WASHINGTON, DC/UPPSALA – When the World Health Organization launched last year’s World Antimicrobial Awareness Week, it expanded the campaign’s focus from antibiotics to all antimicrobials – including antiviral, antifungal, and antiprotozoal drugs. The WHO said that framing the response to antibiotic resistance (ABR) within the broader antimicrobial resistance (AMR) agenda, including HIV and malaria, would “facilitate programmatic synergy and efficiency, and catalyze country-level action to combat drug-resistant infections.” But although there are many commonalities between ABR and AMR, there are also important differences that justify paying specific attention to antibiotics.
ABR has been a slow-growing pandemic, fueled in part by relatively weak political support for implementing national action plans that include the establishment of well-resourced surveillance systems. The resulting lack of context-specific data on the health and economic burden of resistance has created an obstacle to policy action.
Although aggregate numbers on the global AMR burden exist – the most cited, from the United Kingdom’s independent 2014-16 AMR review, chaired by the economist Jim O’Neill, put the toll at 700,000 deaths per year – these underrepresent the ABR problem, owing to the limited scope of bacteria covered. In fact, estimates suggest that ABR alone claims more than 750,000 lives every year, with the largest toll most likely occurring among children in the poorest countries. In a recent global survey, 79% of physicians treating newborns reported an increasing trend of multi-drug-resistant infections over the last five years, while 54% cited ABR as the leading cause of failure to treat neonatal sepsis, a blood infection affecting newborns.
In the past, the drug-resistance problem has typically been addressed by researching and developing new antibiotics. But although R&D is an important element of the ABR response, it is scientifically challenging and expensive. In effect, an arms race between drug development and resistance has ensued. With few novel antibiotics in the development pipeline, we need incentives to spur R&D while decoupling investment returns from sales volumes in order to slow the evolution of resistance.
At the same time, new drugs coming to market must be accessible and affordable for all those who need them. The additional median overall cost of resistance imposed by moving to second-line treatments can be significant, amounting to $700 per infection. In fragile states where out-of-pocket payments by individuals account for 55% of total health expenditure, this can have catastrophic consequences, including increased morbidity and mortality, and long-term impoverishment.
The health and economic costs of ABR must be quantified to convince governments to intervene and strengthen incentives for the development of antibiotics. That, in turn, will justify the investments and public-private partnerships needed to bring new drugs to market.
The fact that ABR seems to be winning the arms race makes it even more important to preserve existing antibiotics. But there is no one-size-fits-all way to do this. In many countries, for example, increased access to drugs is imperative to reduce unnecessary morbidity and mortality from bacterial infections. Initiatives such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria have partly addressed the issue of access to effective antiretroviral, anti-TB, and antimalarial drugs.
But as a WHO report puts it, “there is no similar funding or distribution mechanism to cater for the corresponding needs for effective antibiotics against the broad range of common bacterial infections in developing countries.” In this context, the newly established Multi-Partner Trust Fund is an important step in the right direction. Although the fund’s financial scope is still modest, it will support countries in implementing national action plans against the threat of AMR, including ABR.
Balancing the need to preserve antibiotics’ effectiveness while expanding access to them is challenging, because wider use inevitably will increase ABR. The problem is compounded in many poorer countries, where civil conflicts, poor hygiene and nutrition, and unreliable water supplies risk facilitating the rapid spread of resistant pathogens. But the full extent of the problem remains hidden, owing to the lack of national surveillance systems for monitoring antibiotic drug use and resistance. A health-systems approach is critical to ensure that unintended consequences of controlling ABR do not hamper equitable and sustainable access to life-saving drugs.
Africa has recently made important progress in this regard. Last September, African Union heads of state and government endorsed a common position on controlling AMR. In addition, Africa is leading the way in collaborative efforts on COVID-19, including the roll-out of cutting-edge technologies such as digital surveillance and next-generation sequencing. These could become an essential component of the Africa Centres for Disease Control and Prevention’s AMR Surveillance Network, which aims to connect actors from the human and animal health sectors. Such efforts are particularly important in the African context, where many low-income and fragile countries are expected to bear the brunt of AMR’s negative consequences.
The growing ABR problem does not respect national borders. It is essentially the result of multiple systemic failures, which only urgent global collective action can overcome.