1. 71st UN General Assembly adopts first Political Declaration on AMR
On September 21st, Member States convened together for first High-level Meeting on Antimicrobial Resistance (AMR) during the 71st United Nations (UN) General Assembly. Following HIV/AIDS, non-communicable diseases, and Ebola, AMR is the fourth ever health issue to receive the attention of the United Nations General Assembly. In response to the increasing urgency to address this multisectoral threat, Heads of State adopted a Political Declaration calling for coordinated, global action. Over the past several months, the Ambassador of Mexico to the UN, Mr. Juan Gomez Camacho, facilitated negotiations among the Member States to lay out a set of specific principles, commitments, and a follow-on process to gauge progress achieved in addressing AMR.
The resolution adopted by Member States recognizes the multisectoral nature of AMR and the need for a One Health approach. It also calls for the mobilization of “adequate, predictable, and sustained funding and other resources” from various channels towards national action plans, innovation of health technologies, and improvement of “related infrastructure.” The Political Declaration also calls upon the Secretary-General to establish an ad hoc UN Interagency Coordination Group that would be co-chaired by the Executive Office of the Secretary-General and the World Health Organization (WHO). The Secretary-General is also tasked with providing a report to the 73rd UN General Assembly in 2018 on “further developments and recommendations” from this coordination group as well as to report on progress achieved. The WHO, in collaboration with the Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE), are also called upon to finalize a global development and stewardship framework. A preliminary version of this framework was introduced in May 2016 at the World Health Assembly.
The President of the General Assembly, Ambassador Peter Thomson of Fiji, opened the High-level Meeting acknowledging that AMR will threaten achievement of the Sustainable Development Goals. The UN Secretary-General, Mr. Ban Ki-Moon, spoke of losing the ability to protect against life-threatening infections, from drug-resistant typhoid in Africa and HIV/AIDS drug resistance to MDR-TB in 105 countries and the spread of antibiotic-resistant infections from farms to animal meat. He warned that the failure to address this challenge would undermine hard-won achievements under the Millennium Development Goals. He emphasized the need for long-term commitments to multi-sectoral collaboration and sustained financing. Dr. Margaret Chan, Director-General of the WHO, followed, describing the situation as a “slow-motion tsunami” that recently forced the UN agency to update its treatment guidelines for sexually transmitted infections due to increasing drug resistance. Echoing her oft-repeated warning of a “post-antibiotic era,” Dr. Chan noted the adoption of the WHO Global Action Plan on Antimicrobial Resistance in May 2015. She called upon key stakeholders to do their part. The pharmaceutical industry’s reluctance to invest in antibiotic resistance because of poor returns must be addressed with new incentives. Consumers have to stop demanding antibiotics for viral infections and should demand “antibiotic-free meat.” Providers need diagnostics and vaccines. Dr. Chan said that the food industry must reduce its subtherapeutic use of antimicrobials and that critically important antimicrobials should not be used for animal husbandry and agriculture.
The Director-General of FAO, Mr. José Graziano da Silva, said the FAO welcomes the political declaration and urged the need to use antibiotics in a sustainable way. He called for the phase out of the use of antibiotics for growth promotion in agriculture. Antibiotics should only be used treatment, but left the door open for selected uses for prevention. He underscored the need for a One Health approach and their commitment to the tripartite agreement (with WHO and OIE) as well as collaboration with others on this challenge. He also noted that the FAO five-year action plan on AMR was consistent with the WHO Global Action Plan. He encouraged the donor community to invest in these issues and expressed appreciation for both U.S. and UK support of FAO’s work on AMR.
