|Year : 2017 | Volume
| Issue : 1 | Page : 1-3
Global response to combat antimicrobial resistance
Poonam Khetrapal Singh
Regional Director, World Health Organization, Regional Office for South-East Asia, World Health House, New Delhi - 110002, India
|Date of Web Publication||16-Mar-2017|
Poonam Khetrapal Singh
Regional Director, World Health Organization, Regional Office for South-East Asia, World Health House, New Delhi - 110002
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh PK. Global response to combat antimicrobial resistance. Indian J Med Microbiol 2017;35:1-3
During the mid-1960s, Dr. William Stewart, the then Surgeon General of the United States of America, encouraged by the phenomenal impact of antimicrobial agents on human health, made a forecast. 'It is time to close the book on infectious diseases', he had said. His optimism was based on significant decrease brought about in infectious diseases in the USA because of better living standards, vaccination, sanitation and above all extensive use of antibiotics. This statement was made during the golden period of discovery of new antibiotics. However, he and global community had not reckoned with three critical factors that were to turn upside down his prophecy. These included irrational use of antimicrobial agents in human health and veterinary sectors, ingenuity of microorganisms in developing resistance to antimicrobial agents (AMR) and slow down on development of new agents.
In spite of frequent warnings of emergence of resistance, no concrete, comprehensive and coordinated steps were taken to rationalise the use of these life-saving agents. This resulted in accumulation of resistance in microorganisms and appearance of multidrug-resistant organisms (MDRO). In language of common man, era of superbugs had begun. Diseases such as typhoid fever and gonorrhoea which were hitherto easy to treat with affordable medicines became expensive and difficult to treat., Mortality in children due to typhoid fever reached almost the same level that was seen in pre-antibiotic era. Drug-resistant tuberculosis (TB) became a global challenge to eliminate TB thwarting huge efforts and finances that have been invested in the recent past in controlling TB. Situation worsened significantly in health facilities. MDRO became widely prevalent. Methicillin-resistant Staphylococcus aureus, extended-spectrum beta-lactamases-producing Enterobacteriaceae and multidrug-resistant Acinetobacter baumannii became endemic in health facilities and started negating impact of even modern technologies. Unabated AMR can initiate the end of modern medicine. If the current trends continue, sophisticated interventions, such as organ transplantation, joint replacements, cancer chemotherapy and care of preterm infants, will become more difficult or even too dangerous to undertake.
It is estimated that cost increase for the management of a patient with resistant pathogen can be up to 30%. The cost of treating one patient with multidrug-resistant TB is more than that for treating non-resistant TB in 100 patients. Accordingly, the cost increase to the individual as well as national health services shall be phenomenal. This will force the countries to divert scarce resources towards health sector, thus perforce neglecting the development activities. Obviously, impact of AMR on human health and economy has been massive.
It is estimated that currently, 700,000 deaths globally can be ascribed to infections with drug-resistant pathogens. A study commissioned by the Prime Minister of England has revealed that unless aggressively countered now, AMR shall be causing more than 10 million deaths annually – far more than the people succumbing to cancers and road accidents. Most of these deaths shall be in developing countries. A loss of USD 100 trillion is also anticipated till 2050. The world GDP may fall by 3–3.5% with its resultant economic havoc. Millions of people in developing countries will be pushed into poverty because of high cost of treatment of diseases due to drug-resistant pathogens.
While the occurrence of mutations in microorganisms leading to resistance against antimicrobial agent is a biologically unstoppable phenomenon, the selection of resistant strains and their becoming predominant population is facilitated by selection pressure of the antibiotics. More the use of antibiotics, greater is the emergence of resistance. This selection can occur in environment, health facilities as well as veterinary practices. In several countries, use of antimicrobial agents in veterinary sector far exceeds that in human health. The current data show that against consumption of more than 63,000 tonnes by animals in 2010, there has been an increase of 67% in the next decade. In countries belonging to BRICS group, this increase has been almost 100%. Extensive use of antibiotics in veterinary sector is believed to be a major factor in propagation of AMR and a serious threat to human health.
| ~ Global Response|| |
Past 5 years has seen AMR gaining greater importance and climbing up higher on the global health and development agenda. In 2011, an initiative by India culminated in Jaipur Declaration on AMR by the 11 countries of the World Health Organization's (WHO's) South-East Asia.
There has been growing global political momentum to combat AMR. The response has been consistent and sustained from developed countries. The political momentum in large number of developing countries is yet to take off. This is because of several other competing priorities and lack of adequate awareness amongst the political leadership on current and future implications of AMR.
