Lessons from the pandemic for AMR control
The SARS-CoV2 and its rapid spread across the globe took the world by ‘surprise’, although many scientists and experts would argue otherwise. Many alarming findings are published in academic research but they seldom spark urgent public health action. In hindsight, it is hoped that this warning sign of the SARS-CoV2 would have been noticed and acted on back in 2019 itself, a few months before it crossed international borders. What we have been witnessing thereafter has been an unprecedented and urgent response by the global communities and governments.
Another health emergency, Antimicrobial Resistance (AMR), has started making its presence felt too. Unlike, COVID-19, the effects of AMR have been steadily rising over the past few years, and cases are being reported across the globe. Unlike the previous warnings that went unnoticed, the world has responded to this emerging urgency to some extent, however this is just the tip of the iceberg and a lot needs to be done.
According to a January 2022 publication in The Lancet with data from 204 countries, drug resistant infections were found to have killed 1.27 million people in 2019, this is more than many widely recognized causes of death, such as malaria and HIV/AIDs. A majority of these deaths were reported from sub-Saharan Africa and south Asia. Our present arsenals of drugs for combating deadly infectious diseases would soon be redundant if the emergence and spread of AMR continues unabated.
According to a study published in July 2021 in PLOS Medicine, the first wave of COVID-19 in 2020 in India saw a substantial increase in the sale of antibiotics used in adults and adolescents, especially azithromycin. The pandemic likely contributed to about 216 million excess doses of non-pediatric formulations of antibiotics in total and 38 million excess doses of azithromycin between June and September 2020. Overall, 16.29 million doses of antibiotics were sold in India, which is already the world’s largest antibiotic user. The proportion of non-pediatric formulations of antibiotics increased from 72.5% to 76.8% between 2019 to December 2020. Similar trends are likely to have occurred in other low- and middle-income countries where antibiotics are often indiscriminately used. While evolving evidence did not show any clear need for the use of antibiotics in COVID treatment, there was little governance on the community use of antibiotics, thereby increasing the likelihood of increased community resistance to common antibiotics in India as a result of the pandemic.
In the past two years, we have proven that if we prioritize our health mandates adequately, we can collectively prevent and control healthcare emergencies. The ‘not-so-silent’ epidemic of AMR now deserves this distinction.
India drafted its National Action Plan (NAP) on AMR drawing from the Global Action Plan. The first five years of this plan has seen some movement however momentum and impact has been largely limited due to challenges in implementation.
Our effective implementation and timely response to the pandemic holds many lessons that we can apply for our fight against AMR as well. Highlighting here the ten key lessons;
i) Stepping up Innovations: The urgency brought on by the pandemic prompted innovators to quickly repurpose and re-align their existing platforms and solutions that were already in the market for different indications. On the other hand, mid- to late-stage innovations were fast-tracked for clinical trials and regulatory approvals to the reach the market. These typically comprised of medical devices for screening and diagnostics. For medical devices already in market, such as respirators, ventilators, PPEs etc., this pandemic meant ramping up manufacturing and mass-scale distribution capabilities, to meet the burgeoning needs of the frontline healthcare workers and healthcare facilities at the forefront of the crisis.
ii) Fast tracking regulatory clearances: Regulatory authorities also fast-tracked the validation studies and approvals for these solutions in the wake of the outbreak. ICMR, the apex body for coordinating efforts for these tests in India, empaneled nine of its institutes, five DBT institutes, three CSIR institutes and seven other research institutes, hospitals and universities for the purpose. The prototyping, certifications and scaling of these devices also saw an upswing. Till mid-February 2021, the Drug Controller General of India (DCGI) had approved 179 COVID-19 testing kits, of which 30 to 40 were from Indian companies. As of 22nd February 2022, the regulatory authorities around the world approved many COVID-19 diagnostics tests (595 molecular tests, 396 serological tests and 342 antigen tests) for emergency use.
iii) Optimizing resources: Triaging immunology methods and molecular biology for screening and detection. Most countries upscaled their capacities to indigenously manufacture tests and devices keeping costs in mind. To optimize the use of these resources, processes and protocols were designed such that the resource-intensive and costlier tests were used only for the people who most needed it. This triaging optimized resources and technical capacities. Immunological methods, as the antigen test was used for screening, and the molecular diagnostics tests were used for confirmations. Artificial Intelligence assisted X-Ray imaging was also deployed at many sites in rural India and in other resource poor settings for screening.
iv) Strengthening surveillance for prompt public health intervention: Real-time surveillance through public and private healthcare and diagnostics facilities enabled a daily dashboard of numbers and trends across the country. Other initiatives included, mapping of super-spreader events, and the use of genomic surveillance for the first time. This enabled zeroing in on the hotspots and taking decisions pertaining to public health measures on a timely basis.
v) Deploying new and emerging technologies: In January 2020, 2 months after the SARS-CoV2 was first reported, the sequence of the SARS-CoV-2 was published, after which various diagnostic, therapeutic and vaccine efforts were launched. Now with the emergence and spread of the coronavirus variant, sequencing technologies are again on the forefront to monitor, and track the mutant in a bid to stay ahead of the curve. Till January 2022, 7,985,709 genomes were sequenced and submitted in GISAID which is enabling not just tracking of variants but also for tracking people movement, variant patterns etc which can help define regulation and policies on international and domestic travel, super-spreader events etc. In the UK as part of the COVID-19 Genomics Consortium (COG-UK), the B.1.1.7 variant was identified leading to travel restrictions and policy interventions.
Disclaimer: The blog is a compilation of information on a given topic that is drawn from credible sources; however this does not claim to be an exhaustive document on the subject. It is not intended to be prescriptive, nor does it represent the opinion of C-CAMP or its partners. The blog is intended to encourage discussion on an important topic that may be of interest to the larger community and stakeholders in associated domains.