The World Health Organization Belatedly Acknowledged that Antimicrobial Resistance Poses a Serious Public Health Problem — Yet WHO’s Summary Makes No Mention of Agriculture’s Irresponsible Non-Medical Use of Tons of Antibiotics — and My Comment about Communicating Effectively in a World Filled with Shouting Fools

02 May 2014

Themes today

The basics:

(i) Evolving antimicrobial resistance poses a “here now” public health problem;

(ii) the World Health Organization is only belatedly responding to it —

but

with one important exception

(iii) WHO’s April 2014 Report does a miserable job of communicating the threat in a way that would motivate anyone to recognize, much less deal with the looming disaster.

Take what follows as:

(a) a get off our behinds reminder about the “almost here” end of the antibiotic era

and

(b) my observation that effectively motivating policy changes — in a world filled with shouting fools — requires easily comprehensible, action-inspiring blurbs.

Citation — to the ineptly written WHO report

World Health Organization, Antimicrobial Resistance: Global Report on Surveillance, WHO.int (2014) (PDF)

Citation — to WHO’s innocuously uninspiring press release

Glenn Thomas, WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health, WHO.int (30 April 2014)

Citation — to the contrastingly communicatively competent “fact sheet” which does a much better job of messaging

World Health Organization, Antimicrobial resistance: Fact Sheet No. 194, WHO.int (updated April 2014)

Ineffective communication in the PDF version of the WHO report

The above World Health Organization report was apparently intended to draw attention to:

(a) the development of global antibiotic resistance

and

(b) the lack of proper surveillance of the menace.

Instead, WHO’s report manages to put readers to sleep because it works so hard to avoid making points in quasi-memorable ways.

The Organization’s own press office struggled and failed to make policy-motivating sense of the Report’s poorly summarized mush.

In order to get a basic idea of what WHO was trying to say, one has to click on (the non-intuitively related) Fact Sheet that is accessed via a menu posted off to the side of WHO’s press release.

What the Report was trying to say

Antimicrobial resistance has been growing for years at a rate that is almost surely guaranteed to return us to the pre-antibiotic/antimicrobial era. But the range and magnitude of the various drug resistances are not known because no one is comprehensibly testing for and tracking them.

Note

See sample overviews of the scope of the drug resistance problem here, here and here.

Last month, the World Health Organization finally said something about the menace that antimicrobial resistance poses world health. Unfortunately, WHO communicated its message so ineptly that one can be forgiven for thinking that bored monkeys wrote the main Report’s text — which WHO also unhelpfully prevents us from copying from the posted version.

Why write obscurely and then additionally prevent people from easily transmitting pertinent portions of one’s purported wake-up call?

To find WHO’s main points — one has to go to a “Fact Sheet” that was written before the April 2014 report and updated afterward

The Fact Sheet is the only part of WHO’s communication packet that makes easily accessed sense.

Whoever wrote it did a masterful job at communicating with the public:

Key facts

Antimicrobial resistance (AMR) threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi.

It is an increasingly serious threat to global public health that requires action across all government sectors and society.

AMR is present in all parts of the world. New resistance mechanisms emerge and spread globally.

In 2012, there were about 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB). Extensively drug-resistant tuberculosis (XDR-TB) has been identified in 92 countries. MDR-TB requires treatment courses that are much longer and less effective than those for non-resistant TB.

Resistance to earlier generation antimalarial drugs is widespread in most malaria-endemic countries. Further spread, or emergence in other regions, of artemisinin-resistant strains of malaria could jeopardize important recent gains in control of the disease.

There are high proportions of antibiotic resistance (ABR) in bacteria that cause common infections (e.g. urinary tract infections, pneumonia, bloodstream infections) in all regions of the world. A high percentage of hospital-acquired infections are caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria.

Treatment failures due to resistance to treatments of last resort for gonorrhoea (third-generation cephalosporins) have now been reported from 10 countries. Gonorrhoea may soon become untreatable as no vaccines or new drugs are in development.

Patients with infections caused by drug-resistant bacteria are generally at increased risk of worse clinical outcomes and death, and consume more healthcare resources than patients infected with the same bacteria that are not resistant.

What is antimicrobial resistance?

Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it.

Resistant microorganisms (including bacteria, fungi, viruses and parasites) are able to withstand attack by antimicrobial drugs, such as antibacterial drugs (e.g., antibiotics), antifungals, antivirals, and antimalarials, so that standard treatments become ineffective and infections persist, increasing the risk of spread to others.

