A global momentum
Decision-makers worldwide are increasingly grasping the far-reaching consequences of inaction related to antibiotic resistance, whether at the level of public health, food security and safety, the environment, or the economy and politics. What is at stake goes beyond the management of infectious diseases, since large sectors of modern medicine and food production worldwide rely on effective antibiotics.
In 2001, the World Health Organization (WHO) presented a “Global Strategy for Containment of Antimicrobial Resistance” which revealed that antibiotic resistance was no longer a prediction but was already happening in every region of the world, posing major threats to public health. Since then, only a handful of countries have adopted policies and taken concrete steps to curb antibiotic resistance. However, additional countries are expected to become active soon, since there is now a consensus that the scale of the problem is of global concern.
In 2013, the World Economic Forum Global Risks Report stated that “one of the most effective and common means to protect human life – the use of antibacterial and antimicrobial compounds – may no longer be readily available in the near future.”(11) The 2014 edition of this reports listed “Antibiotic-resistant Bacteria” among the top societal risks confronting the world and its 2015 edition highlighted the growing concern of decision-makers regarding the spread of infectious diseases, partly caused by increasing antibiotic resistance.
In 2014, the G8 joint science ministers and national science academies meeting focused on “antimicrobial drug resistance, as a major health security challenge of the twenty-first century”. This group also emphasized the need to adopt an approach “across the social, human, natural, life and environmental sciences” to tackle it.(12)
In addition, the World Economic Forum listed « Antibiotic-resistant Bacteria” among the top societal risks confronting the world.(90)
In China, public health authorities introduced the National Essential Medicine System in 2009, first for public primary health care facilities, with the intention of later extending it to private providers and hospitals. In 2010, a nationwide “Antibiotic Stewardship Programme” was launched at specialized hospitals. These two initiatives have helped rationalize the use of antibiotics,(13),(14) although over-prescription remains common.(15)
In India, a national policy for containment of antibiotic resistance was adopted in 2011, but put on hold because its major recommendations proved too difficult to implement due to the rising population, liberal access to antibiotics and the fact that antibiotics were viewed as cheaper than microbiology testing.(16) In 2012, Indian experts drafted the Chennai Declaration, a roadmap to tackle the challenge of antimicrobial resistance in India, which could inspire emerging and developing countries across the world.(17) The Chennai Declaration recommended the creation of an implementable national policy on the use of antibiotics, the regulation of over-the-counter sales of antibiotics, the monitoring of in-hospital antibiotic use, measures to step-up microbiology laboratory facilities, and a comprehensive national antimicrobial resistance surveillance system.(18) As a result, India banned over-the-counter sales of antibiotics in March 2014.
Situation in Africa
In Africa, it is estimated that antimicrobial resistance could lead to the death of 4.15 million people in Africa every year by 2050(92), with as many as 80% of Staphylococcus aureus infections reported to be resistant to methicillin (MRSA) in some parts of the region(06), and rising rates of multidrug-resistant tuberculosis (MDR-TB) particularly in West Africa(93). Many countries in the region lack the resources to efficiently track antibiotic resistance and surveillance data is limited. However, some countries have started to implement policies to stem the rise of drug resistance at a national level. For instance, in 2014, South Africa introduced its Antimicrobial Resistance National Strategy Framework 2014-2024, and was followed in 2016 by Zimbabwe, which adopted a national action plan on antimicrobial resistance, bringing together the country’s ministries of Agriculture, Health and Environment.
