Source: World Health Organization

Antibiotics, antivirals, antifungals and antiparasitic medicines constitute a group called antimicrobials that are used to prevent and treat infections in humans, animals & plants. Antimicrobials are one of the key pillars of modern medicine, and a world without antimicrobials could take us back to the pre-antibiotic era; a time when surgeries like C-sections could threaten the life of a pregnant mother due to infections or a child could die of bacterial pneumonia. “Antimicrobial Resistance (AMR)” occurs when infectious agents (bacteria, viruses, fungi and parasites) change over time and become resistant to medications. Simply put, they no longer respond to the medications used against them. AMR makes infections harder to treat and increases the risk of disease spread, severe illness and death (1). While AMR is a natural evolutionary process, its emergence has been rapidly expedited due to the overuse, misuse & inappropriate use of antimicrobials as well as due to inadequate research in discovery of new antimicrobials.

The real-world impact of growing antimicrobial resistance is already becoming apparent. Many treatable diseases like tuberculosis (TB) and malaria are already seeing the impact of the rise of AMR. Drug-resistant Tuberculosis (DR-TB) is the reality today, with an estimated global burden of 450 000 new DR-TB cases (resistant to rifampicin) in 2021 alone (2). As per the Lancet report of 2019, an estimated 1.27 million deaths were attributed to bacterial AMR, which is greater than the global mortality due to HIV/AIDS (864,000 deaths) or malaria (643,000 deaths) (3)(4). Considering the significant impact of AMR on Sustainable Development Goals (SDGs) like SDG-3 (Good health and wellbeing), targets 3.1-reducing maternal mortality, 3.2 ending preventable death of newborns, infants and children under 5 years of age, 3.3 ending the epidemics of AIDS, TB, malaria and other neglected diseases, WHO declared AMR as one of 10 key global public health threats last year. AMR also affects the lives and livelihoods of millions – 28 million people risk being pushed into extreme poverty by 2050 due to AMR, as per the World Bank report (5).

In the past, AMR was considered a tertiary care problem, but today there is no escaping the fact that issues linked to AMR begin right at the primary healthcare level, where practitioners already face significant challenges in diagnosing infectious agents and accordingly prescribing appropriate treatment. The inadequacy or absence of diagnostic facilities at the primary level forces healthcare providers to use empirical treatments and excessively use broad-spectrum antibiotics, among other faulty approaches that have dramatically increased AMR for conditions like TB, malaria and other infectious diseases (11). While such empirical treatments could be adequate in some situations, they are often inappropriate. For example, when a parasitic infection like malaria is treated inappropriately as a bacterial infection or vice-a-versa, the flawed treatment approach could give rise to AMR. Inappropriate treatment of infectious diseases not only fuels AMR, but it also increases morbidity & mortality, with economic implications for patients, their families and health systems (7,8,10,11). When resistance to certain antimicrobials is developed, it is the underserved who are first and most affected because of the lack of access and affordability of newer antimicrobials.

When addressing the challenge of AMR, it’s also important for us to recognize the far-reaching consequences of gaps in primary healthcare facilities. The lack of point-of-care diagnostics at the primary level doesn’t just affect treatment for individual patients, but it also develops into larger public health threat. This is because prevention activities or outbreak response is affected as evidence-based scientific surveillance of disease turns into a major challenge (10, 11). AMR at the primary healthcare level, being such a complex yet looming threat, calls for a multi-pronged strategy to nip it in the bud. Here are some viable approaches:

1. 1. Prevention of infection because this would eliminate the need for antimicrobials. This requires:
      1. a. Community-level awareness and WASH (Water, Sanitation and Hygiene) solution adoption.

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      1. b. Healthcare facility-level infection prevention and control.

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   1. Surveillance of infectious diseases & AMR. Read more
   2. Availability of point-of-care diagnostic solutions for infectious diseases at primary levels. Read more
   3. Antimicrobial stewardship, which includes evidence-based rational treatment of infections by various means, one of them being AI-based clinical decision support systems for digital prescription of antimicrobials. Read more
   4. Discovery and development of new antibiotics and other antimicrobials. Read more
   5. Treatment adherence tools for chronic infectious diseases such as TB and HIV that require longer treatments. Read more

   India Health fund, a non-profit organization seeded by the Tata Trusts, is tackling the issue of AMR at the primary healthcare level by supporting innovative point-of-care screening and diagnostic solutions for infectious diseases like TB and malaria. From AI-based TB screening tools (with Qure.ai), point-of-care blood-based triaging test for TB (with Stellar Diagnostics) and a 1-minute $1 malaria diagnostic test (with Hemex Health) to a TB prognosis solution (with Healseq), a smart AI-based mosquito surveillance device (with TrakItNow) and supporting TB treatment adherence using a smart pillbox (with Sensedose Technologies) – all of India Health Fund-supported last mile solutions will help reduce mortality and morbidity related to infectious diseases, furthering the fight against AMR, and protecting public health at large.

   By Dr. R.K. Lakhani, Senior Portfolio Manager, India Health Fund.

   Dr. Lakhani is a public health professional with over a decade of experience in the health sector. He is a Post-graduate in Public Health Administration form Tata Institute of Social Sciences and graduate in Dental & Medical Science from Maharashtra University of Health Sciences.  He has worked with National & State Governments, National & International NGOs and the World Health Organization. His area of work and interest is in health systems strengthening, infectious disease surveillance and capacity building.

    

    

   

   Source: World Health Organization

    

   This blog was published as part of the World Antimicrobial Awareness Week 2022.

    

    

    

    

   References

   1. WHO Antimicrobial resistance fact sheet 2021 (accessed on 21 November, 2022)

   2. WHO Global TB report 2022 (accessed on 21 November, 2022)

   3. Thompson Tosin. The staggering death toll of drug-resistant bacteria, Nature; Jan 2022 (https://www.nature.com/articles/d41586-022-00228-x) (accessed on 21 November, 2022)

   4. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis, Lancet. Feb 2022 (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext) (accessed on 21 November, 2022)

   5. Adeyi OO, Baris E, Jonas OB, Irwin A, Berthe FCJ, Le Gall FG, et al. Drug-resistant infections: a threat to our economic future. Final report. Washington (DC): The World Bank. 2017 (http://documents.worldbank.org/curated/en/323311493396993758/pdf/114679-REVISED-v2-Drug-Resistant-Infections-Final-Report.pdf) (accessed on 21 November, 2022)

   6. Davies SC, Oxlade C. Innovate to secure the future: the future of modern medicine, Future Healthc J. 2021 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8285149/) (accessed on 21 November, 2022)

   7. Ferreyra C, Gleeson B, Kapona O, Mendelson M, et al. Diagnostic tests to mitigate the antimicrobial resistance pandemic—Still the problem child, PLOS Global Public Health. June 2022 (https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000710) (accessed on 21 November, 2022)

   8. Trevas D, Caliendo AM, Hanson K, Levy J, Ginocchio CC. Diagnostic Tests Can Stem the Threat of Antimicrobial Resistance: Infectious Disease Professionals Can Help. Clin Infect Dis. 2021 (https://academic.oup.com/cid/article/72/11/e893/5989648?login=false) (accessed on 21 November, 2022)

   9. National Action plan for antimicrobial resistance (accessed on 21 November, 2022)

   10. WHO technical series on Primary health care – Antimicrobial resistance & primary care (accessed on 21 November, 2022)

   11. Diagnostic gaps in global health, Catharina Boehme and Madhukar Pai, Think Global Health; Feb 2020 (accessed on 21 November, 2022)

Publication Date: 21st Nov 2022