consultation on a draft global action plan to address ... · actors/stakeholders international...

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Consultation on a draft Global action plan to address antimicrobial resistance

The questionnaire is divided into four sections. The questions are broadly framed and intended to

give you the opportunity to enter into some depth and explain your organization's viewpoint. While

only questions marked with * are mandatory, we would appreciate answers to as many as possible.

Where a choice of answer needs to be selected please highlight your answer.

Before answering the questions, please refer to our list of supporting documents.

http://www.who.int/drugresistance/amr-consultation/en/index.html

About you

1. Name of individual respondent* (deleted)

2. Email address* (preference for official email addresses)

(deleted)

3. Are you authorised to represent your organization or interest group?* Y__

4. Organization Name* a. Centre for Health from Environment, Ryan Institute, National

University of Ireland Galway

5. Address of the organization*

a = Newcastle Road, Galway, Ireland

6. Organization website (if available)

http://www.nuigalway.ie/health_from_environment/

7. Country*

Ireland

8. Type of Organization*

• Academic institution

9. Main sector of interest

• Human health

http://www.who.int/drugresistance/amr-consultation/en/index.html

http://www.nuigalway.ie/health_from_environment/

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10. Would you like to be added to our mailing list to receive updates on the development of the

global action plan?* Yes

General questions

1. From the perspective of your organization, what are the most important areas of concern in

AMR?

Clinical service, teaching, research and community engagement

2. Is your organization currently involved in work related to AMR? Yes

If Yes, How?

a. Clinical service – routine clinical service including diagnostics and management plus

provision of certain national reference laboratory services related to AMR

b. Teaching in undergraduate, post graduate programmes

c. Research activity related primarily to AMR in Enterobacteriaceae

d. Community engagement through talks and mass media

Questions about the draft global action plan outline document

Before the WHA resolution was adopted, two WHO AMR Strategic Technical Advisory Group (STAG)

meetings were held in anticipation, which included members plus a large number of representatives

from other organizations. These meetings identified key issues, concerns and led to the

development of a draft outline.

As this consultation progresses and stakeholder meetings are held, the secretariat will harvest and

incorporate the input into the draft global action plan.

1. How would you rate your understanding of WHO’s intention in the development of a global

action plan to address AMR?

Very good__ Good__

Additional comments

2. From the perspective of your organization, are the major issues relating to AMR outlined in

the draft global action plan?

Yes

If No, what additional issues need to be addressed?

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Questions on the ‘Building blocks’ described in the draft outline.

You will notice, the global action plan has been constructed around “building blocks” in recognition

that different countries will have different starting points. In this situation, countries can choose

building blocks to concentrate upon. Each building block specified has been identified as a key area

where specific attention, planning and work are needed to achieve progress in addressing AMR.

Through questions in this section, we would like to hear your opinions on these building blocks in

more detail.

I. Building block-1: Increasing awareness and understanding about AMR and of the actions and

changes needed

a) What do you consider to be the main issues under this priority?

Poor understanding and suspicion of science generally in much of the public media: lack of access

to primary education in some parts of the world and poor general science education at primary and

secondary education elsewhere make it challenging to communicate messages about cause and

effect.

Accept the Limitations of awareness and understanding: Antimicrobial resistance has many of the

properties of a “wicked problem”. Changing awareness and understanding is highly unlikely to result

in effective individual behavioural change at the prescriber/vendor/consumerlevel in the absence of

effective incentives to support desired behaviour and disincentives to undesirable behaviour.

Awareness -raising may in some circumstances be counter-productive. Increasing awareness at the

policy and institutional level to motivate changes in incentives and control when necessary may be

more effective but achieving a consensus for purposeful action is difficult given competing

perspectives of powerful stakeholders and conflicting perceived short term and long term objectives

at an individual level.

Avoid Exaggerated fear messages; “the boy who cried wolf”:Messages with some positive content

about the value of antibiotics when appropriately used and how individuals actions can work to

preserve this resource for this and following generations should be emphasized more. Regarding

impact of AMR the message should be that in the foreseeable future AMR is likely to impact most on

the life expectancy of those already in poor health and therefore vulnerable – with a positive

message that if people are able to take good general care of themselves and are fortunate not to

suffer major illness most AMR bacteria are likely to be harmless most of the time. Messages

suggesting that people will die from minor infection in substantial numbers because of AMR may well

carry the unintended message that the world is so full of dangerous bacteria that you need to be sure

to take the latest antibiotic to protect yourself. Irrational fear of bacteria is I suggest a non-trivial

component of the problems we have and much of it is fed by marketing.

