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How can I stay safe while travelling?

No matter where you travel to, there are several general guidelines you should follow. For more specific advice and information visit our travel advice page.

  • Make sure all vaccines are up to date
  • Ask your health care professional if you could benefit from any vaccines specific to your destination country
  • Always use safe sexual practices
  • Maintain good hygiene; wash your hands often and especially prior to eating
  • Learn about ways to treat and prevent common travel-associated illnesses such as travelers’ diarrhea
  • Drink only bottled water
  • Avoid eating street food, particularly meat; use your judgement; if a restaurant or food vendor looks unclean your safest option is to eat packaged foods or stick to restaurants that have clear health and safety standards
  • Avoid eating meat in countries where antibiotics are still used incorrectly in animal husbandry
  • If you become sick while on vacation or after returning home, make sure you seek medical attention and let your healthcare provider know what countries you have been travelling in

What is antimicrobial resistance (AMR) and why is it an urgent threat to global health?

AMR is the ability of microbes (such as bacteria, viruses, fungi) to counteract the effectiveness of antimicrobial drugs used against them. There are three main classes of antimicrobial drugs: antibiotics, antivirals and antifungals. Even when used appropriately, antimicrobials can create a selective pressure for resistant microorganisms. However, the development of resistance is accelerated by the misuse and overuse of antimicrobials in human, animal, and plant health along with the pollution of the environment with antimicrobials and antimicrobial resistance genes.

AMR is a serious and urgent threat to global health as antimicrobials have been one of the key pillars of modern medicine since the discovery of penicillin by Alexander Fleming in 1928. Although antivirals and antifungals are indeed susceptible to resistance, antibiotics are of particular concern due to the rapid ways that bacteria can develop resistance mechanisms and transfer them through the population. This website places a heavy emphasis on antibiotic resistance due to the fact that when we talk about infections becoming resistant, this very often means bacteria becoming resistant to antibiotics. Additionally, of the three classes, antibiotics are used and misused at the highest rates which strongly contributes to the development of resistance in bacteria.

Human medicine is only the tip of the iceberg in the development of AMR; antibiotic use in animal husbandry accounts for 73% of all use globally. Any of us could be the next victim of AMR. According to United Nations experts, in the next 30 years 2.4 million people in Europe, North America, and Australia could die from drug-resistant infections (WHO, 2019). As life-saving antibiotics stop being effective, AMR could end our capacity to combat infections and halt all surgical procedures. This makes AMR a global health threat that needs international coordination and legislation to be addressed.

What are the main causes of antimicrobial resistance?

The rampant misuse and overuse of antimicrobials in human, animal, and plant health has exponentially accelerated growing resistance. On top of these factors, ongoing pollution of the environment is contributing to the widespread presence of antimicrobials and antimicrobial resistance genes in the population.

Every year millions of antibiotic prescriptions are written inappropriately (National Institute for Health and Care Excellence (NICE), 2015). Because of incorrect or lacking information, some doctors may end up prescribing antibiotics for infections already resistant to this treatment or even for viral infections which are in no way treated by antibiotics. In other cases, second- or third- line antibiotics that are reserved for last-resort scenarios may be prescribed in situations where the first line antibiotic would have been able to treat the infection.

Antimicrobials, particularly antibiotics, are a critical part of food security which has made agriculture and aquaculture breeding grounds for resistance via improper usage. Antibiotics are used to treat infections in animals and plants; however, a more worrying usage is the practice of using antimicrobials to compensate for poor hygiene conditions and/or to promote growth (AMR Review, 2016).

As more and more antibiotics are becoming ineffective against resistant infections, last-resort antibiotics may be used more frequently. When used in livestock, the risk of AMR increases as low-level consumption of antibiotics in the food chain has the consequent effect of reducing antibiotic efficacy in humans (Allen HK, 2014). Globally, it is not uncommon for more antimicrobials to be used on animals than for human health. In the U.S., for example, over 70% of antibiotics deemed medically important for humans are used in animal husbandry (The Review on Antimicrobial Resistance, 2015).

