Know thine enemy – the value of AMR surveillance

Antimicrobial resistance (AMR) is a growing threat to public health and could undermine decades of medical progress if we don’t act now. Investing in AMR data collection and surveillance on a global scale could transform our ability to protect human health, animal health and the environment in the long term, says Dr Toby Leslie.

Antimicrobial resistance (AMR) is a slow-moving problem but, much like climate change, inaction by global leaders could have immense human and economic costs now and in the future.

Modern medicine relies on the use of antimicrobial drugs to prevent or treat a wide range of infections in humans. The overuse of these drugs in healthcare and food production, however, is making them ineffective at combating some bacteria, viruses, fungi and parasites that are harmful to us.

Greater drug resistance means that untreatable infections are becoming more prevalent, posing a bigger threat to life and requiring higher health spending. Low- and middle-income countries are particularly exposed to this problem because they have a higher burden of disease and fewer healthcare resources to deal with it.

The Global Research on Antimicrobial Resistance (GRAM) report published in 2022 estimated that 5M deaths were associated with AMR and about 1.3M were attributable to it. Bacterial infections as a whole resulted in one in eight deaths globally in 2019 – estimated at 7.7M.

AMR also threatens food security, with important infections in food-producing animals becoming harder to prevent and treat. This could result in lower productivity and ultimately have an impact on the price and availability of quality food, affecting nutrition levels and livelihoods.

The economic impact has been estimated to be up to $100trn in lost productivity and higher costs by 2050 (UK government report, 2016). These alarmingly large figures give an indication of the damage that could lie ahead without global AMR investment directed at low- and middle-income countries, where it will be most effective.

Why surveillance matters

Microbes do not respect borders, which is why it is so important to develop an effective global AMR surveillance system, which can provide a picture of the extent of harmful bacteria in animals and humans and the drug resistance patterns seen in each country.

As management agent for the Fleming Fund, a UK aid programme, we have provided grants over the past five years to establish national AMR surveillance systems in 23 countries that contribute to global efforts to improve AMR monitoring. We are currently preparing for the second phase of the programme.

For a relatively modest investment, hospitals can be linked together in a national surveillance system, feeding in information about who is getting infected, where and with what. When coupled with information on antimicrobial use and data from agriculture, this provides decision-makers with a huge amount of intelligence about drug resistance.

Clinicians can make better informed choices about prescribing antibiotics. Pharmaceutical firms can direct investment toward the new drugs and vaccines most urgently needed to address the emergence of superbugs. Policymakers can better understand the risks of overusing antibiotics in human health and food production and push for changes in healthcare and agricultural practices.

Aside from these specific groups, the data collected is relevant to a wide range of stakeholders because AMR is a cross-cutting issue spanning human health, animal health and the environment, with implications for areas as diverse as genetics, urbanisation, river conservation, and macroeconomics.

Funding better data

Although effective surveillance can add huge value, it is only as good as the AMR data that gets fed into the system.

Therein lies the problem – the bacteriology services needed to produce this data are in short supply in low- and middle-income countries. Bacteriology is one of the corners of health systems in developing countries that international funding has not yet reached.

Without a bacteriology department staffed with trained microbiologists, it is impossible for a hospital to collect good-quality data on drug-resistant bacteria found in patients or to test routinely for antibiotic effectiveness.

Although the level of investment needed is minor in comparison to other mainstream health funding, it is often beyond the overstretched health budgets of developing and middle-income countries. For sustainable solutions, the onus is therefore on global healthcare funders to step in and fund bacteriology and diagnostic services. These should support hospital laboratories to add sustainable bacteriology testing to their existing range of services, such as testing for tuberculosis, HIV, or malaria.

Investment in bacteriology and diagnostic services should be viewed as an opportunity to improve the resilience of existing health programmes, ensuring that drug resistance does not undermine the control of other diseases or improvements in maternal and child health. Critically, new diagnostic units could carry out tests to determine whether a patient really needs antibiotics before they are prescribed, helping to prevent the overuse of drugs and curb the spread of AMR.

Knowledge is power

Evidence suggests that early intervention to prepare for future health threats delivers high returns on investment. The cost of inaction can also be extremely high.

When you are dealing with an unfamiliar and constantly evolving threat, data and evidence is your ally. That is why a global surveillance system is such a critical tool in understanding where to direct investment. Rather than being seen as a cost, it should be used as a form of insurance against the risk of doing nothing.

Global surveillance is the best and most cost-effective approach we have to monitor and control infections. AMR cannot be tackled effectively on a country-by-country basis – and until everyone is safe from AMR, no one is safe.

The Department of Health and Social Care (DHSC)'s Fleming Fund is a UK aid programme supporting up to 25 countries across Africa and Asia to tackle antimicrobial resistance (AMR), a leading contributor to deaths from infectious diseases worldwide.

The Fleming Fund invests in strengthening AMR surveillance systems through a portfolio of country grants, regional grants and fellowships managed by Mott MacDonald, and global projects managed by DHSC.

The views expressed in this article are not necessarily those of the UK DHSC.