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We need stronger leadership on AMR– an interview with Professor Otto Cars

Has antimicrobial resistance worsened during the Covid-19 pandemic and will the tough lessons on disease prevention help? Professor Otto Cars, infectious disease specialist from Uppsala University and founder of the international network ReAct, discusses AMR in the new context, and the opportunities to safeguard the hard-built political momentum amidst the crisis.

Professor Otto Cars, Founder of ReAct and member of the UN Interagency Coordination Group on Antimicrobial Resistance (IACG)

Professor Otto Cars, Founder of ReAct andmember of the UN InteragencyCoordination Group onAntimicrobial Resistance (IACG)

While the world is focused on fighting the Covid-19 pandemic, the less obvious, but equally deadly pandemic of antimicrobial resistance is continuing to spread across the globe.

Is there evidence to suggest that the Covid-19 is fueling antibiotic resistance? Why and how? Has Covid-19 for instance, led to an increase in antibiotic use?

It is too early to draw any general conclusions about the relationships between Covid-19 and the pandemic of antibiotic resistance. Due to the lack of rapid diagnostic tests to identify a secondary bacterial pneumonia, many patients hospitalized with Covid-19 are receiving broad spectrum antibiotics. There is also widespread prophylactic prescription of antibiotics for suspected bacterial infection in Covid-19 patients even with mild disease. This will undoubtedly be a risk for increase antibiotic resistance levels in health care facilities. Antibiotic resistance is however driven both by use and by spread. The latter has most certainly been reduced due to measures taken to contain Covid-19 such as handwashing, social distancing and reduced travel. Some reports have shown a significant reduction in antibiotic prescriptions during the pandemic. This might be indicating lower infection rates. Simultaneously, a worrying effect of Covid-19 is the indirect mortality impact due to disruption of health services in low- and middle-income countries including reduced coverage of antibiotics for pneumonia and maternal and neonatal sepsis", says Professor Otto Cars.

Conversely, has the Covid-19 pandemic in any way helped the AMR agenda forward?

The global urgency of addressing Covid-19 has left little room for other priorities to be addressed in 2020 and many policy processes have either slowed down, or come to a complete standstill. Looking forward, the challenge will be to revive and sustain the political momentum for addressing antibiotic resistance amidst the attention to Covid-19 and emergency preparedness. As global health has become a political top priority during the Covid-19 pandemic, the world now has an unprecedented opportunity to address the unveiled need for resilient health systems and the failures of the global research and development system to meet global infectious challenges. Such efforts will also offer opportunities to strengthen the recognition of antibiotic resistance as an ongoing pandemic with consequences for public health and the global economy. Covid-19 has visualized the importance of sanitation, and infection prevention, which will also facilitate the containment of antibiotic resistance. The Covid-19 has also shed light on significant global shortages of health technologies, including diagnostics, and various drugs including antibiotics. To manage antibiotic resistance and secure access to effective antibiotics, essential specific components in health systems need to come in place, and be coordinated nationally including surveillance of resistance, monitoring of antibiotic use, regulation, education, contextualized guidelines and awareness raising", says Professor Cars.

Following your involvement in the UN Interagency Coordination Group on antimicrobial resistance, what is your impression of the global community’s efforts in terms of following up and implementing recommendations and action plans?

The adoption of the Global Action Plan on Antimicrobial resistance in 2015 increased the global momentum which culminated with the creation of the ad hoc UN Interagency Coordination Group on Antimicrobial Resistance (IACG) two years later. The group delivered its recommendations to the UN Secretary General in April 2019, but since then, even before the current pandemic, my impression is that the global leadership has lost strength. Although antimicrobial resistance has featured in several health related international processes such as Sustainable Development Goals (SDGs) and the UN High level meeting on Universal Health Coverage (UHC), these have not led to the strong political commitments needed to keep the issue firmly on the global and national political agenda. Still, two of the recommendations from the IACG -to establish a One Health Global Leadership Group on Antimicrobial Resistance and to convene an Independent Panel on Evidence for Action against Antimicrobial Resistance- has been moving forward, and the terms of reference for these mechanisms has been published for public consultation but the groups are not yet in place. Actions on other recommendations from the IACG is still pending, and unless the Global leaders group is taking strong leadership to move these forward together with governments and international institutions, there is currently a real threat of losing the political momentum which was built up over the last four years", says Otto Cars.

What would you say is the most pressing challenge?

This is a difficult question and there is no simple answer. In most countries there is now a national action plan against antimicrobial resistance, but a major challenge, especially in low-and middle-income countries is lack of political will and capacity for a coordinated implementation of the plan. It is evident that the way that antibiotic resistance is currently described has been insufficient to generate the major concerted political action needed both globally and nationally, in comparison with for example HIV, malaria and tuberculosis. Neither is there yet a strong global reaction from civil society", says Professor Cars.We are thus facing a dual challenge: improving the current narratives to achieve stronger visibility, awareness and response to antibiotic resistance and place it in the minds of policymakers and people amid the ongoing Covid-19 pandemic. As the problem of resistance involves diverse pathogens, transmitted in unique ways and causing a wide range of diseases, the consequences for the patient, such as a prolonged disease or increased mortality, are hidden within a variety of clinical syndromes, leading to many fundamental knowledge gaps including the health and economic consequences of antibiotic resistance. More data are urgently needed on the burden of antibiotic resistance, especially at the national level, to convince politicians that antibiotic resistance is a real threat for both basic and specialized medicine. Another barrier is the overbelief that the pharmaceutical industry will continue to deliver new antibiotics, while it is obvious that the public sector needs to take a much stronger leadership in transforming the current business model to secure sustainable development and global access to new essential antibiotics", he continues.

What are your expectations for Uppsala Health Summit in March next year on the theme of Antimicrobial Resistance and Behavioural Change?

My expectation for the summit is that it will bring together people from across a range of disciplines to revitalize the antibiotic resistance discussion and seed new ideas for how we can achieve sustainable behavior change, also harnessing learnings from past experiences within other areas such as climate change, vaccination campaigns as well as the ongoing Covid pandemic. Effective communication for behaviour change is a key factor in reducing the gap between science and policy and overcome barriers for implementation of policies and programmes. The Summit is very timely. It could seize the opportunities that will arise in the Covid/ post Covid-19 space to reformulate and tailor messages on antibiotic resistance to key stakeholders in different sectors which could facilitate global collective action as well as implementation of One health national action plans", says Professor Otto Cars.

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