The other ‘pandemic’: Worsening antimicrobial resistance needs to be battled with better vaccine coverage, safe drinking water & proper sanitation

By Jyoti Joshi & Erta Kalanxhi

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As the world deals with the acute ravages of Covid-19, the collateral damage on other public health threats is apparent. The previous decade witnessed an unprecedented global political coordination for control of one of the top global health threats: antimicrobial resistance (AMR).

However, experts fear a surge in antibiotic use and disruption of stewardship practices may have slowed down or even reversed progress. AMR is a natural process that is accelerated by increasing levels of antibiotic use, shortening the time microbes including bacteria need to acquire resistance to new drugs. Such resistance threatens the existence of effective treatment options and our ability to control and prevent infections.

Although AMR is a global problem, its prevalence varies with antibiotic consumption levels, vaccination coverage, and access to clean water, sanitation and quality healthcare. Based on AMR data from 66 countries, the latest WHO report gives a concerning insight into AMR’s global status that countries are increasingly reporting high rates of resistance among common antimicrobials.

Several challenges need to be met to tackle AMR, and multi-sectoral work across the human, animal, and environmental health domains is critical. Though National Action Plans (NAPs) to contain AMR have been announced by almost 100 countries, turning these into action has proven difficult. So while resistant genes to every natural and synthetic antimicrobial compound is known, the inter-linked national surveillance systems that track AMR in human and animal populations are still in a nascent stage in most countries. Unlike humans, drug-resistant pathogens do not need a passport to travel across countries, as evidenced by reports of spillover of resistance into humans and backyard chicken from intensive poultry farms in remote settings with no prior history of agricultural antimicrobial use. Following the current trends, in the absence of stringent measures, antibiotics consumption by 2030 is expected to increase by 11.5% in animals, and by a staggering 200% in humans compared to 2015. One Health, a collaborative, multisectoral, and transdisciplinary approach needs to be implemented at the local, regional, national, and global levels by recognising the interconnection between people, animals, plants, and their shared environment to achieve best public health outcomes. Though complex, it is essential to preserve our antibiotics for future generations.

Increased vaccination coverage, infection control and prevention, and clean water and sanitation can reduce the need for antibiotics in both animals and humans. Stewardship programs are also important to promote the judicious use of antibiotics across all sectors.

Recently, the Center for Disease Dynamics, Economics & Policy, released The State of the World’s Antibiotics in 2021, containing country dashboards showing the status of AMR and use in humans and animals across 40 countries. The dashboards were designed to help countries assess and track their AMR status and prioritise actions.

AMR-relevant measures in the dashboards represented four categories: policy indicators; antimicrobial resistance indicators; antimicrobial use indicators; and public health indicators. Where available, Drug Resistance Index (DRI) scores, an aggregate measure of antibiotic effectiveness to treat bacterial infections, were presented for two groups of important bacterial pathogens. Combining antibiotic use and resistance in one metric, the DRI overcomes the challenge of conveying national AMR burden given the complexity surrounding the drugs’ varying efficacy against different pathogens.

Lower- and middle-income countries (LMICs) are projected to have the highest DRI scores not just because of a high AMR burden but also a lower ability to treat infections due to limited access to newer and more effective antibiotics.

Additionally, the global rise in demand for animal protein also has profound effects on environmental and human health. Antimicrobial consumption in animals is nearly triple that of humans as antibiotics are used to treat and prevent infection as well as to promote rapid growth.

While the danger of drug resistance looms, access to life-saving antibiotics in LMICs remains a critical issue. More people in LMICs die from lack of access to antimicrobials than from resistant infections. Global efforts to mitigate AMR must also increase access to affordable and clinically appropriate antimicrobials.

India announced its NAP-AMR in September 2017 and has since established surveillance systems for tracking AMR. Addressing AMR by the universalisation of Haemophilus type B(Hib) within the Universal Immunization Program (UIP) through pentavalent vaccine, introduction of Pneumococcal Conjugate Vaccine (PCV) and Rotavirus Vaccine (RVV) in select states is valuable. Lowered disease prevalence leads to a reduction in antibiotic misuse, ultimately slowing down emergence of AMR. Swachh Bharat Abhiyan for sanitation, and the Kayakalp Scheme for improved water, sanitation and hygiene services in health care facilities are also likely to impact AMR. However, issues affecting access to health services, lack of regulations and processes for bringing new drugs to local markets, and weak local and national drug supply chains cause frequent drug stock-outs to remain. In the animal sector, work remains for tackling AMR as India (together with China) represents the largest hotspots of resistance.

AMR is a clear and present danger to global health. The DRI and dashboards are designed to help government officials, policymakers, and healthcare stakeholders assess and track AMR status over time and in relation to other countries and then prioritise actions to sustain the effectiveness of current antimicrobials.

Joshi is head (South Asia) & Kalanxhi is post-doctoral fellow, Center for Disease Dynamics, Economics & Policy (CDDEP)