A UN High Level Meeting on Antimicrobial Resistance (AMR) pledged to reduce by 10% deaths from drug resistant bacteria over the next six years in a new declaration on the “silent, slow-motion pandemic” that could kill some 39 million more people by 2050.

Thursday’s milestone statement, the first on the topic since 2016, also pledges to raise $100 million to fund the updating of countries’ AMR action plans and their implementation. 

It also formalizes the standing of the Quadripartite secretariat made up of the World Health Organization (WHO), UN Environment (UNEP), the Food and Agriculture Organization (FAO), and the World Organization of Animal Health (WOAH), as the body coordinating global AMR response across the human, animal and environmental sectors.  

 Step forward despite no target for reducing animal antibiotic use

The final draft of the declaration failed to include an earlier target to reduce the animal use of antibiotics by 30% by 2030, due to pressure from meat-producing nations and the farm industry. 

This, critics say, remains a serious shortcoming in the final draft as livestock use comprises as much as 73% of global sales of a range of antimicrobial agents (including antibiotics, antivirals and antiparasitics). 

Even so, the initiative was hailed as a major step forward in spurring more action on trends that few governments have fully recognized until very recently. 

“This declaration.. is an impressive blueprint for action,” declared Barbados Prime Minister Mia Mottley, who has become a global leader and advocate on AMR. 

“But the truth is the hard work starts tomorrow,” she said. “We’ve set a very, very modest target of $100 million [for national plans of action] and I hope that we can reach out to the leaders within the private sector, the pharmaceutical industries, the meat industries, all of the various players. 

“Because, as I’ve said very often with climate, unless they have a plan to live on a different planet, then we have to define the win-win solution for us all.”

No country is immune

 “No country is immune to this threat, but low and middle income countries bear the greatest burden,” WHO Director General Dr Tedros Adhanom Ghebreyesus warned in his remarks.

“The threat of AMR cuts across the health of humans, animals, agriculture and our environment, and so must its solutions,” Tedros added.  “That’s why WHO, FAO and UNEP are working together closely with the World Organization for Animal Health (WOAH) in a One Health approach.” 

While 90% of countries have developed AMR action plans, only 11% of countries have allocated budgets to implement those plans, he said. 

As next steps, Tedros said that WHO and other members of the Quadrapartite would set up an independent science panel to produce a major report synthesizing evidence for more action on AMR by 2025.  WHO would also update its decade old global strategy on AMR by 2026. 

Deaths from superbugs 

Drug resistant bacteria are estimated to have killed an estimated 1.14 million people in 2021, and were somehow associated with the deaths of 4.71 million people, according to estimates published in The Lancet in mid-September. 

In the declaration, countries committed to reducing annual AMR deaths by 10% using a 2019 baseline level of mortality. In that year, 1.27 million deaths were attributed to drug resistant bacteria while 4.95 million deaths were somehow associated with drug resistant infections.  

Should global efforts to curb AMR fail, drug resistant pathogens could become the number one cause of death by 2050, warned Mottley at a press briefing just ahead of the High Level Meeting.

That would mean just going to the dentist, or getting cut doing garden work could lead to life threatening infections for some people “purely because of the ineffectiveness of the antibiotics,” Mottley warned.

“This, therefore, is a press conference not for us with grey hairs, so much, but for the young people in the world because they are the ones who will have to face the possible threat of a reversal of a century of medical progress in what we dub the ‘silent, slow motion pandemic,'” Mottley said.

Even so, AMR has already hit millions of families in the world, including her own, with tragic results, she added: “When I started this journey, I didn’t know it would become personal for me and my family, and I pray that no family has to experience what we did with respect to the loss of someone purely because of the ineffectiveness of antibiotics to be able to deal with infection.”

Four pronged assault – priorities for health and environmental sector 

The declaration outlines a four-part strategy to combat AMR. It calls for more careful use of antimicrobial agents in healthcare, farming, and animal sectors, alongside improved management of untreated sewage and hospital emissions. These emissions create environments where microbes from urine and feces can mutate and develop resistance to antibiotics, which are also released by hospitals and communities.

Tedros, Mottley and others also called out the alarming dearth of new antimicrobials in the product pipeline. 

The number of pharma firms working on new antibiotics has declined substantially since 2000 due to the perception that there is little profitability in producing new products that can’t be used in large volumes, precisely because that may foster a spiral of new resistance risks.  

Mottley said that antibiotics should be recognized as a “global public good” with “dedicated financing”’ that goes beyond commercial investments.  

“I hope, therefore, that the World Bank in the general discussion as to its own reform and its movement towards the finance of global public goods and the guardian of global public commons, will be able to see appreciable progress in its reform efforts, so that this can be one of the early beneficiaries…  because…, this is as much an existential crisis.” 

Tackling fake medicines, sewage discharge and hospital emissions

Tackling fake and substandard medicines, which can also lead to emergent resistance, is another huge priority cited in the declaration. And along with reducing overuse of antibiotics at risk of becoming impotent, as per WHO’s AWaRe classifications, there is a need to improve access to the right antibiotic formulations in low- and middle-income countries, where many more people still die from lack of any access whatsoever, Tedros emphasized. 

Moreover, some 56% of sewage effluent discharged is untreated, leaving cesspools of pathogens to breed and develop in lakes, rivers and aquifers of developing countries, in particular, pointed out Inger Andersen, Executive Director of the UN Environment Programme. 