Carbapenems & Colistin Are Critical Now – Frame A Global Carbapenen/Colistin (polymyxins)

Challenge. A very specific focus on one critical issue may be of value in gaining awareness, getting

traction by achieving some measure of relatively early success and as a test case to develop

consensus, formulae and frameworks for wider action. Carbapenems and colistinare not only critical

as a last line of treatment for AMR Enterobacteriaceae they should also be relatively easy to gain

consensus on as their use at present is relatively restricted in many countries. They are not used to a

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major degree in food production and the number of pharmaceutical companies and production

plants is limited and they are little used outside of hospitals- therefore there are fewer stakeholders.

Antibiotics are drugs with side effects on you – avoid them if you don’t need them:There is little

prospect of getting the majority of the public or health care workers to care enough about AMR in

general terms to sufficiently influence their day to day practice and choices at individual level if, as at

present, there remain powerful short term incentives/perceived incentives to prescribe /take

antibiotics –messages raising awareness of immediate direct adverse consequence of taking

antibiotics may be more effective.

Profile of AMR and infection prevention and control education in health care professional

education: AMR and infection prevention control are not adequately covered in many undergraduate

and post graduate health care education programmes and where taught are often considered

peripheral. When examining as a visiting examiner in one country in recent years few if any medical

students were able to demonstrate appropriate hand hygiene technique.

Ecological Cut Off Value - Wild Type/Non Wild Type. % of isolatesthat are non-wild type

(microbiological resistance) is a better surveillance measure than % resistant at clinical breakpoints if

the goal is to ensure global consistency, inter-species consistency, facilitate early detection of

emerging changes. Wild type /non wild type (microbiological resistance) may also correlate more

easily with emerging technologies based on detection of nucleotide change.

A non-renewable natural resource:the total number of very good targets of action for antibiotics is

probably very limited. There is a need to raise awareness of the idea that targets for antibiotic action

in bacteria that cause infection are a non-renewable natural resource which has already been

substantially depleted. More investment and research may find some new antibiotics for some

applications but there will probably not be another penicillin or tetracycline.

Links with wider environment issues:The non-renewable resource concept may link AMR to the

environmental consciousness agenda. This can build in of potential harm from antimicrobial agents

and antimicrobial resistant bacteria excreted or discarded into the environment.

There is little discourse that addresses AMR related issues from alternative perspectives that may

be persuasive in particular contexts and for particular target groups e.g. ethical /spiritual context,

security contexts, legal context.

b) What are the main actions that needs to be done -- and who are the main

actors/stakeholders who need to take action -- to go beyond the status quo?

Poor understanding and suspicion of science generally in much of the public media: improve access

to education in particular science education across all levels of society.Actors/Stakeholders

International agencies, Departments of education, NGO’s, Media

Accept Limitations of awareness and understanding: recognise that incentives and control must

accompany or follow raising awareness.

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Exaggerated fear messages; “the boy who cried wolf”: although challenging there is a need to

develop/articulate positive messages as to how individuals, communities and organisation can make

changes that will improve their wellbeing and have wider benefits for control of AMR.

Actors/Stakeholders International agencies, Departments of Health, Health Service Delivery

agencies, Health care professions, NGO’s, Media

Carbapenems & Colistin Are Critical Now – Frame A Global Carbapenen Challenge.

Identify these 2 classes of agents as immediate priority for protection now at global level.


agencies, Health care professions, Pharmaceutical industry

Antibiotics are drugs with side effects – avoid them if you don’t need them:A key focus on

awareness activities should be on the potential direct immediate personal negative consequences of

unnecessary antibiotic use –future resistance/public good messages are abstract and not likely to be

persuasive in influencing choices in the context of an acute illness (even of a minor nature) – suggest

message need to focus on risk of adverse effect of antibiotics – rash, diarrhoea, thrush (candida) and

other specific adverse effects, there is a great lack of awareness professional and public of antibiotic

adverse effects and drug interactions some of them common and some quite serious – also messages

re damage to normal bacteria and avoidable costs - the message needs to be that unnecessary

antibiotics can harm you and cost you in the short term and you would be better off without them.

Encouraging patients to document adverse experience related to antibiotics on a curated searchable

social media platform based for example on Trip Advisor (Antibiotic side effect advisor ?) may be

worth considering.


agencies, Health care professions (human and animal), NGO’s, Media, Social Media Platforms,

Pharmaceutical Industry.


education: ensure that AMR, antimicrobial stewardship and infection prevention and control are core

components in all years of every undergraduate and post graduate programme (human and animal

health care) and that it is both taught and examined – if not examined it will not be effectively

learned. This serves to prepare people to accept changes in incentives and controls.

