Challenges on AMS - the WHO perspective · 20/10/2019 · 20/10/2019 | Title of the presentation 5 UN High level meeting on AMR Requested the UNSG to consult with WHO, FAO and OIE

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Challenges on AMS -the WHO perspective

Smittevernkonferansen, 16 Oktober 2019,

Stavanger, Norway

Ingrid Smith, Technical Officer

AMR Division, Geneva WHO

Outline

• The WHO

• The global picture on AMR and use

• The WHO perspective on AMS

• Challenges and action taken

• Way forward

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What is the WHO?

Work - impact the SDGs

GPW, treaties, resolutions and plans - members states must agree!

WHO is a UN org.; members states

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Global Action Plan on AMR, 2015: 5 objectives

Improve awareness and understanding of AMR

Strengthen knowledge through surveillance and research

Reduce the incidence of infection

Optimize the use of antimicrobial medicines

Ensure sustainable investment in countering antimicrobial resistance

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20/10/2019 | Title of the presentation 5

UN High level meeting on AMR

Requested the UNSG to consult with WHO, FAO and OIE and establish an ad-hoc Inter-Agency Coordination

Group (IACG) to provide guidance and recommendations to coordinate and

expedite global efforts


The global picture on AMR

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Holmes A at al., Lancet 2016

Factors contributing to AMR

Biggest drivers:

• Misuse or overuse in

humans

• Misuse or overuse in

animals

Antibiotics in humans

2000-2015: 65% increase (21-35 billion DDDs) in antibiotic use40% increase (11-16 DDDs/ 1000 inhab.) – most LMICs

Increase:cephalosporins 400%, quinolones 125% and macrolides 120%

Klein. PNAS latest articles, 2018:1-8

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Development of AMR in humans

AMR surveillance in animals

, 2014

NRK, 2015

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Antibiotics in animals

ECDC, EFSA and EMA

second joint report,

JIACRA; 2017

EU summary report on AMR surveillance, 2017

Susceptibility to the whole set of antimicrobials for E. coli in pigs (left) and in cattle (below)

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1st global report

launched in Nov 2017

Over 40% of GSMS

reported cases are

antimicrobials

Antibiotics from Access,

Watch & Reserve Group

90% of reported antibiotics

are listed by WHO as

critically or highly important

antimicrobials20/10/2019

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Quality of antimicrobials: Substandard & Falsified

NCDs 58%

Vaccines2 %

HIV / Hepatitistreatment

3%

Antibiotics17%

Anti-Malarials

20%Annet42 %

*GSMS (Global Surveillance &

Monitoring System) is a case reporting

system in which trained national focal

points send reports to WHO and receive

support when requested

(source: http://www.who.int/medicines/regulation/ssffc/publications/gsms-report-sf/en/)

Access to antibiotics and vaccines

Achieving UHC requires equitable access to health services and affordable, quality-assured health products is a global priority.

450.000 children < 5 yrs die from pneumonia pr yr - lack of access to antibiotics

Universal coverage of Pneumo. conjugate vaccine could avert 11.4 mill days of antibiotics annually in children < 5 yrs; 47% reduction

Vaccine coverage ~ 42%; countries claim it is due to high price

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Antibiotic shortages and “over the counter” sales

2018

Non-sustainable production, fragile supply chains, regulation, procurement and business models etc

Buy medicines over the counter – out of pocket=> Stronger endorsement of regulation on antibiotics (prescription only).

Health consequences of AMR

Patient and healthcare provider:

• Increased mortality and morbidity (young children!!)

• Longer hospitals stay

• Longer & more expensive treatment

• Deliverance of universal health coverage

Laxminarayan. Lancet ID, 2013. Blomberg. BMC infect dis, 2007; O`Neill report, Review on antimicrobial resistance.

Burden of common infections with AMR bacteria in DALY (disability-adjusted life year) by agegrp, EU 2015

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Global societal and economic implications of AMR

World Bank Group Report on Drug-Resistant Infections (March 2017)

Source: World Bank Group Report on Drug-Resistant Infections (March 2017)

LIC: - 5.6 % of

Gross Domestic

Product annually

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"Antimicrobial resistance is a global health emergency

that will seriously jeopardize progress in

modern medicine."

Dr Tedros, Director General, WHO

13th GPW: AMR is a priority for the WHO as 1of 5 Platforms (AMR, climate, human capital, NCDs/mental health, elimination of Communicable Diseases)

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Way forward

AMR • One health• Multi-factorial• Global issue

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Global Action Plan on AMR: 5 strategic objectives

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1. Awareness and education

Improve awareness and understanding of AMR through effective communication, education and training

Health Workforce Department: Lack of local expertise: Outline competencies to guide the education and training of health workers on AMR

In 2018, 131 countries

and ~ 500 events

2. Strengthen knowledge through surveillance & research

Global antimicrobial resistance surveillance system (GLASS)

79 countries 65 countries

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3. IPC, WASH and biosecurity

Water, Sanitation and Hygiene

(WASH) is KEY for Infection

Prevention and Control!

