How One Vaccine Could Help Fight Drug-Resistant Infections – Foreign Policy

Monday marked the start of World Antimicrobial Resistance Awareness Week, recognizing what is perhaps the greatest threat to human health – one that begins at birth. The World Health Organization recently reported that 1 in 6 infections are caused by resistant pathogens, and that antimicrobial resistance is now implicated in up to a third of newborn deaths due to infections.

Ten years after the WHO was tasked with raising global awareness of antimicrobial resistance, surveillance has improved, but the response has stalled. Despite its clear connection to pandemic risks, antimicrobial resistance was marginalized in the WHO pandemic agreement adopted in May. The organization’s approach is reductionist, often focused on developing new antibiotics, which has failed to keep pace with progress. The available drugs of last resort are largely unavailable in the countries that need them most.

Moreover, this narrow framework ignores the realities of fragile health systems where conflict, drain of skilled doctors, collapsing infrastructure, and lack of sanitation make antibiotics the default alternative to basic health care.

In Gaza, for example, where bombing destroyed hospitals, water stations and power supplies, the impact was catastrophic. The under-five mortality rate in the Strip has increased more than tenfold since 2023; About 55% of these deaths are newborns. With sterilization equipment, antibiotics and even chlorine deliberately withheld from Gaza, infection control efforts have collapsed, creating ideal conditions for highly resistant pathogens and the spread of so-called superbugs.

Although universal vaccination in many countries has led to a sharp decline in deaths among children under five, the neonatal mortality rate, or deaths within the first month of life, has declined much more slowly. Unlike the other two leading causes of premature deaths – early complications and events that occur during birth – infections such as sepsis, pneumonia, and meningitis stand out as largely preventable. It is estimated that neonatal sepsis alone affects more than 5 million babies and kills about 800,000 each year.

However, compelling new research points to a practical intervention: the century-old Basil Calmette-Guerin (BCG) vaccine, which is cheap, safe and widely available. Evidence from multiple randomized trials shows that BCG vaccine given within 24 hours of birth almost halves infection-related deaths, including those caused by drug-resistant pathogens. But most of the approximately 100 million infants targeted for the vaccine receive the vaccine weeks or months after birth.

This delay is costing hundreds of thousands of lives and accelerating the spread of the silent epidemic of antimicrobial resistance.

BCG vaccine It was developed in 1921 to combat tuberculosis, so its reuse against neonatal sepsis may initially seem implausible; Tuberculosis develops slowly and rarely kills infants. But although the BCG vaccine provides modest protection against tuberculosis, it is now clear that it strongly stimulates the immune system to defend against a wide range of pathogens responsible for most infections in newborns.

The protection afforded by the BCG vaccine extends far beyond tuberculosis, and was first noted by one of its inventors, Albert Calmette, who discovered and reported in 1931 that the death rate among infants vaccinated with the BCG vaccine was reduced by a staggering 75 percent. However, these remarkable results were not followed up until the late 1990s, when researchers in Guinea-Bissau confirmed that the overall mortality rate among infants vaccinated with the BCG vaccine was much lower than could be explained by TB prevention alone.

Subsequent randomized trials showed that BCG vaccines given at birth reduced newborn deaths by about a third, primarily by preventing fatal infections. Beneficial ‘non-specific effects’ These findings were supported by immunological studies that showed that the BCG vaccine trains the innate immune system – the body’s first line of defense – to respond faster and stronger to pathogens.

This is especially true for newborns, whose immune systems are naturally suppressed in the womb to avoid maternal attack. Premature and underweight babies are most at risk, as they are born with immature organs and underdeveloped immune responses. In modern conflicts, the risks multiply: maternal malnutrition, reduced access to prenatal care and emergency delivery, increased susceptibility to infections, and chronic prenatal stress increase the rates of premature and low-birth-weight babies. (According to UNICEF, one in five children in Gaza is born prematurely or underweight.)

Now, the largest randomized trial to date provides unequivocal evidence of the beneficial nonspecific effects of BCG. Published in BMJThis study in India enrolled more than 5,000 very weak newborns, many of whom were born very early and all of whom weighed less than approximately 4.5 pounds. Under WHO guidelines, these infants are usually considered too weak to be vaccinated at birth, which may delay vaccination beyond the first month.

Among the control group, 1 in 10 children died within one month. But those who received the BCG vaccine at birth had a 17% lower death rate. Nearly half of deaths among unvaccinated infants were due to infection, but BCG vaccination nearly halved this risk, meaning that vaccinating just seven infants would save one life. The benefit during the first 72 hours suggests that BCG may not only prevent hospital- or community-acquired infections but also halt the development of sepsis acquired during childbirth.

The World Health Organization has not found this evidence, although its own 2016 review acknowledged that BCG vaccination reduced overall mortality beyond that expected from TB reduction, and recommended universal administration of BCG vaccination at birth in 49 countries where TB is common. However, because of current WHO guidelines, the babies most at risk – those born prematurely or underweight – are the least likely to be vaccinated. In sub-Saharan Africa, about 14 percent of babies are born underweight; In South Asia, this number reaches 25 percent.

