Access to health care for children in Amazonian Peru : Focus on antibiotic use and resistance

Abstract: Background: Infectious diseases remain a big problem in low and middle income countries (LMIC). Problems of access to adequate health care (including antibiotics) prevail despite the availability of many elaborate interventions. Antibiotic resistance further endangers access to effective infectious illness management. The Peruvian state insurance SIS, had formally granted full access to health care and antibiotics for children living within the study areas. Main objective: To assess health-seeking behaviour, antibiotic use and socioeconomic status for children aged 6 72 months in two communities of the Amazonian area of Peru. In addition, to study associations between antibiotic use and socioeconomic factors related to antibiotic resistance among the same study population. Methods: Two cross-sectional surveys of caregivers were carried out in the two urban Amazonian communities, Moyobamba and Yurimaguas, in 2002. A similar cross-sectional survey was carried out later in 2005, in Moyobamba only. Caregivers were interviewed on health care seeking strategies and medication for their children in relation to reported symptoms and socioeconomic status using a structured questionnaire. Self-reported symptoms were classified into illnesses based on the IMCI algorithm (Integrated Management of Childhood Illnesses). Wealth index was generated by Principal Component Analysis using household assets and characteristics and was used as a proxy for economic status. Faecal samples were collected from the children and the antibiotic susceptibility of E. coli was analysed by a rapid resistance screening method. Results: Many caregivers consulted health professionals for their children s illnesses, (Yurimaguas 42% and Moyobamba 30%) in year 2002 but the poorest caregivers consulted health professionals less frequently (33%) than the least poor (71%) for severe illnesses such as pneumonia (I). In Moyobamba the number of caregivers that consulted health professionals (medical doctors, nurses or health echnicians) decreased from 91% in 2002 to 74% in 2005 (p<0.001) (III). The majority of the antibiotics used were prescribed by health professionals (71%), but the amount of antibiotics recommended by pharmacy staff increased in 2005 (18%) as compared to 2002 (6%) in Moyobamba (III). Health professionals prescribed equally often, whether or not antibiotics were recommended for the illnesses. Pharmacists were more discriminatory (II). Caregivers self-caring for their children were restrictive with antibiotics for all illnesses. The amount of children receiving antibiotics free of charge through the SIS had decreased in 2005 as compared to 2002 (III). There were a high number of children carrying antibiotic resistant clones of E. coli in both communities, more commonly among the least poor children (IV). Discussion: The high affordability mediated by the SIS likely contributed to the high utilisation of the public health services. However, inequitable utilisation and under-use of health services for severe illnesses indicate that there are still barriers to access. Antibiotics were prescribed for illnesses where it is not indicated, wasting resources and potentially contributing to emerging antibiotic resistance. The high carriage of antibiotic resistance in the commensal bacterial flora, more commonly among the least poor than the poorest children, underlines the importance of including all groups in society in attempts to improve adequate use of antibiotics.