Goal 3: ensure healthy lives and promote well-being for all

at all ages.

Fact sheets on sustainable development goals: health targets

Antimicrobial Resistance
Antimicrobial resistance (AMR) is an increasingly serious threat to the gains made in health and development and
for the attainment of the Sustainable Development Goals (SDGs) (1,2). AMR can compromise the achievement
of the SDGs, affecting health security, poverty, economic growth and food security. Action is necessary across
sectors and settings to mitigate prevent and control AMR.

Overview
AMR is defined as the resistance of bacterial, viral, parasitic and fungal microorganisms to antimicrobial medicines
that were previously effective for treatment of infections. It occurs naturally over time but is accelerated by:
• the inappropriate use of antimicrobial medicines in the health, animal, food, agriculture and aquaculture sectors;
• lack of access to health services, including to diagnostics and laboratory capacity; and
• antimicrobial residues in soil, crops and water (2,3).
 AMR and SDGs: facts and figures

If no action is taken to contain AMR, the economic cost in terms of lost global production between
now and 2050 would be US$ 100 trillion (4,5). Low- and middle-income countries would be more
negatively impacted and a widening of the inequity gap within countries is expected (4,5).
• The indirect costs of drug-resistant infections to the individual and society from morbidity,
disability, premature deaths and reduced effective labour supply are estimated to cause a
decrease in the global economic output of 1–3% by 2030, with estimated losses ranging from
US$ 1 trillion to US$ 3.4 trillion annually if no action is taken (4,5).

Ensure sustainable food production systems: antimicrobial agents are essential for food
security. Global consumption of antimicrobials in food/animal production was estimated at
63  000  tonnes in 2010 and is projected to rise by 70% by 2030 (4,6,7). Doubling agricultural
productivity while reducing antimicrobial use is a challenge.

Currently, it is estimated that AMR causes 25 000 deaths annually in the European Union alone (8).
Reduce preventable maternal deaths: globally, it is estimated that more than 30 000 women
die each year as a result of severe infections when giving birth (9).
End preventable neonatal and childhood deaths: estimates suggest that more than 200 000
newborns die each year around the world from infections that do not respond to available drugs;
the vast majority of these deaths occur in developing countries (9). These numbers may rise if and
when the antibiotics that treat these infections become less effective (4,10,11).
End the epidemics of communicable diseases: the emerging resistance to drugs to treat HIV,
tuberculosis and malaria is an obstacle for the achievement of target 3.3.
• With increasing global use of antiretroviral therapy both to treat and to prevent HIV infection, and
increasing global trends in resistance to these drugs, treatment options may become limited. As
a result, more expensive treatment regimens associated with greater long-term toxicity would
be needed (12,13).
• The European Region has the highest rates of drug-resistant tuberculosis (TB) in the world.
Around 73 000 people in the Region are estimated to fall ill with multidrug-resistant TB (MDR-
TB) every year, which requires longer treatment with more drugs and is associated with lower
success rates. In 2014, 966 cases of extensively drug-resistant TB (XDR-TB) were reported in
the Region, accounting for approximately 18% of the cases of MDR-TB (14).
• Worldwide, 357 million new sexually transmitted infections are estimated to occur every year, of
which some are becoming increasingly resistant to drugs (15). These infections can cause long-
term disability, infertility and even death. In particular, gonorrhoea is a major concern as some
gonorrhoeal infections are now completely untreatable with available antibiotics (15).
Universal health coverage: to address AMR it is essential to improve health systems performance
while making progress towards universal health coverage (Box 1).
• In the European Region, gaps remain in surveillance and regulation of prudent use of antibiotics
in community and hospital settings in the European Region (16).
• Prescription rates vary greatly, with higher rates in southern and eastern Europe and approximately
20–30% of antibiotic consumption being without prescription (19–22).
• Total antibiotic use in humans in 2011 ranged from 13 defined daily doses for the Netherlands
to 42 for Turkey (Fig. 1) (19).
• Overall, the sustainability of health system is endangered by AMR. In the EU alone, it is estimated
that AMR annually costs €1.5 billion a year in health care costs and productivity losses (8,23).

2
 Although there is no scientifically documented evidence to date of widespread illnesses among
the general public caused by pharmaceutical and microbial hazard waste from health care, poorly
managed health care waste can reach and contaminate groundwater, drinking-water, soils, food
crops and sediments. This can potentially have serious environmental effects, including toxicity to
wildlife and the generation of antibiotic-resistant bacteria (24–26).

The Global Partnership represents an important prerequisite for addressing AMR worldwide.
Heads of State at the United Nations General Assembly in September 2016 recognized the need
for stronger systems to monitor drug-resistant infections and the volume of antimicrobial agents
used in humans, animals and crops, as well as for increased international cooperation and funding
(Box 2) (2).
Achievements in the dimensions covered by SDG  17 (finance, technology and innovation,
capacity-building, fair trade, policy and institutional coherence, multistakeholder partnership and
data monitoring and accountability) would support efforts to strengthen regulation of antimicrobial
usage. They would also improve knowledge and awareness, promote best practices, foster
innovative approaches using alternatives to antimicrobial agents and support the development of
new technologies for diagnosis and vaccines.