Actors/Stakeholders. Health care professional educators and professional bodies

Ecological Cut Off Value - Wild Type/Non Wild Type. Surveillance of AMR should be re- focused

primarily on % of isolate that are non-wild type (microbiological resistance) rather than % resistant at

clinical breakpoints. Commercial susceptibility test systems should be incentivised / required to

ensure that their systems differentiate wild-type from non-wild type in addition to differentiation

around clinical breakpoints.

Actors/Stakeholders International agencies, EUCAST, CLSI, Pharmaceutical and Diagnostics Industry

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A non-renewable natural resource: develop messages on this theme as part of awareness raising

activities. Training for health care professionals and institutions (human and animal) on links

between their actions and environmental impacts.

Actors/Stakeholders International agencies, Environmental Protection Agencies, Environmental

NGO’s, Pharmaceutical Industry

Links with wider environment issues: engage environmental activists and NGO’s on AMR as a

significant environmental issue for human health and biodiversity The non-renewable resource

concept may link AMR to the environmental consciousness agenda. This can build in potential harm

from antimicrobial agents and antimicrobial resistant bacteria excreted or discarded into the

environment.

Actors/Stakeholders, Professional Societies e.g.(BSAC,SGM, ASM) and Environmental NGO’s,

There is little discourse that addresses AMR related issues from alternative perspectives engage

with focus groups of target audiences to find ways to frame effective messages relevant for different

audiences and optimal ways to deliver the messages

Actors/Stakeholders, Professional Societies e.g.(BSAC,SGM, ASM) and representatives of non-science

based opinion leaders.

c) What steps have already been taken to address this priority? (please provide references

where possible)

Poor understanding and suspicion of science generally in much of the public, politicians and media:

improved access to primary education in MDG and some initiatives to assess and improve science

education in some developed countries.

Significant TV programmes, news paper articles, radio interview, poster campaigns – science

coverage in some non anglopone media (Le Monde) seems to me to be very good but targets those

already quite science literate.

Some professional societies e.g. BSAC and ASM have taken initiative to increase awareness

Royal College of Physician of Ireland at one point organised a briefing for members of parliament –

poorly attended. I understand similar initiatives in other countries.

Games to raise awareness e.g. Bug-run https://itunes.apple.com/gb/app/bug-run-school-

days/id860440510?mt=8

Antibiotics are drugs with side effects – avoid them if you don’t need them:this has been a part of

the message in some awareness campaigns


education:Some European countries have called for increased content and some educational

institutes have responded.

Ecological Cut Off Value - Wild Type/Non Wild Type. EUCAST have done a lot of work developing

ECOFF and promote the concept. (EUCAST web site).

https://itunes.apple.com/gb/app/bug-run-school-days/id860440510?mt=8

https://itunes.apple.com/gb/app/bug-run-school-days/id860440510?mt=8

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Links with wider environment issues: there is a growing body of research work in this area primarily

in Europe, US that I am aware of that may be useful in engagement of environmental activists and

NGO’s.

d) What are concrete and measurable indicators of progress for this priority? (Including, for

example, global and national goals to be achieved within 2, 5 and 10 years)

Poor understanding and suspicion of science generally in much of the public and Anglophone

media: :measures of access to primary & secondary education as already exist. Measures of

performance on science in international educational surveys

Exaggerated fear messages; “the boy who cried wolf”:if possible to develop some measure/index of

positive versus negative messages in media sources and surveys to assess public awareness (e.g.

inclusion of questions in Eurobarometer and equivalent.)

Carbapenemsand Colistin Are Critical Now – Frame A Global Carbapenen/Colistin Challenge.

Formulate a Carbapenem/Colisitn Challenge Pledge in 1 year, Count Number of countries committed

to carbapenem./colistin challenge pledge in 2 years, number of countries fulfilling the pledge at 5

years.

Antibiotics are drugs with side effects – avoid them if you don’t need them:may be possible to

assess acceptance of this message by survey (poll) or tracking social media sites.


education: percent of professional educational institutes e.g. medical school, nursing schools,

veterinary schools in each country that commit to formally examine on AMR and infection prevention

and control in final examinations

Ecological Cut Off Value - Wild Type/Non Wild Type. Within 5 years all countries begin to publish

wild type/non wild type proportions at a minimum for carbapenems and colistin for

Enterobactericeae from blood culture form at least one sentinel site (note: accepting the technical

challenges of Colistin susceptibility testing it may be appropriate to deal with just the carbapenems in

the first instance).

