Jan 22, 2022 Volume 399 Number 10322 p335-410
Antimicrobial resistance: time to repurpose the Global Fund
Antimicrobial resistance (AMR) is a major cause of death globally, with a burden likely to be higher than that of HIV or malaria, according to the most comprehensive assessment of bacterial AMR to date published in The Lancet. The data presented in this analysis are striking: in 2019, the deaths of 4·95 million people were associated with drug-resistant bacterial infections. 1·27 million deaths were directly caused by AMR. For the first time, the study provides estimates for 204 countries and territories, as well as data for the regional impacts of AMR. This study also reports details of AMR burden for 23 bacterial pathogens—Escherichia coli is accountable for the most deaths—and 88 pathogen–drug combinations, with meticillin-resistant Staphylococcus aureus causing the highest number of deaths. These new findings are pivotal to inform location-specific policy decisions and clinical practice.
The threat of AMR has long been signalled. And the steps needed to tackle AMR—boosting public awareness, better surveillance, improved diagnostics, more rational use of antibiotics, access to clean water and sanitation, embracing One Health, and investments in new antimicrobials and vaccines—have been consistently recommended in reports such as The Lancet Infectious Diseases Commission on Antibiotic Resistance in 2013 and the O’Neill report in 2016. There have been some noteworthy responses during the past decade. The Global Antimicrobial Resistance and Use Surveillance System was launched by WHO in 2015. The Fleming Fund (an aid programme supporting 24 countries across Africa and Asia to tackle AMR) was established in 2015. In December, 2021, G7 Finance Ministers issued statements to support antibiotic development.
But action has been episodic and uneven, resulting in global inequities in AMR. Sub-Saharan Africa and south Asia have the highest burden of AMR according to the new study, likely driven by high infection rates and a lack of access to antibiotics, compounded by serious data gaps. Innovation has been extremely slow. Vaccines are available for only one of the six leading pathogens described in the study. The clinical pipeline for antibiotics is too small to tackle the increasing emergence and spread of AMR. A lot of research has described the problem of AMR, but not enough has been done to study the solutions or how to change the political conversation.
National leaders now have an obligation to move AMR to a higher position in their political agendas. Research efforts should be accelerated to address knowledge and innovation gaps and to inform policy and practices. Access to effective antibiotics must be ensured. Above all, AMR must be seen as a global issue, which needs a globally coherent plan with a One Health approach. AMR has too often been viewed as an abstract risk to health, a potential cause of illness and death at some point in the future. This way of thinking makes it easy to ignore. But the new comprehensive estimates show that AMR is killing large numbers of people now. The harms of AMR are with us today. The COVID-19 pandemic could even accelerate the problem of AMR due to antibiotic misuse and prolonged hospital stays. This fact demands that actions to address AMR be scaled up urgently.
One immediate opportunity must be seized. Later this year, The Global Fund to Fight AIDS, Tuberculosis and Malaria will hold its Seventh Replenishment meeting. The focus for inviting donor investment is likely to remain on the three diseases that have been the hallmark of its success. However, the Fund is actively considering how to broaden its remit in response to a very different global context—notably, the need for further measures to strengthen pandemic preparedness and create resilient health systems in an era of climate crisis. 2022 is also the 20th anniversary of The Global Fund’s inception. Now is the right moment to review its fundamental purpose. The Fund was established to invest in programmes to end the infectious diseases that cause the greatest burden of illness and death, especially in low-income and middle-income countries. It has proven itself a highly effective instrument for protecting susceptible populations from preventable and treatable diseases. The existing burden of AMR and its future threat should be an urgent stimulus to revise and widen The Global Fund’s mission. It is now time for the Fund to embrace AMR as one of its core responsibilities. And donors should invest generously in such a renewed and reinvigorated Fund.