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More damages from AMR than 2008 financial crisis – says World Bank
The World Bank issued a well-rounded coherent report on AMR, assessing the impact of AMR from different angles, offering solutions and discussing recommendations. In the report, it was pointed out that in a rather pessimistic scenario where antibiotics and other antimicrobial drugs no longer have the same effectiveness in treating infections, it could cause low-income countries to lose more than 5% of their GDP and force up to 28 million people (mostly in developing countries) into poverty by 2050.
“The scale and nature of this economic threat could wipe out hard-fought development gains and take us away from our goals of ending extreme poverty and boosting shared prosperity,” said Jim Yong Kim, President of the World Bank Group
However, it is clear that, if the governance of the “global antimicrobial commons” does not improve, then any new drugs that may be developed will lose their effectiveness fast and the large investments in developing such drugs will be squandered.
«This report shows the extraordinarily high returns to AMR containment, which is the first-best option for ensuring adequate and equitable access to antimicrobials. » indeed.
In the conclusion section, 2 actions were suggested to be adopted by relevant actors.
- To move from just “Surveillance” to “Surveillance and Action”, important points were raised including focusing on Drug Utilization Studies (DUS), better use of Information, Communication Technologies (ICT), Antimicrobial Stewardship Programmes (ASPs) among others. The incentives factor was also touched upon, where it was recommended to provide positive financial incentives while removing perverse incentives for prescribers. The measures suggested including possible changes in how health care providers are reimbursed, and disallowing AM sales by prescribers to remove the financial incentive for overprescribing.
- The section on “the Prevention of antimicrobials misuse on all levels”. A lot of points were listed under the prevention actions, including but not limited to; governance arrangements, developing new legislations and regulations, oversight of offer and prescribing, harm reduction from non-prescription sales, decreasing the risk of hospital acquired infections, ways to ensure adherence and compliance to treatment regimens, and focusing on spreading the right information and education through campaigns and the new tools for communication.
Lord Jim O’Neill, Chairman of the Review on Antimicrobial Resistance, commented that “This report provides another timely reminder that rising drug resistance is a looming threat to our prosperity and sustained economic development in all parts of the world. As global leaders meet at the UN this week, I hope that this report will help to harden their resolve to take proper, collaborative action on the many challenges of AMR.”
AMR Times editor's note: Surprisingly, the Bank's report discounted developing countries participation in R&D for new AB. Based on what is known and the simulations of economic impacts prepared for this report, without AMR containment, the Sustainable Development Goals for 2030, such as ending poverty, ending hunger, ensuring healthy lives, reducing inequality, and revitalizing global partnerships are unlikely to be achieved.
The Bank is especially explicit on the enormous gains to be achieved in the implementation of infection prevention and control to prevent hospital-acquired infections (HAI), along with safe water and sanitation. It underscored the need for adequate laboratory diagnostics access for surveillance, insisted that we live in a globalized world where none will be spared, but the poor will suffer more. It is important to recall that under PEPFAR, the US budget for overseas action on HIV AIDS provided for lots of funding and yet this IPC prevention of blood born HIV has not been used. Now the well written Bank argument should bring about more efforts on HAI, which would accomplish a lot for the health of patients in general and PLWAs in particular.
(for the effect of AMR on HIV, read Nigel Livesley, (URC, ASSIST project of USAID) AMR Control 2016 downloadable at www.globalhealthdynamics.co.uk)
Web=links: http://www.worldbank.org/en/news/press-release/2016/09/18/by-2050-drug-resistant-infections-could-cause-global-economic-damage-on-par-with-2008-financial-crisis
http://pubdocs.worldbank.org/en/527731474225046104/AMR-Discussion-Draft-Sept18updated.pdf
Exclusive updates, comments and reports from the United Nations General Assembly
THE UNGA high-level meeting on AMR; A quick review
On the 21st of September 2016, the President of the UN General Assembly convened a one-day high-level meeting at the UN Headquarters in New York on Antimicrobial Resistance (AMR) with the participation of Member States, non-governmental organizations, civil society, the private sector and academic institutions. One of the outcomes of the meeting was a political declaration on AMR, drafted by heads of State and Government and representatives of States and Governments.
