Control antibiotic misuse or the drugs won’t work, warn WHO experts

Copenhagen, 23 November 2023 - Antimicrobial resistance (AMR) is recognized by the World Health Organization as one of the ten major global public health threats, with an estimated 5 million deaths annually associated with bacterial AMR worldwide, of which more than half a million occur in the WHO European Region, comprising 53 Member States in Europe and Central Asia.  

AMR occurs when microorganisms develop the ability to resist the antimicrobial drugs that are typically used to kill them and treat infections.  There are different types of antimicrobials, such as antibiotics for bacteria, antivirals for viruses, and antifungals for fungi, each targeting specific types of microorganisms. While AMR is a natural phenomenon, the development and spread of superbugs is being accelerated by the misuse of antimicrobials, rendering infections more challenging to treat effectively.  

The alarming reality is that, without immediate intervention, AMR could result in up to 10 million deaths a year by 2050. Moreover, this burden falls disproportionately on low- and middle-income countries, exacerbating global health inequalities. 

New data 

WHO/Europe has conducted a standardized survey across more than a dozen countries of the WHO European Region, namely in the Western Balkans, the Caucasus, and Central Asia (including Türkiye), shedding light on the knowledge, attitudes, and behaviours surrounding antibiotic use and AMR. The survey is the first of its kind to be conducted in these countries, all of whom gave the research their full support. The results have been published in the journal Frontiers. The survey used the same methodology and questions as an established survey that is periodically carried out in the EU. Conducting surveys in this way, in close collaboration with the European Commission, enables WHO to achieve its goal of having a pan-European overview. Having a clear picture of the current situation makes it possible to monitor progress and evaluate interventions in the future. 

The survey involved 8,221 participants from 14 countries, half of whom reported taking oral antibiotics in the past 12 months. Medical practitioners prescribed or directly administered the majority (67%) of the antibiotics. The reasons cited for taking the antibiotics included colds (24%), flu-like symptoms (16%), sore throat (21%) and cough (18%). This gives cause for concern because these symptoms are often caused by viruses against which antibiotics are not effective. Medical expertise is essential to make a correct diagnosis to determine whether antibiotics are the correct course of treatment. 

The survey further highlighted a lack of enforcement around the use of a medical prescription for every course of antibiotics. Across the 14 countries, a third (33%) of respondents consumed antibiotics without a medical prescription. In some countries more than 40% of the antibiotics were obtained without medical advice. In contrast, the equivalent survey conducted across the EU in 2022 revealed that only 8% of respondents consumed antibiotics without a prescription.   

WHO/Europe’s survey also highlights gaps in people’s knowledge. Just 16% of respondents were able to respond correctly to all of four awareness questions, which could indicate that people are taking antibiotics for the wrong reasons without realizing it. A majority of respondents (67%) were aware that unnecessary use of antibiotics can make them less effective, however nearly half of the respondents (43%) incorrectly said antibiotics are effective against viruses (they are not).  

Equally worrisome is the fact that only 37% (and just 23% in the EU research) reported receiving any information about the importance of avoiding unnecessary antibiotic use in the past year, highlighting the urgent need for clearer and more targeted public health communication. 

“This research clearly shows the need for education and awareness raising,” said Robb Butler, WHO/Europe’s Director for Communicable Diseases, Environment and Health. “All countries in our Region have regulations in place to protect precious antibiotics from misuse, for example preventing over the counter sales without prescription.  Enforcing these regulations would solve most antibiotic misuse among humans. Other drivers of AMR have their roots in the social and cultural norms learned in communities, for example not completing a course of antibiotics in order to save some for the next time you fall ill or share with a sick relative or neighbour. This learned behaviour can take time to change and it’s imperative that behavioural and cultural insights are used to the full when planning interventions.” 

Behavioural and cultural insights  

 As global efforts to control AMR intensify, social and behavioural sciences are emerging as crucial, yet underutilized areas of knowledge and expertise that can guide interventions in AMR control, radically increasing impact.  

