{"id":141169,"date":"2021-11-23T09:54:57","date_gmt":"2021-11-23T08:54:57","guid":{"rendered":"https:\/\/ew-nutrition.com\/two-pandemics\/"},"modified":"2024-05-17T08:12:57","modified_gmt":"2024-05-17T06:12:57","slug":"two-pandemics","status":"publish","type":"post","link":"https:\/\/ew-nutrition.com\/en-uk\/two-pandemics\/","title":{"rendered":"Two pandemics. How antimicrobial resistance will eventually overshadow COVID-19"},"content":{"rendered":"

By Dr. <\/strong>Inge Heinzl<\/b>, Editor, EW Nutrition<\/em><\/span><\/p>\n

Since <\/span><\/span>early 2020<\/span><\/span><\/span>, COVID-19 has been keeping the world under a cloud of <\/span><\/span>uncertainty<\/span><\/span><\/span>.\u00a0<\/span>With all eyes focused<\/span>\u00a0on this pandemic, we\u00a0<\/span>nevertheless must not forget\u00a0<\/span>that another<\/span>,\u00a0<\/span>silent pandemic is\u00a0<\/span>developing:<\/span>\u00a0<\/span>anti<\/span>microbial<\/span>\u00a0resistance (A<\/span>M<\/span>R)<\/span>.<\/span><\/span> U<\/span><\/span><\/span>nfortunately<\/span>,<\/span> <\/span>the COVID-19 could easily exacerbate the AMR pandemic<\/span><\/span><\/span>.\u00a0\u00a0<\/span><\/span>\u00a0<\/span><\/strong><\/p>\n

\"How<\/p>\n

What is the relationship between COVID-19 and AMR?<\/span>\u00a0<\/span><\/h1>\n

The COVID-19 pandemic, as well as AMR, have a direct\u00a0<\/span>health\u00a0<\/span>impact on people<\/span>: <\/span>t<\/span>hey get ill, suffer from\u00a0<\/span>its short- and <\/span>long-term effects, or even die. AMR, on the other hand, is not a disease in itself but makes various bacterial infections difficult to treat and <\/span>is considered<\/span>\u00a0a pandemic due to its\u00a0<\/span>dramatic\u00a0<\/span>global<\/span>\u00a0<\/span>scope (<\/span>Cars et al., 2021<\/span><\/a>).\u00a0Both<\/span>\u00a0pandemics,<\/span>\u00a0the\u00a0\u2018loud\u2019\u00a0<\/span>COVID<\/span>-19\u00a0<\/span>and the\u00a0\u2018silent\u2019\u00a0<\/span>AMR <\/span>pandemic<\/span>, are monitored by official institutions. Still, for both, significant uncertainties around actual case figures\u00a0<\/span>exist<\/span>, especially <\/span>in<\/span>\u00a0<\/span>low-income countries.<\/span>\u00a0<\/span><\/p>\n

Beginning in China\u00a0<\/span>in <\/span>around<\/span> December\u00a02019,\u00a0<\/span>SARS-CoV-2<\/span> spread to the rest of the world within a few\u00a0<\/span>months<\/span>. <\/span>Figures collated by the WHO<\/span><\/a> show<\/span> over 250 million confirmed cases and over 5 million deaths to date<\/span>, with<\/span>\u00a0<\/span>excess mortality rates indicating this to be an under<\/span>estimation. Quantifying the d<\/span>eath toll\u00a0<\/span>due to<\/span>\u00a0AMR\u00a0<\/span>is far more challenging, as disease conditions vary<\/span>, resistant bacteria go undetected,\u00a0<\/span>or the causative pathogens\u00a0<\/span>are<\/span> not identified in the first place (<\/span><\/span>Giattino et a<\/span>l<\/span>., 2021<\/span><\/span><\/span><\/a>)<\/span><\/span>.<\/span><\/span><\/span><\/span><\/p>\n