In this declaration, the United Nations reaffirmed the World Health Organization’s global action plan, and its five overarching strategic objectives for tackling AMR. The UN also reaffirmed the 2030 agenda for Sustainable Development (SDGs) to ensure healthy living and fight communicable diseases especially in developing countries.
The UN recognized that the achievements of the twentieth century in regards to the reduction of death and illness from serious infections are being seriously challenged due to AMR. Due to this challenge, veterinary and human medicine will now have fewer options to protect people suffering from life- threatening infections, especially women giving birth, newborns, and patients undergoing chemotherapy or surgery, as well as to protect the animal stock.
The UN asked relevant ministers to be engaged in the development and implementation of multi-sectoral national action plans, policies, regulations and regional initiatives in order to tackle this issue. It also urged delinking the cost of investment in R&D on antimicrobial resistance from the price and volume of sales to provide affordable access to new medicines, diagnostic tools and vaccines. The UN also highlighted that R&D efforts should be needs-driven, evidence-based and guided by the principles of affordability, effectiveness, efficiency and equity, and should be considered as a shared responsibility among all relevant stakeholders in order to face this challenge, in addition to raising awareness about rational use of antibiotics meanwhile.
AMR-times comments: Mentioned above are the most important points stated in this political declaration. Realizing the threat growing antimicrobial resistance is causing to our current world and sharing responsibility in taking action towards this issue among all relevant stakeholders such as civil society, industry, small-and-medium-sized enterprises, research institutes and academia is the most promising approach to save our world from this growing tragedy.
The commentary of Dr Jean Carlet, President of WAAAR on the UNGA
The United Nations put medical problems only 4 times on the agenda of their General Assemblies. The 4th time occurred very recently (September 21st), with the very important issue of AMR. After the WHO, the OIE, FAO, CDC, ECDC and other international agencies, it was or paramount importance to make the UN receptive to this dramatic public health issue. Their willingness to address this problem was an excellent news.
This was an important event. Most countries were present, and presented in 3 minutes their advice on the field of AMR, and described briefly the program on this issue in their country. It is clear that all the countries which intervened are concerned by the issue of AMR. The programs in the different countries are of course not at the same level of realization, but most countries have made important progress in the last few years.
Many NGOs were present at this meeting (I represented the WAAAR).
Several aspects were frustrating. It was not possible to ask questions to the presenters. At the end of the assembly, the president Ban Ki Moon read a declaration. It was very positive, mentioning clearly that AMR was a key issue, needing effective and immediate international actions. It was, however, difficult to guess if the UN will be a real partner in this program or just a supporter. It has been impossible to react to the declaration of the president, which has been prepared before the event, and therefore without any input of the participants.
Before the general assembly, on September 20th, CCDEP organized a meeting gathering many NGOs and scientific societies, in order to discuss several aspects of AMR. About 200 persons were present. WAAAR was there, of course. It has been a very productive meeting. It was decided to create a coalition between several NGOs called CARA (The Conscience of Antimicrobial Resistance Accountability). WAAAR was among the founders of this alliance. It is very important to cooperate with the international NGOs on the most difficult topics concerning AMR. We will be stronger together. CCDEP will take the lead of this action.
Excerpt from the Group of 77 and China Statement on AMR at UNGA
“We must encourage appropriate use of antimicrobials in animal and human health and agriculture and raise awareness on AMR. Second, we must continue to strengthen our ability to prevent infections, including by ensuring access to clean water, hygiene and sanitation, immunization, and infection control. Third, we must strengthen health systems and promote Universal Health Coverage.
(…) we must support, as a matter of urgency, R&D of antimicrobials, especially new antibiotics, vaccines, diagnostic tools and innovation, including in traditional and herbal medicine. This must be done while ensuring that R&D efforts are needs-driven (…)
MSF commentary; UN Declaration on AMR targets access and R&D
Dr Joanne Liu, International President of Médecins Sans Frontières sent a letter with her comments on the UN political declaration on AMR. She manifested her support for the global commitment taken by governments yet she also claimed that words stated in the declaration need to turn into actions.
