Q&A: Burden of antimicrobial resistance in WHO’s Eastern Mediterranean Region

Antimicrobial resistance (AMR) is an urgent global crisis and one of the world’s most complex challenges. In 2021, there were an estimated 92,800 deaths attributable to bacterial AMR in the WHO Eastern Mediterranean Region (EMR), according to a recent study published in The Lancet Public Health using GBD study data. This research shows that AMR has been a serious public health threat in the EMR for more than 30 years.

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Transcript

This transcript has been lightly edited for clarity

Why is it important to study AMR in WHO’s Eastern Mediterranean region?

The Eastern Mediterranean region has big pressures that can actually fuel antimicrobial resistance a lot. These are fragile health systems, conflict, displacement, even uneven access to medicines. But then leaders often lack solid and comparable numbers to plan and invest. And our study basically fills that gap. And we have comparable estimates for 22 countries from 1990 to 2021.

And we also produced forward-looking forecasts to 2050. And I believe this matters because investments in tackling AMR have to be targeted. And this study shows where the burden is highest and which infections and resistant pathogens drive it, and who is the most affected. So when you have limited budgets and many competing priorities, you really need the robust data to target stewardship for infection prevention and access to quality antibiotics.

And without these numbers, countries risk spending in the wrong places, while at the same time antimicrobial resistance keeps rising. That’s why it’s important.

What is the difference between “attributable” and “associated” AMR deaths?

Attributable mortality, or deaths that are attributed to AMR, are those that are directly caused by resistant microorganisms, in this case resistant bacteria, in our estimates. On the other hand, associated deaths, associated with mortality, or deaths associated with AMR, are those that may or may not be directly linked to resistant bacteria. But we know that in these deaths, these individuals had resistant bacteria in their test results in their medical history.

So they could contribute to the deaths in the chain. And this is also why it’s important to estimate associated deaths as well. And we didn’t just estimate deaths. We also estimate the disability-adjusted life years, or DALYs. And there we also have these two counterfactual scenarios: attributable DALYs and associated DALYs.

What are the key findings of your study, and what needs to be done to combat AMR?

We estimated that in 2021 alone, there were about 308,000 deaths associated with drug-resistant infections in the region and nearly 93,000 deaths directly caused by AMR. And this is a huge burden. And we also saw that over time, deaths in children under 5 have decreased, which is, of course, a positive sign. But deaths in adults, especially people aged 70 years and older, have increased significantly since 1990, which is also influenced, of course, the changed demographics.

In the age associated/attributable chart, we can see age-specific trends in both attributable and associated AMR deaths in 1990 and 2021, so in two years. And between those years, we see significant changes. Associated deaths in children under the age of 5 drop substantially – we have estimated by 50% – while deaths among adults aged 70 years and older increased, we estimated by over 85%. And this shift basically underscores how AMR is increasingly affecting older populations, and why tailored strategies for aging societies are definitely needed. If you look at 1990 maps and figure that map’s age-standardized mortality rates per 100,000 people for the year 1990, we can see both deaths associated and deaths directly attributable to antimicrobial resistance. And for deaths associated with antimicrobial resistance, like we said, where AMR played a role in the outcome but wasn’t necessarily the direct cause, rates can be seen as highest. And in that year, they were the highest in countries like Somalia, Afghanistan, and Egypt. For attributed mortality, where resistance was the direct cause of death, we see lower rates. But our estimates also reveal major hotspots like Somalia and Yemen that was valid even back in 1990.

Now, if we shift our attention to this figure that maps age-standardized mortality rates per 100,000 people for the year 2021, we see that associated mortality remains the highest in Somalia, with persistently high rates also in Sudan and Pakistan. Of course, this reflects broader health system challenges as well. For attributed mortality, Somalia, Afghanistan, and Djibouti are standing out.

So if we compare with 1990, while progress was made in some areas, large gaps remain, especially in countries facing conflict or weak infrastructure. Then, when we talk about projected age-standardized mortality from AMR by 2050, we have estimated that associated mortality will stay the highest in Somalia, with Egypt also projected to carry a significant burden. Attributable deaths in the future will be again concentrated in Somalia, with Afghanistan and Pakistan contributing a significant burden as well.

And the projections suggest that without strong and even stronger interventions, these high-burden patterns will persist.

But I would like to emphasize here that the future is not set in stone. Scaling up infection prevention and control, scaling up vaccination, water sanitation, more reliable diagnostics, more responsible antibiotic usage – these all could actually bend the curve and slow this growth. So these forecasts are actually meant to help countries plan ahead, not just react later.