COVID-19 and antimicrobial resistance: The next health crisis?

Dangerously high levels of antimicrobial resistance and the spread of drug-resistant “superbugs” pose serious risks to public health and entire economies, as we highlighted in a previous article. In the latest urgent development, researchers are contemplating rising levels of antibiotics in wastewater as a result of the COVID-19 pandemic.

Most concerning is the fact that some output from wastewater treatment plants includes traces of antibiotic-resistant DNA.¹ This genetic material is potentially dangerous, as it may not be possible to halt host organisms with common antibiotics.

The implications of this are vast. Ultimately, patients undergoing routine medical procedures could be at risk. Pharmaceutical companies relying on antibiotics to underpin lucrative treatments in oncology, which are expected to deliver some of the highest returns in biopharma,² could see revenues impacted too.

In this Q&A, Aviva Investors’ global head of responsible investment Abigail Herron talks us through the key risks and what investors should do in response.

How has COVID-19 affected the use of antibiotics?

COVID-19 is a virus, so antibiotics will not treat it. However, infected patients in intensive care frequently develop respiratory bacterial infections, particularly those treated on ventilators. If the clinician is not certain about the presence of a bacterial infection and the patient’s health seems to be deteriorating fast, antibiotics may be prescribed anyway. This has been common with COVID-19.

We know that in Wuhan in China, nearly all patients that were hospitalised received antibiotics. Another study carried out across Asia found that only around eight per cent of COVID-19 patients had bacterial co-infections, but more than 70 per cent had antibiotic treatments.³

This may well result in a much larger problem in the future, because growing numbers of bacteria are becoming immune to antibiotics. It is a phenomenon we are very familiar with; heavy use of antibiotics undermines their effectiveness, because natural selection ensures the most resilient bacteria live on. At least 700,000 people already die every year from drug-resistant infections, like tuberculosis⁴ - that’s only slightly less than had been lost to COVID-19 by mid-August.

The conditions are in place for drug-resistant superbugs to proliferate faster, and antimicrobial resistance (AMR) is already a severe health threat. Unlike COVID-19, which has had the greatest impact on the elderly and those with pre-existing medical conditions, AMR is indiscriminate and can affect everyone. Even run-of-the-mill procedures - minor surgery, like joint replacement operations or caesareans, for example - might be threatened if AMR continues to grow.

What do we know about the scale of antibiotic use?

We don’t know the exact scale of the problem, but the World Health Organisation had already stepped up monitoring by collating data from 66 countries in 2019 and hopes to expand this.⁵ However, given the longevity and severity of the pandemic, it’s fair to say that the sheer quantity of antibiotics being used is likely to be much greater than in the last flu pandemic in 2009.

One other observation has been that with the rise in telemedicine prescriptions of antibiotics have also tended to tick up.⁶ As the priority during the pandemic has been to stop people gathering in outpatients’ clinics and doctor’s surgeries to limit the spread of infections, telemedicine has become more common.

What are the immediate implications?    

Many people are not aware that around 98 per cent of antibiotics consumed are still active when excreted. These compounds then make their way into our wastewater systems. This is a ticking timebomb for utility companies yet is rarely discussed. Studies are just starting to understand how wastewater plants can become collection points for drug-resistant microbes, but much more work is needed.⁷

We see risks accumulating right across the water cycle. What we have seen in China and India, where they produce most of the antibiotics, is that factories are not always rigorous in the way they manage the water flowing out of their antibiotic production factories. This can result in festering streams running alongside them – which could even be ground zero for the next superbug.

The monitoring of these sites does not always match what we would expect in Europe, even if production is taking place for large, European-listed companies. There have been several investigative reports, mainly aired in the US, on the water quality in these streams, and the findings are unsettling.

One important consideration is how swiftly a superbug can make its way across the world. If a traveller consumes water from a source in Asia that contains drug-resistant microbes, they can become lodged in the gut and then be transported into health facilities in other destinations very rapidly. This is a largely unseen problem, but one that is growing rapidly. 

Failing to act could have widespread implications. On a human level, the consequences of not being able to deploy commonplace medical interventions are severe. This is not a distant threat – chemotherapy patients in India are already being warned about the dangers of AMR before their treatment begins. 

The investment implications are also serious. Pharmaceutical companies reliant on lucrative oncology revenues may find their star products stranded as oncology therapies require an underpinning of effective antibiotics. Equally, food producers that rely upon mass medication of livestock may be forced to make swift changes throughout their supply chains to reduce their reliance on antibiotics if regulatory or public opinion changes. Water utility companies could also find themselves in the crosshairs of regulation targeting AMR and on the back foot.

What can investors do about it?

We convened and chaired the first investor conference on antibiotic resistance with the UK government’s AMR review team in 2016. Two years later, we co-convened Super Bugs and Super Risks, bringing together international AMR experts with representatives from the public and private sectors, civil society and patients. We are also heavily involved in the Investor Year of Action on Antibiotic Resistance – a collaboration between the FAIRR Initiative, Access to Medicine Foundation, UN Principles for Responsible Investment and the UK government.

Additionally, we meet individually with investee companies, mainly in the pharma and food sectors, to discuss their strategy on antibiotic resistance. Following extensive engagement, several commercial food producers have already committed to phase out mass antibiotic use. However, the wastewater issue is particularly difficult to manage, because the antibiotics flowing into our wastewater are difficult to measure.

We will be speaking to some utility companies we invest in and asking how they are addressing the quality of the water emerging from major hospitals and treatment centres. What is feasible? What can be integrated into their infrastructure? What do they need to do that is new? Recent research suggests new anaerobic sewage treatment processes could help.⁸

This is urgent, because AMR could potentially be a larger public health threat than COVID-19.

Are there any positives you see emerging from the pandemic?

One positive is the renewed focus on public health. The importance of vaccinations, surveillance and the need for infrastructure to support the response to pandemics have been made crystal clear. The willingness of global governments to devote more attention and resources to infectious diseases presents a once-in-a-generation opportunity to make a fresh, practical case for how we address the potentially cataclysmic issue of antibiotic resistance.

Building capacity, embracing new avenues for research and development, and investing in science for the long term is vital. This pandemic will end but, as we saw with the 2009 influenza outbreak, the next pandemic might only be a few years away. And who knows what kind of threat that could pose?