Why antimicrobial resistance (AMR) calls for a multisectoral One Health approach – NOW
Photo: Nadia Said / GIZ
‘A simple operation could lead to a drug resistant infection that is difficult or perhaps impossible to treat. The medicines that we have come to rely on in our modern world are under threat,’ says Professor Lothar Wieler, the President of Germany’s Robert Koch Institute and a Member of the Global Leaders Group for Antimicrobial Resistance (AMR). In his video message to mark the occasion of World Antimicrobial Awareness Week (WAAW) in November 2021 he urged the world to recognise the severity of the AMR challenge.
One of the most serious global health threats of our times
While the world has been fixated with the Covid-19 pandemic and the climate crisis, AMR does not receive the public attention it deserves. The rapid emergence of resistant pathogens has been smouldering for decades threatening health systems, farming practices, animal rearing, the environment and more. In his video message to mark the occasion of WAAW in December 2021, Dr Haileyesus Getahun, Director of Global Coordination and Partnership on AMR at the World Health Organisation (WHO), describes the threat as ‘an active volcano that is on-going’. Perhaps one of the most important things to understand about it is that it is an evolutionary process and, as such, natural and unavoidable. Antimicrobials are drugs – most commonly antibiotics, antivirals, antiparasitic and antifungal agents – that kill or control disease-causing pathogens. AMR occurs when pathogens such as bacteria, viruses, parasites and fungi that antimicrobials are meant to destroy, adapt in response to them, thereby rendering the treatment ineffective. Over time, AMR pathogens are developing resistance and can share their resistance mechanisms with one another, thus enhancing the phenomenon. In concrete terms, if antimicrobials are applied without prudence among humans and the agricultural sector, it selects for resistant strains. Soon enough it becomes harder and harder for clinicians to find effective options to treat infections among the drugs available. Antibiotics (and other antimicrobials) are well on the way to becoming the tragedy of the commons in our times – which implies that when there is open access to a shared resource, people will inevitably overuse it for their own benefit, leading to devastation for everyone. Most antimicrobials around the globe are fully over-utilised/misused (also during the Covid-19 pandemic), and a substantial number have already become ineffective against pathogens.
Infections that used to be curable are again turning deadly
Nowadays, infections that used to be largely curable, such as tuberculosis, blood infections, and pneumonia, are again turning into deadly diseases. When Alexander Fleming won the Nobel prize for his discovery of antimicrobials in 1945, he warned in his acceptance speech that the overuse of penicillin might eventually lead to bacterial resistance. What he feared has come true – here and NOW. AMR is spreading fast across the globe and too few novel antimicrobials are currently under development.
The problem with AMR runs deep – it exists in every country irrespective of its income levels and geographical location.
‘Like Covid-19, AMR knows no borders. The global spread of highly resistant bacteria is well documented and closely linked to the increasing mobility of people, animals, and goods.’Dr Angela Regina Schug
notes Dr Angela Regina Schug, a former veterinary scientist and now an advisor on Animal Health and One Health at the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). In 2019, global annual deaths directly from antibiotic resistant bacteria numbered close to 1.3 million worldwide; killing more people annually then do HIV/AIDS, diarrhoea and malaria (Lancet, 2022). Unless powerful action is taken, this figure could rise to 10 million per year by 2050 (Review on Antimicrobial Resistance, 2016).
Humans, animals and plants are affected
The major drivers of AMR are the misuse and overuse of antimicrobials in both people and animals, plus environmental pollution e.g. from pharmaceutical and hospital waste (UNEP, 2022). A move from extensive to intensive farming also puts pressure on farmers to use antimicrobials as growth promoters – the administration of antimicrobials to animals with no diagnosed illness. Like humans, animals can carry resistant pathogens and can spread to their environment as well as to humans via physical contact with domestic and wild animals or contaminated animal products like meat (see figure 1 below). Plants are not only affected because animals spread resistant pathogens to them – they also get sprayed with antimicrobials for growth promotion. Showering plants with water contaminated with human or animal excreta can equally spread resistant pathogens. Like humans, animals can get sick from pathogens that are resistant to one or more of the drugs that could be used to treat infections. By the same token, the environment, wildlife and plants are affected. In this sense, tackling AMR requires a One Health approach because it depends on the interrelationship between animals, people and the environment.