“From the war-wounded in Jordan to newborns in Pakistan and burn patients in Haiti, to people with multidrug-resistant tuberculosis in South Africa, MSF sees drug-resistant infections everywhere, including infections that can only be treated with the very last lines of antibiotics.” - said Dr. Joanne.
She ended her commentary by stating that she was pleased to see that the declaration called for delinking: “MSF is encouraged to see that this declaration builds on the UN’s recent High-Level Panel Access to Medicines report in recognizing the failures of the current medical research and development system, and by incorporating strong public health commitments to try to ensure that the new antibiotics, vaccines, and diagnostics we urgently need to curb bacterial resistance are available and affordable for those who need them most. We’re also pleased to see this declaration calls for breaking the link between the cost of R&D and the price that companies charge for lifesaving medical tools, and for making sure there is a public return when public funding is used to create new products.”
Web=link: http://www.imt.ie/opinion/letters/2016/09/un-declaration-on-ar-targets-access-and-rd.html
http://www.tnpp.org/2016/09/international-president-of-msf-dr.html
India has a massive antibiotic resistance problem, and it's up to the states to solve it
After the release of the UN political declaration on AMR, India is facing massive pressure to finally implement its action plan to tackle AMR. Dr Jagdish Prasad, director-general of health services said that "In such a big nation, we cannot promise anything. We have promised surveillance, which we will follow through”. Despite the fact that the problem of AMR had been recognized and guidelines have been set in the past few years, Indian States were not able to take real steps in implementing policies for solving such problem. However, some Indian States have already taken some initiatives including the focus on education and advocacy regarding the proper use of antibiotics, as well as including Antimicrobial stewardship programs in the curriculum of some medical schools.
Web=link: http://scroll.in/pulse/817377/india-has-a-massive-antibiotic-resistance-problem-and-its-up-to-the-states-to-solve-it
Australian experts welcome United Nations declaration on antibiotic resistance
Discussing the situation in Australia, a group of experts shed the light on the current situation regarding AMR prior to the UN declaration, that was released recently. Dr Darren Trott, the professor of veterinary microbiology at the university of Adelaide stated that Australia shows low antibiotic resistance levels in the animal production systems. On the other hand, speaking about human prescriptions of antibiotics, Dr Mary-Louise McLaw, professor of infectious disease control at the University of New South Wales, affirmed that not only policies such as banning prophylactic antibiotic use, but also the community’s role in tackling the problem is of crucial importance.
Web=link: http://www.abc.net.au/news/2016-09-26/un-antibiotic-declaration/7873470
WAAAR in Action
Launch of CARA, The Conscience of Antimicrobial Resistance Accountability
The World Alliance Against Antibiotic Resistance WAAAR was happy to join the CDDEP initiative named CARA, a rather unique civil society-public health institutions, and scientific societies alliance. At the launch attended by Dr Jean Carlet and Garance Upham for WAAAR, the CARA included the Norwegian Institute for Public Health, the British Society for Antimicrobial Chemotherapy, the Milken Institute of Public Health, DZIF, The Center for Global Development, the CIDRAP, and others.
Web=link: http://www.forumonantibiotics.org/alliance/
The UN, AMR, and CARA: The Conscience of Antimicrobial Resistance Accountability
From the American NGO CDDEP blog, by Ellen Gelband
CARA is an alliance of a broad representation of organizations from all interests and disciplines. It has just been formed and is seeking partners all over the world, from industry, from academia, from the non-profit sector, and from student groups—inclusive of human health, animal health, and environmental concerns. These are the stated goals:
- monitoring progress toward the agreed upon goals of access to effective antimicrobials for everyone across the globe,
- identifying obstacles to progress and bringing them to light,
- working to offer solutions to problems in all sectors, and
- identifying, publicizing, and celebrating successes.
The early partners in CARA, including CDDEP, will be creating an organizational structure and participatory membership in the months to come. See CARA’s founding document and application form here: http://www.forumonantibiotics.org/alliance/
We will never have a better opportunity to join forces to maintain effective antibiotics for everyone in the world. Please join us.
Hellen Gelband is the Associate Director for Policy at CDDEP.
