News and Opinions  –  2024

AMR or ABR – what is the confusion about?

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More than 1.2 million deaths in 2019. This is perhaps the most widely quoted number in policy documents ahead of the forthcoming United Nations High-Level Meeting on AMR. The number is used to demonstrate the devastating impact of AMR globally today. There’s just one detail - it is not on AMR. It is on antibiotic resistance. This article outlines the difference between the two, and why in the context of the United Nations High-Level Meeting on AMR it is important to start calling things by their right name.

Antimicrobial resistance (AMR) is an umbrella term for microorganisms developing resistance to medicines for treatment of viruses (such as HIV), parasites (such as malaria), bacterial infections including tuberculosis, as well as anti-fungal medicines.

Within this broader term sits antibiotic resistance (ABR) which – as the name implies – means resistance development in bacteria to antibiotics. This is what ReAct has always focused its work on. Because it is not a disease per se, it has been the most overlooked problem in terms of surveillance, financing and global governance within AMR. Whereas for at least the three big diseases – HIV, Malaria and TB – well-developed vertical health programs already exists, nothing of resemblance exists at global level to address bacterial infections (the second leading cause of death globally with 7.7 million deaths each year, not including TB), nor for antibiotic resistance. Of note is also that the UN political declaration on AMR from 2016, clearly stated that within the broader context of antimicrobial resistance, resistance to antibiotics, is the greatest and most urgent global risk.

Resistance to treatment is certainly a problem in HIV, Malaria, fungal infections and for TB – but the sheer numbers of deaths due to resistance in HIV, Malaria and fungi are small compared to deaths due to bacterial resistance to antibiotics (drug resistant TB accounts for roughly 7% out of the 1.27M estimated deaths from bacterial resistance in 2019). Today antibiotic resistance claims an equal number of lives as from HIV/AIDS and Malaria combined (1,24 million), including resistant forms.

Confusing interchangeable use

The broader tongue twisting term antimicrobial resistance – and in particular its acronym AMR – has been established over the last 10 years as the go-to term when referring to the problem of drug resistance. However, against the above numbers, it is perhaps not surprising that people often mean ABR, when they say AMR.

The widespread conflation of terms in policy documents and discussions at global and national level is something that ReAct’s founder Professor Otto Cars, have voiced concern over for years. Recently he published this piece in the journal Infectious Diseases on the issue:

Professor Otto Cars, founder ReAct. Photo: Therese Holm, ReAct Euro

“For scientist and experts, it is of course always a source of slight discomfort, when central terms are used incorrectly. But it is not just about correctness. The AMR-ABR conflation is the source of so many complications and misunderstandings in policy discussions. It adds to the confusing and technical narrative problem when we are not calling things by their right name. This is particularly frustrating when what we need in order to engage politicians and the general public more, is to be able to explain the issue in plain and simple terms”, says Professor Otto Cars.

Implications for policy discussions

Ahead of the United Nations High-Level Meeting, several suggestions for a global overarching target reduction of mortality to be included in the political declaration, are circulating. Some proposals focus on reducing deaths from AMR; others on reducing deaths from ABR; some on deaths from all infections caused by microorganisms (both susceptible and resistant); while yet others focus on reducing all deaths from bacterial infections. For non-experts like politicians and other decision makers it will be hard to both understand the differences, and decide what the most appropriate target.

Several areas are specific to ABR

In fact, many central discussions will benefit from more clearly distinguishing between the terms. When talking about global governance structures and surveillance, it makes little sense to talk about AMR, when such structures to a large extent already are in place and well-functioning for HIV, TB and Malaria, but not for antibiotic (and fungal) resistance. How a potential novel global governance structure for AMR for example would relate to the already existing structures for HIV, TB and Malaria has received little attention so far.

Similarly, the central discussion of how to address the problem of overuse and misuse in the human and animal sector is also quite specific to antibiotics. Rarely do patients take HIV, malaria or even TB medications, unless they have to. Nor do we often feed these drugs to animals. Antibiotics on the other hand are often used when not needed. As such the strategies to address resistance development across the AMR-spectrum varies.

Finally, until just last week the most used numbers to illustrate the economic impact of AMR came from the World Bank showing the economic losses amounting to more than $1 trillion annually by 2050. These simulations were based on the older AMR estimates from the UK AMR review from 2016. The combination of the 1.27 million number and the economic impact numbers from the World Bank therefore doesn’t match, which of course makes it impossible to make a coherent evidence-based argument on the relation between the two.

What do we say from here?

With the GRAM Study from 2022, we now have good global burden estimates, which are on ABR. And also since a few weeks back, when the Global Leaders Group released their recommendation or the UNHLM, new economic estimates have emerged that seem to show the impact of ABR (although it should be noted that the full study and its methodology is yet to be published by the WHO). These figures will most likely form the basis of the discussions on targets, financing commitments, commitments on access and stewardship across sectors in the coming months when the political declaration will be negotiated. Yet the UN HLM will still be on AMR. And so will the political declaration – but probably more by name than content.

Professor Otto Cars says:

“We will likely not get rid of the term AMR. The GRAM study suggested that we start saying “bacterial AMR” when we talk about antibiotic resistance, which from a scientific view is not a particularly logical term. But it is my hope that we can start calling things by their right name now that we indeed have good data on both burden and economic impact of ABR. I think this is a good starting point for developing a more engaging narrative for the problem”.