Conducting Public Health Research Activities in Uzbekistan

抗微生物药物耐药性（AMR）目前被认为是威胁人类健康的一个重大全球卫生问题

Antimicrobial resistance (AMR) is currently recognized as a major global health problem that threatens a return to the pre-antibiotic era with potentially catastrophic social and political ramifications especially in resource-poor countries. Currently, AMR, defined as the resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it, is considered one of the greatest threats to health. Although not a new phenomenon, AMR has become a more pressing issue over recent years as approximately 70% of known bacteria have developed resistance to one or more antibiotics [1]. Resistance has been reported for an entire class of antibiotics and untreatable, multi-drug resistance bacteria are increasingly being documented [2]. As microorganisms are increasingly immersed in environments that favor the existence of AMR leading to de novo resistance or transfer of genetically encoded resistance among themselves, the evolutionary forces affecting resistance seem ever present. There are, however, controllable practices that accelerate its acquisition of resistance genes. These include poor use and abuse of antibiotics (excessive or irrational use for treatment and prevention), availability of substandard. drugs (especially in low-income countries where antibiotics are poorly controlled), increased global travel and medical tourism, declines in research and development for new medicines, poor application of infection control measures, and use of antibiotics in the agricultural industry [3]. Plasmodium falciparum, the most dangerous of the malaria parasites, has developed resistance to nearly all of the currently available antimalarial drugs in parts of Southeast Asia. Sporadic cases of pandemic H1 N1 flu have shown resistance to oseltamivir, one of only two antivirals that work against it. In the United States, methicillin-resistant Staphylococcus aureus, known as MRSA, is a problem in many health care settings. Drug-resistant Klebsiella pneumoniae, previously seen in a limited number of hospitals, has now been reported in at least 36 states. Neisseria gonorrheae is now resistant to 1 cephalosporins, the only recommended class of antimicrobials left to treat this common sexually transmitted infection. Acinetobacter spp. resistant to previously successfully used antimicrobials are now well recognized pathogens affecting military staff in the fields [4]. Data addressing AMR are significantly poor in low- and middle-income countries income countries. Evidence suggests that 70% of healthcare associated infections in these countries are difficult to treat due to resistance to first-line antibiotics and multi-drug resistance Ilas forced clinicians to fall back on second- and third- line treatments which in turn multiplies costs [5]. The effects of resistance manifest themselves not just in the impact on human health, but also in potentially heavy economic costs and difficulties in mobilizing political action to deal with it, nationally and globally. The main political ramification is the dearth of accurate economic estimates indicating antibiotic resistance does not cost enough in evidence-based policy-making to be assigned the priority it deserves [6]. Little is known about prevalence of AMR in Uzbekistan and the other four countries of the Central Asia Region (CAR). Although often of uncertain quality, the scant information on AMR in CAR describes resistance as a common phenomenon. Multidrug-resistant tuberculosis (MDR-TB) has emerged as a major threat to TB control in Uzbekistan reinforces this belief. In the fourth report of the World Project on MDR-TB, the highest prevalence (60%) of MDR-TB was found in Tashkent, the capital of Uzbekistan [7]. Based on results of several studies performed in Uzbekistan, currently, 90% of clinical strains of Shigella flexneri (major cause of shigellosis in Uzbekistan), have lost their sensitivity to ampicillin, chloramphenicol (levomycetin) and tetracycline [8]. Another study reported Salmonella typhi strains as being multidrug-resistant to ampicillin and tetracycline [9]. The 2012 pilot survey performed by public health authorities revealed that 31 % of the doctors in Uzbekistan prescribe antibiotics to treat respiratory viral infections, 50% patients have antibiotics at home, and 35 % start taking antibiotics without consulting with a doctor. One of the main problems in Uzbekistan is the widespread practice of selling antibiotics over the counter without a prescription making the overuse and misuse of antibiotics easy. As a pharmaceutical producing country, there are still major concerns about drug safety, due to the availability of substandard and counterfeit drugs in Uzbek pharmacies. In 2007, Uzbekistan was one of the top ten countries reporting counterfeit drug incidents according to the Pharmaceutical Security Institute [10]. In November 2013, the WHO-EURO AMR assessment team visited Tashkent in order to (i) gain an understanding of the status of national and intersectoral coordination to implement actions to counteract AMR; (ii) to assess the status of national AMR surveillance; and (iii) to discuss technical requirements for joining an international network for AMR surveillance, and antibiotic susceptibility testing. Following the provided recommendations from the AMR assessment mission's results, the following proposed actions will be considered during the project implementation period: (i) identify awareness for AMR in the general and in targeted populations; (ii) implement AMR surveillance and surveillance of antimicrobial consumption; and (iii) support to national plans and strategies to counteract the threat posed by AMR, in accordance with the 2011 European Strategic Action Plan on Antibiotic Resistance (WHO EURO. Aide-Memoire AMR Mission - Tashkent, Uzbekistan. 6.6.2014. Personal communication).