This is why the complete picture on AMR is complex especially when you go beyond the human realm and consider the world around us. The One Health High-Level Expert Panel defines One Health as: ‘An integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems. It recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent’. Given the interconnection of human, animal, plant and ecosystem health, a One Health response to AMR is essential to ensure that medicines continue to work in the future.
Why AMR is an economic and a development challenge
A World Bank report projects that AMR could push up to an additional 24 million people into extreme poverty by 2030 (WB, 2017). The looming ‘post-antibiotic era’ is costly for all countries, because since their discovery nearly 80 years ago, antibiotics have saved countless lives, every day, globally. Today, AMR threatens to overburden fragile health systems: Poorer countries are already struggling to cope under pandemic conditions and now face the emergence and re-emergence of infectious diseases that can no longer be treated with the antimicrobials at their disposal. Economically, AMR spells disaster at the global, national and household level: It causes higher treatment costs due to the need for more expensive drugs, longer hospital stays, missed days of work or school as well as all the costs related to people’s severe illness and death. National economies will be damaged resulting from increasing illness and death, further hitting limited health budgets. Yet sustainable financing for the global response to AMR is insufficient. According to Dr Getahun, there is need for more reliable data to make a compelling economic case on the return of investment in AMR:
‘Better cost-benefit and return on investment estimates are critical to galvanise financing for the response to AMR, globally and in countries.’Dr Getahun
The AMR burden is disproportionately higher in low-income and middle-income countries (LMICs) where many communities lack basic infrastructure and amenities like clean water and electricity. Their healthcare systems often lack the necessary range of antimicrobials as well as the reliable laboratory diagnostics doctors need to prescribe antimicrobials only when truly needed – and then only the correct ones. Undeniably, AMR accelerates the vicious cycle between poverty and infectious diseases which is further fuelled by self-medication with and sharing of antimicrobials.
What can be done, and by whom?
Measures to contain the spread of AMR need to go far beyond the health sector, as shown in figure 2 below. To be effective, they need to encompass five components: (i) reducing the rate of infection (human, animal, plant) through effective sanitation, hygiene and infection prevention measures; (ii) optimising the use of antimicrobials in humans, animals, and food production; (iii) increasing investment in new medicines, diagnostic tools, vaccines, and other interventions (iv) strengthening the knowledge and evidence base through surveillance and research, and (v) improving awareness and understanding of AMR through effective communication, education, and training. Alongside medical professionals, veterinary professionals as well as agricultural workers, need to be involved, sensitised and trained. In addition, strategies need to be tailor-made to specific contexts: ‘A one-size-fits-all solution will not work. There are few measures that will be equally applicable and relevant in different regions, so interventions need to be adapted to the given settings and local surroundings,’ says Dr Schug.
The international response to AMR
Unquestionably, AMR is one of the most complex and multi-faceted global health challenges facing the world community today. And, over the last decade, AMR has moved from a largely technical topic to a political one (see timeline below). Since 2010, the UN Food and Agriculture Organisation (FAO), the World Organisation for Animal Health (WOAH), formally the Office International des Epizooties (OIE), and the WHO have taken leadership roles on informing, coordinating, and driving the response to AMR, as the Tripartite. This increased attention to AMR culminated in the World Health Assembly endorsing the Global Action Plan (GAP) on AMR in May 2015, and called upon member states to develop National Action Plans (NAPs) to combat AMR. The Political Declaration on Antimicrobial Resistance, adopted by the UN General Assembly in September 2016, was yet another major step by the international community to strengthen the fight against AMR. Subsequently, the Interagency Coordination Group on Antimicrobial Resistance was born, and a One Health Global Leadership Group on Antimicrobial Resistance was created. Political awareness of AMR and the One Health approach is gaining traction on the global stage.