Commitment to act
Member States at the Sixty-eight World Health Assembly in May 2015 (28) committed to ensure, for as long
as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe
medicines that are quality assured, used in a responsible way and accessible to all who need them with the
adoption of the Global action plan on antimicrobial resistance (17).
Heads and representatives of State and governments reaffirmed this commitment at the High-level meeting of
the United Nations General Assembly on antimicrobial resistance in September 2016 (2).

Box 1. Leaving no one behind…

Universal health coverage: achieving universal health coverage will support the mitigation and containment
of AMR. Ensuring equitable access to affordable essential medicines for all enables patients to complete
uninterruptedly the full course of antimicrobial drugs. Ensuring access to vaccines for all prevents infections,
thus reducing the need for antimicrobial drugs. Other essential actions to combat AMR include renewing
investment in research and development of new medical products (17,18).

The strategic objectives of the Global action plan are to:

• improve awareness and understanding of AMR through effective communication, education and training;
• strengthen the knowledge and evidence base through surveillance and research;
• reduce the incidence of infection through effective sanitation, hygiene and infection-prevention measures;
• optimize the use of antimicrobial medicines in human and animal health;
• develop the economic case for sustainable investment taking into account the needs of all countries; and
• increase investment in new medicines, diagnostic tools, vaccines and other interventions.
By 2011, all 53 Member States in the WHO European Region had adopted the European strategic action plan
on antibiotic resistance (2011–2020) (23), which is fully in line with the Global action plan (17), and have worked
on its implementation with the support of WHO and its partners.

3
 Box 2. Intersectoral action
One health: under a “one health” approach, AMR containment would be supported by effective
surveillance of trends in antimicrobial consumption and resistance in agriculture and veterinary sectors, the
implementation of animal immunization and the promotion of improved hygiene and biosecurity (3,18).
A manual has been developed by WHO, in collaboration with the Food and Agriculture Organization of the
United Nations (FAO) and the World Organisation for Animal Health (OIE), to assist countries in preparing or
refining their national actions plans. It aim to facilitate the participation of all relevant sectors and outlines an
incremental approach that can be adapted by countries to their specific needs, circumstances and available
resources (27).

Monitoring progress
The WHO Regional Office for Europe is developing a joint monitoring framework for the SDG, Health 2020 and
noncommunicable diseases indicators1 to facilitate reporting in Member States and to provide a consistent and
timely way to measure progress. AMR will compromise all Health 2020 targets (29). The following, as proposed
in the global indicators framework of the United Nations Economic and Social Council (ECOSOC), will support
monitoring progress in AMR (30).

ECOSOC indicators
1.5.2. Direct economic loss attributed to disasters in relation to global gross domestic product
2.4.1. Proportion of agricultural area under productive and sustainable agriculture
3.1.1. Maternal mortality rate
3.2.1. Under-5 mortality rate
3.2.2. Neonatal mortality rate
3.3.1. Number of new HIV infections per 1000 uninfected population, by sex, age and key populations
3.3.2. Tuberculosis incidence per 100 000 population
3.3.3. Malaria incidence per 1000 population
3.3.4. Hepatitis B incidence per 100 000 population
3.8.1. Coverage of essential health services (defined as the average coverage of essential services based on tracer
interventions that include reproductive, maternal, newborn and child health; infectious diseases; noncommunicable
diseases; and service capacity and access among the general and the most disadvantaged populations)
3.9.2. Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene (exposure to unsafe water,
sanitation and hygiene for all (WASH) services)
3.b.1. Proportion of the target population covered by all vaccines included in their national programme
3.b.2. Total net official development assistance to medical research and basic health sectors
3.b.3. Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a
sustainable basis
3.d.1. International Health Regulations capacity and health emergency preparedness
6.1.1. Proportion of population using safely managed drinking-water services
6.2.1. Proportion of population using safely managed sanitation services, including a hand-washing facility with soap and
water
6.3.1. Proportion of wastewater safely treated
8.1.1. Annual growth rate of real GDP per capita
12.4.2. Hazardous waste generated per capita and proportion of hazardous waste treated, by type of treatment
17.16.1. Number of countries reporting progress in multistakeholder development effectiveness monitoring frameworks that
support the achievement of the sustainable development goals

Health 2020 core indicators Health 2020 additional indicators

3.1.a. Infant mortality per 1000 live births, disaggregated 5.1.a. Maternal deaths per 100 000 live births (ICD10
by sex codes O00–O99 (31))
3.1.b. Life expectancy at birth, disaggregated by sex 5.1.c. Government (public) expenditure on health (as a
5.1.a. Private household out-of-pocket expenditure as a percentage of gross domestic product)
proportion of total health expenditure
5.1.c. Total expenditure on health (as a percentage of
gross domestic product)