Exclusive updates from the European Society of Intensive Care Medicine’s (ESICM) meeting in Milan
A round table has been organized during the meeting of the European Society of Intensive Care Medicine (ESICM) in Milan, last October. It was a joint meeting between ESICM and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The meeting was chaired by Jan de Waele, from ESICM from ESICM and Matteo Bassetti, from ESCMID. The topic was antibiotic resistance in the ICU.It is a very important issue since resistance is very high in most ICUs, due to the severity of the patients, who are immunosuppressed, with many invasive devices. In fact, ICUs are factories to create resistance and then diffuse resistant bugs silently in the other wards.
It was decided, during this meeting, that the two societies will organize several common activities, in particular, a mondial point prevalence study looking at AMR in the ICUs, data which are not available presently. Another activity could be to write together a position paper, or guidelines. The projects have not yet been accepted by the executive committees of the two societies and need to be refined. Jean Carlet was present at this round table. He proposed the participation of WAAAR to the programme. This was accepted by all the participants, as well as all members of the executive committee of ESICM.
Clinical Drug Trials; Violations, Fabrications and lack of full transparency
Public Conference on Clinical Drug Trials; An exclusive update from the IP watch
In this report by the IP Watch, The Public Conference on Clinical Drug Trials was covered. The conference was organized by Health Action International and Public Eye (formerly Bern Declaration) and gathered a number of speakers coming from international organizations, academics, public-private partnerships, and public institutions. The organizers mentioned that they invited the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) but that they were unable to participate. The speakers, who were asked by the IP watch, claimed that there is a possible distortion of results. Speakers also noted that there is a “growing trend for pharmaceutical companies to conduct clinical trials in developing countries”. Patrick Durisch from Public Eye said in introductory remarks that data released on clinical trials suffer from manipulation and bias, putting participants at risk but also the public at large. Efficiency results are often overplayed and the harmful side effects downplayed. “Full transparency should be the rule and not the exception,” he said.
According to a source, some pharmaceutical companies are interested in shortening the clinical trial process to bring patented products on the market sooner. In low and middle-income countries, the recruitment of participants is easier, he told IP watch. Egypt is one of the countries which host a large number of clinical drug trials, according to Ayman Sabae, Right to Health researcher for the Egyptian Initiative for Personal Rights. One of the reasons for this trend is that in Egypt, some 60 percent of total health care comes from personal expenses, as only about 8 percent of the population has access to private insurance. Egypt has an attractive research infrastructure, he said, and a fast-growing treatment-naïve population. Clinical trials are much cheaper and the legislation protecting the rights of patients is weak.
AMR-Times comments: Given the current push towards the production of new antibiotics and The IFPMA’s recommendations for a new economic model to incentivise innovation, through push and pull mechanism, to what extent will the clinical trials of these prospective new antibiotics will be “Transparent”? and how will the level of transparency affect the potential patients who are “Eligible” for the clinical trials, and the outcome of those clinical trials, especially given the time pressure to produce new antibiotics.
Web=links: http://www.ip-watch.org/2016/09/30/clinical-trial-reporting-biased-full-disclosure-transparency-needed-speakers-say/
http://www.ip-watch.org/2015/04/30/pharma-offers-view-on-how-to-slow-antimicrobial-resistance-boost-research/
http://haiweb.org/cdtconference/
A recent report shows that 80% of data in clinical trials in China have been fabricated!
According to SBS, and other news sources, and as reported in the Economic Information Daily newspaper in September, the Chinese State Food and Drug Administration performed a one-year review of 1,622 clinical trials of pharmaceutical drugs awaiting approval for entering the market.
It was concluded that more than 80% of the clinical trial data was “fabricated,” and/or failed to meet requirements for analysis. It was mentioned, according to the report that some pharmaceutical companies have allegedly tampered with data that did not match the expectations for the drug, or actively hid the reports showing unwanted side effects.
“More than 80 percent of applications for mass production of new drugs have been cancelled in the light of the findings, with officials warning that further evidence [of] malpractice could still emerge in the scandal,”- Radio Free Asia (RFA).
