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Antimicrobial Resistance: A new global public health “ticking bomb”?

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As the saying goes, in a crisis, we need to be aware of the danger, but also recognize the opportunity. So, while the global media is nowadays full of dispatches about the deadly Ebola outbreak in West Africa, perhaps is time to pause and think about another public health risk that has the potential to wreak similar havoc in our globalized world.

This risk is antimicrobial resistance (AMR), which is resistant to drugs to treat infections caused by microbes (e.g., TB), parasites (e.g., malaria), viruses (e.g., HIV) and fungi (e.g. Candida).  AMR is a natural phenomenon, but human action, such as the inappropriate use of antimicrobial drugs in health care and breeding of crops and animals, inadequate sanitary conditions, inappropriate food handling (e.g., food not properly stored), and poor infection prevention and control practices in health facilities, contribute to the emergence and spread of AMR. 

Should we worry?  The answer is a resounding YES.  The social and economic consequences of AMR are enormous, and they are poised to escalate to ominous levels in the coming years.  The U.S. Centers for Disease Control and Prevention (CDC) estimates that in the United States alone, antibiotic resistance annually causes more than 2 million illnesses and 23,000 deaths, and that each year, nearly 2 million people acquire an infection while in a hospital, resulting in 90,000 deaths. 
Data from the World Health Organization (WHO) show that, in 2012, there were 450,000 new cases of multidrug-resistant tuberculosis (MDR-TB) and that extensively drug-resistant tuberculosis (XDR-TB) has been identified already in 92 countries.
Similarly, resistance to earlier generation antimalarial drugs is widespread in most malaria-endemic countries.  Antibiotic resistance can also be found in bacteria, which causes common infections (e.g., urinary tract infections, pneumonia), and highly resistant bacteria such as MRSA, which contributes to a high percentage of hospital-acquired infections.
Resistance to antiviral drugs to deal with influenza outbreaks is continuously emerging, and HIV drug resistance is strongly associated with failure to achieve suppression of viral replication, and hence with increased risk for disease progression.

While the wider societal impact and economic cost of AMR must be assessed, it should be obvious to us that if nothing is done, AMR has the potential to increase the risk of poor health outcomes and death among patients because it will severely hamper our ability to treat common infectious and viral diseases. This, in turn, can lead to increased spending or waste of limited health care resources, undermining the financial sustainability of health systems and country strategies to expand health care coverage. 

If not controlled, AMR also threatens the viability of global health programs to reduce the burden of malaria, TB, HIV or other infectious and viral diseases, as well as to expand universal health coverage.

What can be done?  Given the interconnection of multiple factors and actions associated with AMR, comprehensive and coordinated action is required to prevent and minimize its spread. Actions need to involve patients, health care providers, pharmacists (in some countries or regions, they are the de facto prescribers of the drugs that are sold and consumed by patients), policymakers and program managers, as well as researchers and the medical industry, for the development of new diagnostic and treatment tools.  And, as in the case of efforts to prevent and minimize the spread of infectious diseases of animal origin, collaboration between public health, veterinary and environmental services is vital.
WHO’s recent global report on surveillance of antimicrobial resistance provides a broad framework to guide action at the national and international levels.  Effective implementation of strategies to combat AMR will require commitment at the highest political level to comprehensive and funded national plans, with accountability and civil society engagement.  It also requires action to: (i) strengthen surveillance and laboratory capacity for the systematic collection, analysis, reporting and utilization of health-related data for policymaking; (ii) assure uninterrupted access to essential medicines of validated quality;  (iii) regulate and promote rational use of medicines in both patient care and animal husbandry;  (iv) reduce use of antimicrobials in food-producing animals; (v) enhance infection prevention and control measures in health facilities; and (vi) innovate and conduct research and development for new medicines and other tools to control infections, as part of public and private partnerships. 
In the health sector, attention to AMR could help overcome the relative neglect of health care processes by making quality improvement approaches an integral and permanent part of health services delivery.
In the same way as uncontrolled outbreaks of infectious diseases of animal origin can spread with impunity across national boundaries, causing social and economic havoc, AMR can negatively impact rich and poor countries alike, because patients who remain infectious for a longer period of time pose an increased  risk of spreading drug-resistant microorganisms to others.  As such, AMR should be seen as another global health security threat that requires a concerted, multisectoral effort by governments and international organizations, including the World Bank Group, to assist countries in developing resilient institutional arrangements to reduce vulnerability across countries by operationalizing the WHO’s framework for action. 

If we aspire to a better present and future for humanity, we must act now with decisive action to prevent and mitigate AMR. Otherwise, we run the risk of slipping back into an era when a simple cut finger could cause a life-threatening infection or kill otherwise healthy people because available drugs and treatments are rendered ineffective. 
Follow the World Bank health team on Twitter: @worldbankhealth



Patricio V. Marquez

Former World Bank Group (WBG) Lead Public Health Specialist

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