Who hasn't abused antibiotics, considering them a miracle cure for the slightest cold? In the UK one out of five antibiotics are prescribed unnecessarily and in the US the number jumps to one in three. Around 34.8 billion antibiotic doses are used each year, with global consumption increasing by 65 per cent between 2000 and 2015.
As a result, a growing list of infections are becoming harder and sometimes impossible to treat. Around 700,000 people, among which two to 300,000 children, die every year worldwide because of drug resistant infections and projections show that the numbers will continue to rise.
Global Antibiotic Research and Development Partnership (GARDP), a Geneva-based not-for-profit organization accelerating the research and development of antibiotics against the growing threat of antimicrobial resistance (AMR), launched its campaign this week in Geneva to raise public awareness on this alarming issue. Dr Manica Balasegaram, its executive director, explained to Geneva Solutions why research for new antibiotics is underfunded and how a post-antibiotic world is not inevitable.
Geneva Solutions: AMR, as the World Health Organization (WHO) puts it, is the world’s “invisible pandemic” that could prove more deadly in the long term than Covid-19. Why did you choose a digital campaign to address it?
Dr Manica Balasegaram: To give a human face to microbial resistance. It's currently seen as a theoretical problem. An estimated 700,000 people are dying every year. Antimicrobial resistance is not something that comes and goes: it's something that's there all the time. It also affects particularly vulnerable populations with an estimated two to 300,000 deaths a year just in the newborn population.
On the postmortem report you will see that the baby died of an infection because [it was born] preterm or fragile but one of the key aspects is often [the baby] was given antibiotics which did not work. People don't associate the fact that they may be dying because they have a bacteria resistant to antibiotics.
GS: Can you give us examples of other populations affected?
MB: In elderly people in care homes. In people who have surgical operations, get an infection and require antibiotics but they don’t work as well and they have complications after the operations because of that. In cancer patients who get an infection because the chemotherapy affects their immune system, if the antibiotics don't work as well, potentially the patient may die. It's hidden behind other problems but it's happening all over the world and it's a problem that's grown.
GS: What are the most urgent challenges in tackling AMR?
MB: We need knowledge and acceptance by policymakers and people who are practicing medicine that we have a problem, otherwise it’s very difficult to put solutions in place. We need solutions happening at a policy level. For instance, finding ways to better control the use of antimicrobials. We need to stimulate more research and development into new therapies, diagnostics, tools or vaccines. We need to find ways to ensure that the general public understands the value of antibiotics and antimicrobials.
We also need much more resources to tackle the problem; to train healthcare workers, educate the general public, develop countermeasures or tools to address antimicrobial resistance. If we are not putting in resources now, we are going to pay a lot more to solve the problems 10 to 15 years down the line.
GS: Who are you targeting with this campaign and what do you hope to achieve?
MB: Policymakers here in Switzerland, a small and very rich country host to global health institutions where global health dialogue happens. We would like the Swiss authorities to prioritise this problem from a national and international perspective because we believe Switzerland has an important role to play.
People also need to understand why the government should be investing in these areas. Individuals have a role and responsibility to play. They need to understand that antibiotics have a huge social value. They're precious but they also need to be protected. They need to be available for people when they're sick but they shouldn't be abused.
GS: When did antibiotics start to face antimicrobial resistance?
MB: The first antibiotic, penicillin, was developed in the 1940s and really scaled up at the end of the Second World War. The resistance to penicillin happened very quickly. This is just nature. If you expose bacteria to an antibiotic, it will evolve to try and avoid being killed. Of course, the more you use the antibiotic, the more likely this resistance is going to emerge, and the more likely it's going to spread.
The way that we use antibiotics can encourage the spread. Most antibiotics are used outside human health, in other areas like agriculture. Because we have used these antibiotics so extensively, and because they've been so successful, resistance has emerged and spread out all across the world.
GS: What are the long term projections on the number of people affected?
MB: We could certainly be looking at a much larger amount of people dying every year, but more importantly healthcare systems will be disrupted. It will not be as safe as it was before to give chemotherapy. Surgery may become riskier. The knock-on effects beyond people dying is also very large. There will also be serious impacts on society and the economy. There are no reliable figures but we know this has been going on for some years and that it is going to get worse over the next 20 years.
GS: According to your experience, where does research and funding need to be prioritised?
MB: We've been underfunded for decades both on the public and private sector side. There needs to be more funding and research across the board: in early stage research but the big gap is in translational research (development, clinical trials, and then looking at how we can bring new antibiotics into the market). We need models for access that will reduce the risk of resistance, to make better antibiotics and new antibiotics available and accessible especially in countries that have a high burden to resistance.
GS: What has been the impact of Covid-19 on tackling AMR?
MB: Obviously for funding but also because it's been difficult to do research and development in other areas than Covid-19. It had an impact on antimicrobial resistance because interestingly and unfortunately there has been a huge increase in the consumption of antibiotics in this period. A study showed that although the majority of hospitalised Covid-19 patients – over 90 per cent – received antibiotics, the percentage of such patients who actually had a bacterial infection was just seven per cent. So, we are concerned about the effect on resistance in the future.
GS: The new antibiotics discovery pipeline has run dry in the past decade – given the severity of this threat – why has this happened?
MB: Since the 1970s and 80s, the number of antibiotics projects being developed has slowed down. Developing new antibiotics is seen as time consuming, complex, expensive and not commercially lucrative. More and more private sector entities have been moving away from this area and there's not been enough public funding to antibiotic research. Therefore, we are losing the arms race against bacteria.
GS: So how do we fix this?
MB: It's not going to happen by magic, you need to put resources into it. There's no other way than to put the investment in and that means that you need to get policymakers, governments and, to an extent, the general public aware of the scale of the problem that we're facing. We are not exaggerating: We know that some of the problems that we see emerging in infectious diseases can actually happen and we need to prepare for it.
GS: Could you provide some examples of the innovative solutions GARDP and partners have been working on to curb the threat of drug resistance?
MB: We are one of the very few actors working on a project to develop new treatments for newborn babies. Babies are very different from adults. They often need a different type form or a different dose but a lot of the time new drugs are developed and then subsequently for children. We’re doing things differently, prioritising newborn babies and children because they are disproportionately impacted.
We are also trying to work directly with small companies who have interesting technologies. We do studies with a global health perspective to identify patients with drug resistance for gonorrhea, a sexually transmitted infection. We identify projects that have public health value and conduct research and development with public and private sector entities. We then look at how we're going to make these drugs available for target populations but also for countries that need them.
GS: More widely, what are the most promising innovations and research projects currently underway globally?
MB: According to our research, there are around 50 projects for new antibiotics that are at clinical development and trial stage. In comparison, there are more than 1,000 for cancer. Most of them are probably not going to succeed and very few of these projects are going to be allocated towards what we call the most resistant bacteria, the multi-drug resistant bacteria. There are very few drugs in the pipeline that are active. There needs to be much more investment because even promising projects in clinical development are struggling and don't have a significant amount of resources behind them. So, we are concerned about the level of how this will get back on resistance in the future.
GS: How can we ourselves improve our chances of better fighting antibiotic resistance?
MB: First of all, we need to realise that antibiotics are important social commodities and that they can't solve all the problems. Particularly if you have a viral infection, the use of an antibiotic is not the solution. As a society we must realise that it's a commodity we’ve had cheaply, widely available for us, especially in high income countries but we need to treat it a bit more carefully. Citizens should understand that this is a solution owned by society, a global public good. It should be made available, but it should be also used carefully.