In the environment there are many so-called “hot-spots” where antimicrobial resistance is more likely to develop due to inappropriate and polluting disposal of antimicrobials. Studies have shown pronounced spikes in resistance around pharmaceutical manufacturing sites, aquaculture, and agriculture runoffs. In household environments, resistance is likely to emerge in areas where knowledge of proper antibiotic disposal is low, and people get rid of old or unused drugs through their toilets, sinks, or general household garbage. (Larsson DG, et al., 2007)  (J Hazard Mater, et al., 2017) (Berendonk, et al., 2015); (Bengtsson-Palme J, et al., 2014),  (Flach, et al., 2015) (Pruden A, Larsson DGJ, Amézquita A et al. (2013) (AMR Review, 2016) (Landers, 2012,)

For plant diseases, some antimicrobials such as streptomycin, kasugamycin, oxytetracycline, and oxolinic acid are important for treatment and control. However, the use of these antimicrobials contaminates the soil which contributes to the development of antimicrobial-resistant bacteria and antimicrobial resistance genes (Stockwell and Duffy, 2012) (Sundin and Wang, 2018)

How does AMR develop and how is it disseminated?

Antimicrobial resistance occurs when a microbe develops a mechanism to counteract the effect of a drug. There are four ways that this occurs: 1) Reducing the amount of drug that enters the cell; 2) Modifying receptors to essentially appear “invisible” to the drug; 3) Rendering the drug inactive; 4) Pumping the drug outside of the bacteria (NCBI, 2018). These mechanisms are developed through the evolution of bacteria as those with the most favourable characteristics to resist antibiotics survive and spread these adaptations through the population.

There are several ways by which these resistance mechanisms can then be spread to other bacteria. By overusing and oversaturating the environment with antibiotics we are contributing to the pressured and rapid evolution of bacteria. In other words, if one microbe develops a mechanism to resist the antimicrobial drug, it can survive exposure to the drug and pass on its adaptation, creating a stronger, more resistant microbial population. Another way for the resistance to spread is through a process called Horizontal Gene Transfer. This is a method by which bacteria can share their traits via genes to a neighbouring bacterium (not a direct descendant). Effectively, one bacterium could give its resistance traits directly to its neighbour (ScienceDirect, 2013).

Often times we assume resistance is spread only when antibiotics are present and give bacteria with resistance genes an advantage over non-resistant bacteria; however researchers have found that resistance genes continue to spread among bacteria populations even in the absence of antibiotics (Bakkeren, et al., 2019). Resistant bacteria known as “persisters” reduce their metabolism and fall into a dormant state in the presence of antibiotics in order to outlast the treatment. These bacteria can remain dormant for months and reawaken to cause the infection to flare up once again and spread resistance genes to other bacteria even long after antibiotics have left the environment.

Dissemination pathways for resistant bacteria:

  • Human to human contact
  • Direct contact with animals
  • Processing, transport, or handling of food animals and food
  • The environment (e.g. contamination of water and soil via manure or waste water discharge from plants manufacturing antibiotics)

 

What does “inappropriate use of antibiotics” mean?

The human health sector accounts for 20% of antibiotic usage worldwide. As such, demanding unnecessary antibiotic therapies from your doctor or pharmacist or buying these drugs over-the-counter can contribute to the spread of resistance which is harmful not only for you, but for society as well.

If you are a patient, you can use antibiotics inappropriately if you:

  • don’t complete a full course of antibiotics as prescribed by your health professional
  • take a lower dose of antibiotics than that recommended to you by your doctor
  • take antibiotics for a wrong indication: viral infections (e.g., colds, flues), coughs, inflammations
  • share the antibiotics prescribed to you with other people

In animal health, antibiotics are used inappropriately when used as a:

  • prophylactic
  • metaphylactic
  • growth promoter

An animal may be treated with antibiotics after undergoing surgery or injurious trauma – preventive use or prophylaxis. Preventive treatment should only be applied to animals diagnosed at high risk of bacterial disease and not as a routine practice or to compensate for poor hygiene and inadequate husbandry conditions.

Antibiotics may also be used for metaphylaxis, to control the spread of disease between animals. When animals are kept in close contact with each other and are not looked after properly, infections are quick to develop and spread (MSU). The low prices of antibiotics, particularly in developing countries that have large meat production industries such as India and China, drive the tendency to overuse antibiotics to curb infections rather than fix the hygiene and health practices that exacerbate them in the first place.

Antibiotics are added to animal feed to promote faster growth by accelerating the rate of weight gain and/or increasing feed conversion efficiency in animals. Antibiotics have been banned as growth promoters in the EU since 2006 (Regulation IP/05/1687) and replaced by feed additives with a similar effect; however, this example has not been followed by many of the top meat exporting countries.

How many people die every year because of AMR?

Currently, at least 700,000 people die every year due to AMR (WHO, 2019). In Europe that number is estimated at 33,000 annually while the U.S. sees 23,000 deaths attributed to AMR each year (CDC, 2013). This number is predicted to rise and by 2050, could reach 10 million per year if no action is taken (UN IACG, 2019).

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