Dr. Monique Eloit, the Director-General of OIE, asked how can we drive sustainable change into our practices. OIE has developed international standards to control animal diseases under veterinary supervision. She noted that alternatives exist and are only waiting to be developed. OIE has developed a standard for monitoring and evaluating AMR use. However, these tools, standards, recommendations and action plans can only be useful and effective if implemented at the national level. The tripartite collaboration among WHO, FAO and OIE needs long-term political commitment. Following these opening remarks, Member States adopted by acclamation the first Political Declaration on AMR.Two parallel sessions then ensued - one being a general session where Member States made individual statements supporting the declaration and the other having two panels with representatives from governments, civil society, and the private sector. The first panel focused on the “relevance of addressing AMR for the achievement of the Sustainable Development Goals, in particular the health-related Goals.” The speakers for this panel were:
Ms. Veronika Skvortsova, Minister of Health Care of the Russian Federation
Dr. Cleopa Mailu, Cabinet Secretary for Health of Kenya
Mr. Vytenis Andriukaitis, European Union Commissioner for Health and Food Safety
Mr. Martin Khor, Executive Director of the South Centre
Dr. Joanne Liu, the International President of Médecins Sans Frontières
Sir Andrew Witty, CEO of GlaxoSmithKline
Martin Khor noted that because of economic interests, we have not taken the actions we should have and that the key issue will not only be access to new antibiotics, but also access to antimicrobials that already exist. Dr. Cleopa Mailu emphasized how the issue affects both animal and human health, was a threat to food security, and posed challenges to the environment through water pollution. Andrew Witty of GSK noted that the company has spent $1 billion dollars over the past decade on antimicrobial drug research, and despite no new classes of antibiotics being discovered in the past couple decades, the company has embarked on phase 3 trials of a new class of antibiotics useful against drug-resistant gonorrhea. He also drew attention to the roadmap, signed off by pharmaceutical companies, to reduce environmental pollution. He committed GSK to 1) agitate within industry to support the roadmap; 2) attend broader gatherings to support innovation; and 3) help set clear targets, assign accountability, and then implementation. Calling antimicrobial resistance as a “public health emergency and a public health failure,” Joanne Liu of MSF described the situation starkly in terms of “my medicine cabinet is bare,” and not having options for treating patients in the field.
The second panel focused on “addressing the multisectoral implications and implementation challenges of AMR in a comprehensive manner.” For this panel, the speakers were:
Ms. Erna Solberg, Prime Minister of Norway
Dr. Paulyn Jean B. Rosell-Ubial, Secretary of the Department of Health of the Philippines
Dr. Jorge Lemus, Minister of Health of Argentina
Mr. Keith Hansen, Vice President of Development for the World Bank (in the latter half of the panel, Dr. Tim Evans, Senior Director, Health, Nutrition & Population for the World Bank replaced him)
Mr. David George Velde, Board Member of the World Farmers’ Organization and Vice- President of the United States National Farmer´s Union
Ms. Marta Tellado, President and CEO of Consumer Reports
Prime Minister Solberg led the panel discussion calling for an international ban on the use of growth promoters and restricting the use of antibiotics only for sick animals. She also noted Norway’s experience in reducing antibiotic use in their fisheries through the development of a publicly funded vaccine. Keith Hansen and Time Evans of the World Bank stressed the need to invest in reducing AMR given the predicted staggering costs of inaction, particularly in developing countries. They also noted the lack of investment into health systems and the importance of promoting stewardship, while enabling access to both drugs and other health technologies such as vaccines. They pointed to the example of Gavi and its work providing access to the pneumococcal conjugate vaccine through advanced market commitments. George Velde of World Farmers’ Organization then emphasized the important role of the agricultural sector in addressing AMR and that producers also have concerns about the impact of resistant on their own health and of their families. He cautioned however that AMR policies should avoid placing a disproportionate burden on food producers and that funding is needed to help producers to transition their practices. Dr. Rosell-Ubial admonished that in regards to local planning and implementation of international standards for AMR, “If you fail to plan, then you plan to fail.” She encouraged the UN to document best practices so that countries could learn from one another on how to address this issue. Marta Tellado of Consumers Reports highlighted how consumer campaigns have played a role in raising awareness and moving food retailers to source meat products without the routine use of antibiotics. These campaigns, like that of Chain Reaction II, have also coupled awareness with transparency around antibiotic use. She cautioned, however, that regardless of how hard and fast these consumer campaigns can be, government and industry involvement is still necessary to effectively address AMR. Dr. Jorge Lemus agreed that while there is a need to empower consumers, there also needs to be informational campaigns and that the WHO should convene experts to support such communication campaigns in countries. He also spoke of Argentina’s experience as a large meat producer and the need for international regulations and resources for surveillance to address this issue within his country.
