Over the last half-century, the number of children who die before reaching the age of five has fallen dramatically, from around 20 million in 1960 to 4.9 million in 2022, largely owing to the Expanded Programme on Immunisation (EPI). Established by the World Health Organization in 1974, the EPI has been extraordinarily successful in providing the youngest people with access to vaccines, saving more than 150 million lives. But while such progress is worthy of celebration, there is still much work to do, because newborns comprise half of all deaths in children under five each year, many of which are caused by infection.
Progress on reducing neonatal mortality has historically been much slower than for children under five, and has begun to stall in recent decades, despite significant reductions in mother-to-child transmission of HIV, syphilis and hepatitis. That is because many of these deaths are caused by treatable – but untreated – bacterial infections. To reverse this trend, the international community must ensure that all children – especially in the African countries where most of these deaths occur – can access antibiotics, much like the EPI has done for vaccines.
Infants are particularly susceptible to infections in the first 28 days of life. As a paediatrician, I saw this firsthand when I was younger, working in the neonatal ICU at the Chris Hani Baragwanath Hospital in Soweto. It is possible to ward off some kinds through infection prevention and control; access to water, sanitation, and hygiene; and vaccines. But for those that cannot be prevented, antibiotics are needed to avert further complications such as sepsis, which affects up to three million newborns per year.
Unfortunately, most African countries lack access to existing and new antibiotics, putting already-vulnerable babies at a much higher risk of dying from treatable infections. Shortages of generic versions can be largely attributed to the steady exit of pharmaceutical companies from the antibiotic market in recent decades, owing to low returns. Similarly, new antibiotics are often sold in only the wealthiest countries or priced out of reach for most African governments and citizens.
For example, less than half of the new antibiotics approved between 1999 and 2014 were registered in more than ten countries. Worse, only four of the 40 new antibiotics approved since 2000 are labelled for paediatric use. When drug development is driven primarily by profitability, rather than public-health needs, infants in poorer countries – one of the world’s most vulnerable populations – get the short end of the stick.
If clinicians cannot access the right first-line antibiotics or use them because of a drug-resistant infection, they often turn to those that are specialised or kept in reserve as a last resort. These substitutes can be less effective, and reliance on them increases the risk of drug resistance developing, making infections more difficult to treat in the long term (although African countries are often priced out of these last-resort antibiotics, too).
As a result, children under five account for one in five deaths caused by drug-resistant infections, with 99.7 per cent of them living in low- and middle-income countries. At the same time, the failure to treat these infections in newborns is fuelling the rise and spread of antimicrobial resistance (AMR), which is already associated with 4.7 million deaths annually.
No country can tackle this problem alone. To ensure that all infants are protected from infection requires an EPI-scale global initiative to help developing countries build their capacity and surveillance, identify the necessary antibiotics and bolster their health systems. Equally important, we must dramatically increase the availability of existing antibiotics and spur the development of new ones that are safe and effective for children. Both imperatives require prioritising public health over profit.
The United Nations High-Level Meeting on Antimicrobial Resistance recently produced a political declaration committing countries to reduce global AMR-associated deaths by 10 per cent per year until 2030. Donor governments can begin doing this – and saving the lives of newborns – by supporting organisations like mine, the Global Antibiotic Research and Development Partnership, which are working to improve access to and encourage the development of antibiotics.
The WHO’s Paediatric Drug Optimisation exercises have made a shortlist of antibiotics that should be prioritised above all others for paediatric use. But stakeholders, including the WHO, regulatory agencies, the pharmaceutical industry, non-profit developers and paediatric experts, must collaborate to shepherd such treatments through development and approval. Preventing infant deaths from treatable infections would go a long way towards stopping the spread of AMR and safeguarding our future. @Project Syndicate, 2024
Glenda Gray
The writer is Board Chair of the Global Antibiotic Research & Development Partnership
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