Prevention is key to stop antimicrobials from leaking into our environment from municipal wastewater, from municipal waste, as well as wastewater from pharmaceutical production, hospitals, and farms that over use and intensify crop production sprayed with antimicrobials, Andersen added.  

“The pharmaceutical sector can strengthen inspection systems, change incentives and importantly, we can change subsidies and ensure adequate waste and waste management containment,” Andersen said. 

“The food and agriculture sector can take preventive action to limit the use of antimicrobials and to reduce the discharge from crops and terrestrial and aquatic, marine and animal and fish production facilities and the healthcare sector can improve access to high quality, hospital-specific wastewater treatment systems.

“This will take political determination, she stressed. “This will take leadership. These actions and more must be backed at the highest level, with policies, with laws and with regulations to reduce effluent releases.”

Animal use remains ‘elephant’ in AMR arena

But in terms of sheer volumes of use, antimicrobial use in the livestock sector remains one of the biggest threats to curbing AMR trends. It is estimated that some 73% of antimicrobials sold globally are used in livestock production, including continued use of antibiotics as growth agents in many nations.

Dropping the 30% target for their reduction significantly weakens the armory of the new declaration, observers said. 

“The AMR political declaration heralds a major shift in the global health response for AMR notably with the inclusion of commitment for targets and accountability including the recognition of the Quadripartite Joint Secretariat as the central coordinating mechanism as well as the call to establish an Independent Panel” said Dr Haileyesus Getahun, CEO of the South-South HeDPAC partnership. He led the foundation of the Quadripartite Secretariat, and served as its first director, in a previous role at WHO. 

“But it is very disappointing to see that the Muscat Manifesto targets on the 30% reduction of antimicrobial use in animals is not included, despite endorsement by 47 countries, ” he added, referring to a November 2022 declaration issued at the end of a High-Level Ministerial Conference on AMR hosted by the Sultanate of Oman in Muscat as part of the lead-up to the 2024 UN High Level Meeting. 

“Commitment for the targets would have galvanised county-level action not only to strengthen the animal health system but also the research and development for alternatives to antimicrobials,” Getahun said.

“It is unfortunate that there was a major push back by the animal food industry who were able to influence some member states and even divide the Quadripartite organizations on this very topic.”

WOAH cites its plans for action in animal sector

There is, however, increasing recognition that overuse of antibiotics and other antimicrobials also represents an economic threat to the meat and dairy industry as the drugs will also become less effective in animal populations, asserted new WOAH Director General, Emmanuelle Soubeyran, at the HLM meeting.

“Drug resistant pathogens could jeopardize food security for over two billion people globally, more specifically on livestock, if no action is taken,” she said. 

“The impacts of AMR on livestock could reduce global GDP by $40 billion per year,” she said.  “But achieving a global 30% reduction in animal antimicrobial use within five years can raise [global] GDP in 2050 by €14 billion. 

“Thus, the World Organization for Animal Health welcomes the political declaration in alliance with our four priorities.”

Improving access to animal vaccination as an alternative to antimicrobials

Soubeyran said that improving access to animal vaccinations for vaccine-preventable diseases can reduce unnecessary use of antimicrobials. 

“We welcome your commitment to define animal vaccination strategies with clear implementation plans… and we’ll update the priority list of diseases of which vaccines could reduce antimicrobial use.”

At the same time, she admitted that the animal sector needs to do more to reduce its use of drugs deemed by the WHO to be “highest priority” for use in human health – and not animals. 

“The use in animals of highest priority antimicrobials to human health has been globally reduced to 16%,” she said.  “Regulation, awareness campaign, trainings, and public private partnerships have allowed such developments. 

“But we strongly encourage all of you, all of our members, to accelerate along this line. So, the important gaps still observed in the compliance with our international standards are closed.”

Economic carrot and stick

Since 2015, WOAH has seen the number of countries reporting quantitative data on antimicrobial use in animals increase three-fold, with 130 member states [of 183] now reporting, she added at a press briefing just before the HLM.

At the same time, the Paris-based WOAH, unlike FAO, WHO and UNEP, is not a UN-affiliated agency. Member states’ reports of their antimicrobial use are voluntary and not made public, leaving researchers to cull regional and country data from surveillance data on international drug sales in the animal health market. 

For instance, a  2019 WOAH report on trends in use of antibiotics as growth promoters, showed a decline in the practice. But not all 183 member states report data, and WOAH does not name the 45 countries that did report but continue antibiotic use for growth promotion.  

Among countries that continue to use antibiotics as growth promoters, the overall use of antibiotics is much higher overall, without much regard for risks, Soubeyran acknowledged. 

“Some 76% of WOAH members still using antimicrobials as growth promoters have not carried out a risk assessment … and countries using antimicrobials for growth promotion in livestock have an estimated average of 45% higher antimicrobial use than countries that do not use growth promoters.” 

Despite the resistance to change, emerging new economic data showing how antimicrobial abuse in livestock could lead to big economic losses over time, while judicious use will yield economic benefits, could begin to make a difference to the industry and policy makers. 

 “It is something very important to say to the sector,” she said. 

Image Credits: Yvan Hutin/WHO, IFPMA, Flickr: Paul van de Velde.