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1h. AMR: Global Interventions to Combat Antimicrobial Resistance
Can the Application of the International Health Regulations to Antimicrobial Resistance Events Help to Preserve Antimicrobials?
Geneva University Hospitals, Switzerland
Problem statement: The public health threat of antimicrobial resistance (AMR) needs to be addressed urgently. In the last decade, challenging multi-resistant bacteria have expanded in the absence of any tangible new antimicrobial drug development or global containment action. Surveillance of AMR pathogens is patchy and limited by financial and technical constraints in large parts of the world. Without a global early warning system, the emergence and spread of AMR often remains unnoticed until a given strain has become endemic.
Objective: The International Health Regulations (IHR), a legally binding agreement between 194 States Parties, whose aim is “to prevent, protect against, control and provide a public health response the international spread of disease...,” deserve critical examination with regard to their applicability to AMR.
Methods: Using the example of carbapenem-resistant Enterobacteriaceae (CRE) as point of departure, we analyze and discuss the potential role of the IHR with respect to AMR. To do so, we assess whether selected CRE events fulfill the four criteria: (1) Is the public health impact of the event serious? (2) Is the event unusual or unexpected? (3) Is there any significant risk of international spread? (4) Is there any significant risk of international travel or trade restrictions? of Annex 2 of the IHR.
Results: We argue that many events marking the emergence and international spread of KPC and NDM-1-producing CRE can be considered to fulfill most Annex 2 criteria and WHO should, therefore, be notified. This argument can easily be extrapolated to other types of AMR (and has, in fact, been made for XDR-TB). “New or emerging antibiotic resistance” is one of the examples listed in Annex 2 for application of the first criterion. Still, due to ambiguities in Annex 2 and limited specific WHO guidance, some may counter that CRE (and other AMR) events are irrelevant to the IHR. The final obstacles are a lack of expertise and capacities within WHO. Although WHO vertical programs have successfully focused on drug resistance in selected areas, including malaria and tuberculosis, WHO arguably does not have the means to comply with its IHR mandate of offering assistance to States Parties affected by the spread of multi-resistant bacteria.
Conclusions: The global threat posed by the spread of AMR cannot be addressed by individual countries alone, but requires a coordinated international response. Recognizing the applicability of the IHR to AMR will serve as a wake-up call and obligate WHO and States Parties to strengthen surveillance and response, which could in turn contribute to containing the spread of AMR and preserving the efficacy of antimicrobials. Although States Parties and WHO share a collective responsibility in the process, WHO must clearly delineate its position with regard to AMR and the intended role of the IHR in this context.
Funding source(s): None
Examples of Interventions to Contain AMR Based on International Consultations
World Health Organization, Switzerland
Problem statement: Coherent and coordinated actions to contain AMR are lacking in many parts of the world. Identifying examples of interventions tried by different stakeholders could help in motivating policy makers to address AMR by developing policies and intervention strategies. National as well as international agencies, including WHO, NGOs, academia, professional societies, all have a role in providing leadership and advice, and setting standards.
Objectives: To develop a reference book of tried and tested interventions targeting policy makers. The book is building on the WHO Global Strategy for Containment of AMR (2001) as well as the WHO World Health Day six point policy package (2011) by utilizing evidence and experiences from interventions to provide examples of a range of potential interventions applicable to all Member States.
Design and setting: The book has been developed following a WHO consultative process with experts in different disciplines related to AMR containment and from different parts of the world over a two-year process.
Development strategy: Many international experts and WHO staff took part in the consultative process and contributed to the development of the document. The book is based on information and experience from different socioeconomic and cultural settings in the form of peer-reviewed articles and other forms of publications, expert opinions, and experiences recorded in WHO regions and Member States.