A non-renewable natural resource:may be possible to assess by periodic survey (poll) or tracking

social media sites

Links with wider environment issues: in 5 years how many major NGO’s in environment and

development spheres have formulated positions on AMR

There is little discourse that addresses AMR related issues from alternative perspectives in five

years have documented engagement with major global religious leaders and studies of other non

health professional opinion leaders in wider society

II. Building block-2: Identifying the most important approaches for preventing development of

infections and the steps needed to move beyond guidance to more effective implementation of such

approaches


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Address poverty, inequity and violence – in resources for life and access to health care – in

particular access to basic sanitation

Build capacity in self care, primary care public health and diagnostics -

Improved use and uptake of immunisation (human and animal)

Improved infection prevention, control and surveillance of infection in health care facilities

Improved care for older people to continue to live in their own homes rather than long term care

facilities – effective infection prevention and control in LTCF is largely impractical because of the

social needs of residents

Improved education, training, support and monitoring of health care professionals and acceptance

of ultimate use of disciplinary processes if necessary

Improved animal husbandry and incentives towards less intensive animal management



Address poverty, inequity and violence– Post 2015 Agenda

Actors/Stakeholders, International agencies, national governments and NGO’s

Build capacity in self care, primary care public health and diagnostics - Post 2015 Agenda and other

global programmes including HIV prevention and treatment.

Specifically for laboratory diagnostics an achievable quality standard for low income country

laboratories is needed – ISO 15189 is unattainable and probably not necessary.

Actors/Stakeholders, International agencies, national governments and NGO’s and ISO

Improved use and uptake of immunisation (human and animal)incentivise vaccine uptake in human

and animal health care, new vaccine development

Develop new vaccines for a number of diseases not currently vaccine preventable.

Develop more efficient, acceptable and low cost vaccines, logistics and delivery systems.

Actors/Stakeholders, International agencies, national governments and NGO’s, research funding

agencies and research institutions.

Improved infection control and surveillance of infectionin health care facilities

Support: education and training must be supported by capacity and resources

Develop a code for ethical/rights based infection control practice to ensure fair access to care for

patients colonised or infected with AMR bacteria (to ensure that patients with specific AMR

organisms are not provided with inferior access to care /excluded from certain facilities)

Surveillance: meaningful and reliable measurement of infection rates

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Audit: unannounced audit of hand hygiene practice with realistic goals and published results. A

global consensus on methodology and reporting

Incentives: to achieve good infection control for institutions and individual health care workers

Discipline: education and training need to be supported by disciplinary process for repeated non-

adherence to infection control practice

Review impacts: some messages in particular the “five moments of hand hygiene” are too complex

and are so far beyond current actual practice in most countries that they make it more difficult to

engage HCW’s on incremental improvement.

If possible to develop specific recommendations/good practice surveillance requirements around

travel for international /intercontinental elective health care e.g. pre departure screening and pre

return screening.


agencies and research institutions, professional societies in domain of infection prevention and

control.


facilities –

review funding systems and priorities to remove incentives to institutionalisation of older people

strengthen community willingness and capacity to support older people in their community

Actors/Stakeholders, International agencies, national governments and NGO’s, representative bodies

for older people.

Improved education, training, support and monitoring of health care professionals modules for all

undergraduate and post graduate courses with practical examinations

Explicitly state adherence to good infection control practice as a requirement in guides to ethical

conduct for all human and animal health care professionals.

Actors/Stakeholders, International agencies, national governments and NGO’s, schools for health

care professionals and professional bodies e.g. Royal Colleges and equivalent


Seek to development branding systems (along lines of fair trade/organic marks) that attach a

premium to less intensively produced food of animal origin

Explore increased taxation of antimicrobial agents sold for use in production of food of animal origin

Actors/Stakeholders, International agencies, national governments, representative bodies for

agricultural and veterinary

c) What significant work has already been done to address this? (please provide references

where possible)

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Address poverty, inequity and violence– MDG

Build capacity in self care, primary care public health and diagnostics - MDG and other global

programmes

Improved use and uptake of immunisation (human and animal)GAVI and other global programmes

Improved infection control in health care facilities

Support: this area has gone into decline in recent years in at least some parts of Europe with

reductions in staffing and basic resources (facilities and PPE)and are largely lacking in many part of

the world

Surveillance: EARS is a useful model but depends on substantial pre-existing diagnostic and IT

infrastructure

Audit: national audit programmes in some counties though some with dubious targets and dubious

methodologies

Incentives: a number of funding mechanisms in Europe and US (state and private) provide incentives

to avoid infection

Discipline: limited progress in many hierarchical professions


facilities –

Some initiatives in a number of European countries but with limited impact

Improved education, training, support and monitoring of health care professionals some

institutions and professional bodies in a number of countries have increase profile but not by enough