In a response to increasing international concern around the rise of drug-resistant infections, UK Prime Minister David Cameron commissioned the renowned economist Jim O’Neill in 2014 to chair a review on antimicrobial resistance. The review will recommend a package of actions that should be adopted at an international level in order to tackle this growing threat. This review has already released reports emphasizing the massive human and economic costs involved, if antibiotic resistance rates were to rise to 100% over the next 15 years - a “worst-case scenario”. If that were to happen with only six major pathogens (four of the many bacterial pathogens - Escherichia coli, Klebsiella pneumoniae, Mycobacterium tuberculosis and Staphylococcus aureus - plus, HIV and malaria), then by 2050 this could result in 10 million deaths per year attributable to antimicrobial resistance (vs. 8 million for cancer) and US$100 trillion in induced world GDP loss. Of course, these impressive estimates are based on a catastrophic scenario. Nevertheless, they do not include indirect consequences, such as higher healthcare costs and the likelihood that some of today’s common medical approaches, such as deliveries by caesarean section or chemotherapy for treating cancer, might become far more dangerous.(10)
In 2014, US President Obama declared that “combating antibiotic-resistant bacteria is a national security priority”. He adopted a national strategy known as CARB (Combat Antibiotic-Resistant Bacteria) to better protect our children and grandchildren from the re-emergence of diseases and infections that the world conquered decades ago” and established a “Task Force for Combating Antibiotic-Resistant Bacteria”.(19) Later in the year, he proposed an historic investment of US$1.2 billion in the 2016 US Federal Budget to combat antibiotic resistance.(20)
2016 has been a pivotal year for the international response to the antimicrobial resistance crisis. In September, the United Nations (UN) General Assembly convened for a high-level meeting on Antimicrobial Resistance. This is only the 4rd time in the history of the UN that a health issue has been taken up by the General Assembly, reflecting the state of urgency surrounding the issue of antimicrobial resistance. Member states reaffirmed their commitment to develop national action plans on AMR and leaders recognized the need for stronger systems to monitor drug-resistant infections and the volume of antimicrobials used in humans, animals and crops, as well as increased international cooperation and funding. Furthermore, they pledged to strengthen regulation of antimicrobials, improve knowledge and awareness, and promote best practices — as well as to foster innovative approaches using alternatives to antimicrobials and new technologies for diagnosis and vaccines. The World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Animal Health Organization (WAHO) will play prominent roles in the coordination of plans and actions to tackle this health issue through a global One Health approach.(73)
The European Commission (EU) has also played a leading role in the fight against AMR for many years, publishing reports, making strong statements as well as significantly encouraging and funding research and public health initiatives. More recently, the EU published its 2017 new EU One Health Action Plan against Antimicrobial Resistance. For example, in the countries participating in the Joint Programming Initiative on Antimicrobial Resistance, a unique international collaborative platform that coordinates national funding and supports collaborative action for filling knowledge gaps on AMR with a One Health perspective, 33% of the total investment in research on solving AMR came from the EU.
In July 2017, the G20 leaders also integrated AMR in their Declaration: Shaping an interconnected world showing that a One-Health approach and access to quality diagnostics are key to fight AMR.
The “Global Action Plan for Antimicrobial Resistance”, issued by WHO in May 2015, is expected to accelerate the adoption and enforcement of national programs. The reduced antibiotic resistance rates registered in some countries - supported by increasing investments and the commitment of the food industry - should be encouraging. Despite these efforts, the global battle against antibiotic resistance is still being lost, as rates of resistance are soaring in most parts of the world, critical scientific knowledge is missing and social engagement remains too weak. Owing to the similarities between antimicrobial resistance and climate change, some experts are calling for the creation of an “intergovernmental panel on antimicrobial resistance”, emulating the “Intergovernmental Panel on Climate Change”; this could be key to fostering scientific consensus and catalysing decision-making.(21) There is a window of opportunity for antibiotic resistance to transform from a technical and medical issue into a political and social concern.
Trends of consumption of antibacterials for systemic use in the community, in selected EU/EAA* countries, 2008-2012, expressed as Defined Daily Doses (DDD) per 1 000 inhabitants and per day.
Adapted from « Surveillance of Antimicrobial consumption in Europe, 2012 », ECDC Report September 2014
(a) Spain (2008 - 2012) reported reimbursement data, i.e. not including consumption without prescription and other non-reimbursed courses.
(b) Hungary and Poland changed the type of data reported between 2008 and 2012 (reimbursement versus sales data).
* EU/EEA = European Union/European Economic Area.
EU/EEA refers to the corresponding population-weighted mean consumption.