Outcome measure(s): Examples of practical interventions in five major areas: surveillance of antimicrobial use and resistance, rational antimicrobial use and regulations, antimicrobial use in animal husbandry, infection prevention and control, and enabling innovations to combat AMR
Results: The book discusses interventions and activities, such as country-focused situation analyses on antimicrobial use both in human and animal sectors; enforcement of regulations, creation of multidisciplinary coordination groups at national levels to develop policies, enabling rational prescribing, building infrastructure capacity for infection prevention and control, building coherent surveillance systems, and setting priorities for R&D in health technologies, innovative financing to facilitate progress in drug development, and measures to raise awareness among all stakeholders from policy makers to health care workers to the general public. Gaps and challenges to implementing interventions may include a lack of political will and weakness of health systems, contributing to entrenched human behaviour and perceived resistance to change.
Conclusion: Intersectoral and multidisciplinary cooperation at country and global levels seem to be important in implementing the multiple interventions that are urgently required. Health systems strengthening may be an important step toward implementing AMR interventions. This depends to a large extend on commitment from national governments while global agencies have important roles in supporting such activities.
Funding source(s): Funding for the consultation process and the subsequent development of the reference book was provided by WHO. SIDA/ReAct (Sweden) provided a grant to support the book development.
Effect of Interventions on Misuse of Antibiotics/Antibacterial Drugs in Developing Countries: a Systematic Review
1Makerere University College of Health Sciences, Uganda; 2University of London, United Kingdom; 3Kampala International University Medical School, Ishaka Campus, Uganda
Problem Statement: Misuse of antibiotics/antibacterial (AB) drugs is global problem, especially in developing countries. This results in an increased emergence of resistance to most common bacteria, higher cost of treatment, and adverse drug reactions.
Obnective: Review to determine effect of various intervention studies on AB misuse in developing countries.
Methods: A systematic review was conducted to determine the effect of different interventions on misuse of AB drugs in developing countries. A search strategy was developed to retrieve relevant articles from various databases like Medline/PubMed, Embase, INRUD, Management Sciences for Health, WHO, and Cochrane. Google scholar search engine was used to retrieve more studies and gray literature.
Results: A total of 722 articles were retrieved and 55 were reviewed—10.9% were from African, 63.6% from Asia, 9.1% from Latin America, and 16.4% from Southeastern Europe. A total of 52.7% were hospital settings, 5.5% outpatient departments, 21.8 public health care facilities, 12.7% private pharmacies/drug stores, and 7.3% communities. Education intervention was 27.3% with group discussion having 19.2% mean reduction in AB use, 27.6% in AB prescription, and 41% belief of no AB use. Community training had 30.5% reduction in AB use, 23.8% mean reduction in AB prescription, and 36% belief of no AB use. Managerial was 20% with 8% improvement in AB dose, 8–100% AB use adherence and 31.8% mean reduction of AB receipt, 29.1% change of AB in resistance cases and 9.8-100% reduction in prophylactic AB use. Managerial/education was 3.6% with 4.7% reduction in AB prescription. Regulatory was 9.1% with 60.5% improvement in AB use in restriction unlike 16.4% in non-restriction. Education/regulation were 9.1% with 8% reduction in nonindicated AB, 24% improved AB use rate, 14% mean appropriate AB use improvement, 11.1% reduction of incidence of bacterial resistance, 75.1% reduction in AB use in diarrhea, 42.4% reduction in scabies, 13.8–33.6% reduction in AB use in acute respiratory infection, and overall 60% reduction in AB use. Diagnostic was 3.6% with 68% reduction in AB use after test as compared to100% control. There was 73% likelihood of AB use in positive results as compared to 87% in negative. Multifaceted were 27.3% with 63% improvement in appropriate doses prescribed, 2.6 mean number of AB encounter reduction, 23% AB prescription reduction, 18.3% generic prescribing improvement, 32.1% reduction in AB use, 89% reduction in AB use in acute respiratory infection, 82% in surgery, 62.7% mean reduction in deliveries, 39% in STDs, 36.3% mean reduction in diarrhea, 14.6% mean reduction in malaria, and 6–11% in the cost of treating bacteria-resistant organisms. Also noted was 6.3 reductions in mean AB encounters after 1 month of intervention, then increased to 7.7 after 3 months, lacking sustainability.
Conclusion: Multifaceted interventions are effective in reducing misuse and inappropriate use of AB drugs and emergence of resistance to the commonest bacteria in the developing countries though they lack sustainability.
Funding Source: Information not provided