Shooting our own foot: Misuse of medicines is making infections difficult to treat

Shobha Shukla & Bobby Ramakant

Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and become resistant to (or no longer respond to) medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result of drug resistance, medicines become ineffective, and infections become increasingly difficult or impossible to treat. That is why AMR ranks among the top 10 global health threats worldwide.

“Antimicrobial Resistance (AMR) is a problem driven by misuse and overuse of antimicrobial medicines, including antibiotics and antivirals, and results in critical medicines losing effectiveness to treat infections,” said Thomas Joseph, Head, AMR Awareness, Advocacy and Campaigns, World Health Organization (WHO), at a recent pre-conference meet of 22nd International Conference on AIDS and STIs in Africa (ICASA).

“AMR is associated with 5 million deaths a year. Besides this, there is a huge burden of morbidity and healthcare expenditure that can affect household welfare severely. The World Bank estimates that Global GDP could fall by $1 to $3.4 trillion annually after 2030 due to AMR,” he added.

The World Bank estimates that an additional 24 million people will be forced into extreme poverty by 2030 if no action is taken on AMR today.

Drawing attention to World AMR Awareness Week (WAAW) which is celebrated between 18-24 November every year, Thomas cautioned that “all stakeholders should realise that if we do not act now, we could go back to a pre-antibiotic era, when even simple infections become untreatable”.

Antimicrobials as global public goods

There are several issues of access and equity affecting AMR. “Research and development of new treatment options, including new antibiotics, is not prioritized due to a sector-wide market failure. As a result, we are running out of treatment options and new drugs are not coming into the market.

“Even when new medicines finally reach the market, low and middle-income countries are not able to access these due to intellectual property and pricing constraints. Antimicrobials should be regarded as global public goods. Governments should strengthen their health systems and push for universal health coverage so that all have access to the needed antimicrobials prescribed by registered healthcare providers,” said Thomas.

Be the change

Vanessa Carter, an AMR patient survivor, One Health advocate, Chairperson of the WHO Taskforce of AMR Survivors, and founder of The AMR Narrative was one of the speakers at the 3rd Annual Global Media Forum on AMR, hosted by Global AMR Media Alliance in lead up to WAAW 2023.

She shared her eye-opening personal experience of her battle with AMR.

“In 2004, I was 25 years old. I had a severe car accident in Johannesburg, South Africa, and ended up in a hospital with a lot of massive injuries. I had been resuscitated on the side of the road, I was put on life support, I had multiple fractures in my face- a broken jaw and a broken nose- and also lost one eye. I also had a head injury, major abdominal injury, fractured pelvis, neck, and back injury. But the most complicated injuries were to my face, and it took me 10 years to recover from them, during which time I have had 4 different facial prosthetic implants,” said Vanessa.

But the worst was yet to come. Six years into the accident and after her fourth implant, one day, while getting into her car, Vanessa saw moisture seeping all over her face. It was pus oozing out from her 4th implanted prosthetic. She underwent emergency surgery, and the doctors did “debridement” and reconstructive surgery to fix up the damaged tissue. Two weeks later, the infection returned. She got more tissue reconstruction done. But the infection kept on returning and it worsened over time. This went on for the next 11 months during which she was kept under the care of several specialist surgeons.

Vanessa was eventually diagnosed with highly antibiotic resistant form of MRSA (Methicillin-resistant Staphylococcus aureus) infection. She could not undergo any more surgeries for one year, as the doctors had to wait for the tissue to recover. “I had to cover my face as I looked terrible. My face was very red, full of fluid and swollen. I could not wear my artificial eye. I could not go to fetch my child from school because the kids would get scared looking at me,” she recalls.

“I lost ten valuable years of my life between 25-35 years of age, being in and out of hospital, and not being able to look in the mirror without seeing a changed face. I nearly got a bloodstream infection and sepsis and almost died. But I am also living with a severe disability now- facial disfiguration which was partially caused by the accident but exacerbated by the fact that we could not treat this infection. When I learned about antibiotic resistance, it came as a surprise that why was it not a common knowledge even though it is such a widespread global threat,” she shared in the forum.

Political commitment to AMR

World leaders at next year’s UN General Assembly will be convening a United Nations High Level Meeting on AMR. “We are at a critical point in time to act against AMR. The attention to AMR is growing and it is rightly so. The UN High Level Meeting on AMR next year is a critical opportunity to further accelerate the response to AMR,” said Beatrice Atim Odwong Anywar, Uganda’s Minister of State for Environment, and Member of Global Leaders Group on Antimicrobial Resistance (AMR).

“Out of the 5 million AMR-related human deaths that occur every year, most of them are happening in low- and middle-income countries. These are the countries where the burden of diseases is also higher. That is why Uganda is spearheading action against AMR across sectors such as human health, animal health, food and agriculture, and the environment,” added Minister Beatrice.

One Health Approach

The health of humans, animals, (domestic and wild), plants and our environment are closely interlinked and interdependent. “This means that whatever happens to one of them, the others will be inevitably affected and impacted for better or for worse”, says Javier Yugueros-Marcos, Head of the Department Antimicrobial Resistance and Veterinary Products at World Organisation for Animal Health (WOAH). We cannot ignore one at the cost of another.

Agrees Emmanuel Kabali, AMR Project Coordination Consultant at Food and Agriculture Organisation (FAO), that “AMR is a complex issue that impacts human, animal, plant and environmental health. Antimicrobials are used extensively in humans, and in animal and plant production”.

“The drivers of AMR are in several sectors. Misuse or overuse of antimicrobials happen in human health, animal health, food and agriculture, and several other sectors”, adds Dr Philip Mathew, Technical Officer, World Health Organisation (WHO).

As per WHO, One Health is an integrated unifying approach to sustainably balance and optimise the health of people, animals and our environment. By linking humans, animals and the environment, One Health can help to address the full spectrum of disease control and contribute to global health security.

Information, knowledge, action gap?

“When it comes to addressing AMR, mere information is not enough. Information has to be translated into knowledge and action. We need to bridge that knowledge-action gap. In the context of sustainability, we often say – think global, act local. What we do at the local level or what we do in our house, community, school, or organisation, also makes a huge difference. Key message is grounded in promoting appropriate use of antimicrobials, and to stop misappropriate or inappropriate use of antimicrobials in human health, animal health and livestock, food and agriculture, and environment. That is why quadripartite agencies of Food and Agriculture Organization of the United Nations (FAO) United Nations Environment Programme (UNEP), World Health Organisation (WHO) and World Organisation for Animal Health (WOAH) have united to advance progress on One Health approach in addressing challenges such as AMR,” said Wondwosen Asnake Kibret, Policy and Partnerships Coordinator, UNEP.

“Calling AMR a ‘silent pandemic’ might convey a wrong message that ‘it is a very distant issue which may affect us sometime in the future’. AMR is not a distant issue as it is killing millions right now – even one death is a death too many when it comes to preventable threats like AMR. AMR can happen to anybody at any time”, cautions Philip.

That is why all sectors across the One Health spectrum spanning human, animal, plant, and the environment must work together to ensure the responsible use of antimicrobials while taking preventive measures to decrease the incidence of infections. The medicines which we have today to combat diseases have to be handled with care and used responsibly.

(The authors lead the editorial team of Citizen News Service)