Antimicrobial resistance: The silent pandemic killing 700,000 a year

Pharmacies handing out antibiotics to people without prescriptions; the proliferation of fake drugs with watered-down active ingredients; the blanket use of antibiotics in livestock production and agriculture; and the reckless handling of waste from manufacturing and health facilities — these are all reasons antimicrobial resistance is on the rise. This abuse and overuse of antibiotics already kill at least 700,000 people each year from drug-resistant disease, including 230,000 that die from multidrug-resistant tuberculosis. Without action, this could spiral to 10 million deaths each year by 2050, including 4.1 million people on the African continent. In the next 10 years, it could push another 24 million people into extreme poverty. This slow-burning public health threat has been referred to as a “silent pandemic.” And it is the “quintessential threat” to overall development, including the sustainable development goals and efforts to reduce poverty, according to Dr. Walter Fuller, antimicrobial resistance stewardship and awareness lead at the World Health Organization Regional Office for Africa, during a recent conference. Following a global push in 2016, 144 countries, including 97 low- and middle-income countries, have developed national action plans committing to better manage antibiotics. But there is concern that when it comes to implementation, inadequate levels of financing limit progress in low-resource settings. “In designing a national action plan, there is a danger that it can become a bit of a tick box exercise,” said Michael Anderson, research officer in the department of health policy at the London School of Economics and Political Science. The push for a plan In 2015, the World Health Assembly adopted a global action plan on AMR. The assembly also called on countries to develop their own multisectoral national action plans, with guidance from WHO, the Food and Agriculture Organization of the United Nations, and World Organization for Animal Health. The same year, WHO also launched the Global Antimicrobial Resistance and Use Surveillance System, or GLASS, as the first global effort to standardize the collection and analysis of data around AMR, including in areas such as the spread of drug-resistant gonorrhea, surveys around antibiotic use in health facilities and estimates around mortality linked to AMR within a country. This data is critical in driving policy, research, and advocacy, as well as adjusting treatment guidelines and interventions, said Dr. Laetitia Gahimbare, antimicrobial technical officer at WHO’s Regional Office for Africa, with a focus on surveillance, evidence and laboratory strengthening. “Antimicrobial resistance is not prioritized maybe because they don't see the immediate effect … And that's where our problem comes because we solve the immediate pressing needs without thinking about the future.” --— Joachim Osur, public health specialist, Amref Health Africa In their national plans, countries were encouraged to include measures on strengthening regulations of medicines, as well as enforcement; working to ensure those prescribing antimicrobials are trained on how to do so appropriately; fostering research and development of new drugs; increasing efforts around infection prevention; and public awareness so patients understand the value in going to a health provider for a prescription rather than directly to the pharmacy. In WHO’s Africa region, 38 out of 47 countries developed national plans, with national authorities approving 27 of them, Fuller said. Plans vs. reality Countries are now facing the difficult part. “Now the biggest challenge is not just writing a national action plan, but implementing it and demonstrating sustained action,” Anderson said. When it comes to surveillance, 30 African countries are enrolled in GLASS, and last year 15 of these countries reported data, Gahimbare said. But not all the reporting countries provided actual data on AMR — some provided data on the progress made in establishing surveillance efforts. The LSE conducted research on the implementation of programs in Egypt and South Africa. Both countries report high drug resistance levels for certain bacteria. From interim results in Egypt, which has a national plan in place for 2018 through 2022, the extent of public involvement in implementing the plan was unclear; it is not widely available in the country; there is a lack of legislation on prescription-only access to antimicrobials or for their use for non-therapeutic purposes in animal and plant health; and there is not yet a public awareness campaign around the issue. In South Africa, which has a national plan that runs from 2014 to 2024, there was also unclear public involvement in the development or coordination of the plan. And while regulation for antimicrobial use in human health exists, its enforcement varies between public and private sectors. There was also weak regulation of access to over-the-counter antimicrobials in the animal health sector and no evidence of a national awareness campaign. Limits on funding and foresight Without adequate funding, many of these plans move at a pace that doesn’t match the magnitude of the threat, health experts said. “Unfortunately, a majority of the national action plans … were developed sort of in a rush, just to meet the deadline that had been offered … and did not really take into consideration the costing bit of it,” said Dr. Tracie Muraya, policy officer at ReAct Africa. “This is then riddled with little or no political commitment.” Regulation is one of the areas that needs substantial investment, said Joachim Osur, public health specialist at Amref Health Africa. Governments might have a regulatory presence in capital cities, but not throughout the country. “If you have a strong regulatory system, you're most likely going to limit misuse of antibiotics,” he said. Another area deserving investment is digitalization, Osur said, adding that if countries trade in their manual systems for digital ones, it can help track the movement of medicines from the port of entry to the patients, which can help flag overuse as well as identify counterfeit drugs. But because AMR is often considered a future threat, it's often not prioritized within a country’s budget over other health concerns, such as infectious diseases that are currently killing people on a large scale, health experts said. Managing the COVID-19 pandemic has consumed a lot of national resources and is also fueling the problem. A recent study found 72% of patients admitted to hospitals received antimicrobial therapy, but only 8% actually needed it. “Antimicrobial resistance is not prioritized maybe because they don't see the immediate effect,” Osur said. “When you have minimal resources, you tend to be more reactive than proactive. And that's where our problem comes because we solve the immediate pressing needs without thinking about the future.” Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildingBackBetter.