The Silent Tsunami of Superbugs
The Silent Tsunami: Antimicrobial Resistance
In the wake of the Covid-19 pandemic, a new, potentially more devastating threat looms on the horizon: antimicrobial resistance (AMR). Dame Sally Davies, England's former chief medical officer and current UK special envoy on AMR, warns that the consequences of unchecked AMR could dwarf those of the recent pandemic. The loss of her goddaughter to a drug-resistant infection has made this issue deeply personal for Davies, who now tirelessly advocates for global action.
Drug-resistant infections, also known as superbugs, are already a significant global health concern. They are estimated to cause at least 1.2 million deaths annually, a figure that could rise dramatically if the issue is not addressed. AMR occurs when bacteria, viruses, fungi, and parasites evolve to resist the drugs designed to kill them. This evolution is accelerated by the overuse and misuse of antimicrobials, particularly antibiotics.
The implications of widespread AMR are profound. Many common medical procedures, from caesarean sections to cancer treatments, rely on antibiotics to prevent and treat infections. Without effective antimicrobials, these procedures would become significantly riskier, potentially setting modern medicine back decades. Davies paints a bleak picture of a future where untreatable infections are rampant, necessitating the isolation of infected individuals to protect their families and communities.
The Global Threat of Antimicrobial Resistance (AMR)
The World Health Organization (WHO) has identified AMR as one of the top 10 global public health threats facing humanity. It poses a significant risk to global health security and could undermine decades of progress in medicine and public health. The economic impact of AMR is also substantial. A 2016 report estimated that by 2050, AMR could cause 10 million deaths annually and cost the global economy up to $100 trillion.
Despite these dire warnings, progress in tackling AMR has been slow. Few new antibiotics have been developed in recent years, and the pipeline for new drugs is worryingly thin. The Covid-19 pandemic further exacerbated the problem, diverting resources and attention away from the fight against AMR.
Davies, however, remains optimistic. She points to recent advancements in genomics and artificial intelligence that are revitalising the science of antibiotic discovery. She also highlights the growing recognition of the AMR threat at the highest levels of government and international organisations. In 2016, the United Nations General Assembly adopted a political declaration on AMR, committing member states to develop national action plans to tackle the problem.
The UK government has recently announced a national action plan on AMR, pledging to reduce the use of antimicrobials in both humans and animals, strengthen surveillance of drug-resistant infections, and incentivize the development of new drugs and vaccines. These are positive steps, but much more needs to be done.
A Personal Tragedy Fuels a Global Mission
The death of Davies' goddaughter, Emily Hoyle, from a drug-resistant infection, has further fuelled her determination to tackle AMR. Hoyle, who suffered from cystic fibrosis, had undergone two lung transplants before succumbing to a Mycobacterium abscessus infection, a bacterium known for its resistance to multiple antibiotics. Hoyle's tragic death underscores the urgency of the AMR crisis and its devastating impact on individuals and families.
Davies recalls the last months of Hoyle's life with a mix of sadness and admiration. Despite knowing her prognosis, Hoyle maintained her dignity and humour, even joking about her situation with family and friends. Her courage in the face of death inspired Davies to share her story and raise awareness about AMR.
Hoyle's death serves as a poignant reminder of the intergenerational injustice inherent in the AMR crisis. Older generations have benefited from the widespread availability of antibiotics but have not done enough to ensure the development of new drugs to replace those that are becoming ineffective. This leaves younger generations vulnerable to untreatable infections.
The burden of AMR is not evenly distributed. Children under five, particularly those in sub-Saharan Africa, are disproportionately affected. In these regions, where access to healthcare is often limited, drug-resistant infections are a major cause of death. This disparity highlights the global inequities in health and the urgent need for coordinated international action to address AMR.
The Link Between AMR and Climate Change
The AMR crisis is further compounded by the climate crisis. Rising temperatures, changing rainfall patterns, and extreme weather events can all contribute to the spread of drug-resistant infections. Floods and droughts can contaminate water sources, increasing the risk of waterborne diseases. Displacement of populations due to climate-related disasters can lead to overcrowding and unsanitary conditions, creating ideal breeding grounds for superbugs.
Davies warns that if left unchecked, AMR could kill more people than climate change in the coming decades. The two crises are interconnected, and addressing one will require tackling the other.
The Overuse of Antibiotics in Agriculture
One of the main drivers of AMR is the overuse of antibiotics in agriculture. More than two-thirds of antibiotics produced globally are used in farm animals, often to promote growth or prevent infections in crowded and unsanitary conditions. This widespread use of antibiotics creates a selective pressure that favours the survival and spread of drug-resistant bacteria.
The problem is particularly acute in some Asian countries, where antibiotics are routinely added to fish food, contributing to the rise of drug-resistant bacteria in aquaculture. The lack of research into fish diseases and vaccines further exacerbates the problem.
Davies emphasises the importance of responsible antibiotic use in agriculture. She advocates for a "One Health" approach that recognises the interconnectedness of human, animal, and environmental health. This approach calls for coordinated action across sectors to reduce the overuse of antibiotics and prevent the spread of drug-resistant infections.
Environmental Contamination and the Spread of AMR
The environmental impact of antibiotic overuse is another critical aspect of the AMR crisis. Animals, including humans, excrete a significant portion of the antibiotics they ingest, contaminating the environment. This contamination can occur through various pathways, including wastewater from farms and pharmaceutical factories, runoff from agricultural fields, and the disposal of animal waste.
The presence of antibiotics in the environment creates a selective pressure that favours the survival and spread of drug-resistant bacteria. These bacteria can then be transmitted to humans through contaminated food and water, direct contact with animals, or inhalation of contaminated air.
The environmental dimension of AMR is often overlooked, but it is an essential piece of the puzzle. Addressing AMR requires a comprehensive approach that considers not only human and animal health but also the health of the environment.
Innovations and Incentives: A Glimmer of Hope
Despite the challenges, there are reasons for optimism. Scientific breakthroughs, such as the development of rapid diagnostic tests that can identify drug-resistant infections, are helping to improve the appropriate use of antibiotics. These tests can help doctors determine which antibiotic, if any, is needed to treat a particular infection, reducing the unnecessary use of these drugs.
New approaches to drug development, such as the use of artificial intelligence to screen vast libraries of compounds for potential antibiotics, are also showing promise. These approaches could help to accelerate the discovery of new drugs and replenish the dwindling arsenal of effective antimicrobials.
Governments and international organisations are also taking steps to incentivise the development of new antibiotics. These incentives include push and pull mechanisms. Push mechanisms provide funding for research and development, while pull mechanisms provide market incentives, such as extended patent protection or guaranteed purchase agreements, to encourage companies to invest in antibiotic development.
One example of a pull mechanism is the subscription model being explored by NHS England. Under this model, the NHS would pay a fixed annual fee for access to a portfolio of antibiotics, regardless of how much they are used. This approach aims to delink the profitability of antibiotics from their sales volume, incentivizing companies to develop new drugs even if they are not expected to be blockbusters.
The Role of Global Leadership and Collaboration
International collaboration is essential to tackle the global AMR crisis. In 2015, the World Health Assembly endorsed a Global Action Plan on AMR, which outlines five strategic objectives: improving awareness and understanding of AMR, strengthening surveillance and research, reducing the incidence of infection, optimizing the use of antimicrobial medicines, and ensuring sustainable investment in countering AMR.
The UN Global Leaders Group on AMR, of which Davies is a member, is working to accelerate progress towards these objectives. The group is pushing for ambitious targets to be adopted at the UN high-level meeting on AMR in September 2023. These targets include reducing global human deaths from AMR by 10%, cutting antimicrobial use in agriculture by at least 30%, and ending the use of medically important antimicrobials for growth promotion in animals.
Davies stresses the need for a formal intergovernmental body on AMR, similar to the Conference of the Parties (COP) on climate change. Such a body could provide a platform for global cooperation and coordination, ensuring that all countries are working together to tackle this shared threat.
A Global Call to Action
The fight against AMR is not just a matter of scientific innovation and policy change; it also requires a fundamental shift in societal attitudes towards antibiotics. Davies emphasises the importance of public awareness and education. People need to understand that antibiotics are not a panacea for all infections, and their overuse can have serious consequences.
The Covid-19 pandemic has demonstrated the power of public health messaging and behaviour change. Similar campaigns are needed to educate the public about AMR and promote responsible antibiotic use. This includes raising awareness about the importance of vaccination, good hygiene practices, and infection prevention and control measures.
The pharmaceutical industry also has a crucial role to play. Companies need to invest in research and development to bring new antibiotics to market. However, they also need to ensure that these drugs are used responsibly and not overpromoted or misused.
The AMR crisis is a complex problem with no easy solutions. However, with concerted global action, it is a problem that can be solved. By reducing the overuse and misuse of antibiotics, investing in new drug development, and promoting responsible antibiotic use, we can protect ourselves and future generations from the devastating consequences of AMR.
One Health: A Holistic Approach to AMR
The One Health concept is central to the fight against AMR. It recognises that the health of humans, animals, and the environment are inextricably linked. This means that addressing AMR requires a coordinated effort across sectors, involving healthcare professionals, veterinarians, farmers, environmental scientists, policymakers, and the public.
The One Health approach is not new. It has been used to address other global health challenges, such as zoonotic diseases like Ebola and SARS. However, its application to AMR is relatively recent.
The One Health approach to AMR involves several key strategies:
Surveillance and monitoring: This includes tracking the emergence and spread of drug-resistant infections in humans, animals, and the environment. This information is essential for identifying trends, assessing risks, and guiding interventions.
Infection prevention and control: This involves implementing measures to prevent the spread of infections in healthcare settings, farms, and communities. This includes promoting hand hygiene, vaccination, and the safe disposal of waste.
Antimicrobial stewardship: This involves promoting the appropriate use of antibiotics in both human and veterinary medicine. This includes ensuring that antibiotics are prescribed only when necessary and that the correct drug is used at the right dose and for the right duration.
Research and development: This includes investing in research to develop new antibiotics, alternative therapies, and vaccines. It also involves research to better understand the mechanisms of AMR and how to prevent and control its spread.
Collaboration and communication: This involves fostering collaboration between different sectors and stakeholders, including healthcare professionals, veterinarians, farmers, environmental scientists, policymakers, and the public. It also involves communicating effectively with the public about AMR and the importance of responsible antibiotic use.
The One Health approach is a comprehensive and integrated approach to AMR. It recognises that the health of humans, animals, and the environment are interconnected and that addressing AMR requires a coordinated effort across sectors.
The Path Forward: A Collective Responsibility
Tackling AMR requires a multi-faceted approach that addresses the root causes of the problem. This includes:
Reducing the demand for antibiotics: This can be achieved through improved sanitation and hygiene, vaccination programmes, and public education campaigns promoting responsible antibiotic use.
Improving access to quality healthcare: This includes ensuring that people in low- and middle-income countries have access to affordable diagnostics and treatments for infections.
Investing in research and development: This includes developing new antibiotics, alternative therapies, and vaccines, as well as improving our understanding of the mechanisms of AMR.
Strengthening regulatory frameworks: This includes implementing and enforcing regulations to control the use of antibiotics in both human and veterinary medicine.
Promoting international collaboration: This includes sharing data and best practices, coordinating research efforts, and supporting capacity building in low- and middle-income countries.
Conclusion
The AMR crisis is a global challenge that requires a global response. No single country or sector can solve this problem alone. We need a coordinated effort from governments, international organisations, the pharmaceutical industry, healthcare professionals, farmers, and the public.
The fight against AMR is a race against time. The longer we delay, the more difficult and costly it will be to address this problem. The Covid-19 pandemic has shown us the devastating consequences of inaction in the face of a global health threat. We cannot afford to make the same mistake with AMR.
Dame Sally Davies's warning is a stark reminder of the urgency of the AMR crisis. Her personal loss has given her a unique perspective on the devastating impact of drug-resistant infections. Her tireless advocacy and leadership are an inspiration to us all.
The fight against AMR is a fight for the future of global health. It is a fight for our children and grandchildren, for the millions of people who are already suffering from drug-resistant infections, and for the countless others who could be affected in the future.
We have the knowledge, the tools, and the resources to tackle AMR. What we need now is the political will and the collective commitment to act. The time to act is now.
