To mark One Health Day, we revisit the holistic concept spanning human, animal, and environmental health, which is one of the Fleming Fund’s guiding principles.
Drug-resistant infections in the time of COVID-19
As the global health community rallies to support the COVID-19 response, the Fleming Fund is committed to continuing crucial work on AMR, during this crisis and beyond.
Public health systems in Africa are coming under severe strain as the unprecedented COVID-19 pandemic persists. But as countries battle to bring the outbreak under control, efforts must also be maintained on other health emergencies.
Dr Matshidiso Moeti, WHO Regional Director for Africa
Since the COVID-19 outbreak began in January 2020, the world’s attention has been understandably focused on the spread of the virus and its impact on communities. We want to make sure that our partners can focus on this work as a priority where necessary. However, as Dr Moeti, the WHO Regional Director for Africa, pointed out, we cannot stop working to address existing global health emergencies, such as antimicrobial resistance (AMR), even during a viral pandemic.
While much of the world’s resources are committed to finding a vaccine or treatment for COVID-19, many health systems would not cope if an additional health crisis took hold, potentially resulting in a huge impact on human health and life. The Fleming Fund is continuing to support low- and middle-income countries to generate, share and use data on AMR throughout the current outbreak, to enable governments to make informed policy decisions, to reduce this growing global threat and guard against an additional health crisis emerging.
AMR poses a serious threat to public health with long-term negative humanitarian and economic consequences. The O’Neil review estimated that drug-resistant infections already kill 700,000 people per year which, if left unchecked, could rise to 10 million people per year. The COVID-19 pandemic could lead to a further increased use of antibiotics, possibly resulting in antibiotic misuse and the subsequent emergence and further spread of antibiotic resistance.
The link between viral outbreaks and secondary bacterial infections has been well established. During the Spanish Influenza outbreak of 1918, secondary bacterial infections such as pneumonia killed the majority of influenza patients as modern antibiotics had not yet been discovered. Similarly, studies show that bacterial co-infection was common in patients suffering from H1N1 influenza during the 2009/10 outbreak and caused between 29% and 55% of all H1N1 deaths.
Early evidence indicates that COVID-19 can also cause pneumonia in severe cases, and that oral antibiotics are the recommended treatment when the type of pneumonia, whether viral or bacterial, is unknown. There are also reports of azithromycin and other antibiotics being arbitrarily prescribed as treatments for COVID-19 or as preventative measures. Current literature suggests that only 8% of hospitalised COVID-19 patients experience a bacterial or fungal infection, yet 72% of these patients receive antibiotic treatment. Widespread use of specific antibiotics increases the likelihood of bacteria becoming resistant with catastrophic effects. For example, resistance to azithromycin could compromise the treatment of an already extensively resistant outbreak of typhoid in Pakistan.
Obstructions in pharmaceutical supply chains threaten to empty already low stocks of antimicrobials. This could lead to antibiotics on the AWaRe Watch and Reserve lists, which should only be used sparingly to treat serious infections, being used in place of those in the Access group, further exacerbating the issue of AMR in the long term.
The global response to the COVID-19 pandemic provides the perfect opportunity to strengthen health systems in a way that can both tackle the current pandemic and limit the spread of AMR over the long term. Activities such as Infection Prevention and Control (IPC) measures, water, sanitation and hygiene (WASH), and immunization will help prevent COVID-19 and bacteria from spreading, thus reducing the need for antibiotic treatment. Similarly, improved AMR surveillance can provide clinicians with the diagnostic capacity to test patients suspected of having a bacterial infection to improve prescribing practices and overall patient care.
It is therefore essential that the Fleming Fund continues to support low- and middle-income countries to generate, share and use AMR data to strengthen global AMR surveillance systems, better establish the impact of COVID-19 on AMR, and enable governments to make informed policy decisions to create a healthier and safer world.
List of sources
- Review on Antimicrobial Resistance. Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. 2014. https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf
- Morens, D.M., Taubenberger, J.K. and Fauci, A.S. (2008). Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza Preparedness. The Journal of Infectious Diseases, 198(7), pp.962–970. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599911/
- C, C., S, E., R, M., M, F., E, P., S, R., A, G., Ma, M., J, C., J, M. and A, T. (2012). Bacterial Co-Infection With H1N1 Infection in Patients Admitted With Community Acquired Pneumonia. [online] The Journal of infection. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22543245. https://www.ncbi.nlm.nih.gov/pubmed/22543245
- STAT. (2020). Antibiotic resistance: the hidden threat lurking behind Covid-19. [online] Available at: https://www.statnews.com/2020/03/23/antibiotic-resistance-hidden-threat-lurking-behind-covid-19/
- www.nice.org.uk. (n.d.). 4 Managing suspected or confirmed pneumonia | COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng165/chapter/4-Managing-suspected-or-confirmed-pneumonia.
- Morris, A. and Wright, G. (2020). The dangerous legacy of COVID-19: A rise in antimicrobial resistance. [online] The Globe and Mail. Available at: https://www.theglobeandmail.com/opinion/article-the-dangerous-legacy-of-covid-19-a-rise-in-antimicrobial-resistance/.
- Fisher, N. (n.d.). Superbugs: What You Need To Know About The Secondary Effects Of COVID-19. [online] Forbes. Available at: https://www.forbes.com/sites/nicolefisher/2020/04/22/superbugs-what-you-need-to-know-about-the-secondary-effects-of-covid-19/#7f573d066e41
- Chen, T., Wu, D., Chen, H., Yan, W., Yang, D., Chen, G., Ma, K., Xu, D., Yu, H., Wang, H., Wang, T., Guo, W., Chen, J., Ding, C., Zhang, X., Huang, J., Han, M., Li, S., Luo, X., Zhao, J. and Ning, Q. (2020). Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ, p.m1091. https://doi.org/10.1136/bmj.m1091
- Kirchhelle, C., Dyson, Z.A. and Dougan, G. (2019). A Biohistorical Perspective of Typhoid and Antimicrobial Resistance. Clinical Infectious Diseases, 69(Supplement_5), pp.S388–S394. https://academic.oup.com/cid/article/69/Supplement_5/S388/5587095
- HRABOVSZKI, G. (2020). Availability of medicines during COVID-19 pandemic. [online] European Medicines Agency. Available at: https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/availability-medicines-during-covid-19-pandemic.
- ReAct. (n.d.). Shortages and AMR – why should we care? 4 consequences of antibiotic shortages – 2020. [online] Available at: https://www.reactgroup.org/news-and-views/news-and-opinions/year-2020/shortages-and-amr-why-should-we-care-4-consequences-of-antibiotic-shortages/.
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As part of World Antimicrobial Awareness Week 2022 in November last year, Head of the Fleming Fund’s Expert Advisory Group Dr Catriona Waddington joined an esteemed panel of speakers from the AMR community at the symposium, ‘The rising tide of antimicrobial resistance – a high price to pay’ hosted by Ineos Oxford Institute, Oxford Martin School.