Ignorance of disease causation (vector, breeding sites)  Poor coordination between public/private health care  There is state care in India but very underfunded, so they have to go to private practitioners  Private doctors, very unregulated in terms of qualifications  A lot of people are risk to the practioners. Diagnosing Malaria in Private Care  6% of practitioners said that they relied exclusively on clinical symptoms which they noticed in their patients. 4% percent said that they relied exclusively on symptoms their patients reported to the, while 58% of the practitioners relied on both indicators.  23% said that, in addition to the two symptom indicators above, they practiced “diagnosis by treatment”. in which efficacy of the drug determined the illness, which might be some other disease, or relied on what they considered typical distinguishing symptoms  The same logic was used by some practitioners to determine whether the patient was infected with P. vivax or P. Falciparum  Only 15% said they relied on the patient's blood-smear report  Majority (65%) of practitioners said that they rarely advised their patients to go for a blood-smear test  Three main reasons why private doctors did not refer blood-smear tests:  1) Patients who came to see them rarely had enough money to fill the prescription, let alone to get the blood test  2) Most of the patients presented symptoms that so clearly indicated malaria that a blood-smear test would be redundant  3) Practitioners feared that they would lose the patronage of patients whose primary concern was low-cost symptomatic relief (would go elsewhere) Treatment  Over two-thirds of the practitioners in Mumbai and Navi Mumbai did not prescribe a line of treatment that followed biomedically defined dosage levels and schedules of anti-malarials appropriate for different age/weight categories  More than 2/3 of patients had not been prescribed a full prescription (usually 1-2 days, when some require 7 days)  With respect to antimalarials, lay interpretations of medicine efficacy, compliance of patients with the recommended schedule and dosage, and the practice of self-regulation of prescriptions are important issues  Great competition b/w pharmaceutical companies  Often times pressure from pharmaceutical companies to prescribe drugs, because they make money. Anti-malarials, Antibiotics, Corticosteroids ...  requesting drug by IV  Saving vitamins through IV drip; to reassure patients to do the best they can for you  Doctors did these things intensively, for just one day (so one day-treatments, very rigorous) Doctor-Patient Interaction  Power struggle : best way to keep that patient as a customer  Doctors’ claims of patient demands (for treatment)  Doctors’ per
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