Some initiatives on organic food but limited penetration of mass market



Address poverty, inequity and violence– HDI and other established measures

Build capacity in self care, primary care public health and diagnostics- some measure of population

health literacy , access to primary care, access to quality diagnostics,

Improved use and uptake of immunisation (human and animal)Vaccine uptake rates and delivery of

new vaccines

Improved infection control in health care facilities

Support: measure of uninterrupted access to hand hygiene materials and gloves % of hospitals and

clinics with these on 365 days per year

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Surveillance: % blood stream infection of S. aureus and E. coli susceptible to key agents

Within 5 years global standard on methodology and reporting of hand hygiene audits

Audit: number of countries with national audit programmes / Number of countries with credible

methodology and results

Incentives: number of countries with incentives to avoid infection in state funded health care

Discipline: number of countries where state supported health care has documented and applied

disciplinary process related to IPC non-adherence

Improved care for older people to continue to live in their own homes rather than long-term care

facilities –

% of people over 75 living in the community

Improved education, training, support and monitoring of health care professionals % of countries

with specific requirements in this area for professional registration

% of countries publishing audits of hand hygiene performance


Number of countries with assured branding systems to allow identification of less intensively

produced food of animal origin

Development of documents to help establish uniform standards for such assured branding systems (?

Codex alimentarius)

III. Building block-3: Optimizing the use of existing antimicrobials for human and animal health

and in agriculture


CarbapenemsandColistinAre Critical Now – Frame A Global Carbapenen and Colistin Challenge. As

carbapenems and colistin are critical, already under threat but perhaps still salvageable in many

countries, essentially not used in animals and little used other than in acute hospital care they can be

used as the first test of ability to achieve something worthwhile and build momentum.

Steps in Optimising Existing antimicrobial agents

i) Avoid use in situations where harm is the most likely outcome, where there is no likelihood of

benefit, where there is some benefit which could be achieved by other means – e.g. other

interventions or rest and fluids, lower stocking levels or better nutrition/husbandry in food

production

ii) Delay – for test results if non urgent

iii) Test – before starting to help avoid or guide

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iii) Aim administration (dose and duration) where benefit is likely - guided empirical therapy where

can’t wait for treatment

iv) Focus/De-escalate based on regular clinical review and laboratory test results as they become

available (Start Smart then Focus project)

v) Stop – as early as safe to do so – there is little evidence for how long many courses of treatment

need to be and where there is evidence for short course it is widely ignored.

v) Contain unwanted consequences e.g. environmental contamination with AMR organisms and

excreted antimicrobials – in health care environments, production of food and wider environment

End of life issues: a specific challenging issue for avoidance of use relates to intense broad spectrum

antimicrobial use in hospital and LTCF patients approaching end of life to delay death or support

invasive and toxic treatments of patients that in many cases are unsupported by evidence or which

are known to be ineffective. This is centrally related to societal incapacity to deal in a humane and

reasoned way with end of life by limiting intervention. Similar issues arise for veterinarians with

companions animals.

Focus on Critically Important Antimicrobial Classes (Carbapenem and ColistinChallenge) although

all antimicrobials agents (therapeutic and non therapeutic) may support emergence and

dissemination of resistance it is pragmatic to review existing lists of critically important antimicrobial

agents - carbapenems as the most urgent issue - ban their use in animals, monitor and report

volume of production and use in humans, limit who can prescribe and dispense, prioritise infection

control measures on those with organisms with acquired carbapenemase enzymes – similar

approach to polymyxins and then extend to aminoglycosides and others as possible



Carbapenem and Colistin challenge pledge. World Health Assembly pledge on key actions to protect

carbapemens and colistin now, global ban on use for any purpose other than human health care,

POM in all countries, national reporting of volume produced, exported, imported, national guideline

of use, some level of testing and reporting of carbapenem-resistance in E. coli and K.

pneumoniaefrom blood stream infections, restricted right to prescribe/dispense carbapenems.