Following these panels and the remaining country statements on the declaration, the President of the General Assembly closed the meeting with a statement that now, after the adoption of this document, it is time for all stakeholders across sectors to get to work. He called for Member States and others to work together to transform the words of the Political Declaration as well as the Global Action Plan on AMR into action. He also emphasized that decision makers need to adopt a long-term perspective to effectively address the global and multisectoral threat of AMR. Before and after the UN High-level Meeting, various stakeholders including country missions, the pharmaceutical and diagnostics industry, UN agencies, foundations, and consumer groups hosted 12 side events focused on AMR, highlighting both the importance of the issue as well as opportunities for public and private sector engagement in the follow-on process. Across these different side events, there was a resounding call to ensure that the words of the Political Declaration would be met with action by actors across all sectors.
Around the UN High-Level Meeting on AMR
2. World Bank releases report on the need for investment for AMR across sectors
Just prior to the UN High-level Meeting on AMR, the World Bank released the report “Drug Resistant Infections - A Threat to Our Economic Future”, describing the economic and development consequences of AMR, focusing primarily on low- and middle-income countries (LMICs). The report also includes a series of recommendations across the health and agricultural sectors to help minimize the staggering health and economics costs of AMR.
For these analyses, the World Bank used their primary model for the global economy to simulate three different scenarios for AMR by 2050:
Base: No AMR present
Low: Substantial reduction in AMR
High: No reduction in AMR
Simulations of high AMR impact, where antimicrobial drugs are no longer effective, predict that low-income countries will experience the most staggering effects including a loss of more than 5 percent of their GDP. They also estimate that this scenario would lead to an increase of 28 million people, primarily in LMICs, living in poverty by 2050. The report also found significant impacts to world trade, health care costs, and livestock production:
By 2050, the high AMR impact scenario would cause global real exports to decrease by 3.8 percent, while the low-impact scenario would decrease such exports by 1.1 percent.
By 2050, these simulations found that global healthcare costs would increase between $300 billion to more than $1 trillion. In low-income countries, the annual healthcare costs would exceed the base-case amount by 25 percent while in middle-income countries, annual costs would exceed the base level by 15 percent and in high-income countries, by 6 percent.
By 2050, global livestock production is projected to decrease from 2.6 to 7.5 percent per year. In low-income countries, livestock production would decrease even further, by 11 percent under the high AMR impact scenario.
The report then demonstrates that global AMR containment is a “hard-to-resist” investment based on a series of analyses. By measure of net present value and of the economic rate of return, the World Bank’s analysis showed significant benefits for upfront investment to mitigate the high costs of resistance. The report concludes there is an “overwhelming rationale for reallocating resources from public investments with lower returns toward AMR containment” across both the human and animal health sectors.The report finally delves into three policy areas related to national action plans with specific recommendations focused on LMICs. These include:
investing in disease surveillance as part of strengthening human and animal health systems in LMICs;
increasing global coordination to monitor, regulate, and reduce the use of antimicrobial drugs, to mobilize adequate and predictable funding for AMR containment in LMICs, and to support the tripartite collaboration of the WHO, FAO, and OIE;
ensuring veterinary capacity in low-income countries to support a One Health approach to effectively address the impact of AMR in food animal production on the human health burden; and
piloting measures to examine incentives for reducing the need for antimicrobial drugs in animal husbandry and aquaculture and the impact of such reductions on farmer livelihoods in LMICs.
