A Global Health Security Threat
Antimicrobial resistance may claim more lives than cancer by 2050
By Dr Shirshendu Mukherjee
Over the last century, advancements in health technologies have been key in combating various diseases and significantly bringing down morbidity and mortality rates. The discovery of penicillin marked a turning point in history, when finally, the world had a tool to cure deadly infectious diseases that took countless lives. Since then, antibiotics have been an unshakeable pillar in improving public health outcomes, especially in developing nations like India, where the burden of infectious diseases is extremely high, and the healthcare spending has been consistently low.
While antibiotics were considered a boon and deemed as a ‘wonder drug’, their indiscriminate use has made them a victim of their own success. In 1945, while delivering his Nobel lecture Sir Alexander Fleming, who discovered penicillin stated, “The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under-dose himself and by exposing his microbes to non-lethal quantities of the drug, make them resistant.” More than 70 years later, his statement holds true, as the World Health Organization (WHO) in its 2014 surveillance report on antimicrobial resistance (AMR) has deemed it as a ‘global health security threat’.
Extensive and inappropriate use is making bacteria increasingly resistant to existing antibiotics rendering standard treatments ineffective, leading to persistent infections and widespread disease outbreaks. In a post-antibiotic world, simple infections may become life-threatening. In his report, economist Jim O’Neill estimated that by 2050 more than 10 million people will die worldwide due to AMR, more than the current deaths caused by cancer. Increasing rates of resistant infections and the loss of frontline antibiotics to resistance mean that even routine surgical procedures may become increasingly difficult, as may current cancer treatments, all of which rely on the cover that antibiotics provide.
AMR, despite being a global threat, is predicted to have an unequal distribution across the globe, with developing countries in Asia and Africa bearing the brunt. This holds true for India as well, as we have some of the highest antibiotic resistance rates among bacteria that commonly cause infections in the community and healthcare facilities. Resistance to the broad-spectrum antibiotics, such as fluoroquinolones, and third generation cephalosporin has been found to be more than 70% in several common bacteria such as E. coli. Furthermore, according to a study, resistance to Colistin, a last resort antibiotic, has accounted for 69.3% mortality amongst Indian patients. The high consumption and prescription of broad-spectrum antibiotics and the paucity of awareness around AMR, make for a grave reality wherein potentially our time with antibiotics is coming to a worrisome end.
Tackling antimicrobial resistance, in India, as in most developing countries faces a paradox. Given the already high rates of infection and deaths, limiting access to antibiotics is not the solution. Instead, increasing awareness about the perils of indiscriminate use of antibiotics, would play a key role in limiting the increase of AMR within the country.
To further exacerbate the issue, weak surveillance methods, high population density and only a very recent focus on AMR, have caused limited data availability on the AMR burden across India, with large
variations in data amongst the different states. Together, this has made it difficult to analyse emerging resistance patterns, their origin and economic impact.
To this end, the Grand Challenges India initiative called for proposals in May 2018 to encourage innovations in three areas under the greater AMR challenge. The call was designed as a global call in partnership with Grand Challenges country partners in three separate geographies – Africa, South Africa and Brazil. Three mandates were set, looking at the research requirements that were particular to each geography. GCI set the mandate on three pillars: innovations for surveillance, infection prevention and control and removal of antibiotics from effluents.
Under the innovations for surveillance mandate, applicants were encouraged to develop innovations to understand resistance patterns and their epidemiology. The GCI AMR Challenge looked to fulfil the unmet need to explore new data sources, analytical techniques and biomarkers, which would aid in gathering better and more accurate data about how resistance develops and spreads in the community. This data would also prove particularly useful in establishing algorithms that can predict trends in resistance development and its associated factors so that appropriate interventions can be planned.
Since drug development takes a very long time, another alternative to tackle resistance is to break the chain of transmission of resistant microbes. Keeping this is mind, the second mandate looked at research in developing innovative low-cost products and technologies that can be used to break the cycle of infections, especially in healthcare settings.
The issue of AMR and the environment is one where there is much that is still unknown. However, there have been many studies that show that there is a large concentration of antibiotics that are found in effluents and sewage. This formed the third mandate, where applicants were encouraged to submit ideas on low-cost tools and technologies to remove antibiotics from effluents.
Our overuse and misuse of antibiotics is creating the perfect conditions for the silent epidemic of AMR, threatening to overpower our ability to fight and combat infections, such as malaria, tuberculosis and pneumonia. In a developing nation like India, a struggle with AMR could force millions towards crippling poverty. Now is the time to focus on developing holistic and comprehensive approaches to AMR reduction, to ensure the health and safety of not just our citizens but also of the global community.
Dr Shirshendu Mukherjee is the Mission Director, Grand Challenges India.