Web=links: http://www.sbs.com.au/topics/science/fundamentals/article/2016/10/03/report-reveals-80-data-chinese-clinical-trials-have-been-fabricated
http://www.rfa.org/english/news/china/clinical-fakes-09272016141438.html
AMR in the News
CDC awards more than $14 million on innovations to combat antibiotic resistance and to understand the microbiome
As part of its continued efforts to protect patients and slow antibiotic resistance, CDC is investing in research to discover and develop new ways to prevent antibiotic-resistant infections and their spread, as well as unlock the mysteries of the microbiome.
“Understanding the role the microbiome plays in antibiotic-resistant infections is necessary to protect the public’s health,” said CDC Director Tom Frieden, M.D., M.P.H., “We think it is key to innovative approaches to combat antibiotic resistance, protect patients, and improve antibiotic use.”
Research projects will study:
- How antibiotics disrupt a healthy microbiome
- How a disrupted microbiome puts people at risk
- How antibiotic stewardship protects the microbiome
Web=link: http://www.cdc.gov/drugresistance/solutions-initiative/microbiome-innovations.html
New Vaccines Are Essential to Fighting Antimicrobial Resistance
In this Chatham house article, which was written by the by Professor David Heymann, and Abbas Omaar, it was highlighted that Vaccine development is often underrated when addressing AMR. Among the proposed solutions for tackling AMR, vaccines are a major tool that eliminates the need for antimicrobials.
It was also mentioned that more efforts should be dedicated to a cost-benefit analysis of vaccines for AMR control, and their relative value compared with investments in stewardship of antimicrobials and better pipelines of new antibiotics. “However, the universally accepted declaration will likely encourage commitments to intensify efforts and mobilize sustainable funding. In planning how the resources are allocated in the fight against AMR, the enormous potential of vaccines must not be relegated to the sidelines”- stated the authors.
Web=link: https://www.chathamhouse.org/expert/comment/new-vaccines-are-essential-fighting-antimicrobial-resistance
25-year-old stuns medical community with possible solution to antibiotic-resistant superbugs
This article highlighted a promising step towards tackling AMR. It says that: Shu Lam, a 25 years old Ph.D. student found a way to kill antibiotic resistance superbugs. The peptide polymers she invented via "polymerization" is able to interfere with the survival of the bacteria and instigate its self-destruction. Besides being safe targeting selectively the superbug and its inability to enter normal cells due to its relatively big size, these polymers could have a crucial role in the fight against AMR. Despite being tested several times against different superbugs and proving its effectiveness and safety, Lam's supervisor stated that these polymers would need five more years of investigations and testing before developing a final cure.
Web=link: http://indiatoday.intoday.in/story/antibiotic-resistant-superbug-cure-peptide-polymer/1/775363.html
The UN just categorized antibiotics in the food system as a crisis on par with AIDS and Ebola
For the fourth time in the history of UN, subsequent to AIDS, NCDs and Ebola, a high-level UN general assembly has been committed to discuss AMR and the roadmap of tackling it. The usage of antibiotics in the food sector plays a huge role in AMR and cannot be overlooked. The article discusses the policies that the US-based fast food chains have adopted to decrease their usage of antibiotics in livestock and food products.
Web=link: http://qz.com/788548/the-united-nations-historic-meeting-on-antibiotic-resistance-puts-the-threat-on-a-level-with-hiv-and-ebola/
Uganda conference 21st – 22nd November 2016, Mbale, Eastern Uganda; Theme: “Promoting Best Antimicrobial Practices in Uganda"
In this concept note for the expected conference, it was mentioned that Antibiotic resistance has become a significant problem and a threat to Uganda and that the misuse of antibiotics in agriculture, inadequate infection control in health facilities, as well as poor quality control of drugs are among the many challenges the country is facing. The national conference is planned to be held in November, with objectives including bringing together stakeholders to discuss the challenges and agree on a multi-sectorial resolution. The conference is expected host participants from the Ministry of Health, Ministry of Agriculture Animal Industry and Fisheries, National Drug Authority, World Health Organization, the private sector, laboratory sciences, clinical practice, pharmacies, health care students, veterinary medicine and research institutions.
More details about the conference including its subthemes, formats, documentation, participation and expected outcomes can be found in the link below.
