Can we afford to lose effective drugs?

(published in The Bangkok Post, Thailand | 22 November 2021)

"Antimicrobial resistance is undermining a century of progress in medicine - infections that were previously treatable and curable with drugs, are becoming (or at risk of becoming) incurable" said  Thomas Joseph, head of World Health Organization (WHO)’s Antimicrobial Stewardship and Awareness.
Simply put, AMR develops when microbes - like bacteria, viruses, fungi, and parasites - undergo genetic changes, and no longer respond to antimicrobials (antibiotic, antiviral, antifungal and antiparasitic drugs). “When microbes become resistant to drugs, the latter lose their efficacy, making hitherto curable infections untreatable or harder to treat and increasing the risk of disease spread, severe illness and death” said Dr Haileyesus Getahun, WHO’s Director of the Department of Global Coordination and Partnership on Antimicrobial Resistance. 
WHO experts spoke to CNS for The Bangkok Post around World Antimicrobial Awareness Week (WAAW) which is being observed in Thailand and other countries worldwide during 18-24 November 2021 to raise awareness on the importance of tackling antimicrobial resistance to avoid further emergence and spread of drug-resistant infections.
Many medicines under threat to become ineffective against diseases due to AMR

“Ever since penicillin, the first antibiotic, was discovered by Alexander Fleming in 1929, antimicrobials have saved millions of lives. But many of these medicines are now under threat of becoming ineffective, due to antimicrobial resistance (AMR)”, said Dr Haileyesus Getahun, who is also the Director of Joint Tripartite Secretariat on AMR (comprising United Nations Food and Agriculture Organization - FAO, World Organization for Animal Health – OIE, and WHO) that coordinates the joint work of the organisations across the #OneHealth spectrum).

On a very conservative estimate AMR kills 700,000 people every year - the actual number could be much higher. TB bacteria are becoming resistant to many antibiotics fuelling drug resistant TB and threatening progress in containing the global TB epidemic. Thailand reported around 1,400 laboratory-confirmed cases of drug-resistant TB in 2020 as per the latest Global TB Report of WHO 2021, which is difficult, longer and more expensive to treat, and treatment outcomes are also far from satisfactory.

One of the major threats looming over Thai success in malaria control is drug resistance. Historically, the Greater Mekong Subregion comprising Thailand, Myanmar, Cambodia, Vietnam and Laos has been an epicentre of antimalarial drug resistance. Forty to forty-five years ago, resistance to chloroquine, a medication used to prevent and to treat malaria, started in this region and spread globally. Now, fears about the resurgence of malaria are due to artemisinin resistance.

Thailand has made commendable progress in rolling out lifesaving antiretroviral therapy for people living with HIV. But antiretroviral medicines are at risk of becoming less effective due to the emergence of drug-resistant HIV, said Dr Ishwar Gilada, who is elected from Asia Pacific to the Governing Council of International AIDS Society (IAS).

“Prevalence of drug-resistant fungal infections is increasing; and widespread resistance to ciprofloxacin that is commonly used to treat urinary tract infections and pneumonia, has been reported. No wonder, the WHO has declared antimicrobial resistance (AMR) as one of the top 10 global health threats” added Dr Gilada.

Is AMR a human-made disaster?

Although it is an evolutionary process, many irresponsible human actions are contributing to a galloping rise of AMR. Dr Getahun lists poor infection control in clinical, veterinary, and food-producing settings, as well as poor access to clean water, sanitation and hygiene as the main drivers of AMR.

Use of poor quality drugs and irrational use of medicines in humans, livestock and agriculture is also fuelling AMR. The most recent example of irresponsible use of drugs has been seen in the treatment of Covid-19 infection. In one review study, while only 6.9% of the Covid-19 patients had bacterial infection, 72% of them had received antibiotics. The adverse impact of this irrational use of antibiotics will manifest itself in future, fears Dr Getahun.

Connect the dots: AMR, human health, agriculture and livestock

Humans are misusing antibiotics not only in the human health sector, but also in agriculture and livestock, rightly points out Dr Elizabeth Tayler, WHO Technical Lead in the global Tripartite Joint Secretariat for AMR. Sub-therapeutic doses of antibiotics used for growth promotion in livestock and also for blanket prevention in animal herds; spraying of citrus trees with antibiotics like streptomycin and tetracycline to promote growth; and use of antifungals by the flower industry to increase production, are some of the examples how antimicrobials are misused in livestock and agriculture.

Dr Tayler alerted that the more we use antimicrobials in any sector, the greater are the chances that resistance will develop and the drugs will become ineffective.

Moreover, drug resistant antimicrobials leak into the environment. Significant antibiotic residues have been found in effluents from intensive agriculture and from hospitals - all ending up in the river waters used by people to bathe and drink and thus further increasing the spread of drug resistant diseases in humans.

Can we afford to lose the medicines that work against diseases?

While the call for accelerating research and development for new treatments is rightly getting more attention, we cannot afford to lose the efficacy of existing drugs because of AMR.

According to Dr Getahun, good infection control and proper sanitation in all settings are key to controlling AMR. This will help to control the spread of infection, which in turn will reduce the use of antimicrobials to treat those infections. Other mechanisms include regulations to ensure that antimicrobials are not sold over the counter, and are prescribed as per need and not because of oversight of medical professionals.

One Health mantra is the guiding light

Dr Tayler calls for different sectors (food, veterinary, human health, and environment) to work together with 'One Health' approach, and preserve human, animal, plant, and environmental health. Without a coordinated multisectoral response across this entire spectrum, disease management will become more difficult and food security will be compromised due to infections in agriculture production.

Joseph Thomas rightly underlined that we need more political commitment, and greater action at country, community, and individual level, to stop indiscriminate use of antimicrobials and put in place strong infection control measures. And we have to act fast. The cost of inaction has already become very high.

Let us all heed the call to “Spread awareness, Stop resistance”.

Shobha ShuklaBobby Ramakant - CNS (Citizen News Service)

published in The Bangkok Post, Thailand
22 November 2021