1
EUR/RC67/Inf.Doc./1: joint monitoring framework: proposal for reducing the reporting burden on Member States.
4
Fig.1. Total antibiotic use in 2011, expressed in number of defined daily doses (DDD) per 1000 inhabitants per day
in 29 countries reporting to the European Surveillance of Antimicrobial Consumption network (ESAC-Net)
and 12 countries reporting to the Antimicrobial Medicines Consumption network (AMC)

45
DDD/1000 inhabitants per day

40

35

30

25

20

15

10

0
Turkey*
Montenegro
Greece
Tajikistan
Cyprus
Belgium
France
Italy
Luxembourg
Serbia
Kyrgyzstan
Malta
Portugal
Ireland
Slovakia
Finland
Iceland
Poland*
Croatia
Republic of Moldova
Georgia*
Bulgaria
Spain*
Denmark
Lithuania
United Kingdom*
Czech Republic*
Bosnia and Herzegovina
Norway
Belarus
Azerbaijan
Romania
Slovenia
Sweden
Latvia
Armenia
Hungary*
Austria*
Germany*
Estonia
Netherlands
Other antibacterials (J01X) Antibacterial combinations (J01R)
Aminoglycosides (J01G ) Amphenicols (J01B)
Sulfonamides and trimethoprim (J01E) Tetracyclines (J01A)
Quinolones (J01M) Macrolides, lincosamides and streptogramins (J01F)
Other beta-lactam antibacterials, cephalosporins (J01D) Beta-lactam anDbacterials, penicillins (J01C)

Notes: *Countries reporting only outpatient antibiotic use; Romania and Spain provided reimbursement data; Other beta-lactam
antibacterials, cephalosporins (ATC group J01D) includes carbapenems and monobactams; Other antibacterials (ATC group J01X)
includes glycopeptide antibacterials, polymyxins, fusidic acid, imidazole derivates, nitrofuran derivates and other antibacterials.
Source: Supplementary material in Versporten et al. (19) on behalf of the European Surveillance of Antimicrobial Consumption Project
Group of the WHO Regional Office for Europe.

WHO support to its Member States

WHO, in collaboration with the FAO and the OIE, supports the development, control, distribution and appropriate
use of new antimicrobial medicines, diagnostic tools, vaccines and other interventions (2).
The WHO Regional Office for Europe, together with a broad range of partners, works actively to contain the
spread of AMR in the Region through a multidisciplinary and office-wide approach (23), supporting Member
States in the development and implementation of national plans to combat AMR by:
• facilitating intersectoral coordination;
• providing policy advice and technical guidance;
• building capacity for surveillance of antimicrobial use and AMR;
• promoting antimicrobial stewardship;
• supporting the implementation of core components for infection prevention and control programmes in health
care facilities; and
• raising awareness among professionals and the general public, as well as assisting with the development of
behaviour change campaigns in specific target groups.

5
 Resources
• Global action plan on antimicrobial resistance
http://www.who.int/antimicrobial-resistance/publications/global-action-plan/en/
• European action plan on antibiotic resistance
http://www.euro.who.int/__data/assets/pdf_file/0008/147734/wd14E_AntibioticResistance_111380.pdf?ua=1
• Manual and tools for the development of national action plans on antimicrobial resistance
http://www.who.int/antimicrobial-resistance/national-action-plans/en/
• Central Asian and Eastern European Surveillance of Antimicrobial Resistance (CAESAR)
http://www.euro.who.int/en/health-topics/disease-prevention/antimicrobial-resistance/about-amr/central-asian-and-eastern-
european-surveillance-of-antimicrobial-resistance-caesar
• European Surveillance of Antimicrobial Consumption Network
http://ecdc.europa.eu/en/healthtopics/antimicrobial-resistance-and-consumption/antimicrobial-consumption/ESAC-Net/Pages/
ESAC-Net.aspx
• Surveillance and disease data for antimicrobial resistance
http://ecdc.europa.eu/en/healthtopics/antimicrobial-resistance-and-consumption/antimicrobial_resistance/EARS-Net/Pages/EARS-
Net.aspx
• Antimicrobial Medicines Consumption (AMC) Network. AMC data 2011–2014 (2017)
http://www.euro.who.int/en/health-topics/Health-systems/health-technologies-and-medicines/publications/2017/antimicrobial-
medicines-consumption-amc-network.-amc-data-20112014-2017
• Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level
http://www.who.int/infection-prevention/publications/ipc-components-guidelines/en/
• World Antibiotic Awareness Week
http://www.who.int/campaigns/world-antibiotic-awareness-week/en/

Key definitions
• Defined daily dose (DDD). Unit of measurement of drug consumption: the assumed average maintenance dose per day for a drug
used for its main indication in adults (32).
• Extensively drug-resistant tuberculosis (XDR-TB). Infection resistant to the main first- and second-line drugs and, therefore, with
very limited chances of cure.
• Multidrug-resistant tuberculosis (MDR-TB). Infection resistant to two of the most potent anti-TB drugs, resulting from inadequate
treatment of TB or poor airborne infection control in health care facilities and congregate settings.
• Rational use of antibiotics. Patients receive medications appropriate to their clinical needs, in doses that meet their own individual
requirements, for an adequate period of time and at the lowest cost to them and their community (33).

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