- Prof. Rasika Jinadasa warns that AMR on the rise in SL
- Calls for strategies to reduce growth and mitigate impact
- A need to improve agro and livestock management practices
Antimicrobial Resistance (AMR) poses one of the most significant threats to modern medicine, public health, and global sustainability.
As disease-causing microorganisms increasingly evolve to withstand previously effective treatments, the world faces the alarming prospect of untreatable infections, compromised surgeries, and a return to pre-antibiotic mortality rates.
In an interview with The Daily Morning, Prof. Rasika Jinadasa, a Professor in Microbiology at the Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Sri Lanka, delved into the multifaceted implications of AMR, elaborating on its impact on healthcare, food security, and the economy, while shedding light on global efforts, innovative technologies, and localised solutions to combat this critical challenge.
Following are excerpts from the interview:
What is Antimicrobial Resistance (AMR), and why is it a threat to modern medicine?
AMR can be defined very simply as disease-causing microorganisms (pathogens) becoming unresponsive to drugs that were previously used to treat infections caused by these organisms. As a result, infections caused by these organisms become untreatable. Without effective antibiotics, certain benefits of modern medicine that we take may become largely obsolete. For example, we may not be able to perform major surgeries as there are no antibiotics to be used as preventive medicine against infection. Similarly, a patient may die from a simple wound infection following a minor cut. AMR is one of the major challenges faced by mankind at present.
What are the factors contributing to the development and spread of AMR?
The factors contributing to the development and spread of AMR can be categorised as AMR-specific drivers or AMR-sensitive drivers. AMR-specific drivers are the factors directly related to the use and misuse of antibiotics. This creates pressure on the microbes to develop AMR and maintain it. Bacteria may acquire multiple mechanisms of resistance against one drug. To make matters worse, there are no significant efforts to develop new antibiotics. This is because of the lack of private sector investment, as the development of antibiotics is very costly, and the profits are relatively low for pharmaceutical companies. In addition, rapid, effective diagnostics are lacking in many developing countries for deciding on the selection of antibiotics. It is estimated that at least 30-50% of all antibiotic prescriptions are inappropriately prescribed in human health. AMR development is not limited to the human health sector. Large quantities of antibiotics are used for growth promotion and disease prevention in food animals. These quantities are far greater than the amount of antibiotics used for treating sick animals. Furthermore, agricultural crops are frequently sprayed with antibiotics for disease prevention, often in addition to insecticide and fungicide sprays. Therefore, AMR development and selection occur virtually everywhere and in all One Health sectors.
AMR-sensitive drivers are factors that release and spread drug-resistant microbes to the environment. This includes the human, farm, animal product processing, and pharmaceutical industry waste released into the environment. This is especially problematic in underprivileged communities where water, sanitation, and hygiene (WASH) provisions are inadequate, and infection prevention and control (IPC) programmes are insufficient. Additionally, AMR spread in these may be aggravated by low vaccination rates to prevent infections.
Why is AMR particularly significant in bacterial infections?
Drug resistance development is more commonly seen in bacteria than in other pathogens. Drug-resistant bacterial infections currently cause almost five million deaths worldwide, annually. Low- and middle-income countries are more vulnerable to the AMR burden. The highest mortality rates are seen in sub-Saharan Africa and South Asia. It is projected that, if unattended, mortality due to drug-resistant bacterial infections may increase up to 70% by 2050. In addition to the potential increase in deaths, the negative impact of AMR on the world economy is equally important.
How significant is the issue of AMR in Sri Lanka’s healthcare system, and what steps are currently being taken to address it?
AMR is increasing rapidly in the healthcare facilities in Sri Lanka, and it’s high time to undertake sound strategies to mitigate it. Certain bacteria such as Staphylococcus that may cause life threatening bloodstream infections and E.coli that may cause severed urinary tract infections are particularly notorious to have resistance against multiple antibiotics. Sri Lanka has an ongoing ‘sentinel sites’ system where AMR development is routinely monitored at selected healthcare facilities. In recent times, the country has demonstrated its commitment to address AMR through its five-year National Strategic Plan (NSP) for AMR (2023-2028). This is the second cycle of the NSP, and the current plan has a strong one health approach. The plan has comprehensive strategies to combat AMR. However, the budgetary support for the plan has not been materialized fully. We are very thankful that Sri Lanka received support from the Fleming Fund, UK to fund some of the activities of NSP AMR.
In Sri Lanka, how does the misuse of antibiotics in farming and livestock affect the spread of AMR, and what can farmers do differently?
Highest AMR reported in the animal health sector is reported from poultry farms in Sri Lanka. The Veterinary Drug Control Authority of the Department of Animal Production and Health regulates the antibiotic usage for animals in the country. Encouragingly, the use of antibiotic growth promoters for poultry has been banned since 2018. Furthermore, veterinary products containing some important antibiotics used in human medicine such as colistin, and 3rd and 4th generation cephalosporins have been discontinued. Importation of bulk pack antibiotic products weighing more than 1 kg/1 letre intended for farm animal usage has also been banned. Furthermore, veterinary antibiotic importers are now required to report previous year sales volumes to place new orders. The most important thing the farmers can do is prevent infections by adopting good farming practices. Some of such practices include maintaining clean, dry well-ventilated animal houses, providing good nutrition, regular vaccination, and avoiding overcrowding the farms.
What challenges does Sri Lanka face in improving WASH and IPC programmes, and how can these be overcome to reduce AMR spread?
This needs planning and policy decisions. Unhygienic environments are usually the result of poorly planned investment going on for some time. General inadequacy of clean water and sanitation services including manpower is the prime cause.
How can Sri Lanka’s policymakers encourage the development and use of alternatives to antibiotics in agriculture and healthcare?
