Antibiotic resistance

Population Mobility, Globalization, and Antimicrobial Drug Resistance
Douglas W. MacPherson, Brian D. Gushulak, William B. Baine, Shukal Bala, Paul O. Gubbins, Paul Holtom, and Marisel Segarra-Newnham

Population mobility is a main factor in globalization of public health threats and risks, specifically distribution of antimicrobial drug–resistant organisms. Drug resistance is a major risk inhealthcare settings and is emerging as a problem in community-acquired infections. Traditional health policy approaches have focused on diseases of global public health significance such as tuberculosis, yellow fever, and cholera; however, new diseases and resistant organisms challenge existing approaches. Clinical implications and health policy challenges associated with movement of persons acrossbarriers permeable to products, pathogens, and toxins (e.g., geopolitical borders, patient care environments) are complex. Outcomes are complicated by high numbers of persons who move across disparate and diverse settings of disease threat and risk. Existing policies and processes lack design and capacity to prevent or mitigate adverse health outcomes. We propose an approach to global publichealth risk management that integrates population factors with effective and timely application of policies and processes.

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uman mobility is causing an increase in antimicrobial drug–resistant organisms and drug-resistant infectious diseases. International population movement is an integral component of the globalization process. Current population movement dynamics rapidly and effectively linkregions of

Author affiliations: Migration Health Consultants Inc., Cheltenham, Ontario, Canada (D.W. MacPherson); McMaster University, Hamilton, Ontario, Canada (D.W. MacPherson); Migration Health Consultants Inc., Singapore (B.D. Gushulak); Agency for Healthcare Research and Quality, Rockville, Maryland, USA (W.B. Baine); Food and Drug Administration, Rockville (S. Bala); University of Arkansasfor Medical Sciences, Little Rock, Arkansas, USA (P.O. Gubbins); Keck School of Medicine, Los Angeles, California, USA (P. Holtom); and Veterans Affairs Medical Center, West Palm Beach, Florida, USA (M. Segarra-Newnham) DOI: 10.3201/eid1511.090419

marked health disparity, and these linkages can be associated with risk for importation of drug-resistant infectious diseases. During the pastcentury, developments in public health sanitation (1), infrastructure engineering (2), vaccines (3), and antimicrobial drugs have contributed substantially to the control of infectious diseases, markedly decreasing associated illness and death. These developments have largely occurred in economically advanced regions and have produced complacency and a belief that the public health threats posed byinfectious diseases have been conquered. However, by the early 1990s, infectious diseases were again being identified as substantial domestic and international public health threats in and to western nations (4). Although many infections of clinical relevance are effectively managed with the use of vaccines, antimicrobial drugs, or newer therapies, challenges to the control of infectious diseasesremain. These challenges occur in industrialized and in developing countries and result at least in part from the failure of antimicrobial drugs to meet expectations for management and control of disease in clinical and public health contexts. Declining antimicrobial drug effectiveness has current and future consequences that affect all elements of the health sector, e.g., research and development,public health policy, service delivery, and payment programs. The emergence of antimicrobial drug resistance adversely affects patient care and threatens effective management of public health infectious diseases globally (5). Antimicrobial drug failure may occur for many reasons, e.g., reduced adherence to drug therapy, suboptimal dosing, diagnostic and laboratory error, ineffective infection...