“The use of antimicrobial medicines is intrinsically tied to human behaviour and deeply entrenched in social and cultural contexts, shaped by our attitudes, policies, and available choices,” commented Dr Danilo Lo Fo Wong, Regional Adviser for the control of antimicrobial resistance. “Conserving the effectiveness of antimicrobial medicines requires interventions at many levels, such as timely vaccination, improving hygiene or reducing inappropriate prescribing. Behavioural science and cultural context analysis have a pivotal role to play in understanding and addressing all these behaviours. They can provide critical insights into the barriers and drivers of behaviour, aiding in the development of effective interventions. We encourage and support countries to design and conducting targeted behavioural interventions, using the guidance provided in our ‘Tailoring antimicrobial resistance programme’.” 

ENDS

Link to newly published ‘WHO Europe Antimicrobial Consumption report 2020-2021’ https://www.who.int/europe/publications/i/item/9789289060042 

Link to article on Roadmap adoption: https://www.who.int/europe/news/item/26-10-2023-countries-in-the-who-european-region-commit-to-action-on-antimicrobial-resistance-by-endorsing-a-new-european-roadmap

Link to global BCI resolution: https://www.who.int/europe/news/item/20-06-2023-new-global-resolution-calls-for-establishment-of-behavioural-science-units-or-teams

Link to regional BCI resolution: https://www.who.int/europe/teams/behavioural-and-cultural-insights 

Notes to editors:  

• Countries participating in the WHO/Europe survey: Albania (ALB), Armenia (ARM), Azerbaijan (AZB), Bosnia and Herzegovina (BIH), Belarus (BLR), Georgia (GEO), Kazakhstan (KAZ), Kyrgyzstan (KGZ), Montenegro (MNE), North Macedonia (MKD), Republic of Moldova (MDA), Tajikistan (TJK), Türkiye (TUR) and Uzbekistan (UZB). 
• To address the lack of data on knowledge, attitudes and behaviour from the above-mentioned countries, the WHO Regional Office for Europe conducted a survey using the same questionnaire used by the European Commission for the Eurobarometer survey, Antimicrobial Resistance - November 2022 - - Eurobarometer survey (europa.eu), which is conducted regularly, most recently in 2022. The survey aims to establish harmonized baseline data on KAB (knowledge, attitudes, and behaviours) on antibiotic use and AMR in 14 WHO European Region Member States. The data are expected to support participating Member States in the development of targeted awareness raising and education interventions, and subsequently the evaluation of their impact. This survey combined with the Eurobarometer data gives WHO/Europe a pan-European overview making it possible to monitor progress and evaluate the effectiveness of interventions. 
• Several factors contribute to the development and spread of AMR including: the misuse and overuse of antimicrobials in the human health, veterinary and agricultural sectors; inadequate access to clean water, sanitation and hygiene for both humans and animals; suboptimal infection prevention and control practices in health-care facilities and farms; limited availability of quality, affordable medicines, vaccines and diagnostics; inadequate awareness and knowledge among healthcare providers and the public; and inadequate enforcement of legislation to regulate antimicrobial use. 
• A 2022 study in the Lancet estimated 4.95 million deaths associated with bacterial AMR in 2019 worldwide. Likewise, more than 35,000 people reportedly die from antimicrobial-resistant infections in the European Union and European Economic Area (EU/EEA) annually while another publication estimated 541,000 deaths associated with bacterial AMR and 133 000 deaths attributable to bacterial AMR in the WHO European Region in 2019. 

'One Health' is an integrated, unifying approach to balance and optimize the health of people, animals, and the environment. It is particularly important to prevent, predict, detect, and respond to global health threats such as the COVID-19 pandemic. One Health involves the public health, veterinary, and environmental sectors. The One Health approach is particularly relevant for food and water safety, nutrition, the control of zoonoses (diseases that can spread between animals and humans, such as flu, rabies, and Rift Valley fever), pollution management, and combatting antimicrobial resistance (the emergence of microbes that are resistant to antibiotic therapy). 

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