The monitoring carried out by the World Health Organization also lags behind the science. The BCG vaccine is also more effective in preventing deaths from childhood tuberculosis if given at birth. However, the World Health Organization measures BCG coverage after only 12 months, which incorrectly implies timely administration of the vaccine. If coverage is measured in one week, healthcare workers will be incentivized to provide it earlier, maximizing its life-saving potential against TB and other infectious diseases. (Many health care workers, to avoid waste, wait to administer the BCG vaccine until at least 10 children are available to use a typical 20-dose vial.)

Moreover, correct technique is important. Most vaccines — influenza, tetanus, and COVID-19 — are given by intramuscular injection; Some, such as measles, mumps, rubella and chicken pox, must be given under the skin. The BCG vaccine is unique in that it must be given intradermally, leaving a small blister — a papule that leaves a scar — when done properly, indicating a successful immune reaction. Among children vaccinated with the BCG vaccine, those who develop the scar have a 39 percent lower death rate than those who do not develop the scar. In places where there are untrained vaccinators, up to half of vaccinated children become infected.

In addition, not all BCG strains are equal: there is significant variation in the immunogenic ability of different strains to protect against tuberculosis and stimulate trained immunity. Only the Danish and Japanese strains reliably stimulate trained immunity. The Russian strain, which is still used in parts of Asia, shows little or no specific protection, as shown in another Indian trial. Ensuring the use of highly effective strains is essential to avoid tarnishing the reputation of this vital tool.

Minor political changes It could save countless newborns around the world: WHO should clearly state that all babies – including premature, weak and underweight infants – should receive the BCG vaccine at birth. Vaccinators must open a BCG vial for even one child. Coverage should be assessed after one week and scar examination added after six weeks.

Along with updating WHO guidelines, national immunization programs and donors need to act. Ministries of health, with support from WHO Gavi and UNICEF, should classify BCG as a core vaccination at birth, and administer it within 24 hours alongside polio and hepatitis B vaccines. Midwives, primary health care practitioners and pharmacists should be trained in BCG vaccination. Financing mechanisms should reward early rather than blanket coverage, and procurement policies should prioritize the Danish and Japanese strains. New delivery systems, such as patches or oral formulations, should also be pursued.

In short, implementation policy must keep pace with the evidence. The WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS), which tracks resistant infections and antibiotic use worldwide, should also monitor how TB vaccination at birth reduces neonatal sepsis and deaths from drug-resistant pathogens, and link immunization to laboratory data to show how trained immunity helps reduce antimicrobial resistance.

The latest report from the Global Antimicrobial Control System (GLASS) rightly identifies antimicrobial resistance as one of the world’s most pressing health threats, but ignores the role of conflict and the untapped potential of the BCG vaccine to enhance innate immunity and reduce resistance.

In conflict zones and beyond, BCG vaccination can be transformative. War zones are now factories for drug-resistant infections: after 2022, for example, Poland reported that more than half of its multidrug-resistant or rifampicin-resistant TB patients were Ukrainians. Throughout Europe, it is resistant to carbapenems Klebsiella pneumoniae Infections are on the rise, which is exactly what we see in blast wards and crisis intensive care units. Strikingly, the Indian experience showed a much lower number Klebsiella infections among vaccinated newborns, suggesting that non-specific immune training for BCG may mitigate the effect of resistant infection.

Because the BCG vaccine is safe and effective even in premature and low-birth-weight infants, it is particularly suitable for conflict areas. Despite severe restrictions on humanitarian access, the risk of vaccine-induced polio outbreaks among under-immunized populations can still be leveraged in polio vaccination programmes.

The additional risk of antibiotic-resistant bacteria and other pathogens that are resistant to antibiotics as a last resort strengthens the case for giving BCG at birth as well. When antibiotics fail, they fail everywhere, leading to concurrent epidemics of drug-resistant infections. A newborn with an AMR infection is not only more likely to die, but also poses a threat to others, both locally and globally.

Even with foreign aid crippled in the wake of the White House’s dismantling of USAID, BCG remains one of the few feasible, high-impact interventions available: it is cheap and cost-effective, and can be easily paired with oral polio vaccine at birth.

Economically, the issue is irreplaceable: the BCG vaccine is cheap enough to be included in current immunization budgets or even the Global Polio Eradication Initiative. Including delivery, cold chain, and staffing, the total cost per dose is less than $2, making the cost of preventing a newborn’s death from sepsis less than $25. In fact, few public health interventions achieve this kind of return.

At the UN General Assembly in September, a review of progress towards the 2030 Agenda for Sustainable Development was notably silent on ending preventable newborn deaths. This omission indicates the unwillingness of the World Health Organization and other UN health agencies to confront how far the world has strayed from achieving its goals – and to face the consequences of destroying USAID. The fact that the United States has left the World Health Organization should not be an excuse for inaction; These policy adjustments do not require Washington’s approval.

Repurposing the BCG vaccine provides a rare win for global health. It could push the world toward achieving the neonatal mortality target set by the UN’s 2030 Agenda – saving half a million newborns every year – while combating antimicrobial resistance. After decades of failure to eliminate newborn deaths, it turns out that the means to eliminate unnecessary newborn deaths have been in our hands all along. Now we just have to use it.