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United Nations meeting on antimicrobial resistance


World leaders gather at the United Nations General Assembly in New York this month to mount a response to the growing
threat of antimicrobial resistance. Gary Humphreys and Fiona Fleck report.

Dr Abdul Ghafur, a consultant in infec- on antibiotic resistance. “Losing it would The gathering in New York is the
tious diseases in Chennai, had become put many lives at risk.” result of efforts led by WHO, the Food
alarmed by the number of multidrug– Ever since antibiotics were de- and Agriculture Organization (FAO),
resistant infections in patients at major veloped in the 1940s, scientists have the World Organisation for Animal
hospitals across India. warned that using them improperly Health and several governments. It
In desperation, he and his col- leads to bacterial resistance and that comes in the wake of national, regional
leagues issued the Chennai Declaration overuse of antibiotics only increases that and international initiatives, including
in 2012, calling on policy-makers to take risk because microbes naturally adapt to the Chennai Declaration, regional dec-
action to address the growing problem their environment. larations, World Health Assembly reso-
in India. Today’s threat of widespread an- lutions and gatherings of high-ranking
Four years later little has changed timicrobial resistance (AMR) – in decision-makers across the world.
and now they fear that patients in India bacteria, parasites and viruses that Recent high-profile reports warn of
may be acquiring infections that are cause infections and disease – raises the dangers of not taking action. A bleak
resistant to an antibiotic of last resort, the prospect of a world without effec- report by economist Jim O’Neill, com-
colistin. tive antimicrobials, where a patient can missioned by the British government and
Due to its high toxicity, colistin die from previously treatable infections. released in May, estimates that 700 000
has been used primarily as a growth This month global leaders gather at deaths globally could be attributed to
promoter for livestock. However, as the United Nations General Assembly in AMR this year and that the annual toll
more bacteria become resistant to other New York to discuss the AMR problem would climb to 10 million deaths in
classes of antibiotics, colistin is increas- and agree on a response. the next 35 years. The report projects
ingly being used in humans. For Dr Marc Sprenger, director of US$ 100 trillion in losses by 2050 if noth-
The widespread use of colistin in the World Health Organization’s AMR ing is done to reverse the trend.
animal farming has resulted in resistant Secretariat, the United Nations gather-
infections that are spreading fast and ing on 21 September represents a signifi-


weakening its power as a drug of last cant ramping up of the global response.
resort. “There has been discussion of AMR Countries with
“Colistin is the only treatment in WHO since the 1960s, and plans since weak and poorly-
option with a reliable effect against 2000, but it is now shifting from being a resourced health
multidrug-resistant bacteria in many technical problem to a much higher level systems will have the
regions,” says Professor Otto Cars of political issue,” Sprenger says, adding greatest problems
Uppsala University, Sweden, the found- that this shift and the broad consensus in managing drug


ing director of ReAct, an independent on what needs to be done are reasons
network campaigning for global action for optimism.
resistance.
Marc Sprenger

WHO’s Global action plan on an-


timicrobial resistance, adopted at the
World Health Assembly last year by
Member States, proposes a way forward.
The plan has five objectives: to
improve awareness and understanding
of antimicrobial resistance in policy-
makers and professionals; to strengthen
surveillance and research; to reduce
Wellcome Images/Anthea Sieveking

infection; to encourage the rational


use of medicines in human and animal
health care; and to increase investment
in developing new medicines, diagnos-
tics and vaccines.
Key to making the plan work is the
“one-health” approach that reflects the
links between human health, animal
health and the environment, and re-
Pigsty at a farm in the United Kingdom. Pigsties have nearly become a thing of the past with the growth of quires many different sectors to come
intensive farming methods. together to address the problem.

