By Dorien Lijnzaad and Candela Iglesias Chiesa
For years, we’ve been used to the fact that the biggest infectious killers are HIV, Tuberculosis and Malaria. Then COVID-19 came to disrupt that notion. And earlier this year a report by the Lancet came out with a new shocking finding altering this top list of the biggest infectious threats. So what is this new menace?
Well, we’ve known about it for a while, but we just didn’t know it was responsible for so many deaths. It’s antimicrobial resistance (AMR). That is, infections by pathogens for which we have curative treatments (such as antibiotics and antivirals), but which develop resistance against those treatments.
The Lancet report found that whereas it was previously estimated that 700,000 people die yearly as a result of antimicrobial resistant infections, this number is now estimated to be close to 1.3 million deaths annually (2019). Antimicrobial resistance was confirmed as a leading cause of death from infectious diseases worldwide (pre-COVID-19), more than TB, HIV or Malaria, with the biggest burden of disease being carried by low-resource regions.
It is clear that antimicrobial resistance is one of the major health challenges of our time, but the sheer size of the problem and its complexity (we’re dealing with a variety of different pathogens and it cuts across sectors) can feel daunting to tackle. At Alanda, we think it’s important that we all become knowledgeable about AMR, and what we can do at the individual level to fight it and to protect ourselves and our loved ones. So let’s break it down.
What is AMR?
Antibiotic or antimicrobial resistance (AMR) is the capacity of microbes – like bacteria, viruses, parasites and fungi – to become resistant to the drugs that are designed to kill them. In the case of bacteria, this means that antibiotics lose their effectiveness, and we lose the ability to treat and cure even common infections.
When exposed to antibiotics or antifungals, microbes develop defence strategies against the drugs called resistance mechanisms. Although a majority of microbes will not survive the drugs, a portion of microbes will have the right combination of resistance mechanisms necessary to fend off the attack – meaning they survive. Surviving microbes will then multiply and can also share their resistance mechanisms with other microbes, and so resistance spreads.
Figure 1. How does AMR develop? (1) Bacteria cause an infection in a person. The person is treated with antibiotics .The red bacteria are resistant to the treatment. (2) The red bacteria survive while the blue bacteria are killed. (3) The red bacteria now have no competition from the blue bacteria, and can multiply (even in the presence of the initial antibiotic). (4). Red resistance bacteria can also share their resistant attributes (red sticks) with other bacteria (here in blue), in a process called horizontal transfer, resulting in an altered (blue) bacteria that has gained the antibiotic resistance traits (red sticks).
So why should I care? – The consequences of AMR
AMR has been around since the very first antibiotic – penicillin – was discovered. It is nothing new. However, the Lancet report shows that AMR has grown into a much bigger public health issue with serious consequences than it has been in the past.
But what does a world with high levels of AMR look like? Why are scientists and medical staff so scared?
Modern medicine as we know it relies heavily on antibiotics and other antimicrobial treatments. We are so used to a world where antimicrobials are easily available to treat so many of our infections that it is easy to take them for granted:
Vaginal infection? It’s easy to get an over the counter antifungal for the most common causes of infection and get rid of it in a day or two.
Tonsillitis caused by streptococcus? A short antibiotic treatment should make you feel better in no time.
Had unprotected sex with someone who turned out to have chlamydia? An easy antibiotic course solves the issue just like that.
In a world where AMR is much more widespread, treating some of these common infections will become difficult. The most commonly used type of antibiotics against them will be useless, and so-called second, third or fourth-line treatments, which tend to be longer and have more side effects, might be needed.
For some bacteria, we might actually run out of options. Unthinkable today, people may die of gonorrhoea, pneumonia or diarrhoea, because there will be no antibiotics available that are still effective.
Antibiotics are also used to prevent infections in many medical interventions, such as chemotherapy, transplants, and many common surgeries from caesarean sections to appendicitis. Widespread AMR will also mean that these common interventions will become too dangerous to perform due to the increased risk of infection that cannot longer be prevented by antibiotics.
