Preventing antimicrobial resistance together

Antimicrobial resistance (AMR) is a global health and development threat. It is everywhere. It can affect anyone, of any age, in any country. It is a threat to humans, animals, plants and the environment. Antimicrobials—including antibiotics, antivirals, antifungals and antiparasitics—are medicines used to prevent and treat infections in humans, animals and plants. Microorganisms that develop antimicrobial resistance are also referred to as ‘superbugs’. Antimicrobial resistance occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to existing medicines. Medicines become ineffective leading to treatment failure, increasing the risk of disease spread, severe illness and death. The magnitude of the problem is reflected in the fact that in 2019, nearly 5m human deaths worldwide were associated with bacterial AMR, of which 1.3m human deaths were directly attributable to bacterial AMR.

Though the emergence of resistance in microorganisms occurs naturally over time, its amplification and spread are the result of human behavior. Antimicrobial resistant organisms are found in people, animals, food, plants and the environment (in water, soil and air). They can spread from person to person, between people and animals, from food of animal origin. The main drivers of antimicrobial resistance include the misuse and overuse of antimicrobials; lack of access to clean water, sanitation and hygiene (WASH) for both humans and animals; poor infection and disease prevention and control in health-care facilities and farms; poor access to quality, affordable medicines, vaccines and diagnostics; lack of awareness and knowledge; and lack of enforcement of legislation.

WHO has declared that AMR is one of the top 10 global public health threats facing humanity. Many of the medical breakthroughs of the last century could be lost through the spread of antimicrobial resistance. Previously curable infectious diseases may become untreatable and spread throughout the world. This has already started to happen. A growing number of infections—such as pneumonia, tuberculosis, gonorrhea, and food borne diseases such as salmonellosis—are becoming harder to treat as the antibiotics used to treat them become less effective. Older and cheaper antibiotics like penicillin, tetracycline and ciprofloxacin have been effective in the past, but now all of the 82m cases of gonorrhea detected each year are resistant to one or all of these. The last effective drug, ceftriaxone, already indicates increasing gonococcal resistance. Antibiotic resistant Mycobacterium tuberculosis strains are threatening progress in containing the global tuberculosis epidemic. Antimalarial drug resistance is another serious cause for concern. Parasite resistance to artemisinin—the core compound of the best available medicines to treat malaria has been reported. HIV drug resistance (HIVDR) poses the risk of compromising the effectiveness of antiretroviral therapy (ART) in reducing HIV incidence and HIV-associated morbidity and mortality. In Nepal, national surveillance shows that around 80 percent of typhoidal salmonellae (the bacteria causing typhoid fever) is now resistant to ciprofloxacin which used to be the treatment choice for typhoid fever. Approximately half of the hospital acquired infections are multidrug resistant. The cost of AMR to the economy is significant. In addition to death and disability, prolonged illness leads to higher medical costs due to longer hospital stays, and the need for more expensive medicines. Left unchecked, in the next decade, AMR could result in a global GDP shortfall of $3.4trn annually and push 24m more people into extreme poverty. The WHO South-East Asia Region of which Nepal is the member state is likely the most at-risk part of the world. As recent history demonstrates––given the ease and frequency with which people now travel, AMR is a global problem, requiring efforts from all nations and many sectors. Combating the complexities of AMR requires a multisectoral One Health approach. Multiple sectors and stakeholders engaged in human, terrestrial and aquatic animal and plant health, food and feed production and the environment need to communicate and work together in the design and implementation of programmes, policies, legislation and research to attain better public health outcomes. Together they need to focus on:

• Improving awareness and understanding of antimicrobial resistance through effective communication, education and training in the appropriate use and prescription of antimicrobials in human health, animal health and agricultural practice. It includes making antimicrobial resistance a core component of professional education, in the health, veterinary and agricultural sectors.
• Strengthening surveillance and research across human, animal, plant, food, and environment sectors in efforts to tackle antimicrobial resistance (AMR).
• Strengthening policies and implementation of infection prevention and control measures through effective sanitation, hygiene and infection prevention measures. Infections can be prevented by washing hands regularly, preparing food hygienically, avoiding close contact with sick people, practicing safe sex, and keeping vaccinations up to date. Good husbandry practices, biosecurity, sanitation, hygiene, vaccination and other infection prevention measures are essential to reduce the need for antimicrobials in animals and antimicrobial pesticides in plants.
• Optimize the use of antimicrobial medicines in human and animal health through effective and enforceable regulation and governance for licensing, distribution, use and quality assurance of antimicrobial medicines in human and animal health and appropriate use of antimicrobial agents in agriculture.
• Ensure sustainable investment in countering antimicrobial resistance and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

As a WHO member state, Nepal endorsed the global action plan to tackle AMR during the 68th World Health Assembly. The same year during the WHO South East Asia Regional Committee Meeting in Timor Leste, member states passed a key resolution for steadfast political commitment and multisectoral coordination for AMR control. The Ministry of Health and Population in Nepal has drafted a National Action Plan (NAP) to contain AMR. This plan provides the necessary framework for action. WHO remains committed to supporting the Government of Nepal in its implementation. The author is the WHO Representative to Nepal