By guest blogger, Paul Kiet Tang, Senior Assistant Editor at The Lancet*
Since its discovery and widespread use, antibiotics have been marvelled as a panacea that has revolutionised modern day medicine. Routine surgical procedures, childbirth, and open wounds are no longer associated with high risks of mortality from infections. However, the overuse and misuse of these drugs have led to increased concerns of antibiotic resistance worldwide, with up to 700,000 people dying globally from antibiotic-resistant infections. In the final 2016 report of The Review on Antimicrobial Resistance from the UK Government and the Wellcome Trust, this incidence was projected to increase to 10 million people per year by 2050, costing the global economy up to 100 trillion US dollars and pushing about 28.3 million people into extreme poverty. These statistics must not be ignored if health-care professionals, stakeholders, and governments worldwide are to avert this catastrophic outcome.
International bodies, such as the United Nations (UN) and the World Health Organization (WHO), in the past decades have continuously recognised this threat of a post-antibiotic era. Global efforts to tackle antibiotic resistance have now only started to physically emerge, with the 193 UN member states signing a declaration in September 2016, that recognises the threat of antibiotic resistance to global health security. Since then, actions have taken place worldwide, including surveillance to fully understand the scale of drug resistance and awareness programmes to inform the public about this issue.
18 November, 2017, is the European Antibiotic Awareness Day and 13-19 November marks World Antibiotic Awareness Week. Campaigns and initiatives throughout Europe are aiming to increase public awareness of the risks associated with inappropriate use of antibiotics and how the community itself can play a responsible part. For example, in the UK, Public Health England have launched the Antibiotic Guardian and the Keep Antibiotics Working campaigns to help the community understand the issues with overusing and misusing antibiotics.
However, the issues arising from antibiotic resistance is not only limited to human medicine, but expands towards the fields of veterinary medicine and agriculture too. Since the mid-1900s, the use of antibiotics in livestock feeds have increased: industrial farms have relied heavily on these drugs to promote growth and prevent infectious diseases in order to yield higher profits from livestock. Although routine use of antibiotics have been banned in Europe, many other countries such as the USA continue this practice with antibiotics that are deemed critically important for human medicine by the WHO. According to the 2015 summary report by the US Food and Drug administration (FDA), in the USA, more than 70% of these medically important antibiotics are sold and used in livestock.
These findings are unsettling, because increase agricultural use of antibiotics also contributes to resistant bacteria strains that can subsequently infect humans. Such bacteria could be transmitted directly to humans who are in close contact with livestock, particularly farmers; they can also be transmitted during the preparation and consumption of contaminated meat; and can be excreted by the animals into the environment and eventually spread.
On 7 November, 2017, WHO announced new guidelines to farmers and the food industry. These guidelines aim to assist the agricultural use of antibiotics that are deemed medically important for human health. WHO recommends that both farmers and the food industry stop using these drugs routinely to promote growth and as prophylaxis in healthy animals. The evidence for such recommendations is based on a systematic review and meta-analysis of 181 studies published in The Lancet Planetary Health. Findings from this study showed that restriction of antibiotic use reduced resistant bacteria strains from 1% to 39%; however, the findings in this study are limited by considerable heterogeneity and will be difficult to generalise to various specific settings. Nonetheless, the overall message is clear: resistant bacteria strains arising from livestock can be reduced.
However, the WHO guidelines are mandatory and not legally binding. Since this announcement, global outcries opposing these guidelines have emerged, with criticism from the Trump Administration and the National Pork Producers Council in the USA. They argue that WHO has conflated disease prevention with the promotion of growth in livestock, in which the use of antibiotics to help livestock gain weight has been enforced by the FDA as a federal law in early 2017. Individuals in the UK have also criticised the WHO guidelines, citing that many small-scale farmers around the world will lose out on business against large-scale producers, as they are dependent on antibiotics in animal feeds to promote growth and to prevent diseases spreading in their livestock.
It is clear that the issues are complex. If humans are to avert a post-antibiotic era, global efforts in tackling antibiotic resistance must be taken seriously. Innovative interventions and public awareness are just a few pieces to the puzzle. The new WHO guidelines are a welcomed addition to policy makers and governments worldwide, for whom these guidelines provide further evidence to refine and advise judicious antibiotic use. For now, it is undeniable that antibiotic resistance is a true global health issue that can affect anyone, anywhere.
*The views expressed here are that of the author and do not reflect that of The Lancet medical journals, Elsevier, or the RELX group.