\"World<\/p>\n

O\u2019N<\/span>e<\/span>ill (2014)<\/span><\/span><\/a>\u00a0<\/span>report<\/span>ed<\/span>\u00a0about\u00a0<\/span>7<\/span>0<\/span>0,000 people d<\/span>ying<\/span>\u00a0from infections with resistant pathogens every year<\/span>. He<\/span>\u00a0forecast<\/span>ed<\/span>\u00a0that<\/span>,<\/span>\u00a0by 2050, 10 million people per year\u00a0<\/span>w<\/span>ill<\/span>\u00a0<\/span>die if we\u00a0<\/span>do<\/span>n<\/span>\u2019<\/span>t change anything. This figure would represent twice the number of people who die<\/span>d<\/span> from COVID-19 within <\/span>the last\u00a0<\/span>two years.\u00a0<\/span><\/span> In the US and the EU, according to\u00a0<\/span>CDC<\/span><\/a>, antibiotic resistance causes 23,000 and 25,000 deaths per year, respectively. In Thailand, 38,000 deaths are attributable to ABR. And in India, 58,000+ babies died from infections with resistant bacteria, usually passed on from their mothers.<\/span>\u00a0<\/span><\/span><\/p>\n

Woerther\u00a0et al.\u00a0(2013)<\/span><\/a>\u00a0note\u00a0a continuous increase of resistant strains globally. In 2010\/11, ESBL carriage rates of 3\u00a0to\u00a020 %\u00a0were the \u201cnorm\u201d, but some WHO regions already showed 60\u00a0to\u00a070% carriage rates by 2011.\u00a0In the US, 223,900 cases of\u00a0<\/span>Clostridium difficile<\/span><\/i>\u00a0occurred in 2017, and at least 12,800 people died\u00a0(<\/span>CDC, 2019<\/span><\/a>).<\/span>\u00a0<\/span><\/p>\n

As in the case of <\/span>SARS-CoV-2,\u00a0<\/span>the\u00a0<\/span>sprea<\/span>d of AMR organisms can be prevented by hygiene measures<\/span>. E<\/span>xcept for hospital settings reported<\/span>\u00a0in developed countries<\/span>,\u00a0<\/span>the\u00a0<\/span>spread of resistant bacteria is\u00a0<\/span>invisible. Regardless of how little we know about it from official reports, there are indications that bacteria resistance is <\/span>ubiquitous, triggered to a large extent by the <\/span>(over)use of antibiotics in community settings<\/span>.\u00a0<\/span>Moreover, it is far more dif<\/span>ficult to<\/span>\u00a0ident<\/span>ify that a patient suffers from AMR\u00a0<\/span>infection than from SARS-CoV-2. The latter is easily detected with widespread testing systems<\/span>, including self-testing.\u00a0<\/span>\u00a0<\/span><\/p>\n

COVID and AMR\u00a0have severe economic consequences<\/span>\u00a0<\/span><\/h3>\n

Besides claiming many lives, both COVID and AMR increase the costs for healthcare. Additionally, due to high sickness ratios and lockdowns, economic losses are tremendous. For COVID as well as for AMR patients, the hospitals need specialized systems and procedures (ventilation apparatus, extraordinary hygiene measures) and specially qualified personnel to treat the infected persons. In addition to the cases of infection, mental illness increases due to these exceptional circumstances.<\/span>\u00a0<\/span><\/p>\n

US study extrapolates\u00a0ten-figure\u00a0costs due to AMR<\/span><\/i>\u00a0<\/span><\/h4>\n

In a US cohort study\u00a0based on records\u00a0of\u00a025,000 patients from\u00a02007-2015,\u00a0<\/span>Nelson et al. (2021a)<\/span><\/a>\u00a0calculated the treatment costs for\u00a0infections\u00a0with methicillin-resistant\u00a0<\/span>Staphylococcus aureus<\/span><\/i>\u00a0or carbapenem-resistant\u00a0<\/span>Acinetobacter<\/span><\/i>\u00a0to be\u00a0$4.6 billion.\u00a0<\/span>\u00a0<\/span><\/p>\n

Another study done by\u00a0<\/span>Nelson et al. (2021b)<\/span><\/a> with 87,509 elderly patients suffering from infections with the same resistant pathogens showed estimated costs of $1.9 billion, with 11,852 deaths and 448,224 inpatient days. In these two studies, only two resistant bacteria species were considered \u2013 and they alone triggered costs of more than 4 billion US dollars.<\/span>\u00a0<\/span><\/p>\n

Estimation of COVID costs\u00a0shows\u00a0long-lasting negative economic impact<\/span><\/i>\u00a0<\/span><\/h4>\n