3. Pharmaceutical manufacturers release an industry roadmap to addressing AMR
During the week of the UN High-level Meeting on AMR, thirteen pharmaceutical manufacturers jointly released an industry roadmap to addressing AMR. These companies, also signatories to the Davos Declaration on AMR released in January 2016, noted their responsibility around this issue and the need for collaboration among stakeholders to achieve progress in addressing this multisectoral challenge. They reaffirmed their commitment to engaging with and partnering with governments, global institutions, academia, health professionals, and patients and that “access and appropriate use of new antibiotics, vaccines, and diagnostics remains of critical importance.” They also noted the need to “attract sustained investment” for innovation of new technologies to address drug resistance.
The roadmap outlines four areas of action and commitments by the pharmaceutical industry:
Measures to reduce the environmental impact from antibiotic production. The signatory companies commit to reviewing their own antibiotic manufacturing and supply chains to determine best practices to control antibiotic emissions into the environment. They also will establish a unified framework for managing this antibiotic waste and will implement this across their supply chains by 2018. These manufacturers will also develop a mechanism to make transparent to show that their supply chains meet these framework standards. By 2020, the companies will also develop evidence-based targets and mechanisms to reduce the environmental effects of manufacturing waste in collaboration with independent technical experts.
Measures to ensure that antibiotics are only being used in patients who need them. These companies will support governments and others to educate healthcare providers and patients on the appropriate use of antibiotics and the importance of vaccines as a cost-effective intervention towards antibiotic stewardship. By the end of 2017, they would have reviewed their current promotional activities to ensure that they are solely aligned with the goal of appropriate use of antibiotics. The manufacturers also commit to sharing surveillance data with healthcare professionals and public health institutions and work with them to increase surveillance capacity globally, while informing rational use of antibiotic drugs and vaccines as well as resistance trends. They also will coordinate with governments and other stakeholders to reduce unregulated antibiotic sales, including over-the-counter and Internet sales.
Measures to improve access to existing and future antibiotics, diagnostics, and vaccines balanced with appropriate use. Companies would work with international organizations, governments, and other stakeholders to identify and target specific bottlenecks to access, market sustainability, and supply. The companies will also work with these actors to create innovative financing and procurement mechanisms as well as new business models to address these bottlenecks and ensure adequate return on investment. The companies also specifically note that an “adequate Market Entry Reward” would “greatly facilitate global access and stewardship for those products.” They also will work “to accelerate the introduction of processes, technologies, and regulations” to reduce substandard/counterfeit antibiotic drugs in the market.
Measures to support open collaborations between industry and public researchers to overcome the scientific challenges of creating new antibiotics, vaccines and diagnostics. The companies commit to progressing incentives including novel intellectual property mechanisms, insurance models, and lump-sum payments that would reflect the societal value of new antibiotic drugs and vaccines and ensure investment in R&D. They also will explore pre-competitive collaboration mechanisms building on the work of the TB Accelerator, Global Health Innovative Technology fund, and the Innovative Medicines Initiative. They will also support the creation of open clinical trial networks globally to improve the speed and efficiency of conducting clinical trials. The manufacturers also commit to engaging with other stakeholders such as the Global Antibiotic R&D Partnership (GARDP) to facilitate exchanges of data on old antibiotics to address specific bottlenecks in the global pipeline.
4. Consumer advocates grade food retailers on their antibiotic use policies, call for governments to take action to address AMR
On the eve of the UN High-level Meeting on AMR, the Natural Resources Defense Council, Center for Food Safety, Consumers Union, Food Animal Concerns Trust, and Friends of the Earth released Chain Reaction II, an annual scorecard that grades the top 25 fast food and casual dining restaurants in the United States on their antibiotic use policies. The restaurants assessed include some of the largest global food retailers such as McDonald's, Subway, Burger King, and KFC. This second annual report specifically grades these chains’ policies based on whether the retailer sources meat and poultry products raised without the routine use of antibiotics. The scorecard not only makes transparent these companies’ antibiotics use policies, but also identifies which retailers need to improve their policies to compel their suppliers to phase out the routine use of these life-saving drugs and prevent the further spread of AMR.
