Photo: Srikant Chaudhary
Photo: Srikant Chaudhary

Coming up in 2020: Measles, AMR big health challenges

Many countries are no more 'Measles-free'; antimicrobial resistance is a;worry for India too

The risk of a resurgent measles and an ever-growing threat of antimicrobial resistance (AMR) will challenge the global medical community to look for answers in 2020 and beyond.

The year gone by caught the global health community almost unawares against an enemy they thought they had defeated: Measles. As many as 187 countries reported an incidence of measles, or its widespread outbreak.

Some had even received ‘elimination’ certificates from the World Health Organization (WHO). As the third decade of the 21st century begins, this contagious disease will present a formidable challenge for agencies around the world to grapple with.

“Preliminary global data shows that reported cases rose by 300 per cent in the first three months of 2019, compared to the same period in 2018. This follows consecutive increases over the past two years,” the WHO said.

The World Bank, in a year-ender review, posted the number as 413,308 reported cases globally, plus an additional 250,000 reported cases in the Democratic Republic of Congo, versus 333,445 for all of 2018, quoting WHO figures.

Add to this, another disclaimer of WHO, and the reality become much graver. “The actual number of cases — captured in global estimates — will also be considerably higher than those reported. WHO estimates that less than 1 in 10 cases are reported globally, with variations by region,” it said.

The Centers for Disease Control and Prevention (CDC) on May 30, 2019, announced that the number of cases reported in the first five months of the year in the United States (US) surpassed the worst number in the last 25 years.

Four European countries — Albania, Czech Republic, Greece and the United Kingdom (UK) — lost measles elimination status ‘following protracted outbreaks of the disease’. This happens if measles re-enters a country after it has been declared eliminated, and if transmission is sustained continuously in the country for more than a year.

Experts globally have pegged the insufficient coverage of measles immunisation has been as one of the primary reasons for this. Increased coverage of vaccines that contain — dosages 1 and 2 — decreased incidence and mortality by 63 per cent and 73 cent from 2000-2018, according to CDC.

“Despite this progress, the 2015 global milestones were not met: MCV1 coverage has stagnated for nearly a decade and MCV2 coverage is only 69 per cent. Reported measles incidence has increased in five regions since 2016 and estimated global measles mortality has increased since 2017,” according to a joint report of WHO and CDC.

However, the causes were not limited to poor measles vaccination coverage. The joint report said they were multi-factorial and varied from country to country.

Supplementary immunisation activity has led to poor immunity among older children and adults in many countries. Another reason pointed out was the ‘importation’ of measles.

“For example, in 2018, Israel experienced nearly 100 measles importations from multiple countries including the Philippines, Ukraine, and the UK; and importations from Israel and Ukraine led to outbreaks in the US,” the report said.

In fact, after having experienced more than 100 importations in 2018, an endemic measles virus transmission had been re-established in the UK.

The ever-present threat of AMR 

While the world continues to struggle against the newly active stagnant enemy, another issue over which the scientists are spending sleepless nights is antimicrobial resistance (AMR).

On the one hand, it is going to test the doggedness of the medical fraternity to find ways and means to deal with it. On the other, it will test the restraint of physicians from prescribing antibiotics and antivirals in a manner that the problem, which is already quite serious, is not appended.

A report submitted to the secretary general of the United Nations titled AMR: A global crisis that threatens a century of progress in health and achievement of the Sustainable Development Goals, urged prompt action as there was no time to sit back.

“Alarming levels of resistance have been reported in countries of all income levels, with the result that common diseases are becoming untreatable, and lifesaving medical procedures riskier to perform,” it warned.

Talking about numbers, it said drug-resistant diseases already caused at least 700,000 deaths globally a year, including 230,000 deaths from multidrug-resistant tuberculosis.

This figure could increase to 10 million deaths globally per year by 2050 under the most alarming scenario if no action was taken. Around 2.4 million people could die in high income countries between 2015 and 2050 without a sustained effort to contain antimicrobial resistance.

“In The Lancet Infectious Diseases, Alessandro Cassini and colleagues measured the health burden of five types of antibiotic-resistant infection (invasive and noninvasive) caused by eight bacteria with 16 resistance patterns in the European Union (EU) and European Economic Area (EAA),” a commentary published in The Lancet in January 2019, said.

“The estimates, presented as disability-adjusted life years (DALYs), are shocking. The overall DALY rate is 170 per 100,000 population, which is similar to the combined burden of HIV, influenza, and tuberculosis in the same year in the EU and EAA. The burden has doubled since 2007 and is highest in infants (aged <1 year) and older people (aged ≥65 years),” the commentary added.

AMR a major threat in India

Back home, in India, AMR has emerged as a major threat to public health estimated to cause 10 million deaths annually by 2050 as India carries one of the biggest burdens of drug-resistance pathogens, worldwide.

Various causes are attributed to growing AMR burden, worldwide. The irrational and overuse of antibiotics being one of the most important.

Three reports, on antibiotic consumption in India, the UK and the US in December 2019, established what has been widely reported as a global trend. India’s rate of antibiotic prescription is less when compared to European countries.

However, when it comes to the antibiotic drugs which are third and fourth line, India beats a number of countries, said a study published in PLOS One. As much as two fifths (43 per cent) of antibiotic prescriptions in the US could be inappropriate, warned a BMJ study.

Of this, 43 per cent, T24 million prescriptions were without a documented indication and rest were deemed inappropriate.

In 2017, the WHO classified antibiotics in three groups. ‘Aware’ — which has lower resistance potential, followed by ‘Watch’ and ‘Reserve’. A WHO report on the implementation of this programme showed ‘great diversity in the level of consumption of antibiotics in the Watch category, which accounted for less than 20 per cent of the total antibiotic consumption in some countries, but more than 50 per cent in others’.

However, only 16 countries shared their data for this report and the global health body said this was a major lacuna in the programme implementation. Other causes of AMR include growing resistance of microbials themselves by mutating over a period of time.

This gets further compounded due to the fact that no new classes of antibiotics have been invented for decades. The result is there in the ever-growing burden of all drug resistance in all four major diseases — TB, HIV, Malaria and influenza.

Most of the countries have come out with National Action Plans for AMR but the implementation remains a challenge.

“Antimicrobial resistance is a complex problem that affects all of society and is driven by many interconnected factors. Single, isolated interventions have limited impact. Coordinated action is required to minimise the emergence and spread of antimicrobial resistance. Greater innovation and investment are required in research and development of new antimicrobial medicines, vaccines, and diagnostic tools,” according to the WHO.

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