Web=link: http://conference.bufhs.ac.ug/Conference%20concept%20paper%20v3.pdf
AMR-related scientific articles
Prevalence of Methicillin-Resistant Staphylococcus aureus and Other Staphylococcus Species in Raw Meat Samples Intended for Human Consumption in Benin City, Nigeria: Implications for Public Health
Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that has become resistant to many of the antibiotics used to treat ordinary staph infections. Most MRSA infections occur in people who've been in hospitals or other health care settings. This study, which was held in Benin, Nigeria, aimed to detect MRSA in raw meat samples. Different tested samples from pork, beef, and chicken were collected from consumer markets during February - April 2015. After Staph isolates were identified, antibiotic susceptibility tests were performed to detect resistant species. The results revealed that not only Methicillin Resistant Staphylococcus Aureus (MRSA) was found, but also penicillin, clindamycin, chloramphenicol, trimethoprim-sulfamethoxazole, kanamycin, amoxicillin, cloxacillin, erythromycin, vancomycin, and gentamycin resistant strains. In the conclusion, it was mentioned that “the incidence of methicillin-resistant staphylococci from retail raw meat confirms methicillin-resistant staphylococci is no longer only a problem for hospitals and has also entered the food chain, suggesting gene transfer of bacterial pathogens.”
Web=link: http://www.mdpi.com/1660-4601/13/10/949/pdf
Dietary zinc alters the microbiota and decreases resistance to Clostridium difficile infection
Clostridium difficile is a major health care-associated pathogen that is responsible for a wide spectrum of disease, ranging from mild diarrhea to life-threatening complications, such as pseudomembranous colitis and toxic megacolon. The severity of Clostridium difficile infections is highly affected by the antimicrobial therapy intake as a result of antibiotic disruptive action on gut normal flora. In this study, new findings suggested that excess Zinc diet has the ability to change gut's flora in a similar way the antibiotics do which subsequently can increase susceptibility to Clostridium difficile infections.
Web=link: http://www.nature.com/nm/journal/vaop/ncurrent/pdf/nm.4174.pdf
Acquired resistance to chlorhexidine- is it time to establish an ‘antiseptic stewardship’ initiative?
Chlorohexidine digluconate (CHG) is an antibacterial agent used for several applications in hand hygiene, skin antisepsis, oral care and patient washing. In this study, scientists tested the resistance of various bacterial species to CHG. They concluded that bacterial species such as: Enterobacter, Pseudomonas, Acenitobacter, Proteus, Providencia, Enterococcus and multi-drug resistant Klebsiella pneumoniae acquired stronger resistance to CHG than other species, with the possibility of cross-resistance to antibiotics. This resistance has resulted in several outbreaks and infections. Liquid soaps or alcohol-based hand rubs containing CHG used in intensive care units do not have a clear evidence-based benefit, thus their use can be stopped. It was advised by researchers in this study to limit the use of CHG containing agents to applications with a clear patient benefit, such as treatment of puncture sites of central venous catheters to reduce central-line associated blood-stream infections. The study presented several proposals to initiate a “biocidal stewardship” with CHG in order to maintain its valuable effect.
Web=link: http://www.journalofhospitalinfection.com/article/S0195-6701(16)30374-7/abstract (not open access)
Diluted honey inhibits biofilm formation: potential application in urinary catheter management?
Urinary catheters inserted in patients for long periods of time are usually susceptible to biofilm formation leading to infections and accumulation of pathogens. In this in vitro study, scientists from the UK were testing whether diluted honey is effective in inhibiting biofilm formation. They used Manuka honey (Unique Manuka factor 15+) and observed its effects on Escherichia coli and Proteus mirabilis when it was added either with the bacteria or 72 hours later. Researchers in this study concluded that diluted Manuka honey showed a dose-dependent response, with maximal inhibition of biofilm formation on a vinyl substrate using the lowest concentration of honey tested (3.3%) after 72 hours at 37 °C. It was also observed that the effects of honey on E. coli were much stronger than P. mirabilis.
Web=link: http://jcp.bmj.com/content/early/2016/08/26/jclinpath-2015-203546.abstract (not open access)
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