This second version of the scorecard found that twice as many food retailers, nine in total, received a passing grade compared to the year prior as a result of their recent commitments to source chicken raised without the routine antibiotics. A majority of these retailers are clustered in the “B” or “C” range with no new restaurants receiving an “A” grade. Commitments by these same companies to transition their beef and pork supplies, however, are lacking. Panera and Chipotle continue to be the only two “A” restaurants which have policies to limit the routine use of antibiotics across all meat and poultry products served and also publicly reporting that a majority of their products are already sourced this way. Subway, which received an “F” last year, earned a “B” grade on the scorecard this year by adopting a policy to serve only meat and poultry products raised without antibiotics.Conversely, Dunkin Donuts moved down in the scorecard, receiving an “F” this year after weakening its antibiotics policy. Sixteen companies also received an “F” grade for either non-transparency of their antibiotics use policy or for having policies allowing for the routine use of antibiotics in their meat and poultry products. The report acknowledges that the market alone will not be enough to address the threat of AMR and that governments need to set regulations across the food industry to ban the routine use of antibiotics for non-therapeutic indications including growth promotion and disease prevention. It also calls standards to be set that would restrict the use of antibiotics to treatment or control of identified disease outbreaks. This year’s Chain Reaction II report concludes that “government response to this major public health threat has been woefully inadequate.”
These consumer groups also called upon Member States to affirm such commitments in the UN political declaration on AMR. Just days before, the U.S. Public Interest Research Group (PIRG) delivered a health professionals letter to the U.S. delegation to the United Nations, asking them to push for a strong resolution “to call for the use of antibiotics in agriculture only to treat sick animals or control a verified disease outbreak, not for growth promotion or routine disease prevention.” At the UN High-level Meeting on AMR, they also organized an action asking country representatives and other attendees to commit through publicly posted photos calling for a stop to the overuse of antibiotics in food animal production. Participating in this action, the Minister of Health, Welfare, and Sport of the Netherlands, Ms. Edith Schippers, posed for a photo (see above), which ran in the Telegraaf, the largest newspaper in the country. As of this year, Netherlands has successfully lowered its use of antibiotics in food animal production by 58 percent and has committed 6 million euros towards research and development of new antibiotics and alternatives as part of a new National Antibiotics Development Platform at the Netherlands Centre for One Health.
5. Experts call for the UN General Assembly to form a Global Antimicrobial Conservation Fund for Low- and Middle-Income Countries
In an editorial published in the International Journal for Infectious Diseases, experts around the world recommended the formation of a Global Antimicrobial Conservation Fund to complement the number of innovation funds proposed to effectively address AMR. This fund would not be a permanently established fund, but a fund that would provide transitional financial and technical support for LMICs to build capacity until the conservation programs could be taken over domestically. They also stress that by contributing to such a global fund, wealthier countries would be able to protect their domestic investment and in a cost-effective way, mitigate the threat of the transnational spread of resistant microbes.
The Global Antimicrobial Conservation Fund could be allocated in four ways:
capacity for surveillance of antimicrobial resistance and consumption through increased human resource capacity, formation and strengthened regional collaborative networks, and documentation of antibiotic consumption
support for sustainable public awareness campaigns taking into account the different ways LMICs delivery health information
increase of human resources in healthcare settings to undertake communication and other stewardship facets in resource-limited settings including financial support for healthcare workers to administer these stewardship programs
delivery of basic infection prevention and control measures including support for basic necessities such as clean water and sanitizing agents in health facilities, essential vaccination programs, and biosafety and biosecurity measures to help transition agriculture systems to adapt to regulations that would phase out the use of growth promoters or prophylaxis
The authors called for the recently mandated UN interagency coordinating group on AMR to support the formation of the Global Antimicrobial Conservation Fund as a necessary component for how funds from governments and foundations should be spent to address this issue.