Six years after the Political Declaration, at their meeting in May 2022, the Group of Seven (G7) health ministers reaffirmed their support to tackle AMR: ‘we want to step up our efforts to tackle AMR – the “silent pandemic” that is already under way – and to develop appropriate medical countermeasures (…) in line with the One Health approach’. In doing so, they restated their support for the Global Antibiotic Research and Development Partnership (GARDP) and aim to have national measurable targets on AMR by the end of 2023. In what appears to be a strong sign, ministers from different sectors, for instance agriculture, finance and development, released communiques addressing the issue of AMR.
In May 2022, the Tripartite became the Quadripartite Alliance on One Health as it welcomed the United Nations Environment Programme (UNEP) to join the trio formally and endorsed a One Health approach with an ambitious goal to “preserve antimicrobial efficacy and ensure sustainable and equitable access to antimicrobials for responsible and prudent use in human, animal and plant health.” Dr Getahun, underlines the need for a systematic and holistic approach across these three interdependent domains and recognises the importance of applying strict hygiene measures as a key element in AMR prevention and response:
‘We must prevent infection in the clinical, veterinary and food production settings, through effective water, sanitation and hygiene measures.’Dr Getahun
This is in tune with the Quadripartite organisations, hot off the press announcement of this year’s (2022) theme of WAAW: ‘Preventing antimicrobial resistance together’.
‘We need good and integrated surveillance systems in all One Health sectors, locally, nationally and globally, to inform an effective response that is aligned with the WHO’s Global Action Plan,’ says Professor Wieler. In addressing this very issue, the Tripartite launched the AMR Multi-Partner Trust Fund (MPTF) in 2019, initially for a period of five years, and recently extended to 2030, to provide catalytic support of One Health approaches to LMICs in the implementation of their NAPs on AMR.
Germany’s commitment to halting AMR
AMR has caught the attention of the German government and is a recurrent theme of the German G7 and the Group of Twenty (G20) Presidency. During its G7 Presidency in 2015, the German government pledged support to the WHO Global and National Action Plan on AMR and committed to a One Health approach. During its G20 Presidency in 2017 the German government initiated the creation of the Global Antimicrobial Resistance Research and Development Hub, and it put the issue again on the agenda during its G7 Presidency in 2022.
The German Antibiotic Resistance Strategy (DART 2020) supports a One Health approach and is part of the German Government’s 10-year National Action Plan for AMR which includes benchmarks at international level. Since 2021, Germany is a contributor to the MPTF, and gives financial backing to the Quadripartite Joint Secretariat on AMR via GIZ’s Global Programme on Pandemic Prevention and Response – One Health project, supporting LMICs. This testifies to Germany’s leading role in the global response to AMR and its commitment to invest in comprehensive AMR measures in the places where it is taking its greatest toll. Through bilateral cooperation Germany continues to support partner countries in the design and implementation of National Action Plans within the framework of the Global Health Security Agenda. In Liberia, BMZ supported an antimicrobial surveillance and stewardship project and, as part of its Hospital and University Partnership programme, it facilitated the development of a digital innovation tool to enhance collection and practical use of AMR data in five countries across sub-Saharan Africa.
As AMR continues to spread across the globe, the international community has its work cut out. The next few years will define the trajectory of the long-term AMR response and how successful it can be. All of mankind would benefit from limiting access to antimicrobials; this means prescribing and using drugs judiciously across sectors in the present moment because we need the same (and novel) drugs to work against dangerous pathogens in the future. ‘Inaction is no longer an option’ warns GIZ’s Dr Schug.
Rupal Shah-Rohlfs, August 2022