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The AMR threat

The scale of the antimicrobial resistance challenge

Dame Sally Davies

One of the major public health threats of the modern age, antibiotic resistance can affect anyone, of any age, in any country.

The misuse and overuse of antibiotics in humans and animals is causing resistance to accelerate and leading to a growing number of infections - among them pneumonia, tuberculosis and gonorrhoea - becoming harder to treat as the antibiotics used to treat them become less effective.

Despite this increase in prevalence, it is also often poorly understood. For those charged with safeguarding our health it's a challenging combination as they seek to influence multiple stakeholders and communicate a complicate message.

One of those at the forefront of the fight against antibiotic, or antimicrobial, resistance is Professor Dame Sally Davies. Appointed as the UK government's chief medical advisor in 2010, she has proved herself to be - and continues to be - a leading voice in the fight against antibiotic resistance.

Dame Sally has worked hard to raise awareness of the challenges involved in tackling antibiotic resistance, and she helped bring it to a world stage via the innovative Longitude Prize. Launched at the 2013 G8 meeting, the prize supports research into a simple diagnostic test to determine if an infection is caused by bacteria - and therefore can be treated with antibiotics - or if it is caused by a viral infection.

It was these efforts that saw her receive the Healthcare Communications Advocate at the 2015 Communiqué Awards, joining recent past recipients of the trophy such as Professor Sir Mike Richards, the UK's first national cancer director, and chief executive of mental health charity SANE, Marjorie Wallace.

Commenting on Dame Sally's award last year the Communiqué judges highlighted her “lifelong commitment to not just increasing understanding of the threat of antibiotic resistance, but actually doing something about it”.

They added: “Dame Sally is at the forefront of antibiotic resistance, which will continue to be the curse of the modern age unless tackled.”

The pressing need for action is clear from some of the numbers attached to it. Across Europe around 25,000 die each year as a result of hospital infections caused by resistant bacteria, adding €1.5bn to hospital treatment and societal costs.

Ultimately, if the number of hard-to-treat infections continues to grow, then it will become increasingly difficult to control infection in a range of routine medical care settings.

Across Europe around 25,000 die each year as a result of hospital infections caused by resistant bacteria, adding €1.5bn to hospital treatment and societal costs

The AMR threat
“The threat of antimicrobial resistance is akin to climate change and, despite two and a half years of hard work by many people, we have not yet got on top of it,” Dame Sally explains. “Everywhere you look, more and more antibiotics are prescribed and resistance of bacteria to antibiotics is going up.”

In the case of HIV, for example, about 7% of viruses are now resistant to first-line retroviral treatments.

Emblematic of the picture Dame Sally paints of a problem that, at the moment, continues to get worse, was the recent news from China showing that pigs given antibiotics, not for ill health but for growth promotion, have developed resistance to colistin. The last-line drug is “a horrible antibiotic that you wouldn't want to use in humans” - and in fact it wasn't originally used because of its side effect profile, Dame Sally explains, however, it is the last drug now available for some drug-resistant bacteria.

With researchers reporting the 'horizontal gene transfer' of colistin resistance between animals and humans after a small number of hospital patients in China were also found to be resistant to the antibiotic, they concluded that plasmid-mediated resistance had breached the last group of antibiotics. That means, Dame Sally explains, “it can go into all future generations, and that's very scary news”.

The roots of the AMR problem lay in over-prescribing and the use of antibiotics for growth promotion in the agricultural sector outside Europe. Misuse of antibiotics - and not just patients demanding antibiotics for virus infections where they won't work - is also a factor.

“If you take a suboptimal dose, instead of killing the bugs, you allow some to escape because they develop a resistant gene and they will multiply, whereas if you really hit it over the head with a very high dose, you might well have killed them all before resistance developed,” Dame Sally says.