Actors/Stakeholders, International agencies, national governments and NGO’s, pharmaceutical

industry


A key focus on awareness activities should be on the potential direct immediate personal negative

consequences of unnecessary antibiotic use (see previous)

surveillance and reporting of production, export, import and consumption – critically important

antimicrobials or at least of the most critical classes – by or on behalf of state agencies and UN

agencies

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Negotiation of targets for reduction of volume of production and consumption by or on behalf of

state agencies and UN agencies

Antimicrobial tax /resistance trading systems (state agencies and UN agencies)

Develop and promote alternative positive messages and actions that can be offered by health care

workers so that the message is not “I won’t give you antibiotic now ” but rather “I will do this which

is likely to be better/safer than antibiotic)

Incentivise antimicrobial avoidance for public (e.g. waive or reduced out of pocket charges if

antimicrobial are not taken) and for health care professionals (incentives for reduced antimicrobial

prescribing)

Remove incentives to prescribe – separation of prescription/dispensing decisions from direct

personal income gain (human and veterinary) at least for key antimicrobial agents.

Incentivise alternative antimicrobial free or antimicrobial reduced approaches in production of food

of animal origin – consider global ban on use of third generation cephalosporins, fluoroquinolones

and carbapenem use in food production- explore codex requirements on monitoring meat for

antimicrobial resistant organism specifically for E. coli resistant to third generation cephalosporins,

fluoroquinolones, carbapenem and Gentamicin

Reduced diagnostic uncertainty to support health care workers in offering alternative interventions

(improved decision supports and immediate access to basic diagnostics)

Ensure access to and incentivise use of quality diagnostic systems to reduce uncertainty

Readily available non-prescribing and prescribing guidelines/smart phone applications – limited

effect in isolation but necessary

Review legal barriers to non-prescription of antimicrobial agents (fears of litigation)

Promote wider societal engagement with acceptance of and planning for end of life including in

particular readily accessible legal systems for advance directives. There are some parallels in

practices related to companion animals.

Control/Prohibit marketing (direct and indirect) of antimicrobial products including

disinfectants/personal care products/paint etc in particular code of practice/regulation around

frightening imagery and messages and unjustified health claims

Electronic prescription systems, automatic substitution and stop orders, antimicrobial stewardship

systems in hospital and community (in particular LTCF’s)

Improved regulatory controls on access and use (but note in absence of access to health care making

antibiotics POM medicines may deny access to the poor)

Systems for safe disposal of unused antimicrobials (and other medicines)

Control of environmental contamination of antimicrobial agents from production facilities and

centres of intense use (hospitals and LTCF’s)

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agencies and research institutions, pharmaceutical industry, environmental protection government

agencies and NGO’s, agricultural representative bodies and pharmaceutical industry.

Focus on Critically Important Antimicrobial ClassesPrioritise initiative around critically important

antimicrobial agents e.g. carbapenem and colistin.

Surveillance and reporting of production and consumption at least of most critical classes of

antimicrobial (e.g. carbapenem and colistin) for all countries

In countries with capacity limit use of these agents to infection specialists for human use


agencies and research institutions, pharmaceutical industry, professional societies.


where possible)


Surveillance and reporting of consumption (DDD) in some countries in Europe

Remove incentives to prescribe – separation of prescription/dispensing decisions from direct

personal income gain (human and veterinary) –some measures implemented in some European

countries in human and or animal health care

Incentivise alternative antimicrobial free or antimicrobial reduced approaches in production of food

of animal origin – EU ban on antimicrobial as growth promoter, US ban on fluoroquinolone in poultry

Australia ban on fluoroquinolone use in food animals

Readily available non-prescribing guidelines/smart phone applications - significant progress on this

in many developed countries for human health care particularly in hospitals.

Promote wider societal engagement with acceptance of and planning for end of life – advance

directive legislation in some countries

Control marketing (direct and indirect) – direct marketing of pharmaceuticals not permitted in EU but

increasingly this is circumvented –with industry funded “support/awareness groups”

Explore mechanism to compensate manufacturers of critical antimicrobial agents (e.g.

Carbapenems/Colisitin) for cooperating with reduced sales – e.g. assess credible volume of sales

within patent life based on current trends and apply patent life to sale to that volume (if legally

possible) or connect patent life to sustained activity e.g. patent life extended if % of non wild type in a

credible surveillance system for a representative target organism does not increase by two-fold per

5/10 years of use.

Reduced diagnostic uncertainty to support better targeting of antimicrobial – significant technical

progress in diagnostics in high and some low income countries –more limited progress in improving

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use in animal health care although I understand there may be progress on this in some Scandinavian

countries

Electronic prescription systems, automatic substitution and stop orders, antimicrobial stewardship

systems in hospital and community (in particular LTCF’s) - there are good models in some developed

countries particularly in hospitals

Improved regulatory controls on access and use – changes towards POM in some countries recently

(india)

Systems for safe disposal of unused medicines including antimicrobial – Netherlands and Sweden

have systems for safe disposal of unwanted pharmaceuticals including antimicrobials EPA Ireland

have called for similar in most recent hazardous waste plan.