• 2 billion use a drinking water source contaminated with faeces

• In least developed countries, • 22% of health care facilities

have no water service, • 21% no sanitation service, and • 22% no waste management

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4. Optimize antibiotic useProvide standards but also training and follow up in the countries

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5. Sustainable funding for AMR efforts andPriority setting for R&D

Critical needs:

• Drug-resistant TB

• Gram-negative bacteria:

• Carbapenem-resistant A. baumannii

• Carbapenem-resistant P. aeruginosa

• Carbapenem-resistant and 3rd

generation cephelosporin resistant

Enterobacteriaceae

Source:http://www.who.int/entity/medicines/areas/rational_use/

PPLreport_2017_09_19.pdf?ua=1

Preclinical pipeline

Priority pathogens list for R&D

Target product profiles for needed antibacterial agents

Impact Investment Fund for Abx & DiagnosticsThe European Investment Bank & World Bank:Finance phase 2 and 3 clinical trials

IPC versus AMS

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Two sides of the same coin

IPC

Prevent spread, colonization and

infections

AMS

Prevent selectionpressure and AMR

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Efficient antibiotic treatment for patients today AND tomorrow

Antimicrobial stewardship (AMS) –definition, objective, action & outcome

Optimize antibiotic use• Improve health-care, prolong use of existing

antibiotics, save lives and costs, reduce AMR

Change prescribing practices and use• No antibiotics when not needed• Old antibiotics when sufficient (generic)• New antibiotics only when necessary

A strategy and coherent set of actions to promote using antimicrobials responsibly

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Antimicrobial consumption data

WHO report on surveillance of antibiotic consumption: 2016–2018 early

implementation. Geneva: World Health Organization; 2018.

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EML AWaRe classification of antibiotics

Access group:

Empiric 1st & 2nd choice abx for treatment of most common infections

Should be widely available, at affordable prices, in appropriate formulations & of assured quality

Access should expand and be widely available at affordable prices, in appropriate formulations and of assured quality

Watch group:

Subgroup of the Access group, but with higher resistance potential

Use as 1st & 2nd choice treatment should be limited

Access should be expanded, but be prioritized targets for antimicrobial stewardship programmes

Reserve group:

Mainly ‘last resort’ treatment options

Key targets for antimicrobial stewardship programmes

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WHO toolkit for AMS prog. in facilities in LMIC

1. Structures

2. Governance

3. Planning AMS interventions


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4. Performing AMS interventions

5. Monitoring AMSinterventions

6. Education and training

Close links to IPC Training of trainer educational materials being developed

WHO toolkit for AMS prog. in facilities in LMIC


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IPC

Optimize

Use

Capacity building on AMS & related topics

Provide standards & training

Integrating different topics• AMS• IPC/ WASH• Surveillance (AMR, AMC)• EML/ AWARE• Monitoring• Pre-service/ in-service

education and training

To tailor to country needs

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The WHO policy package to combat AMR, 2011

Bulletin of the World Health Organization 2011;89:390-392

Involves• Governments• Global organisations• Civil society• Private investors• NGOs• Professional org.• Academia

• Ensure necessary expertise

Tripartite Joint Secretariat on AMR

• Established following request by the UN SG• Integrate WHO, FAO and OIE and promote a global response

on AMR, with UN orgs, World Bank, international organizations, member states, civil society and private sector.

• Hosted in WHO with liaison full time officers in OIE and FAO• Technical Coordination of the Multi-Partner Trust Fund• Independent Panel on Evidence for Action against AMR

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Global coordination & funding of action against AMR

The costs for global AMR containment measures:estimated US$ 9 billion annually in LMICs

Half invested in and operation of core veterinary & human public health systems in 139 countries

The recommended investmentsare justified because putting resources into AMR containment now is one of the highest-yield investments countries can make

A new AMR Division – a new day?

AMR has been all about bugs, but it is

all about people!

• Should we rewrite the narrative?!

WHO`s mission:

• Promote health

• Keep the world safe

• Serve the vulnerable!!

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Thank you!

Documents

Challenges on AMS - the WHO perspective · 20/10/2019 · 20/10/2019 | Title of the presentation 5 UN High level meeting on AMR Requested the UNSG to consult with WHO, FAO and OIE