A lesser-known silent pandemic- Antimicrobial resistance (AMR)

Today, we live amidst a viral pandemic, COVID-19. In more ways than one, so much of our world has changed. COVID-19 has taught us that a small virus can almost shut the world’s social and economic machinery down. It is certainly a phenomenon the world was not prepared for.

This case study talks about yet another possible pandemic and what we can do to circumvent this. It is caused by bacteria which can survive for long periods outside the body unlike the coronavirus. Thereby, causing it to spread through food, air and water. As a result, social distancing would be ineffective and one can only imagine its magnitude. Speaking of which, AMR kills about 700,000 individuals annually and if left untreated, it is estimated to take away 10 million lives by the year 2050. This is more lives than cancer and is a greater threat to human life than COVID-19.

**Fig 1**, it is estimated that if AMR is left uncontrolled, it is expected to kill 10 million individuals worldwide. This is more than cancer and road traffic accidents put together. Source: https://www.statista.com/chart/3095/drug-resistant-infections/

WHO-Director General, Tedros Adhanom stated that Antimicrobial resistance (AMR) is a “slow tsunami that threatens to undo an entire generation of medical progress.” This is because bacterial infections cause common surgeries that have been performed for decades very risky. Healthy individuals who may undergo normal surgeries such as C-sections, joint replacements or even tooth extractions are at a high risk of death. They may contract fatal bacterial infections from the site of surgery, since, we may not have the antibiotics to treat such infections.

AMR- A Global Problem

The hotspots of resistant bacteria are places where there are poor hygiene systems and insufficient waste management. This could be residues from our homes or hospitals or pharmaceutical manufacturing sites. These residues seep into water and soil forcing normal bacteria in such environments to develop genes that resist these antibiotics. Such bacteria are called ‘Superbugs’ and these resistance genes are like their superpowers.

One of the many unique things about bacteria is that they love sharing their superpower resistance genes even with other unrelated bacteria. This inter-species transfer of resistance genes continues to happen even after the antibiotic is removed from the environment. This means that there is a strong need to control antibiotic waste at source.

It is true that a handful of countries such as the Nordics have largely mastered waste management. However, much like the corona virus, resistant bacteria in one part of the world can rapidly spread to another part in just a couple of hours when someone takes a flight or when someone sends a parcel or sometimes even through migratory birds. (Fig 3) This is because bacteria can survive a wide variety of harsh environmental conditions even outside the body by switching to a low energy state. A state in which some bacteria remain undetectable by routine quality control methods. So, by and large, this is an urgent global problem that needs a collaborative solution.

**Fig 3.,** shows the global spread of three bacteria from their point of origin to other parts of the world within a time-frame of 10 and 20 years. Source: https://science.sciencemag.org/content/360/6390/733/tab-figures-data

Lack of pharma investment in the antibiotics space

One may ask why pharma companies have not come with new antibiotics. The answer lies in the game-changing play of profit and loss. According to a 2017 estimate, the cost of bringing an antibiotic to the market is about US$1.5 billion. However, the revenue generated by the sale of antibiotics is roughly US$ 46 million per year. Also, governments in the developed world try to keep the price low and physicians do not prescribe large volumes of antibiotic to prevent further build-up of resistance.

These price and volume factors result in diminishing profits and have resulted in decreased investment in the antibiotics space and poor replenishment of the antibiotic pipeline. As a result, pharma companies are choosing to invest in other profitable sectors such as cancer (Fig 4). The world has not seen a new class of antibiotic since 1987 (Fig 3)

**Fig 3.,** shows that no new class of antibiotics with a novel mechanism of action has been discovered since 1987 resulting in an antibiotic discovery void. Source: https://www.reactgroup.org/toolbox/understand/how-did-we-end-up-here/few-antibiotics-under-development/

**Fig 4.,** shows that starting from 1987, in the US, antibiotic approvals have been diminishing, however, a spike in cancer approvals is observed. Source: https://www.nature.com/articles/d41586-020-02884-3

Building a more resilient world

Below is a brief glance on how Antimicrobial resistance (AMR) can be controlled in various sectors.

Let us craft more solutions together to build a more resilient world with NAI’s unique case study programmes.

Event:

Large-scale overuse of antibiotics by the public even for non-bacterial infections.

Possible root causes:

Lack of sufficient regulations in dispensing Over-the-Counter (OTC) bacterial antibiotics in developing economies such as India and Nepal.

Solutions:

Government regulations that make declaring the number of OTC drugs sold available. So, governments can keep track of OTC drugs dispensed to the public.

Policies that allow doctors to prescribe antibiotics on a need basis as much as possible. This could tackle the off-label public use of antibiotics for non-bacterial infections.

Event:

Overuse of antibiotics in the livestock sector.