Understandably, massive response needs to be mounted immediately to prevent emergence and spread of AMR. In 2014, all Member States requested WHO to develop a global action plan for AMR which can act as a framework for the countries to develop their respective national action plans. The World Health Assembly in 2015 endorsed the global action plan  which pertains to following five objectives:
- To improve awareness and understanding of AMR
- To strengthen knowledge through surveillance and research
- To reduce the incidence of infection
- To optimise the use of antimicrobial agents
- Develop the economic case for sustainable investment and R&D for new medicines, diagnostic tools, vaccines and other interventions.
During 2015, GAP has also been endorsed by governing bodies of the Food and Agriculture Organization and World Organisation for Animal Health., Both agencies, in collaboration with WHO under a tripartite agreement, have agreed to work together in implementing One Health approach to contain AMR.
The United Nations General Assembly in its High-Level Meeting in September 2016 has given a call to collectively fight the burgeoning problem of AMR. This is only the fourth time in the history of United Nations General Assembly that a health subject has been debated. It indicates the recognition of AMR as a problem with immense implications for global development. AMR can adversely impact the global efforts to accelerate development.
The United Nation Sustainable Development Goals (SDGs) have recognised the importance of AMR and hence articulated it in the text of the SDG declaration (paragraph 26). Like the Millennium Development Goals (MDGs), several SDGs will depend on sustained availability of affordable and efficacious antibiotics. Mortality and morbidity, especially in vulnerable populations of new-borns, children and women, could escalate if AMR is not effectively contained.
Governments need to develop and harmonise national policies and plans that are implemented through sustainable financing and are based on the WHO global action plan on AMR. Approaches that incorporate the whole of society and are based on the concept of One Health (approaches aim to improve health for people, domestic animals, wildlife and the environment), with cooperation among health, agriculture, water and waste, finance and civil society, are essential.
National action plans should aim at improving awareness, strengthening of critical national capacities, such as surveillance, infection prevention and control, optimal use of antibiotics and immunisation for both people and animals.
In many developing countries, the national burden of AMR remains unknown. Existing AMR data are primarily from tertiary health-care facilities which carry questionable quality and lack geographical representativeness. Epidemiological linkages between rampant use of antibiotics in veterinary and environment sectors and AMR are not fully established. There has not been any significant study to demonstrate any evidence on impact of antibiotic residues in environment on AMR. This is an area in which medical microbiologists need to play an active role and contribute significantly.
Antibiotic resistance is a cross-sector issue that affects all of society. It needs to be addressed by all. It is a complex issue with profound impact on all developmental activities. It needs a proactive and aggressive approach.
To fight AMR and to pre-empt its major crisis now are the opportunity. It can be implemented at a fraction of the cost of responding to the crisis once it escalates manifold destroying the achievements made in the past 50 years and risking not only the benefits of medicine and associated technological advances but also the entire global development agenda as enunciated in the SDGs. A global multi-sectoral approach, with clearly defined roles, responsibilities and accountability, is key to combatting AMR.
The battle to combat AMR is a long drawn one and to win it the countries have to allocate adequate financial resources and sustained political commitment, ensure inter-sectoral response with focus on changing behaviour of prescribers and users and advocating with local authorities to implement activities in a concerted, efficient and effective way.
| ~ References|| |
Ochiai RL, Acosta CJ, Danovaro-Holliday MC, Baiqing D, Bhattacharya SK, Agtini MD, et al.
A study of typhoid fever in five Asian countries: Disease burden and implications for controls. Bull World Health Organ 2008;86:260-8.
Sutrisna A, Soebjakto O, Wignall FS, Kaul S, Limnios EA, Ray S, et al.
Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from East Java and Papua, Indonesia, in 2004-implications for treatment. Int J STD AIDS 2006;17:810-2.
Gupta A. Multidrug-resistant typhoid fever in children: Epidemiology and therapeutic approach. Pediatr Infect Dis J 1994;13:134-40.
Mauldin PD, Salgado CD, Hansen IS, Durup DT, Bosso JA. Attributable hospital cost and length of stay associated with health care-associated infections caused by antibiotic-resistant gram-negative bacteria. Antimicrob Agents Chemother 2010;54:109-15.
Farmer P, Walton D. The social impact of multi-drug-resistant tuberculosis: Haiti and Peru. In: Gandy M, Zumla A, editors. The Return of the White Plague: Global Poverty and the 'New' Tuberculosis. London: Verso; 2003. p. 167.
Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, et al.
Global antibiotic consumption 2000 to 2010: An analysis of national pharmaceutical sales data. Lancet Infect Dis 2014;14:742-50.