A university student in India with tuberculosis, a veterinarian in Kenya hospitalized for months with a post-surgery infection, a US gymnast suffering from staph bacteria, an Indonesian baby plagued by respiratory illness, vomiting and diarrhea: all are suffering from what the World Health Organization (WHO) describes as a “silent pandemic” of antibiotic-resistant bacteria.
These antibiotic-resistant bacteria are responsible for almost 5 million deaths each year, even when other causes of death are recorded, and are the direct cause of 1.27 million deaths. Sub-Saharan Africa and South Asia have the highest antibiotic resistance mortality rates, with over 20 deaths per 100,000 people, compared to an average of 13 in developed countries.
Improved measures such as hand washing and disinfection in health care settings, access to clean water, and more widespread use of childhood vaccines could prevent around 750,000 deaths per year linked to superbugs, especially in low- and middle-income countries. This is one of the conclusions of a series of four articles on “Sustainable Access to Effective Antibiotics” recently published in the scientific journal The Lancet. The authors, 38 experts in antimicrobial resistance and global health from around the world, warn that this is a growing problem and that the number of deaths will increase if not addressed. A 2016 study estimated that by 2050, there could be 10 million deaths per year, most of which will occur among the world's most vulnerable groups.
“Particularly in resource-poor settings, the pool of effective antibiotics is smaller, leaving young children, the elderly and seriously ill patients particularly vulnerable to resistant infections,” says the first of four reports, which highlight the global scale of the problem and how to measure it. Antibiotic resistance “poses a major obstacle to achieving the Sustainable Development Goals, including goals such as newborn survival, healthy ageing and poverty alleviation.”
Without action, more people will become infected with resistant infections and die, and treatment will become more expensive and inaccessible to those in the most resource-limited settings.
Iluka Okeke, Professor of Pharmaceutical Microbiology, University of Ibadan, Nigeria
Co-author Iluka Okeke, professor of pharmaceutical microbiology at the University of Ibadan in Nigeria, described what will happen if urgent action is not taken: “If we do not take action, more people will become infected and die from resistant infections. Resistance to last resort drugs may more than double by 2035 compared to 2005. Treatments will become more expensive and may become inaccessible to people in the most resource-limited settings.”
These resource-limited settings, with their high incidence of infections and low healthcare capacity, are “the ones that stand to benefit most from curbing antimicrobial resistance” through existing measures, Okeke explains. Improving infection prevention and control in low- and middle-income countries could prevent 337,000 deaths per year from resistant bacteria acquired in health centers (one of the most common forms of infection) out of the 1.7 million deaths currently occurring in these countries annually.
Prevention and control primarily require strict adherence to hygiene standards, including hand washing by health care workers, environmental cleanliness, antiseptic techniques, and improved disinfection and sterilization measures to prevent the infection from spreading to patients through catheters, ventilators, and surgery. To reduce the number of deaths, prevention and control standards in these countries need to be aligned with those in high-income countries, according to a mathematical model developed by the study authors and discussed in the second article in the series.
Triple Goal
The study also estimates how many deaths could be averted through universal access to water, sanitation and hygiene services in these countries, which it says could prevent 247,800 deaths related to antimicrobial resistance, but the article warns that reaching this figure would require higher quality interventions than those currently proposed.
Another strategy is to achieve universal access to childhood vaccines, which the analysis found could avert 181,500 deaths by directly preventing resistant infections and reducing antibiotic consumption.
Okeke believes these interventions would reduce mortality from resistance by 18% in developing countries, which he believes is “realistic even in resource-limited settings.” In their fourth paper, the authors of the Lancet series set out three global goals for 2030: a 10% reduction in antimicrobial resistance, a 20% reduction in inappropriate use of antibiotics in humans, and a 30% reduction in inappropriate use of antibiotics in animals. To achieve these goals, the authors call for the UN General Assembly to prioritize their proposed actions in September.
According to the study, “Our findings indicate that a 10% reduction in the global incidence of antimicrobial resistance by 2030 is achievable with existing interventions. Our findings should guide investments in public health interventions directed at those with the greatest potential to reduce resistance.”
But these efforts alone are not enough to ensure that everyone who needs them has access to affordable and effective medicines: “The rise in bacterial infections around the world that are resistant to currently available antibiotics highlights the need for investment in and access to new antibiotics, vaccines and diagnostics,” notes the third article in this series.
Ensuring Access
“Traditional drug development models that rely on large revenues to drive investment are no longer economically viable without incentives,” the study states. “Furthermore, medicines developed through these mechanisms are unlikely to be affordable for all patients who need them, especially in low- and middle-income countries.” The authors call for “new public financing models based on public-private partnerships” to support investment in antibiotics and new alternatives and reduce the burden on patients.
Nour Shamas, 36, a Lebanese clinical pharmacist specializing in infectious diseases, is aware of the problem not only through her job, but also because several years ago, her mother, now 69, suffered from difficult-to-treat, recurrent urinary tract infections after being hospitalized for spinal surgery. Shamas praises the measures suggested in the Lancet article, but points out that even though they seem so simple, “each one has its own challenges.” “For example, hand-washing. Even if there is clean water and soap, hospitals may not have enough nurses, so they are severely overwhelmed,” she points out. “Nurses may not wash their hands, or if they do wash their hands, they may not scrub them for 30 seconds, or they may forget as they go from patient to patient. Also, some get tired and burnt out.”
Speaking from Riyadh, where she works, Shamas says she is blessed to have access to the costly antibiotics and tests her mother needs every two to three months in Lebanon, a country in a time of crisis where it is difficult to access even for those with money. “We paid for a test to see what resistance she has, to identify the best antibiotic to treat the first episode,” she explains. Now, whenever the infection returns, her mother has to undergo another test to determine which antibiotic to use. “Usually we start with one type of antibiotic and then have to switch to another after a few days.”
Shamas is part of a WHO working group of 12 antimicrobial resistance patients and their families, which published a comment in response to the Lancet article, saying: “We call on all those working on antimicrobial resistance to consider the patient voice and adopt a people-centred approach in their work. Antimicrobial resistance transcends borders, visa requirements and conflict zones. It can affect anyone, regardless of wealth, race or region of the world.”
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