“Some of this suboptimal dosing is also because people have got heavier and we haven't changed our dosing regimes; some are given the wrong drugs because we don't have rapid diagnostics; and some are given drugs when they're not needed. And then a lot of people stop the drugs before they've finished the course. They feel well, but there will still be bugs around that mean they should have gone on taking the drugs.”

However, data showing increases in antibiotic use across the world have also to be seen in the light of a tension between access and excess. For example, a lot of the increase in the BRIC countries is down to their continued development and ability to facilitate access to antibiotics for those that need them.

Ultimately, however, it's a complicated picture with many different dynamics in play.

I was taught, very early on that one of the things about leadership was to have a vision, but another was to have a simple message

Communicating a complex message
Key to successfully communicating such a complicated message is, Dame Sally says, tailoring your messages.

“You've got to think about who you're talking to. So if I'm talking to the government, I want to set it in economic terms. If you're talking to the public, then it's more about homing in on the 'end of modern medicine' and what that could mean to them. Then, for healthcare professionals, it is about education.”

Many of the economic figures that the government needs have come from the AMR Review, chaired by noted economist Lord O'Neill, which published its first paper on the subject in December 2014.

The Review makes stark reading: drug-resistant infections could kill an extra 10 million people around the world each year by 2050 if they are not tackled. Moreover, it says the global economic cost by that date will stand at around $100 trillion in lost output - roughly equivalent to the world losing the output of the UK economy every year … for 35 years
Given the strength of the government's backing for the fight against AMR, the Review can certainly claim to have been a useful tool for getting the message across.

On the international stage too, there have been successes. Resolutions at the World Health Assembly have led to a global action plan. The work of the European antibiotic awareness day, first held in 2008, has spread and last year saw the first, and WHO-backed, World Antibiotic Awareness Week to further highlight the need for global action to tackle antimicrobial resistance.

Dame Sally, along with the prime minister, the chancellor and the foreign office, is working to secure a high-level meeting at the UN General Assembly later this year on the issue of AMR. There were also the 2015 visits to the UK by China's President Xi and India's Prime Minister Modi, which yielded commitments to joint action on the area.

“There is a terrific amount of work underpinning all of this,” notes Dame Sally, “much of which I lead, but the prime minister himself and his office play a key role in it too.”

Tailored campaigns
Talking to the WHO, UN, governments and this country's ministers clearly demands a certain communications strategy, but what of the public? There Dame Sally and her comms team are focusing on making their messages relevant to people or even talking about their grandchildren. “Looking at the pattern of diseases, one in two of us will have cancer before we die. If resistance continues as it is at the moment and there are no new antibiotics, then will we want to go on using very heavy chemotherapy and radiotherapy to kill those cancers? They make you particularly prone to infection and, without effective antibiotics, those infections may not be treatable.”

The challenge is to pick out something - the relatively low rate of infection - that many of us take for granted, and then frame it in a way that means something to the public. For example, before antibiotics 43% of people died of infection, now only 7% of us do, and the World Health Organization believes they've added 20 years to our lifespan.

With patients, the message is about the 'here and now' and their own situation, but it's quite different when it comes to general practitioners. They already face the difficulty of treating patients who often feel validated by being given a treatment, even when doctors know that antibiotics don't work against viruses. But Dame Sally acknowledges that doctors often face difficult conversations about this with their patients.

“I'm not beating up GPs. It is very difficult when you're faced with a patient who wants antibiotics and you think they don't need them. So it's about helping to build the educational tools for them to use with their patients.”

The messages, across all the stakeholders, are beginning to resonate, Dame Sally says, but she adds “we can never just stop”. To that end she's presented at a TEDx event in London and written a book with colleagues - both titled The Drugs Don't Work.

“I was taught, very early on - two decades ago actually - that one of the things about leadership was to have a vision, but another was to have a simple message and to keep repeating that simple message. And this message is so important, I just keep repeating it.”

Article by
Dominic Tyer

is PMGroup's editorial director

12th February 2016

From: Healthcare

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