Treatment of hospital waste to remove pharmaceutical agents in some hospitals (some hospitals in

Netherlands for example)

Focus on Critically Important Antimicrobial Classes– there is a WHO/OIE list of critically important

antimicrobial agents

Surveillance and reporting of consumption in EU for humans and animals

EARS Network surveillance of resistance also joint ECDC –EFSA reports on AMR in zoonoses



Carbapenem/Colistin Challenge: WHA resolution in 2 years, number of countries committed to

pledge each year, number with implementation each year.


% of countries with surveillance and reporting of consumption (DDD) of most critical agents

% of countries that separate prescribing decisions from sale (human and animal)

% of countries with national, state or regional readily available non-prescribing/prescribing

guidelines/smart phone applications –

% of countries that prohibit marketing of antimicrobial agents

% of countries where antimicrobial agents are POM

% of hospitals with ready access to quality basic diagnostics (full blood count, U&E, CRP (or

equivalent), malria, blood culture, urine dipstick / culture)

% of hospital with ready access to antimicrobial susceptibility testing

% of countries with systems for safe disposal of unused antimicrobial

% of countries with minimal programme of surveillance of production and use

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% of countries complying with minimal programme of surveillance for resistance

% Reduction in Total quantity of carbapenem, colistin, aminoglycoside, fluoroquinolone, third

generation fluoroquinolone produced at national and global level

IV. Building block-4: Identifying and closing critical gaps in knowledge needed to address AMR


The most critical issues are knowledge of human behaviour, economics and society relevant to

influencing change

Surveillance data on production, sale, consumption and disposal of antimicrobial agents at global

level

The extent of counterfeit (below stated dose) antimicrobial consumption and illegal sale and

distribution of antimicrobial agents in countries with regulatory control.

Surveillance data on AMR and patterns of antimicrobial consumption in low and middle-income

countries is particularly lacking even for most critical antimicrobial agents

The role of long term care facilities in dissemination of AMR is not adequately understood

The potential role of food, water and the wider environment in dissemination of AMR is not well

understood (particularly in low income countries).

Surveillance data on AMR in food and food producing animals and the environment is very limited in

particular outside of a number of developed countries.



Anthropological, economic, sociological and social marketing research to understand how to

influence behaviour in relation to antimicrobial use and infection control in each specific cultural

context and within professional groups and hierarchies –

Actors/Stakeholders, NGO’s, research funding agencies and research institutions

Building capacity for surveillance of production and consumption of antimicrobial agents.

Actors/Stakeholders, International agencies, national governments, NGO’s, research funding

agencies and research institutions, pharmaceutical industry, trade associations

Building capacity for microbiology (detection of organism and antimicrobial susceptibility testing to

differentiate wild-type form non wild-type), surveillance and ICT capacity in low and middle income

countries (note possibly could leap frog to NGS approaches to tracking resistance) to enable

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Actors/Stakeholders, International agencies, national governments, NGO’s e.g. professional bodies

and standards bodies CLSI, EUCAST, ASM, SGM, research funding agencies and research institutions,

pharmaceutical industry, trade associations

Studies of the dynamics of AMR in LTCF and interactions with hospitals and community

Actors/Stakeholders, research funding agencies and research institutions.

Research to clarify the potential role of food, water and the wider environment in dissemination of

AMR

Actors/Stakeholders, research funding agencies and research institutions food safety agencies

Establish a methodology to measure, track and report counterfeit antimicrobial consumption and

illegal sale and distribution of antimicrobial agents in countries with regulatory control

Actors/Stakeholders, International agencies, national governments, NGO’s e.g. professional bodies

pharmaceutical industry, trade associations


where possible)

Limited social sciences research published – but growing

There has been some capacity building – WHONet related activity is a good example also some

professional societies (ASM) have worked to develop capacity. Provision of EUCAST methods and

guidelines free of charge on internet is very valuable initiative.

Some studies on antimicrobial consumption in LTCF(HALT study in Europe) and some published

material on LTCF but mostly point prevalence studies.

Some publications on food water and environment – growing body of work but limited and mostly in

developed countries.



Within 5 years a series of studies on sociological and economic opportunities and barriers in dealing

with ARM in different cultural and political contexts. Within 10 years outputs of intervention studies

based on these reports.

Within 5 years an agreed process for global surveillance for production and consumption of critical

antimicrobial agents.