638 Bull World Health Organ 2016;94:638–639 | doi: http://dx.doi.org/10.2471/BLT.16.020916


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Under the plan, WHO Member Sprenger says, adding: “The lack of data rural areas. In poor areas, farmers tend
States have until May 2017 to adopt for low- and middle-income countries to be more dependent on antimicrobi-
national AMR action plans. means that we are unsure about the exact als to control animal diseases and may
One of the toughest challenges is scale of the AMR problem, but that we struggle to reach a registered veterinar-
to reduce the use of antimicrobials as have a problem is clear.” ian and get a prescription on time.
growth promoters in animal husbandry. “Most of the future burden of According to the FAO, a high-level
Global consumption of antimicro- disease will be in Africa and Asia, veterinary committee discussed a study
bials in food animals was estimated at and countries with weak and poorly- published in the Lancet in February
63 151 tons in 2010, of which the largest resourced health systems will have the by Yi-Yin Liu and colleagues linking
share, 23%, was in China, 13% in the greatest problems in managing drug the heavy use of colistin to promote
United States of America, 9% in Brazil resistance,” he says. livestock growth with the emergence of
and 3% in India, according to Thomas China is pushing forward on several resistance to colistin in human bacterial
Van Boekel and colleagues’ 2015 study in fronts. Stand-out initiatives include the infections.
Proceedings of the National Academy of three-year campaign for rational antibi- The committee agreed that a thor-
Sciences of the United States of America. otic use launched by the National Health ough risk analysis of AMR in the animal
The authors predict a 67% increase and Family Planning Commission of the production system should be carried
in the global consumption of antimi- People’s Republic of China (NHFPC) out. A 2016–2020 plan is expected to
crobials by 2030, given the “shifting in 2011. address the issue.
production practices in middle-income China has also committed consid- China’s centralized government
countries where extensive farming erable resources to monitoring, having structure may also help the national
systems will be replaced by large-scale established more than 2400 monitoring policy response to AMR, but the chal-
intensive farming operations”. network points that track the clinical ap- lenge is implementation: making the
Use of antibiotics as animal growth plication of antimicrobial drugs. policy a reality.
promoters was banned in the European India released the National policy
Union (EU) in 2006, although these are for containment of AMR in 2011 aiming
commonly used for mass prophylaxis in
some countries.
Even within the 28-country bloc
there is a 100-fold variation in antibiotic
“ There has been a
lot of denial about the
gravity of the situation.
to rationalize the use of antibiotics in
hospitals, reduce over-the-counter sales
of antibiotics and improve infection
control in hospitals.
use between countries, without apparent Now it is time to But, while India’s national AMR
differences in the productivity of farms.
Northern European countries, such as
Denmark, the Netherlands, Norway and
Sweden have made particular progress
act.
Otto Cars
” policy was drawn up in New Delhi, in-
dividual states have considerable auton-
omy when it comes to implementation.
There have been some restrictions
in developing food production systems Surveillance from hospitals showed on the prescription of antibiotics for
using low levels of antibiotics. that the proportion of outpatients in-patients, but enforcement remains
In June, EU member states adopted receiving prescriptions for antibiotics weak. According to Ghafur only a few
the one-health approach to antimicrobi- decreased from 22% to 14.7% between of India’s 74 000 hospitals actually follow
al resistance in a decision by the Council 2010 and 2012, and that of inpatients infection control guidelines.
of the EU, calling on countries to comply from 68.9% to 54%, according to Chi- “Some health centres report suc-
with the ban on using antibiotics as nese research collaboration, the Collab- cessful initiatives,” says Ghafur, “but
growth promoters and to minimize their orative Innovation Center for Diagnosis there is a paucity of published data on
prophylactic use in farming. and Treatment of Infectious Diseases. whether Indian hospitals are compliant
“Across the world, countries are The use of antibiotic prophylaxis in with existing policies.”
developing national AMR action plans,” surgery decreased from 95% to 44.6% With an estimated 10–15% of E. coli
during the same time period. infections and 30–40% of K. pneumoniae
China is also committed to the one- infections already resistant to standard
health approach to fighting AMR, with treatment, India faces a new reality: that
12 ministerial departments meeting soon it may not be possible to treat these
regularly to discuss progress, according infections with colistin either.
to WHO’s China Country Office. These “That is the nightmare scenario,”
are led by the NHFPC and include says Cars, “and without concerted,
Ministry of Agriculture representatives global action, including perhaps legally
and others. binding conventions, it is a scenario we
Pablo Rojas

According to the FAO in China, the will have to face. There has been a lot of
government has issued several orders denial about the gravity of the situation.
restricting the use of specific antibiotics Now it is time to act.” ■
in animal husbandry, but, despite this,
Colonies of Salmonella typhimurium DT104b, tackling the misuse of antimicrobials
one of the pathogens with multiple antibiotic in livestock is a challenge, as it affects
resistance genes. the income of millions of households in

Bull World Health Organ 2016;94:638–639| doi: http://dx.doi.org/10.2471/BLT.16.020916 639

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