A UN High Level Meeting on Antimicrobial Resistance (AMR) last week has pledged to reduce – by 10% – deaths from drug-resistant bacteria over the next six years.
The new declaration on the “silent, slow-motion pandemic” that could kill another 39m people by 2040 – the first statement on the topic since 2016 – also pledges to raise $100m to fund the updating of countries’ AMR action plans and their implementation.
Health Policy Watch reports that it formalises the standing of the Quadripartite secretariat, comprising the WHO, UN Environment (UNEP), the Food and Agriculture Organisation (FAO), and the World Organisation of Animal Health (WOAH), as the body co-ordinating global AMR response across the human, animal and environmental sectors.
The final draft of the declaration failed to include an earlier target to reduce the animal use of antibiotics by 30% by 2030, due to pressure from meat-producing nations and the farm industry.
This, critics say, remains a serious shortcoming in the final draft as livestock use comprises as much as 73% of global sales of a range of antimicrobial agents (including antibiotics, antivirals and antiparasitics).
Even so, the initiative was hailed as a major step forward in spurring more action on trends that few governments have fully recognised until very recently.
“This is an impressive blueprint for action,” said Barbados Prime Minister Mia Mottley, who has become a global leader and advocate on AMR.
“But the truth is the hard work starts tomorrow. We’ve set a very modest target of $100m (for national plans of action) and I hope we can reach out to the leaders within the private sector, the pharmaceutical industries, the meat industries, all of the role-players.
“As I’ve said very often with climate, unless they have a plan to live on a different planet, then we have to define the win-win solution for us all.”
No country unaffected
“No country is immune to this threat, but low and middle income countries bear the greatest burden,” WHO Director-General Dr Tedros Adhanom Ghebreyesus warned.
While 90% of countries have developed AMR action plans, only 11% of countries have allocated budgets to implement those plans, he said.
As next steps, WHO will establish an independent panel to produce a major report synthesising evidence for action on AMR by next year, as well as update its decade old global strategy on AMR by 2026.
Deaths from superbugs
Drug-resistant bacteria are estimated to have killed around 1.14m people in 2021, and were somehow associated with the deaths of 4.71m people, according to estimates published in The Lancet.
In the declaration, countries committed to reducing annual AMR deaths by 10% using a 2019 baseline level of mortality. In that year, 1.27m deaths were attributed to drug resistant bacteria while 4.95m deaths were somehow associated with drug resistant infections.
Should global efforts to curb AMR fail, drug resistant pathogens could become the number one cause of death by 2050, warned Mottley at a press briefing just ahead of the High Level Meeting.
That would mean just going to the dentist, or getting cut while doing garden work could lead to life threatening infections for some people “purely because of the ineffectiveness of the antibiotics”.
Four pronged assault – priorities for health and environmental sector
The declaration outlines a four-part strategy to combat AMR, calling for more careful use of antimicrobial agents in healthcare, farming, and animal sectors, alongside improved management of untreated sewage and hospital emissions.
Tedros, Mottley and others also called out the alarming dearth of new antimicrobials in the product pipeline.
The number of pharma firms working on new antibiotics has declined substantially since 2000 due to the perception that there is little profitability in producing products that can’t be used in large volumes, precisely because that may foster a spiral of new resistance risks.
Mottley said antibiotics should be recognised as a “global public good” with “dedicated financing”’ that goes beyond commercial investments.
Fake meds, sewage discharge and hospital emissions
Tackling fake and substandard medicines, which can also lead to emergent resistance, is another priority cited in the declaration.
And along with reducing overuse of antibiotics at risk of becoming impotent, as per WHO’s AWaRe classifications, there is a need to improve access to the right antibiotic formulations in low- and middle-income countries, where many more people still die from lack of any access whatsoever, Tedros said.
Moreover, some 56% of sewage effluent discharged is untreated, leaving cesspools of pathogens to breed and develop in lakes, rivers and aquifers of developing countries, in particular, said Inger Andersen, executive director of the UN Environment Programme.
“The pharmaceutical sector can strengthen inspection systems, change incentives and importantly, we can change subsidies and ensure adequate waste and waste management containment,” Andersen said.
“The food and agriculture sector can take preventive action to limit the use of antimicrobials and to reduce the discharge from crops and terrestrial and aquatic, marine and animal and fish production facilities and the healthcare sector can improve access to high quality, hospital-specific wastewater treatment systems.”
Animal use remains ‘elephant’ in AMR arena
In terms of sheer volumes of use, antimicrobial use in the livestock sector remains one of the biggest threats to curbing AMR trends. It is estimated that some 73% of antimicrobials sold globally are used in livestock production, including continued use of antibiotics as growth agents in many nations.
Dropping the 30% target for their reduction significantly weakens the armoury of the new declaration, observers said.
“The AMR political declaration heralds a major shift in the global health response for AMR notably with the inclusion of commitment for targets and accountability including the recognition of the Quadripartite Joint Secretariat as the central coordinating mechanism as well as the call to establish an Independent Panel,” said Dr Haileyesus Getahun, CEO of the South-South HeDPAC partnership.
He led the foundation of the Quadripartite Secretariat, and served as its first director, in a previous role at WHO.
“But it is disappointing that the Muscat Manifesto targets on the 30% reduction of antimicrobial use in animals are not included, despite endorsement by 47 countries,” he added, referring to a November 2022 declaration issued at the end of a High-Level Ministerial Conference on AMR hosted by the Sultanate of Oman in Muscat as part of the lead-up to the 2024 UN High Level Meeting.
“Commitment for the targets would have galvanised county-level action not only to strengthen the animal health system but also the research and development for alternatives to antimicrobials.
“It is unfortunate there was a major push back by the animal food industry who were able to influence some member states and even divide the Quadripartite organidations on this very topic.”
WOAH cites animal sector action plans
There is, however, increasing recognition that overuse of antibiotics and other antimicrobials also represents an economic threat to the meat and dairy industry, as the drugs will also become less effective in animal populations, asserted new WOAH Director General, Emmanuelle Soubeyran, at the HLM meeting.
“Drug resistant pathogens could jeopardise food security for more than 2bn people globally, more specifically on livestock, if no action is taken,” she said.
“The impacts of AMR on livestock could reduce global GDP by $40bn per year,” she added. “But achieving a global 30% reduction in animal antimicrobial use within five years can raise [global] GDP in 2050 by €14bn.
“Thus, the World Organisation for Animal Health welcomes the political declaration in alliance with our four priorities.”
Improving access to animal vaccination an alternative
Soubeyran said that improving access to animal vaccinations for vaccine-preventable diseases can reduce unnecessary use of antimicrobials, and admitted that the sector needed to do more to reduce its use of drugs deemed by the WHO to be “highest priority” for use in human health – and not animals.
“The use in animals of highest priority antimicrobials to human health has been globally reduced to 16%,” she said. “Regulation, awareness campaign, trainings, and public private partnerships have allowed such developments.”
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