Tackling antimicrobial resistance globally

There is an urgent need to translate high level commitments into concrete actions to protect future generations

Antimicrobial resistance (AMR) is where microorganisms (eg, bacteria) can alter their genetic make-up to withstand the drugs (eg, antibiotics) used to treat the infections they cause in humans and animals. The emergence and spread of AMR is complex1 (Box 1) and the underlying dynamics are not fully understood, but AMR is an inevitable biological process that has been accelerated by the inappropriate use of antibiotics in humans, animals and the environment.2-4 AMR provides bacteria with a survival advantage in many situations and enables the proliferation in humans, animals, food and the environment.1 Given that bacteria do not respect international borders, AMR can spread rapidly and undetected and is, therefore, a global concern for all.

Without effective antibiotics, people will die of untreatable infections, and the advances in modern medicine over the past 80 years will be lost. However, AMR does not only affect human health but also threatens agricultural livelihoods and global food security; hence, AMR is a major public health and economic problem for the world to be concerned about.6

In 2014, the O’Neill review estimated that AMR currently kills 700 000 people annually and will result in up to ten million deaths per year by 2050, costing the global economy about US$100 trillion if we do not act now.4 The World Banks’ report in 20166 reinforced the need for action by estimating that, by 2050, the global gross domestic product will fall by up to 3.8% — exceeding 5% in low income countries — and will result in an additional 28.3 million people living in extreme poverty. The world is currently on track to eliminate extreme poverty by 2030, but AMR jeopardises the progress made.6

AMR is not only a concern for low and middle income countries as, according to conservative figures reported in 2013, there are at least two million resistant infections and at least 23 000 deaths directly attributed to AMR in the United States each year.7 For now, most infections are treatable, but the selection of effective antibiotics is running out. These calculations are likely to be an underestimate because, due to the lack of global data, it is not possible to present the full picture of AMR and its true health and economic consequences.4 What we do know is that it is currently having an impact on society in all countries and that it is disproportionally affecting young, old, pregnant and immuno-compromised people,4,6,8-10 so we must act now.

Efforts of the global community to manage antimicrobial resistance

Over the past 3 years, there has been significant political commitment internationally to tackle AMR. In 2015, there was the adoption of the Global Action Plan on AMR at the 68th World Health Assembly,11 with the subsequent adoption at the general assemblies of the Food and Agricultural Organization of the United Nations12 and the World Organisation for Animal Health.13 In addition, AMR was addressed in the 2015 UN 2030 Agenda for Sustainable Development.14 In 2016, there was a high level meeting and a political declaration on AMR at the UN General Assembly, which recognised the scale of the problem and the Global Action Plan on AMR as the blueprint, and called for the establishment of an ad hoc Inter-Agency Coordination Group (IACG) on AMR.15 In March 2017, the UN Secretary General in consultation with the World Health Organization, the UN Food and Agricultural Organization and the World Organisation for Animal Health established this multidisciplinary group16 (Box 2). The IACG is mandated to report back during the 73rd session of the UN General Assembly, which culminates in September 2019, on progress and recommendations for the next steps to deal with AMR globally. Moreover, AMR has also been high on the agenda of the G20 Summit held in Germany in July 2017; particularly, on reinvigorating the research and development pipeline, and emphasising the responsible and prudent use of antibiotics in agriculture and elimination of antibiotics for use as growth promotion.17

Alongside these political commitments, there has been positive tangible progress. The World Health Assembly resolution 68.718 called for all countries to have their national action plan completed by May 2017; according to the WHO,19 67 countries had completed the plan and 62 were in the process of doing so, covering around 90% of the world’s population. A third of countries — mainly small, fragile or affected by conflict — are not currently developing a national action plan.19

An AMR Industry Alliance, with over 100 companies and trade associations signing an industry declaration on AMR at the World Economic Forum in Davos, was established in January 2016,20 and 13 companies signed a subsequent roadmap in September 2016.21 The Industry Alliance will report on progress at the World Economic Forum in January 2018. In addition, there has been progress with the food industry, most recently with McDonald’s,22 who have committed to eliminate the use of critically important antibiotics to human medicine in broiler chickens in all markets around the world by 2027. By January 2018, the McDonald’s policy will be largely implemented in Brazil, Canada, Japan, South Korea, the US and Europe.

Lastly, there has been significant progress in research and development from public, private and philanthropic funders internationally through, for example, the Innovative Medicines Initiative in the European Union, CARB-X and the Joint Programming Initiative on AMR and also through domestic funding channels.

