13 June 2000

Text: WHO Report on Dangers of Microbial Resistance

Infectious diseases currently under control could soon become incurable, reversing decades of medical progress and putting the world population at great risk, according to a World Health Organization (WHO) report released June 12.

Dr. Gro Harlem Brundtland, Director-General of the WHO, said in a press release, "If the world fails to mount a more serious effort to fight infectious diseases, antimicrobial resistance will increasingly threaten to send the world back to a pre-antibiotic age."

The report shows that almost all major infectious diseases are beginning to exhibit resistance to existing treatments. More than 10 percent of tuberculosis (TB) patients in Estonia, Latvia, and parts of Russia and China have strains resistant to two of the most powerful TB medicines. Small but expanding numbers of HIV-infected patients are already showing primary resistance to AZT and other new therapies.

The economic consequences of antimicrobial resistance are also staggering, according to the WHO research. New York City needed to spend nearly one thousand million dollars to control an outbreak of multi-drug resistant TB in the early 1990's. Expenditures on such a scale are clearly beyond the scope of most of the world's cities.

Due in large part to under-use of the drugs in poorer countries and over-use in wealthy countries, microbial resistance is encouraged by agricultural and animal uses. This is especially alarming, WHO officials said at a Washington news briefing, given that there has been relatively little development of new antimicrobial drugs since the 1970's. Given industry estimates, development of one such drug could take over 500 million dollars and between 15 and 20 years.

In it's final chapter, the WHO report prescribes the following "Wisely and Widely Points of Action:"

1. Adopt existing WHO strategies and policies to deal with most infectious diseases, including routine vaccination and surveillance programs;

2. Educate public health workers and the public in the use of medicines to halt the spread of resistant disease strains;

3. Contain Resistance in the Hospital with new policies designed to monitor drug use and enhance surveillance;

4. Reduce the use of antimicrobials in the livestock production where the drugs are used as growth enhancers;

5. Increase research for new drugs and vaccines;

6. Build alliances and partnerships to increase access to antimicrobials to achieve coordinated dissemination of effective drugs, which is vital to retarding microbial evolution;

7. Increase availability of essential drugs, at the same time, encouraging wiser use of the drugs;

8. Make effective medicines available to poor people to reduce deaths from the highest-burden diseases in low-income countries by 50 percent within the next decade.

Further information about WHO programs can be obtained at www.who.int.

Following is the text of a WHO press release:

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WORLD HEALTH ORGANIZATION
PRESS RELEASE
12 JUNE 2000

DRUG RESISTANCE THREATENS TO REVERSE MEDICAL PROGRESS

• Curable diseases -- from sore throats and ear infections to TB and malaria -- are in danger of becoming incurable

• New report warns that increasing drug resistance could rob the world of its opportunity to cure illnesses and stop epidemics

• WHO call's for "Wiser and Wider" effort against infectious diseases

"We currently have effective medicines to cure almost every major infectious disease," said Dr Gro Harlem Brundtland, Director-General of WHO. "But we risk losing these valuable drugs -- and our opportunity to eventually control many infectious diseases -- because of increasing antimicrobial resistance."

WHO sounded this alarm with the release of its annual Report on Infectious Diseases, titled "Overcoming Antimicrobial Resistance." The report is the first of its kind to present a comprehensive picture of the perilous situation the world is facing as once-effective medicines become increasingly ineffective.

The report describes how almost all major infectious diseases are slowly -- but surely -- becoming resistant to existing medicines. In Estonia, Latvia, and parts of Russia and China, over 10% of tuberculosis (TB) patients have strains resistant to the two most powerful TB medicines. Because of resistance, Thailand has completely lost the means of using three of the most common anti-malaria drugs. Approximately 30% of patients taking lamivudine -- a drug recently developed to treat hepatitis B -- show resistance to therapy after the first year of treatment. In India, 60% of all cases of the tropical disease visceral leishmaniasis no longer respond to first-line drugs. A small but growing number of patients are already showing primary resistance to AZT and other new therapies for HIV-infected persons.

In many instances, poorly planned or haphazard use of medicines has caused the world to lose these drugs as quickly as scientists have discovered them.