The evolution of resistant strains is a natural phenomenon that occurs when microorganisms replicate themselves erroneously or when resistant traits are exchanged between them. The use and misuse of antimicrobial drugs accelerates the emergence of drug-resistant strains. Poor infection control practices, inadequate sanitary conditions and inappropriate food-handling encourages the further spread of AMR.

What is the difference between antibiotic and antimicrobial resistance?

Antibiotic resistance refers specifically to the resistance to antibiotics that occurs in common bacteria that cause infections. Antimicrobial resistance is a broader term, encompassing resistance to drugs to treat infections caused by other microbes as well, such as parasites (e.g. malaria), viruses (e.g. HIV) and fungi (e.g. Candida).

Why is antimicrobial resistance a global concern?

New resistance mechanisms emerge and spread globally threatening our ability to treat common infectious diseases, resulting in death and disability of individuals who until recently could continue a normal course of life.

Without effective anti-infective treatment, many standard medical treatments will fail or turn into very high risk procedures.

Why this matters

Motivating people and government officials to act sensibly in the face of imminent threats that require major behavioral changes is very difficult. Clearly communicating the problem and its solution, in believable ways, is a necessity.

Here is how the World Economic Forum wrote about the issue last year:

Many people take for granted that antibiotics will always be available when we need them, but soon this may no longer be the case. Every dose of antibiotics gives an advantage for those small numbers in a bacterial population that are resistant to the drug.

The more a particular antibiotic is used, the more quickly bacteria resistant to that antibiotic will be selected and increase in numbers.

Until now, leaders have been able to turn a blind eye to this problem, as new antibiotics have always emerged to replace older, increasingly ineffective ones. This is changing.

Although several new compounds for fighting bacteria are in development, experts caution that we are decades behind in comparison with the historical rate at which we have discovered and developed new antibiotics.

More worryingly, none of the drugs currently in the development pipeline would be effective against certain killer bacteria, which have newly emerging resistance to our strongest antibiotics (carbapenems) and fatality rates of up to 50%.

As shown by the death of six patients – from 18 infected – at the US National Institutes of Health in 2011, antibiotic-resistant infections can kill, even at the world’s most advanced medical centres.

What the World Economic Forum touched on — that WHO ignored — is agriculture’s huge contribution to drug resistance

The business people at the World Economic Forum noted that:

Meanwhile, antibiotics are over-used around the world in livestock and fish farming (e.g. as growth promoters).

Resistant bacteria can be transferred to humans through contact with livestock, through the food chain, and through wastewater from these operations, as well as wastewater from hospitals and pharmaceutical plants.

One study found 45 kg of ciprofloxacin (an antibiotic commonly used to treat bladder and sinus infections) – the equivalent of 45,000 doses – leaking daily from factories into a nearby river.

Environmental contamination like this has led to an antibiotic-resistant bacteria being detected as far afield as Antarctica.

More quantitatively stated:

Approximately 70% of all antibiotics used in the United States are given to healthy farm animals at low doses to promote faster growth and compensate for unsanitary living conditions — a practice that has increased over the past 60 years despite evidence that it breeds antibiotic-resistant bacteria dangerous to humans.

The antibiotics, mixed into feed or water for pigs, cows, chicken, and turkeys, are used at levels too low to treat disease, leaving surviving bacteria stronger and resistant to medical treatment.

The lawsuit filed today by the Natural Resources Defense Council, Center for Science in the Public Interest (CSPI), Food Animal Concerns Trust (FACT), Public Citizen, and Union of Concerned Scientists (UCS) was spurred by growing evidence that the spread of bacteria immune to antibiotics around the world has clear links to the overuse of antibiotics in the food industry.

The coalition suit would compel FDA to take action on the agency’s own safety findings, withdrawing approval for most non-therapeutic uses of penicillin and tetracyclines in animal feed.

The moral? — Think clearly, motivate concisely, and in easily remembered fashion

WHO’s recommendations about limiting human use of antimicrobials to medically necessary conditions in human beings ignores the fact that making gains in the medical arena will be grossly offset by agriculture’s massive continuing and irresponsible use of antimicrobials worldwide.

We cannot fix a public health problem, when we (a) communicate it poorly and (b) ignore its most gargantuan contributor.

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