The other side of the AMR threat is economy-related, affecting individuals, governments and societies. That’s because second, third and fourth line treatment options are usually more expensive, treatments are longer, and may even require longer stays in hospital, adding to the healthcare costs. Additionally, infections in general will last longer as doctors fight with diminishing tools to get rid of them.
The World Bank estimates that by 2050, 28.3 million people will be pushed into extreme poverty by AMR due to catastrophic out-of-pocket expenditures. The annual global Gross Domestic Product (GDP) could drop by 3.8%, with low-income countries potentially losing more than 5% of their GDP. The impact of AMR will thus fall disproportionately on already vulnerable populations where health systems are not well-equipped to cope with this pressing issue.
Ok, this is serious, but what got us here? – The causes of AMR
Figure 2. How does AMR spread? (1) When antimicrobials are consumed by people or animals, resistant bacteria can develop in their systems. (2) Through consumption of animal products (3) or physical contact with people (in particular in a hospital setting), this can be spread to the general population. In addition, (4) through waste water and manure, resistant pathogens can end up in our soil and waters. (5) When we eat crops or drink water, these can also be transmitted to the general population .You can see that all of the sectors are interconnected, so we have the opportunity to tackle AMR at all these different levels.
A big reason why AMR is such a complicated issue is that its roots lie not only inside the health sector, but also outside of it. As a general rule, AMR is caused by excessive and inappropriate use of antimicrobials. This excessive and inappropriate use certainly happens in the health sector. But other, bigger sources of AMR lie in agriculture and livestock (industrial practices). Waste disposal practices and international travel can also be apportioned their share of responsibility. Let’s look at each in more detail.
Health sector – AMR can develop because of overprescribing of antibiotics, incorrect diagnosis (e.g. prescribing antibiotics, which kill bacteria, for a viral infection), not finishing the treatment course and self-medication.
Agriculture and animal breeding – Antimicrobials are used in treating livestock and plant disease to help ensure food security. Antimicrobials are often also used preventatively and for animal growth promotion, especially in industrial farming. Recent estimates reveal that 73% of all antibiotics worldwide are used in animals raised for food. Due to the high exposure to antimicrobials in the livestock sector, AMR can develop and spread to humans through the food we eat and the physical contact we have with animals.
Water disposal – any time we use antimicrobials, some form of the medicine ends up in our environment via sewages and waste-water. Even low doses of antimicrobials in our soil and drinking water can promote the development and spread of AMR. Particularly in health care facilities, inadequate disposal of waste containing high amounts of antibiotics can create the rise and spread of ‘superbugs’ that are resistant to multiple types of antimicrobials.
International travel and migration – Although international travel does not directly cause development of AMR, it does facilitate global spread of resistant microbes. Continuous movement of people and goods across the world means that emergence of resistance in one place in the world poses a problem for all of us.
Looking at the topics above, it would seem that AMR would be easy to solve: impose strict regulations on antibiotic use in people, prohibit or restrict their use in agriculture and enforce safe waste water disposal. The challenges in establishing rules across sectors are however, huge, due to short term economic interests, among other issues.
Moreover, solutions that work in high income countries might infringe basic human rights in a different context. For example, should a severely ill child be denied treatment if the only antibiotic available is broad-spectrum? Should a struggling small-scale farmer risk their livelihood letting their cattle get infected? Solving AMR must therefore avoid a one-size-fits-all but take a holistic approach.
This is terrible, what is being done to tackle AMR? – The way forward
So, where do we go from here? Although AMR has been long recognised as a global health threat, progress has been slow due to its complexity and not enough political commitment.
To ensure the holistic approach mentioned above, the WHO and many governments have adopted the One Health approach to AMR: a collaborative, multisectoral and transdisciplinary approach that recognises the interconnection between people, animals, plants and their shared environment.