Further actions required to tackle antimicrobial resistance

Within the political forum, we need to sustain interest and keep AMR high on the agenda, while turning the high level political commitments made into concrete actions on the ground. Therefore, we need to align the various political commitments made to the UN General Assembly AMR declaration, the Global Action Plan on AMR and the 2030 Agenda for Sustainable Development, and truly integrate a One Health approach (https://www.cdc.gov/onehealth). The IACG Framework for Action23 is a good step forward and will be used by the IACG over the next 2 years.

As presented at the World Health Assembly, there has been good progress on developing national action plans, but it is clear that implementing these plans is the greatest challenge, particularly for low and middle income countries that need technical and financial support. Moreover, there is a need to increase country ownership, get AMR into budgets and plans for national governments and donors, and leverage existing programs. To achieve these goals, countries need to fully recognise the seriousness of this long term threat that requires sustainable and permanent changes, and one way to do it would be to put AMR on government risk registers, as it is done in the United Kingdom.24 There is sufficient evidence to support immediate action that can be tailored to individual countries.

With the increase in research investment globally,25 we must enhance coordination efforts internationally, which will not be successful unless better national coordination is achieved. The UK AMR Funders Forum26 is a good example of how national coordination can be conducted and feed into the international coordination efforts. In addition to domestic research, we need to continue to increase multidisciplinary research efforts across international borders including humans, animals, agriculture and the environment1 to provide the scientific evidence to inform policy and to evaluate what works in different contexts.

Although investing in the research and development pipeline to address the scientific and economic challenges is essential, it must be recognised that even if there is a steady supply of new antibiotics, if we continue to inappropriately use them globally, they will inevitably become ineffective due to resistance. At the same time, we must also ensure access to antibiotics for all who need them, and while we increase efforts to develop new interventions, we must not forget the importance of preserving the effectiveness of existing antibiotics through stewardship and ensuring the supply of many old antibiotics that are currently not universally available.27

Overall, we must fundamentally change how we deal with infections and society’s behaviour, reinforcing that prevention is better than cure. Hence, new antibiotics are only part of the solution alongside vaccines, alternative treatments and diagnostics, as well as infection prevention and control to reduce antibiotic need, a better understanding of behaviours and transmission pathways, and strategies to best use existing and new interventions, when available, in humans, animals, agriculture and the environment.

Going forward, there needs to be a greater focus on understanding the ecology and drivers of AMR in the environment and its impact, which has not been adequately dealt with in most national action plans due to complexities and lack of information.28 While, in parallel, we need to increase the quantity and quality of surveillance efforts to determine the true scale of the problem and control outbreaks when they emerge. Finally, we must get more creative and forward looking in our approaches; for example, given that the demand for animal protein for human consumption is rising globally,29 we need to increase efforts to ensure that we preserve antibiotic effectiveness while maintaining food supply and meeting the sustainable development goals (http://www.un.org/sustainabledevelopment/sustainable-development-goals/) on these issues.

The role of the Inter-Agency Coordination Group in tackling antimicrobial resistance

Current approaches are essential and positive steps forward, but they are not enough and do not reflect the scale and scope of the challenge. Given that the IACG is mandated to report back on progress to the UN Secretary General and recommend next steps, there is a need for the IACG to accelerate momentum over the next 2 years across the full range of organisations required to tackle AMR, beyond the health and scientific fields. Therefore, the IACG must actively reach out, convene and facilitate cooperation and coordination among sectors, which will require significant support beyond the UN agencies involved in the IACG, including member states, civil society and private and philanthropic organisations.

There is also a real opportunity for the IACG, with support from leaders and like-minded champions at all levels, to push the boundaries, ensure progress and put forward the necessary recommendations to pave the way for the future and protect the next generation. AMR is one of the most complex health and economic challenges today, and will be for the foreseeable future, and gaps may always exist. These gaps should not be a barrier for action, but rather a call for increased and harmonised efforts from all sectors of society across the globe. No country or organisation can tackle AMR in silo, everyone has a role to play.

Box 1 – The complex transmission dynamics of antimicrobial resistance1

Box 2 – Membership of the United Nations ad hoc Inter-Agency Coordination Group (IACG) on antimicrobial resistance and roles*16

---

* There are 13 UN agencies or organisations in the IACG as members — they are represented here through their logos (dotted circle). The Tripartite (the World Health Organization, the Food and Agricultural Organization of the United Nations and the World Organisation for Animal Health) are three of these members, but they have a special role as the secretariat, which is why they are at the centre. This group also has 14 independent experts — their names are included as they represent expertise not an organisation or a country (solid line). The IACG has two chairs: the World Health Organization Director General and the UN Deputy Secretary General (boxes outside of the circle). There are then three conveners of this group (green circles).