AMR is a threat to global development: Urgent multi-sectoral actions needed

By Dr. Shibu Vijayan

Alexander Fleming’s chance discovery of the first antibiotic – penicillin has shaped human history. It ushered in better health outcomes that subsequently enabled development. However, like many times in our human history, we have abused our boons to the point where they turn into banes. The issue of antimicrobial resistance (AMR) is one such classic example where due to unsustainable practices we stare at a man-made disaster. Disease-causing microbes like bacteria, fungi, parasites, etc., are naturally prone to mutation over time. However, with prolonged overexposure to antimicrobials like antibiotics, this natural phenomenon accelerates. The microbes develop resistance against the very drugs that could once treat them leading to reduced efficacy of medical interventions. The uptick in AMR can be attributed to overuse of antibiotics and other antimicrobials in humans, misuse of antibiotics in the livestock sector, and unregulated discharge of antibiotic-laden pharmaceutical effluents by manufacturing units.

The Global Antimicrobial Resistance and Use Surveillance System (GLASS) Report 2021 critically highlights the high rates of AMR in the bloodstream, urinary and gastroenteric infections in most countries. Despite the growing AMR, the development of antibiotics has stuttered since 1987 as no new antibiotics have been discovered. Additionally, the World Health Organization (WHO) has warned that none of the 43 antibiotics in the pipeline are sufficient to combat AMR.

COVID-19 has accelerated AMR

Exclusively from the point of view of AMR, the COVID-19 pandemic has fast-forwarded our march to a drug-resistant future. As an outcome of non-standardized treatment protocols and desperation; management of COVID-19 saw overuse of antibiotics across the world, including India. Early research suggests that between June and September 2020, 216.4 million additional antibiotics were sold in India. The antibiotic – Azithromycin is classified for usage in a discrete and limited number of infections by the WHO due to its proclivity towards drug resistance. Despite this, Azithromycin and other antibiotics have been heavily used for the treatment of mild and moderate cases of coronavirus outside the ICU. The scientific community already fears that COVID-19 induced AMR has infiltrated large swathes of the Indian population, the adverse effects of which would be visible in a year.

Worsening of TB management

The adverse repercussions of AMR are already being felt on the global and national realization of TB eradication. The global incidence of multi-drug resistance in TB (MDR-TB) has increased by 10 % in 2019. The problem is compounded further as the resistance to rifampicin (an antibiotic used for the treatment of TB) has increased from 7 % in 2012 to 61 % in 2019. With 26 % of the global TB burden being in India, our aspirations to eradicate TB by 2025 would never be realized if drug resistance is unchecked. Apart from the encroachment of TB goals, AMR threatens to upset the Indian health paradigm. With one of the heaviest burdens of infectious disease in the world, an uncontrolled AMR will run through our population like a wildfire. Even though concerted efforts have brought down the incidence of HIV per 1000 uninfected population from 0.07 in 2017 to 0.05 in 2019, increased AMR will reverse the trend. Another important health goal for India is bringing down the under-5 mortality rate in India to 25 per 1000 live births. A spurt in AMR would be a roadblock as already India loses over 56,000 newborns to sepsis caused by bacteria resistant to first-line antibiotics. Global and national health paradigms would be paralyzed as AMR will push 24.1 million people into poverty by 2030, effectively reducing their health expenditure.

Synergized approach needed

AMR is a complex issue. Its uptick is due to unsustainable practices in overlapping ecosystems of animal, environmental and human health. Therefore, it requires a harmonized approach spread across sectors that contribute to drug resistance. While the pandemic has reenergized the debate to revisit the National Essential List of Medicines (NLEM), decisive policy actions are needed to deter the sale of drugs without prescriptions. Additionally, antimicrobial stewardship is required in hospitals to check the AMR resulting from incorrect prescription behavior and irresponsible disposal of bio-medical waste. The agriculture and the livestock industry are amongst the prominent misusers of antibiotics. Apart from surveillance and appropriate regulations, farmers and the livestock industry should be educated about the harmful effects of antibiotics on human health. Actions to curtail drug resistance would be superficial if environmental AMR is not mitigated. The interconnected nature of the environmental and human ecosystems makes it vulnerable to AMR resulting from pharmaceutical manufacturing plants. In the absence of the formalization of the Ministry of Environment’s draft regulation limiting the concentration of pharmaceutical discharge, the free flow of antibiotic-laden compounds into water bodies surreptitiously increases AMR. Given that India is a hub of pharmaceutical manufacturing, we need stringent regulations and incentives that nudge the industry to move to greener pathways of procurement and production.

Borrowing from the realm of complexity sciences, policymakers should stop seeing AMR as a health issue but rather as the greatest threat to human prosperity and development.

(The columnist is Global TB Technical Director, PATH. Views expressed are the author’s own.)