Deforestation, shifting climate zones, globalised travel and trade and intensive farming and livestock raising practices have drastically altered the way humans, animals and plants co-exist. One Health dictates that our interaction with the world around us should be centred in our efforts to prevent the rise of new epidemics and resistant pathogens.
The plan to solve AMR will include many different interventions, stakeholders and considerations, and the WHO has put forward a Global Action Plan on AMR. This plan focuses on a number of things, including prevention and access, which we describe below.
A) PREVENTION of infection is the most effective way to reduce antimicrobial consumption and thus AMR. Examples of this are improving sanitation and hygiene and access to safe water, accessible vaccination programs that protect people from vaccine-preventable diseases and good sexual education so that people can protect themselves from STIs.
B) EQUITABLE ACCESS to and APPROPRIATE USE of existing and new antimicrobial medicine so that treatment of infections remains possible. This means, among others, investing in the research and development of new antibiotic classes in a way that guarantees access to affordable medication for all, as well as establishing stronger regulation mechanisms to make already existing antibiotics accessible to those in need.
Governments across the globe have started to establish their own action plans, but many countries struggle to implement such a plan and usually lack policies aimed at agricultural, livestock, and environmental sectors.
However, the COVID-19 pandemic has brought the danger of infectious diseases to a much broader audience and has proven that it is possible to have collective forward action with effective international cooperation. This presents a new opportunity to revitalise and expand infectious disease preparedness and recovery plans, including for AMR, at a high political level.
What can I do at the individual level?
Figure 3: What can you do? (1) Be critical of your own medical consumption of antibiotics and listen to advice from medical professionals, keeping in mind not all infections respond to antibiotics. (2) Dispose of your unused antibiotics in a safe way by handing them in at your local pharmacy. (3) Get vaccinated with the available vaccines in your country and follow general hygiene practices. (4) Advocate for reduced use of antibiotics in animal products and agriculture by using your voice or money. (5) Raise awareness of AMR and its importance in your own personal and/or professional circles.
An issue as big as AMR can feel daunting to the individual. Although the main drivers and responsibility for large-scale AMR reduction lies outside the scope of any individual, there is still plenty that you can do to help in the effort to reduce the negative effects of AMR.
First, you can be critical of your own medical consumption of antibiotics, especially if you live in a place where you have affordable access to medication.
– Keep in mind that there are infections that do not respond to antibiotics, such as viral throat infections which often do not require treatment other than rest, fluids, etc.
– Follow the advice from medical professionals when taking your antibiotics, ensure you take all recommended doses of treatment course even if your symptoms have already gone away. Taking all your antibiotic pills helps ensure that all of the illness-causing bacteria are killed or prevented from multiplying! If you stop the treatment midway there is a much higher chance that some bacteria may develop resistance.
Second, hand-in old antimicrobials to your pharmacy instead of throwing it in your regular trash. The pharmacy can dispose of it in a safe way.
Third, get vaccinated with the available vaccines in your country, and practice general hygiene measures such as washing hands, preparing food properly, safe sex practices and staying home to recover when ill. In this way, we can reduce the general spread of disease-causing microbes and as a result also prevent our use of antibiotics.
Fourth, you can advocate for the reduced use of antimicrobials in agriculture and meat, poultry and fish production. This can look like supporting animal welfare organisations, writing to supermarkets for affordable access to organic produce, or simply using your money to choose non-animal products or animal products with no antibiotic use.
Lastly, you can use your voice to advocate in your own circles and health care systems, by raising awareness and educating those around you and online. Education of school children, training of employees, empowerment and networking are all valuable ways to include everyone in the effort of reducing AMR. Health is precious to us all, and engaging your community in taking charge of their health and of generations to come can be a driving force of change.
To wrap it up, we are likely to enter an age where many infectious diseases may once again be a more imminent threat to populations across the globe. Thanks to COVID-19 now we know how disruptive and scary that can be. AMR has the potential to be an even bigger problem, which is why we need collective action at all levels.
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