In the case of COVID, an estimation done by\u00a0<\/span>Tan-Torres\u00a0Edejer\u00a0et al. (2020)<\/span><\/a>\u00a0yielded\u00a0<\/span>$<\/span>52.45 billion in added healthcare costs worldwide over four weeks in a status quo scenario. The costs would increase\/decrease if the transmission increases\/decrease. More detailed consideration is provided by <\/span>Cutler and Summers (2020)<\/span><\/a>.\u00a0\u00a0<\/span>\u00a0<\/span><\/p>\n\n\n\n\n\n\n\n\n\n\n
Category<\/strong><\/td>\nCost (billions) in USD<\/strong><\/td>\n<\/tr>\n
Lost GDP<\/td>\n7592<\/td>\n<\/tr>\n
Health loss<\/td>\n<\/td>\n<\/tr>\n
\n
    \n
  • Premature death<\/li>\n<\/ul>\n<\/td>\n
4375<\/td>\n<\/tr>\n
\n
    \n
  • Long-term health impairment<\/li>\n<\/ul>\n<\/td>\n
2572<\/td>\n<\/tr>\n
\n
    \n
  • Mental health impairment<\/li>\n<\/ul>\n<\/td>\n
1581<\/td>\n<\/tr>\n
Total<\/td>\n16121<\/td>\n<\/tr>\n
% of annual GDP<\/td>\n90<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Estimated Projected\u00a0health cost of the COVID-19 crisis (Cutler and Summers, 2020<\/a>)\u00a0\u00a0<\/span><\/em><\/p>\n


\nEconomic losses due to Corona are tremendous \u2013 What about losses due to AMR?<\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n

Some of the costs arising during the corona pandemic are partially compensated. New jobs within the health system, industries providing healthcare materials or developing vaccines\/medicine partially cover the damages caused to the economy. <\/span>\u00a0<\/span><\/p>\n

Additional to the healthcare costs, costs due to the impact on the economy arise. According to\u00a0<\/span>Maliszewska\u00a0et al.\u00a0(2020)<\/span><\/a>, financial losses because of the COVID-19 pandemic can be attributed to four categories:<\/span>\u00a0<\/span><\/p>\n

    \n
  1. the direct impact of a reduction in employment\u00a0(shutdowns of operations), but also labor shortage due to illness of the personnel<\/span>\u00a0<\/span><\/li>\n
  2. the\u00a0increase in costs of international transactions<\/span>\u00a0<\/span><\/li>\n
  3. the sharp drop in travel\u00a0(caused by travel bans in\u00a0certain countries)<\/span>\u00a0<\/span><\/li>\n
  4. the decline in demand\u00a0for services that require proximity between people\u00a0(e.g.,\u00a0down periods of restaurants).<\/span>\u00a0<\/span><\/li>\n<\/ol>\n

    According to\u00a0a\u00a0<\/span>UN (2020)<\/span><\/a>\u00a0early estimate, the\u00a0\u201ceconomic\u00a0uncertainty it has sparked will likely cost the global economy $1 trillion in 2020\u201d.\u00a0<\/span>\u00a0<\/span><\/p>\n

    Comparing the costs for both pandemics, AMR does not seem to be as scary as COVID. However, we are only at the beginning. AMR figures are constantly increasing. If <\/span>O\u2019Neill (2014)<\/span><\/a>\u2019s scenario\u00a0occurs, we will\u00a0witness more AMR-caused deaths than deaths from COVID-19, as well as higher\u00a0costs.\u00a0<\/span>\u00a0<\/span><\/p>\n

    Antibiotic use promotes the development of resistances<\/span>\u00a0<\/span><\/h4>\n

    Antimicrobial resistance is natural; Alexander Fleming mentioned it as early as 1929, soon after discovering penicillin. Most of the antibiotics are derived from natural substances. Penicillin, for instance, is produced by a mold fungus. This is why completely isolated cultures such as the Yanomami in Venezuela, who have never taken antibiotics, can also show resistant bacteria in their gut flora (<\/span>Lahrtz, 2015<\/span><\/a>). Every contact with an antibiotic has the potential to promote resistance.<\/span><\/p>\n

    Bacteria\u00a0develop resistance\u00a0in different ways<\/span>\u00a0<\/span><\/h4>\n

    In a typical situation, an antibiotic has an impact on \u201cgood\u201d and \u201cbad\u201d bacteria. One bacterium, due to a random mutation, can develop resistance to antibiotic treatment. Suddenly, that resistant bacterium has survived the battle, remains the \u201cking of the castle\u201d, and can use all the space and nutrients to proliferate.<\/span>\u00a0<\/span><\/p>\n

    Different\u00a0types of resistance\u00a0are possible\u00a0(Levy, 1998). The bacteria can\u00a0<\/span>\u00a0<\/span><\/p>\n