Within 5 years a core consensus list of key pathogens and a core set of antimicrobials for each

pathogen –every country to have access to reference laboratory services for key pathogens and core

antimicrobial agents and at least one sentinel site reporting AMR data

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Within 10 years all hospitals above a specified capacity (e.g. > 100 000 bed days) have ready

consistent access to and are using core quality microbiology diagnostics (e.g. blood count, CSF and

urine culture and AST)

Within 5 years agreement on a consensus global approach to surveillance monitoring and reporting

AMR in food, water and the environment in a format that enables linkage to human data

Within 5 years a global consensus on a methodology to measure, track and report counterfeit

antimicrobial consumption and illegal sale and distribution of antimicrobial agents in countries with

regulatory control

V. Building block-5: Developing an innovative and sustainable approach to develop and

distribute critical products and technologies needed to address AMR


Consistent access to quality assured older low cost antimicrobial agents because non-availability can

force use of newer broader spectrum agents even though isolates have been shown to be susceptible

to older agents.

In resource limited settings in particular when human health care costs are paid out of pocket there is

a powerful incentive to obtain and consume (by purchase or prescription) low cost antimicrobial

/illicit agents without diagnostic testing

In animal health there are powerful incentives to purchase /prescribe/consume low cost

antimicrobial agents without diagnostic testing

Developing incentives to encourage the pharmaceutical industry to conserve antimicrobial activity of

agents for the longer term as a valuable asset.

Affordable point of care/close to point of care access to rapid quality diagnostics that can largely

exclude bacterial infection.



State funded health care systems or other agents need to guarantee prices for older antimicrobials

that ensure that they are profitable to produce and distribute or state actors need to find some other

mechanism to sustain access.

Actors/Stakeholders, International agencies, national governments, pharmaceutical industry

Explore funding models/regulatory mechanisms for both human and animal health care that

package diagnostic testing with antimicrobial costs in a price package that is competitive with blind

antimicrobial use, at least for critically important antimicrobial agents.

Actors/Stakeholders, International agencies, national governments, NGO’s, diagnostics and

pharmaceutical industry

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Perform studies to assess overall costs and outcomes in test-then treat approaches compared with

no test –just treat approaches.

Actors/Stakeholders - research funding agencies and research institutions, pharmaceutical industry,

trade associations

Explore novel crowd funding and similar unconventional financing systems to support innovative

solutions.

Actors/Stakeholders - Venture capitalists

Explore systems to link patent life to preservation of wild-type susceptibility test profiles

Actors/Stakeholders, International agencies, national governments, pharmaceutical industry,

accountants and economists


where possible)

I an not aware of work in this domain



Measure and report the frequency of occurrence of limited access to antimicrobial agents for any

reason – aim to reduce the frequency of such occurrence by 50% in 10 years

Develop, record and report national data on the % of carbapenem/colistin prescriptions that occur in

the context of a susceptibility report on relevant isolate from a non sterile body site (probably based

on sentinel sites).

Develop, record and report national data on the % of third generation cephalosporin, fluoroquinolone

prescriptions that occur in the context of a susceptibility report on relevant isolate from any site

(probably based on sentinel sites)

In relevant countries develop, record and report national data on the % of third generation

cephalosporin, fluoroquinolone prescriptions that occur in febrile patients in the absence of a report

indicating neutrophilia or elevated CRP or similar indicators of infectious/inflammatory process

VI. Building block-6: Assessing the long term economic, developmental and social costs and

implications of AMR as a basis for sustainable investment and action


Existing systems for quantifying these costs have so much imprecision that they are likely to lack

credibility and may be of limited value in influencing change.



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Develop and validate credible models that are appropriate to different economic and cultural

contexts and health care delivery models – research funding agencies and research institutes.

Actors/Stakeholders, International agencies, national governments, research funding agencies and

research institutions


where possible)



A credible validated consensus model adaptable to different economic and cultural contexts and

health care delivery systems within 10 years

Concluding questions

3. What contribution would your organization be able to make in implementing the global

action plan?

Participation in policy discussion and document development, technical support for education and

capacity building, clinical and laboratory research, advocacy

4. Additional input that you feel would facilitate development of the GAP.

If not already sought then targeted consultation with major social media operators regarding how to

harness social media systems effectively for awareness and surveillance/reporting of antimicrobial

adverse reactions and other objectives.

If not already sought then targeted consultation with major private philanthropic funding sources

and development and environmental NGO’s to determine where AMR stands in their system of

priorities.

consultation on a draft global action plan to address ... · actors/stakeholders international...

Documents