MIN RATNA BAJRACHARYA FINISHED WITH MY PILLS: Nepalis can buy antibiotics over-the-counter without prescription

Every time Maya has a sore throat, she visits her neighbourhood medicine shop, gets her tonsils checked by the pharmacist and returns home with a packet of antibiotics. It's quick, easy, and cheap. The medicine is available over-the-counter so she doesn't even need a prescription.

Thousands of Nepalis like Maya pop antibiotic pills for common cold and flu. However, antibiotics are only effective against bacterial and fungal infections and certain kinds of parasites, not against viruses that cause cold and flu.

"In Nepal, people with no medical background act as experts and advise friends and families to take antibiotics. And since antibiotics are readily available at most pharmacies, people start taking them when they experience even minor discomforts," says Buddha Basnyat, medical consultant at Patan Hospital.
Such misuse of antibiotics, especially in developing countries, means that many significant bacterial infections are now becoming resistant to commonly used antibiotics leading to a major health crisis.

"When bacteria (pic below) become drug resistant, patients need more and more antibiotics. It is a waste of money and time. A person may take antibiotics for a throat infection, but the infection may spread to other parts of the body," explains Rajendra Pant, director of National Tuberculosis Centre.

Antibiotics resistance can be fatal as was the case in Prasuti Griha last month. The maternity hospital in Kathmandu closed down for a week in September after staphylococcus, an antibiotics-resistant pathogen, was found in equipment used in the operation theatre. The infection resulted in the death of Lata Gurung who had just delivered a baby and another new born. Outbreaks of 'super bugs' resistant to antibiotics have been found in other countries as well.

Operating rooms and intensive care units around the world usually shut down from time to time to undergo a complete sterilisation to kill off drug resistant bacteria and infections. Although Prasuti Griha claims it follows this accepted procedure, the hospital seems to have fallen behind on its monthly sterilisation routine and failed to maintain proper hygiene standards thus allowing the staphylococcus to spread.

Besides the health risks, antibiotics resistance also puts a heavy financial burden on patients and their families. As drugs become increasingly ineffective against certain types of bacteria, the illness is prolonged and the cost of additional tests, treatment, hospitalisation, along with loss of income due to absence at work can put serious dent on their finances.

It is not only humans who are developing antibiotics resistance, livestock and poultry are also becoming immune because of the gross abuse of antibiotics by farmers who self-administer the drugs.

While unregulated use of antibiotics is a major cause of drug resistance, failure to complete the full course of treatment is also responsible.

"Once patients start feeling better, they stop taking drugs halfway through the prescribed course. The bacteria that survive become more resistant, stronger, and keep multiplying," explains Basnyat. Lack of sanitation and hygiene, which enables proliferation and spread of pathogens, also helps spread the resistance.

The threats of multi-drug resistant tuberculosis (TB) have major public health implications in Nepal, where more than half the local population are carriers of the bacillus (see box) according to reports. The main case of death from HIV/AIDS is also through resurgent TB. The only way to control this is through stricter regulations at pharmacies, public awareness, and planning contingency measures for a super bug outbreak.

Resisting tuberculosis

Tuberculosis (TB) is endemic in Nepal and it can be transmitted from person to person through breathing. More than half the population are carriers of the tuberculosis bacillus, but not everyone develops the full-blown disease.

Due to the magnitude of the infection, the government made TB treatment a health priority starting from early 1990 and provided greater access to DOTS (directly observed treatment). Nepal's DOTS program is internationally recognised as being very effective, and serves as a role model for other developing countries.

Drugs for TB work in the same way many common antibiotics do: if the treatment is not completed, or the drugs are not right, there is a chance of the bacteria multiplying and becoming stronger. And that is when the bacteria return with increased levels of resistance.

The second line of antibiotics which is required to treat the multi-drug resistant TB is not only much more expensive than regular antibiotics, but the treatment takes longer and the side effects can be severe.

TB patients in Nepal cannot buy antibiotics over-the-counter as drugs and treatment are only administered by the government free of charge. Although this helps in the regulation of antibiotics, it is difficult to ensure whether patients actually finish their course and controlling drug resistant TB becomes complicated.