GARP-Nepal National Working Group (NWG) Dr. Buddha Basnyat, Chair GARP- Nepal, Researcher/Clinician, Oxford University Clinical Research Unit-Nepal\ Patan Academy of Health Sciences Dr. Paras K Pokharel, Vice Chair- GARP Nepal, Professor of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan Dr. Sameer Mani Dixit, PI GARP- Nepal, Director of Research, Center for Molecular Dynamics, Nepal Dr. Abhilasha Karkey, Medical Microbiologist, Oxford University Clinical Research Unit-Nepal\ Patan Academy of Health Sciences Dr. Bhabana Shrestha, Director, German Nepal Tuberculosis Project Dr. Basudha Khanal, Professor of Microbiology, BP Koirala Institute of Health Sciences, Dharan Dr. Devi Prasai, Member, Nepal Health Economist Association Dr. Mukti Shrestha, Veterinarian, Veterinary Clinics, Pulchowk Dr. Palpasa Kansakar, Microbiologist, World Health Organization Dr. Sharada Thapaliya, Associate Professor, Department of Pharmacology and Surgery, Agriculture and Forestry University–Rampur Mr. Shrawan Kumar Mishra, President, Nepal Health Professional Council Dr. Shrijana Shrestha, Dean, Patan Academy of Health Sciences GARP-Nepal Staff Santoshi Giri, GARP-N Country Coordinator, Global Antibiotic Resistance Partnership- Nepal/Nepal Public Health Foundation Namuna Shrestha, Programme Officer, Nepal Public Health Foundation International Advisors Hellen Gelband, Associate Director, Center for Disease Dynamics, Economics & Policy Ramanan Laxminarayan, GARP Principal Investigator, Director, Center for Disease Dynamics, Economics & Policy Nepal Situation Analysis and Recommendations Preface Nepal Situation Analysis and Recommendations Nepal Situation Analysis and Recommendations Acknowledgement This report on "Situation Analysis and Recommendations: Antibiotic Use and Resistance in Nepal" is developed by Global Antibiotic Resistance Partnership (GARP Nepal) under Nepal Public Health Foundation (NPHF). First of all, we are thankful to Center for Disease Dynamics, Economics and Policy (CDDEP) for their financial and technical support. Their expertise, knowledge and experience, has been very essential throughout the study. We express our sincere gratitude to Honorable Minister Mr. Khaga Raj Adhikari, Ministry of Health and Population, for gracing the dissemination workshop of 15 December 2014 and motivating us with his wonderful speech. We are grateful to the honorable minister for writing immensely encouraging foreword for the report. We would like to express our sincere thanks to Dr. Ramanan Laxminarayan, Director of CDDEP for his valuable support; Ms. Hellen Gelband, Assistant Director and related experts of CDDEP for their guidance and technical support in completion of this report. A sincere thanks to GARP-Nepal working group members who provided insight and expertise that greatly assisted the study. We highly acknowledge representatives from government, INGOs, NGOs, clinicians, academicians, veterinarians, microbiologist and journalist for attending our seminars and workshops; and providing invaluable suggestions and recommendations. We would like to express our deep sense of appreciation to Dr. Badri Raj Pande, Acting Executive Chair of NPHF and entire NPHF team for continuous support. We wish to thank Ms. Santoshi Giri, Country coordinator for GARP Nepal and Program Officer Ms. Namuna Shrestha for their hard work in preparation and production of this report. Buddha Basnyat, MD, MSc, FACP, FRCP (Edinburgh) Chair Global Antibiotic Resistance Partnership-Nepal Nepal Public Health Foundation Nepal Situation Analysis and Recommendations Table of Contents CHAPTER 1: SUMMARY AND RECOMMENDATIONS ............................................................................10 CHAPTER 2: POPULATION HEALTH AND BACKGROUND ................................................................18 HUMANS ........................................................................................................................................18 2.1 POPULATION ....................................................................................................................................18 2.2 ECONOMY ..........................................................................................................................................18 2.3 HEALTH SYSTEM .............................................................................................................................18 2.4 AVAILABILITY OF AND ACCESS TO ESSENTIAL MEDICINES .................................... 25 2.5 GOVERNMENT POLICIES AND REGULATORY ENVIRONMENT ............................. 25 2.6 DISEASE CONTROL PROGRAMS ..............................................................................................29 ANIMALS ........................................................................................................................................31 2.7 LIVESTOCK FARMING ..................................................................................................................31 2.8 FOOD AND ANIMAL CONTRIBUTIONS TO THE ECONOMY ..................................... 31 2.9 LIVESTOCK SERVICES IN NEPAL ............................................................................................32 2.10 GOVERNMENT POLICIES ...........................................................................................................33 2.11 GOVERNMENT AGENCIES AND OFFICES WITH MISSIONS RELATEDV TO ANIMAL HEALTH AND PRODUCTION .................................................................................33 CHAPTER 3: NATIONAL BURDEN OF DISEASE ........................................................................ 37 HUMANS ....................................................................................................................................... 37 3.1 BACTERIAL DISEASE BURDEN .................................................................................................37 3.1.1 Acute Respiratory Infections ...............................................................................................37 3.1.2 Diarrheal Infections ..............................................................................................................38 3.1.3 Bloodstream Infections and Meningitis .............................................................................39 3.1.4 Tuberculosis ...........................................................................................................................42 3.1.5 Urinary Tract Infections .......................................................................................................43 3.1.6 Sexually Transmitted Infections ..........................................................................................43 3.1.7 Healthcare-Associated Infections .......................................................................................44 3.2 HUMAN DISEASE SURVEILLANCE .........................................................................................45 ANIMALS ....................................................................................................................................... 47 3.3 NATIONAL BURDEN OF DISEASE IN ANIMALS ...............................................................47 3.3.1 Bovines and Ruminants ........................................................................................................47 3.3.2 Poultry .....................................................................................................................................48 3.3.3 Zoonoses ................................................................................................................................49 Nepal Situation Analysis and Recommendations CHAPTER 4: ANTIBIOTIC RESISTANCE ...................................................................................... 57 HUMANS ....................................................................................................................................... 57 4.1 ACUTE RESPIRATORY INFECTIONS (ARI) ...........................................................................57 4.2 DIARRHEAL DISEASES .................................................................................................................59 4.3 BLOOD STREAM INFECTIONS ..................................................................................................60 4.4 URINARY TRACT INFECTIONS .................................................................................................62 4.5 SEXUALLY TRANSMITTED INFECTIONS .............................................................................64 4.6 TUBERCULOSIS ................................................................................................................................65 4.7 HEALTHCARE ACQUIRED INFECTIONS ..............................................................................66 ANIMALS ....................................................................................................................................... 67 4.8 ANTIBIOTIC RESISTANCE IN ANIMALS ...............................................................................67 4.8.1 Poultry ...........................................................................................................................................67 4.8.2 Cattle .............................................................................................................................................68 CHAPTER 5: ANTIBIOTIC SUPPLY CHAIN .................................................................................