Why don’t we know the exact death toll of AMR in Australia?

Republished from AMR-action.au. View original article here.

For complex reasons, we don’t know the exact death toll caused by antimicrobial resistance (AMR) in Australia. Researchers are working to fill the data gap but fear that, without accurate statistics, AMR will miss out on critical funding and policy action.    

In 2023, bowel cancer claimed more than 5000 lives in Australia. The number tells a powerful story of loss in families, workplaces and communities. It indicates economic burden, drives prevention programs, healthcare funding and advocacy efforts. It justifies public awareness campaigns and supports fundraising for a cure. 

But antimicrobial resistance (AMR), in Australia at least, has no corresponding number. For complex reasons, its mortality rate is challenging to calculate, and without accurate numbers, AMR researchers, clinicians and policy advocates fear it won’t receive the attention it urgently needs.  

The landmark 2018 OECD report, Stemming the Superbug Tide, predicted global AMR deaths would reach 10 million by 2050, raising alarm bells through much of the world. But using its global estimates, it ranked Australia’s risk as low, predicting 290 deaths a year by 2050 which is five fewer than road fatalities in Victoria in 2023, and a figure widely disputed. 

“It’s always helpful to have as much information about any problem that you’re trying to solve, but the OECD report figure for Australia was, clearly, way too low,” says Andrew Bowskill, co-chair of the Australian Antimicrobial Resistance Network (AAMRNet), an expert coalition formed by MTPConnect to promote Australia’s response to AMR. 

Using figures from the Global Research on Antimicrobial Resistance (GRAM) Report, MTPConnect and CSIRO’s Antimicrobial Resistance Impact Report estimated that more than 1600 deaths were directly attributable to AMR and that more than 5000 were associated with AMR in Australia in 2019 alone. “For now, that’s probably the best figure we’ve got,” he says.  

Associate Professor Teresa Wozniak is the Principal Research Scientist at the Australian eHealth Research Centre, CSIRO. An epidemiologist and public health informatics specialist, it’s her job to establish an accurate picture of the burden of AMR.   

AMR deaths are a complex calculation for researchers 

“Antimicrobial resistance is the ability of bacteria, virus, fungi or protozoa to become resistant to treatment and cause a whole multitude of infections and diseases,” says Assoc Prof Wozniak. “Unlike the single coronavirus that caused COVID infections and deaths, AMR affects not only viruses but also other micro-organisms. So measuring the death toll properly is complex, as we need to know who is affected and what their health outcomes are.” 

AMR affects many patient groups – from those with cancer to diabetes and chronic urinary tract infections – but it can also afflict those recovering from trauma or even small injuries, like an abrasion while gardening. A patient who has battled cancer for years, undergoing multiple therapies and with compromised immunity, might die with a resistant bacterial infection. But is that the identified cause of death? This kind of reporting makes collecting accurate data difficult.  

Resistance is varied – Assoc Prof Wozniak focuses on bacteria, but many fungal and viral infections are also due to resistance and AMR pathogens vary according to geography. Research to produce accurate mortality data is expensive and time-consuming even with technical expertise and it’s impractical to try to measure the impact of all resistant pathogens. 

Global researchers identify ‘priority pathogens’, which include: methicillin-resistant Staphylococcus aureus, or MRSA – commonly known as golden staph which is responsible for many difficult to treat infections in humans; and, ESBL-producing Escherichia coli and Klebsiella pneumoniae, responsible for urinary tract infections. 

In many cases Australian hospitals have the resources to measure the burden of AMR infections but that isn’t the case for AMR in community. 

Measuring AMR’s impact in hospitals 

“A hospital-acquired infection is one that is detected 48 hours after admission,” Assoc Prof Wozniak explains. “If pathology results detect an infection in less than 48 hours, it was probably acquired in the community, but how and where is a mystery. Most of our understanding of the death toll due to AMR is generated from hospital-acquired infections as it’s much easier to assess patient health outcomes during their hospital stay.” 

Assoc Prof Wozniak’s work includes a study that links the health outcomes and pathology results of all hospital patients in Queensland to estimate the risk of dying due to five common resistant bacteria. Researchers used these estimates to extrapolate to the Australian population and the result, published in 2022, estimates that between 1000 and 2500 deaths from resistant bacteria causing infection in Australia’s hospitals each year. It was an alarming tenfold higher than the OECD’s estimate in 2018. 

But those results are built on hospital data. AMR deaths are certainly happening, and will continue to happen, in the community – in regional areas, in Indigenous populations, in people’s homes. Stemming the Superbug Tide used data from a few hospitals in large Australian centres to produce its mortality estimate of 290. 

“That certainly was a trigger for us, because 290 doesn’t sound so bad and we knew from conducting pilot studies that there was a lot more AMR than what was reported. The 1,000 to 2,500 deaths are just the deaths in hospitals and only for five bacteria becoming resistant. We actually don’t know what’s happening in the community or what the death toll is for other resistant pathogens – resistant fungi is certainly on the radar.” 

Research hampered by siloed data 

Australia’s federated system means abundant health data are available but siloed and, for various reasons including state legislation obstacles, is not shared: when public health professionals don’t have access to data they can’t model an accurate snapshot of AMR’s impact. 

“We have a lot of the information we need. It’s about connecting the dots and bringing this to the agenda for consolidated action,” she says. “Maybe the establishment of the Australian Centre for Disease Control can lead our preparedness for the AMR public health emergency. I compare work done in Europe across different countries, health systems and languages, yet they have a surveillance system that can actually give you a sense of the burden of AMR. We’re struggling to do that across one country.” 

Mr Bowskill, however, is interested in actions that can make a difference now: he’s pushing for urgent policy reform to improve Australia’s, and our region’s, access to new and life-saving antibiotics, and funding to drive next-gen antibiotic development and solutions for a crisis that threatens our entire healthcare system. 

“It almost feels as though we’re sitting back and admiring the problem,” he says. “I find it really frustrating. Certainly, we need an accurate picture of the burden of AMR, and the reality is that the bigger the number, the more likely there’ll be resources and progress on policy reform. 

 “But we have a good enough understanding of the enormous scale of the global AMR crisis, and there are steps we can take now to make a difference. So, getting better data, while really important, should not come at the expense of implementing initiatives we know will make a difference now.”