"It took 20 years to develop penicillin for medical use, and then 20 years for this drug to become virtually useless for treating gonorrhoea in most parts of the world," said Dr David Heymann, Executive Director of WHO's programme on Communicable Diseases. In much of South-East Asia, resistance to penicillin has been reported in 98% of gonorrhoea strains.

A decade ago in New Delhi, India, typhoid could be cured by three inexpensive drugs. Now, these drugs are largely ineffective in the battle against this life-threatening disease. Likewise, ten years ago, a shigella dysentery epidemic could easily be controlled with cotrimoxazole -- a drug cheaply available in generic form. Today, nearly all shigella are non-responsive to the drug.

Those admitted to hospital wards are especially vulnerable. In the United States alone, some 14,000 people are infected and die each year as a result of drug-resistant microbes picked up in hospitals. Around the world, as many as 60% of hospital-acquired infections are caused by drug-resistant microbes.

Antimicrobial resistance is a naturally occurring biological phenomenon amplified many-fold due to human misuse and neglect of antimicrobial drugs. The effect of antimicrobial resistance is that it can reduce the curative power of once life-saving medicines to that of a sugar pill.

The social causes fuelling the spread of antimicrobial resistance are paradoxical. In some settings -- especially in poorer countries -- the under-use of drugs encourages the development of resistance. For example, where patients are unable to afford the full course of the medicines to be cured of their illnesses, or can only afford to purchase counterfeit drugs on the black market, the weakest microbes in the body may be killed by these insufficient doses while the more resistant microbes are given opportunity to survive and multiply.

In wealthy countries, resistance is emerging for the opposite reason -- the overuse of drugs. Unnecessary demands for drugs by patients are often eagerly met by health services prone to over-prescription. Similarly, overuse of antimicrobials in food production in wealthy countries is also contributing to increased drug resistance. Currently, 50% of all antibiotic production is used to treat sick animals, promote livestock and poultry growth, or rid cultivated foods of destructive organisms.

Regardless of where drug resistance originates, globalization, increased travel and trade ensure that these strains quickly travel elsewhere. With new DNA finger-printing technology, scientists have been able to identify drug resistant TB strains originating in Eastern Europe, Asia and Africa and track them as they increasingly reappear in patients in Western Europe and North America.

"The world may only have a decade or two to make optimal use of many of the medicines presently available to stop infectious diseases," said Dr Heymann. "We are literally in a race against time to bring levels of infectious disease down worldwide, before the diseases wear the drugs down first."

The economic consequences of antimicrobial resistance can be staggering. The cost of treating one person with multidrug-resistant TB is a hundred times greater than the cost of treating non-resistant cases. New York City needed to spend nearly US$1 billion to control an outbreak of multi-drug resistant TB in the early 1990s; a cost beyond the reach of most of the world's cities.

"If we fail to make full and proper use of medicines discovered in our lifetime, many of these drugs will slip through our grasp," said Dr Rosamund Williams, who heads WHO's team working on drug resistance. "Before long, we may have missed our opportunity to control the most dangerous infectious diseases. Indeed, if we fail to make rapid progress during this decade, it may become very difficult and expensive -- if not impossible -- to do so later."

A common misconception is that the pharmaceutical industry is frequently making new drug discoveries to replace those drugs that become ineffective in fighting the major infectious diseases. In reality, while new versions of older drugs continue to be developed, there is a dearth of new classes of antibacterials. On average, research and development of anti-infective drugs takes 15 to 20 years, and can cost-over $500 million, according to pharmaceutical companies.

"Currently, there are no new drugs or vaccines ready to quickly emerge from the research and development pipeline," said Dr Heymann. "We are making a high-risk gamble with the public's health if we are betting on the discovery of new medicines and vaccines, and neglecting our opportunity to make wiser and wider use of the effective medicines we currently have available."

According to the report, the most effective strategy against antimicrobial resistance is to get the job done right the first time -- to unequivocally destroy microbes -- thereby defeating resistance before it starts. The challenge is to get the right treatment to the patient, each and every time.

"Used wisely and widely, the drugs we have today can be used to prevent the infections of today and the antimicrobial-resistant catastrophes of tomorrow," said Dr Brundtland. "However, if the world fails to mount a more serious effort to fight infectious diseases, antimicrobial resistance will increasingly threaten to send the world back to a pre-antibiotic age. Our grandparents lived during an era without effective antibiotics. We don't want the same situation for our grandchildren."

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