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(2000; 36 pages) [French] [Spanish]
Editorial - Antimicrobial resistance: A global threat
Twenty years ago physicians in industrialised countries believed that infectious diseases were a scourge of the past. With industrialisation came improved sanitation, housing and nutrition, as well as the revolutionary development of disease-fighting antimicrobials. Populations living in those nations were not only enjoying an unprecedented decrease in mortality and morbidity but a corresponding increase in life expectancy. In the developing world - where poverty and ongoing civil disturbance offset often modest health gains - people could nevertheless look forward to a time when an increased quality of life might one day lead to a relatively disease free future. The tools were there. Confident in the available pharmacopoeia, the major drug manufacturers turned away from intensive antibacterial research and concentrated their energies on seeking cures for heart disease and other chronic conditions. Since the 1980s significant breakthroughs have been largely confined to the development of antiviral agents targeting the ever-widening HIV epidemic.
But tragically, and even before developing countries were able to fully benefit from medical advances, we face a major risk that diseases considered vanquished in industrialised countries, will once again become killers stalking society, bringing an ever present threat of sudden death and disability. The risk that threatens to turn back the clock to a darker age in industrialised countries and to block health progress in the developing world is antimicrobial resistance.
As early as half a century ago - just a few years after penicillin was put on the market - scientists began noticing the emergence of a penicillin/resistant strain of Staphylococcus aureus, a common bacterium in the human body’s normal bacterial flora. Resistant strains of gonorrhoea, dysentery-causing shigella (a major cause of premature death in developing countries) and salmonella rapidly followed. From that first case of resistant staphylococcus, the problem of antimicrobial resistance has snowballed to a serious public health concern with economic, social and political implications that are global in scope, and cross all environmental and ethnic boundaries. Multi-drug resistant tuberculosis (MDR/TB) is no longer confined to any one country or to those co-infected with HIV, but has appeared in locations as diverse as Africa, Asia and Eastern Europe, among health care workers and in the general population. Penicillin resistant pneumococci are likewise spreading rapidly, while resistant malaria is on the rise, disabling and killing millions of children and adults each year.
In 1990 almost all cholera isolates in New Delhi, India, were sensitive to the cheap, first-line drugs furazolidone, ampicillin, cotrimoxazole and nalidixic acid. Now, formerly effective drugs are largely useless in the battle to contain cholera epidemics.
Although most drugs are still active, the lengthening shadow of resistance means that many of them may not be for long. In the case of tuberculosis, the emergence of multi-drug resistant bacteria means that medication that once cost US$ 20 must now be replaced with drugs a hundred times more expensive.
Spread of resistant pneumococcus first identified in Spain
Source: K. Klugmann, South African Institute of Medical Research
Pathogens develop resistance to antimicrobials through a process known as natural selection. When a microbial population is exposed to an antibiotic, more susceptible organisms will succumb, leaving behind only those resistant to the antimicrobial onslaught. These organisms can then either pass on their resistance genes to their offspring by replication, or to other related bacteria through “conjugation” whereby plasmids carrying the genes “jump” from one organism to another. This process is a natural, unstoppable phenomenon exacerbated by the abuse, overuse and misuse of antimicrobials in the treatment of human illness and in animal husbandry, aquaculture and agriculture. Disease - and therefore resistance - also thrives in conditions of civil unrest, poverty, mass migration and environmental degradation where large numbers of people are exposed to infectious diseases, with little in the way of the most basic health care. Our challenge is to slow the rate at which resistance develops and spreads.
This Monitor examines the growing spread of antimicrobial resistance and its underlying causes. It reports on the actions of WHO and others to raise awareness of the issue and to counteract this serious menace to public health. And it looks at what you, the reader, whether you are a policy-maker, health care professional, health advocate or member of the public, can do to help tackle the problem.