The Strait of Hormuz and global antibiotic security

Seyed Aria Nejadghaderi, is a research fellow at Kerman University of Medical Sciences, Kerman, Iran; Sahar Saeedi Moghaddam is a  PhD candidate at Kiel Institute for the World Economy, Kiel, Germany; Mohammad Sharif Razai is a NIHR Clinical Lecturer in Primary Care, University of Cambridge; Hamid Sharifi is a professor at Kerman University of Medical Sciences, Kerman, Iran; Michael Stolpe is a professor at Kiel Institute for the World Economy, Kiel, Germany

When war effectively closed the Strait of Hormuz in March 2026, early concern centred on energy security and fertilisers.^1,2,3 The same waterway carries petrochemical feedstocks that manufacturers in India use to produce active pharmaceutical ingredients for millions of generic drugs, including antibiotics, worldwide.^4,5 This crisis exposes a blind spot in antimicrobial resistance (AMR) policy: the security of the antibiotic supply chain.

India supplies about 47% of generic medicines used in the United States by volume and relies on the Strait for around 40% of its crude oil imports.⁶ When shipping lanes seize up, the effects move quickly through pharmaceutical production and distribution. Air cargo from India can become 200-350% more expensive, rerouting can add weeks of delay, and cold-chain integrity for temperature-sensitive products may be put at risk.⁷ Inventories are often thin, typically covering only 30–60 days in many markets.⁴ About 10 –15% of global pharmaceutical commerce usually flows through hubs in West Asia, so disruption can soon translate into higher prices and shortages. Common first-line antibiotics, including generic amoxicillin, are especially exposed because they are essential, high-volume products with limited room for supply shocks.⁶ In European markets, including the UK, pharmacists have already warned of price increases of up to 30% for medicines such as paracetamol and some antibiotics, with suppliers facing 40–50% higher stock costs.⁸

Antibiotic shortages can harm patients immediately and can also drive AMR.⁹ Shortages of narrow-spectrum first-line agents force clinicians to use broader-spectrum alternatives that may be less appropriate, more expensive, or more toxic. Patients may delay treatment, split courses, self-medicate, or buy medicines from unregulated sellers. These patterns increase exposure to inadequate treatment and create selective pressure for resistant bacteria.¹⁰ Shortages also open the door to substandard and counterfeit medicines, which may deliver sub-therapeutic doses without clearing infection.⁹ Antibiotic availability is therefore part of antimicrobial stewardship. Fragile supply lines can undermine stewardship as surely as overprescribing.¹¹

Conflict settings can accelerate AMR through several interconnected pressures such as medicine shortages, high burden of casualty, weak infection prevention and control, and environmental contamination.¹² Due to the high volume of inappropriate use and AMR transmission through milk or meat, this issue takes on added urgency during conflicts, when veterinary oversight often collapses. These risks should be understood as part of the public health harms of war, including the ongoing war against Iran. The World Health Organization’s (WHO) 2025 policy brief on AMR in fragile and conflict-affected settings, identifies seven domains for action: infection prevention, diagnosis, treatment, surveillance, community engagement, primary and mobile care, and the wider determinants of health.¹³ The challenge is to translate these domains into operational protection during war: keeping essential antibiotics available, preserving laboratory capacity, preventing avoidable infections, and maintaining basic health services under pressure. Reported damage to the Pasteur Institute of Iran—a century-old public health and biomedical research institute with national reference laboratories, WHO collaborating centres, disease surveillance, diagnostics, biobanks, and medical countermeasure functions—also threatens the capacity to detect resistant infections, monitor AMR, guide antibiotic treatment, and respond to outbreaks.¹⁴

The combination of restricted antibiotic access and rising resistance can increase the risk of epidemics and outbreaks. Patients with multidrug-resistant infections often need longer hospital admissions, have higher mortality, and require more costly treatment.¹¹ Vulnerable populations can be disproportionately affected, while travel and trade can spread resistant strains across borders.¹⁵ Maritime disruption may add further risk, with delayed crews, ballast water and crowded ports creating conditions for resistant bacteria to spread. Previous antibiotic shortages have been associated with greater use of last-resort agents, more treatment failures, and measurable increases in resistant infections.¹⁰

The 2026 Hormuz crisis shows that AMR is a geopolitical and supply-security problem as well as a biological one. To be better prepared for sudden supply interruptions, governments and health systems should expand strategic stockpiles of critical antibiotics, prioritise air and alternative sea routes for essential medicines, and reinforce antimicrobial stewardship programmes to prevent wasteful antibiotic use. Longer-term, countries need more diversified production, less dependence on single-country manufacturing, stronger incentives for domestic or near-shore active pharmaceutical ingredient production, and international agreements that protect medical supply routes.^9,10 Market reforms should aim at sustainable pricing models that reward reliable production of low-margin generic medicines including antibiotics, supported by better demand forecasting and regional stockpiling networks.¹¹ WHO and national regulators should integrate supply resilience into AMR national action plans, treating medicine security as a complement to infection prevention. The Strait of Hormuz crisis shows why investment in resilient, diversified, and transparent antibiotic supply systems is essential to global health security.

References

Featured Photo by Planet Volumes on Unsplash