Authors of this piece include Marc Mendelson of University of Cape Town and Groote Schuur Hospital, Osman Dar of Chatham House Centre on Global Health Security, Steven Hoffman of University of Ottawa and Havard T.H. Chan School of Public Health, Ramanan Laximinarayan of the Center for Disease Dynamics, Economics, and Policy, John-Arne Rottingen of the Norwegian Public Health Institute and University of Oslo, and Mirfin Mpundu of the Ecumenical Pharmaceutical Network and ReAct Africa Node.
Further Global Commitments on AMR
6. FAO releases Action Plan on Antimicrobial Resistance (2016-2020)
On September 14th, the Food and Agriculture Organization (FAO) to the United Nations released their “Action Plan on Antimicrobial Resistance” as a pledge to assist countries developing ways to address AMR in their food systems. In their launch of the plan, the FAO emphasized that AMR not only contributes to significant public health costs, but also impacts the food safety, food security, and the economic livelihoods of farming households around the world. FAO aims to help country governments put in place national strategies to address antimicrobial use and resistance in their food systems by the middle of next year.
The plan identifies four specific areas for action in the food system to address AMR:
Increasing awareness of resistance and its impact among farmers and producers, veterinary professionals, policymakers, and consumers through appropriate, culturally sensitive ways
Developing national capacity for monitoring and surveillance of antimicrobial use and resistance in the food system through improved laboratory capacity and country-specific integrated systems
Strengthening the governance structures related to antimicrobial use and resistance in the food system through technical assistance for regulations and regulatory frameworks in line with internationally agreed principles and standards
Promoting good practices and appropriate use of antimicrobial drugs in the food system through application of international standards and guidelines at the country-level as well as good hygiene and biosecurity practices through the food value chain
Through the organization’s Strategic Framework, FAO will implement this action plan across the global, regional, and national levels and will be aligned the activities of the tripartite collaboration of WHO, FAO, and OIE. The FAO has also stated that the implementation of this action will require coordination with relevant public and private sector stakeholders. FAO will also pursue human and financial resource support towards the plan’s implementation.
7. G20 Leaders Communique outlines future commitments to address AMR
At the conclusion of the 2016 G20 Summit held in Hangzhou, China, G20 leaders released a communique in which they highlighted AMR within the section entitled “further significant global challenges affecting the world economy.” Here, they call upon the WHO, FAO, OIE, and OECD to report back the following year on options to address AMR including the economic aspects from a G20 perspective. Under paragraph 46 of the G20 Leaders Communique, they state:
46. Antimicrobial resistance (AMR) poses a serious threat to public health, growth and global economic stability. We affirm the need to explore in an inclusive manner to fight antimicrobial resistance by developing evidence-based ways to prevent and mitigate resistance, and unlock research and development into new and existing antimicrobials from a G20 value-added perspective, and call on the WHO, FAO, OIE and OECD to collectively report back in 2017 on options to address this including the economic aspects. In this context, we will promote prudent use of antibiotics and take into consideration huge challenges of affordability and access of antimicrobials and their impact on public health. We strongly support the work of the WHO, FAO and the OIE and look forward to a successful high-level meeting on AMR during the UN General Assembly. We look forward to the discussion under the upcoming presidency for dealing with these issues.
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Note: The ARC Newsletter will periodically capture key meetings and developments, as well as news and resources, on antibiotic resistance for Coalition members and partners. This newsletter is prepared and published through ReAct North America/Strategic Policy Program at Johns Hopkins Bloomberg School of Public Health. The ARC Declaration on Antibiotic Resistance can be found here. Please share items for consideration for inclusion in future newsletters by writing to Reshma Ramachandran at email@example.com.