Most important aspects would be improving the compliance with good farming practices that promotes infection prevention. Another most important aspect is vaccination. Adopting a proper vaccination programme prevents a lot of infections and thus reduces the need for antibiotics. Regulatory framework shall be strengthened in this regard and farmers may be incentivised for compliance.
What role can Sri Lankan communities, including medical practitioners, pharmacists, farmers, and others play in promoting better awareness and practices to prevent the rise of AMR?
Most important aspect here is to avoid misuse or overuse. Antibiotics shall be used only on prescription.
How does AMR affect global food security and livestock farming?
One of the most serious challenges currently faced by the world is providing food for the rapidly growing population, particularly the supply of good-quality protein, which comes from farmed animals. Livestock farming is heavily dependent on antibiotics to prevent and treat diseases. It is estimated that the annual livestock production losses due to AMR may negatively affect the food security for more than 2 billion people by 2050. The impacts of AMR in pet animals are not well documented. However, given the possibility of transmission of AMR bacteria between people and pets and the use of medically important antimicrobials on pets, AMR in pets should be given due consideration.
What are the projected global economic impacts of AMR?
Overall, some predictions show that AMR could lead to a decline of 4% of the annual global Gross Domestic Product (GDP) by 2050. This will result in nearly 30 million more people falling into extreme poverty, leading to an increase in global annual healthcare costs by over $ 1 trillion. Low- and middle-income countries (LMICs) carry disproportionately high AMR burdens.
What global measures have been implemented to combat AMR?
Given the importance of AMR, The United Nations General Assembly (UNGA) declared AMR as a global public health priority in September 2024 and passed the Political Declaration of the High-Level Meeting on AMR. This declaration aims to mobilise governments to prevent, contain, and mitigate AMR by setting achievable targets and allocating sustainable funding solutions to help implement multi-sectoral National Action Plans on AMR. The 2024 Declaration highlights the need to implement a ‘One Health’ approach to combat AMR, with a particular focus on LMICs. ‘One Health’ is an integrated, unifying approach to optimise the health of people, animals, and the environment. It is important to have a One Health approach to prevent, predict, detect, and respond to global health threats such as the Covid-19 pandemic. The approach involves the mobilising of multiple sectors, disciplines, and communities at varying levels of society to work together. This way, root causes are identified and addressed to create long-term, sustainable solutions.
Why is unsatisfactory biosecurity a critical concern in AMR spread?
Unsatisfactory IPC programmes, frequently associated with poor biosecurity and animal husbandry practices, particularly in low- and middle-income countries, lead to increased antimicrobial usage to treat bacterial infections, resulting in increased AMR emergence and spread from such sites. Wastewater management in animal and crop operations is often less stringent than in human systems, and some developing countries do not even have enough regulations to cover these aspects. Animals generate about four times the mass of waste compared to humans. Therefore, unsatisfactory biosecurity and animal husbandry can increase drug-resistant bacteria entering the environment on a massive scale, leading to increased transmission and spread of AMR. Factors driving AMR at ‘One Health’ interfaces are more important as they present risks to more than one sector. For example, antibiotics used in food animal production in sub-therapeutic doses over long periods create optimal conditions for bacteria to develop resistance. The AMR genes present in these bacteria are subsequently transferred to human pathogens via food chain or farm workers and may contaminate the environment as well.
How can governments incentivise the pharmaceutical sector to develop new antibiotics?
It is a very sensitive issue. Most private companies are not investing in new antibiotic development due to high cost and low financial returns. One of the potential areas where governments can incentivise the pharmaceutical sector is by providing research grants for new antibiotic development. Also, the governments may provide subsidies to the manufacturers. Additionally, the governments can protect the genuine high quality drug manufacturers by implementing strict regulatory frameworks, so that low quality drugs or counterfeit drugs will not flood the market.
What specific policies can reduce antibiotic misuse in agricultural practices?
One of the important things is disease prevention. This can be achieved by adhering to improved phytosanitation and good agricultural practices. Resistant crop varieties should be used whenever possible, and good extension services to provide timely and accurate advice to farmers is a must. Use of medically important antibiotics in crop production must be restricted, and the sale of agricultural antibiotics must be well regulated. In addition, farmers must be trained for the proper Use and Disposal of agricultural antibiotics to prevent environmental contamination. This is particularly true when the chemicals are used close to water sources. Used containers must be collected and properly disposed to prevent localised hotspots of concentrated chemical leaching into groundwater.
How can LMICs improve their WASH and IPC programmes to curb AMR spread?
Improving WASH requires functioning, safely managed water and sanitation services, hygiene facilities, products and practices, health care waste management. Improving IPC needs strong policies and funding commitments. Improved WASH and IPC also reduce the demand for antibiotics and reduce the opportunity for resistant strains to emerge. Fewer resistant infections save money which can be invested for improving overall community health.
What are the most promising technologies for monitoring and combating AMR?
Traditional culture-based AMR surveillance is time-consuming and less sensitive. It does not capture the spectrum of AMR, evolutionary trends, and epidemiological patterns of AMR spread. Whole genome sequencing (WGS) has revolutionized AMR surveillance. It captures the full AMR spectrum with minimum samples, aids identifying contamination sources, and provides insights on trends of AMR spread. Combating AMR needs strong policies and regulations for the overall infection prevention that will result in reduced demand for antibiotics, which will eventually reduce resistant strain emergence.
How can the ‘One Health’ approach be localised to specific regions with unique challenges?
It needs strong collaboration between local authorities, including the healthcare services, veterinary services, wildlife and environment protection agencies and law enforcement. Joint workforce training and development has been identified as a key solution to address this issue.