Experts propose global targets for cutting antibiotic use

Arguing that antimicrobial resistance (AMR) threatens to erase decades of progress in medicine, public health, and food security, a group of global health experts is urging the United Nations (UN) to set global targets for reduced antibiotic consumption.

In a commentary published yesterday in Science, the authors argue that countries should aim to consume no more than the current median global level of antibiotics (8.54 defined daily doses per capita per year), an amount they say would reduce global antibiotic use by more than 17.5%. How each country would get there would have to be determined at the national level, with solutions tailored to each country's situation.

The paper comes ahead of a Sep 21 meeting of the UN General Assembly, at which world leaders will discuss ways to preserve global access to effective antimicrobials. The meeting marks only the third time the UN has called on world leaders to discuss a health issue. The UN held General Assemblies in 2001 to address the AIDS crisis and in 2014 to discuss the Ebola epidemic.

Public health approach

Reducing antibiotic consumption, the authors argue, can be achieved by improving public health and sanitation in lower- and middle-income countries that lack public health infrastructure, a target that can be linked to UN Sustainable Development Goals. But they also call for public campaigns, aimed at both physicians and patients, to discourage the inappropriate use of antibiotics.

That type of antibiotic misuse is more common in wealthier nations. An accompanying chart shows that antibiotic sales in many high-income countries, including the United States, are well above the target figure of 8.54 daily doses per capita per year.

Part of the problem is a lack of understanding among the general public of when antibiotics should be used. According to a recent European Commission survey on AMR and antibiotic use, 57% of respondents gave the wrong answer when asked if antibiotics can kill viruses. In a recent US survey, 40% said antibiotics are the best treatment for a runny nose or sore throat.

But the authors also argue that there is much room to reduce antibiotic consumption in the animal sector, which is projected to rise 67% by 2030 because of a growing demand for meat, milk, and eggs in the developing world. They call for a "complete global phasing out" of the use of antimicrobial growth promoters in farm animals over the next 5 years, a move they acknowledge will be costly for the agriculture sector in many countries but will ultimately be less burdensome than the cost of AMR.

This phasing out, they say, would be similar to global efforts to end the use of asbestos and chlorofluorocarbons.

The commentary also calls for reducing levels of resistance to first-line antibiotics nationally, regionally, and globally within 5 years.

Why targets are necessary

Setting targets is critical, says lead author Ramanan Laxminarayan, PhD, MPH, director of the Center for Disease Dynamics, Economics & Policy in Washington, D.C., because that's the only way public health officials will be able to assess whether efforts to reduce AMR are working. "We need to measure progress, and have some idea of what progress will look like," Laxminarayan told CIDRAP News.

And while governments are always wary of targets, he says, the UN has always been more successful at making progress on health issues when it articulates goals and defines ways to measure those goals. "There's no point in just saying you want to respond to an issue," he adds.

Laxminarayan places equal weight on reducing antibiotic consumption in humans and animals, and says the argument about whether humans or animals are contributing more to the problem of antibiotic resistance misses the point. "Any selection pressure is going to destroy the antibiotics we have, and any new antibiotics we create," he says.

Laxminarayan says the upcoming UN meeting is important, because for the public, AMR is a different kind of public health threat than acute health crises such as Zika and Ebola, where the threat appears imminent. AMR is more of an evergreen issue, something that people have been hearing about for a while but don’t have a sense of how it affects them personally. In that way, he says, it's similar to climate change.

"Getting people to respond to a problem that is creeping up slowly…is difficult," he says.

Money and infrastructure also needed

In addition to setting targets for reduced antibiotic consumption, Laxminarayan and his co-authors also identify money and infrastructure as significant elements in the battle against antimicrobial resistance. "Substantial funds have been committed in the United States and Europe to tackle AMR, but success will be limited without global-scale investments," they write.

The money—they estimate $5 billion annually is needed—would go toward the development of new vaccines that would reduce the need for antibiotics, diagnostic tools that can determine the nature of an infection more quickly, and novel alternatives to antibiotics. But while new antibiotics are needed as well, the authors write, they can't be a long-term solution because resistance will develop quickly to those drugs.  

To oversee these efforts, the authors call for the creation of a High-Level Coordinating Mechanism (HCLM) that would bring together the World Health Organization, the UN Food and Agricultural Organization, the World Organization for Animal Health, other UN agencies, and additional stakeholders that would coordinate support for the development, implementation, and monitoring of national AMR plans. They liken the HCLM to the Joint UN Program on HIV/AIDS, created in 1996.

Laxminarayan says having this kind of infrastructure to guide the process is essential. "Having goals is one thing, but having the architecture is absolutely critical," he said.

See also:

Aug 18 Science Policy Forum

Jun 2016 Eurobarometer survey on AMR

Jun 2 CIDRAP News story "US survey shows gap in understanding of antibiotic resistance"

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