Anti-Microbial Resistance (AMR) Control 2015

This book gathers more than 30 outstanding authors on a broad range of topics and concepts, from proposals for new Intellectual Property Rights approaches to R&D for antibiotics, to the latest data showing that the 44 billion dollars spent on antibiotic for animal husbandry may only be wasteful, to the need for urgent investments in water and waste management by banks and investors, or, last but not least, as it is top in the just adopted United Nations Global Plan of Action on AMR: infection prevention and control (IPC) as a must against AMR, Ebola and MERS

by Garance Fannie Upham

Deputy General Secretary, AC2BMR/WAAAR World Alliance Against Antibiotic Resistance

Anti-Microbial Resistance (AMR) Control 2015


The book AMR Control 2015 gathers more than 30 outstanding authors on a broad range of topics and concepts, from proposals for new Intellectual Property Rights approaches to R&D for antibiotics, to the latest data showing that the 44 billion dollars spent on antibiotic for animal husbandry may only be wasteful, to the need for urgent investments in water and waste management by banks and investors, or, last but not least, as it is top in the just adopted United Nations Global Plan of Action on AMR: infection prevention and control (IPC) as a must against AMR, Ebola and MERS.

Let me tell you a secret: the book is intended for the lazy professional, the investment decision makers, because it gives a pocket overview of all the different facets of AMR, all into one single book!

The book was put together by the President and Deputy Secretary of the Paris based World Alliance Against Antibiotic Resistance (WAAAR). It can be consulted on line, articles downloaded individually. Printed copies can be ordered on line.

Global overview of Antimicrobial Resistance. A world leader in the drive to control AMR, Professor Dame Sally Davies, Chief Medical Officer of England, along with Professor John Watson, Deputy Chief Medical Officer and Dr Laura Shallcross, UCL Research Department of Infection and Population Health, present here a succinct overview of the need for action: “Individual nations have recognised the importance of antimicrobial resistance as a health issue, but countries have different needs and priorities. In many parts of the world, those with treatable infections lack access to antibiotics, particularly in rural areas. Here the challenge is to improve access without making the drugs so readily available that they can be used inappropriately, the so-called paradox of controlling drug resistance.”

Antibiotic Innovation– Some Lessons from the WHO Processes on Public Health, Innovation and Intellectual Property. This very comprehensive overview, from the Norwegian Institute of Public Health Professors Jens Plathe and John-Arne Røttingen provides us a well informed overview of business models, inspired by the experience of  WHO’s Consultative Expert Working Group on Research and Development (CEWG), which the second author had chaired: How to combine reduction of ‘excess use’, with ‘equitable access’? Experience from neglected diseases can be brought to bear. “How can IPR be mobilized and harnessed in ways that contribute to a feasible economic reward model for sustainable access to effective antibiotics, and in this respect what experiences can be drawn from the field of neglected diseases generally and from the recommendations proposed by the CEWG under the auspices of WHO?”

Creating an Intergovernmental Consortium for New Antibiotics. WHO Assistant Director-General Dr Marie-Paule Kieny has given a lot of thoughts to the kind of new development models which would carry the features necessary to satisfy the need to reward R&D. She proposes an “Intergovernmental Consortium for New Antibiotics” that would feature: 1) mostly public sector funded research and clinical trials, 2) grants to small and medium-size innovative companies or universities to develop new products, 3) milestone and end prizes to reward innovation, 4) patent pools to bring together Intellectual Property Rights generated by public sector funded research, 5) production and marketing agreements for a needs-based number of treatments per year”.

Surveillance and Monitoring of Antimicrobial Resistance. US Centers for Disease Control Director for AMR, Professor Steve Solomon, with Dr Kashef Ijaz, unlike many norm setting institutions or public health specialists, do not in the least “demand” yet another load of data to LMICs. On the contrary, they write from the standpoint of how low income countries can be partners in the needed global effort. For example, on the need for Improving laboratory capacity: «The ability of laboratories to accurately and consistently identify pathogens and their antibiotic susceptibility varies greatly. Trained personnel are the single most important asset in any laboratory» Further down he writes «Prioritize which bacteria are most important to track» which is so important in view of the ‘kitchen sink’ approach to bacterial resistance which is a tendency in some resource poor countries after years of not looking at all.

Antimicrobial Resistance Control in Asia. From South Korea, Professor Jae-Hoon Song, a member of STAG (the WHO initiated expert working group on AMR), takes us through the “six major action plans to control and prevent AMR in the Asian region can provide Asian countries: 1) Strengthen the surveillance of AMR and antibiotics use; 2) Improve awareness of AMR; 3) Promote appropriate uses of antimicrobial agents; 4) Strengthen hospital infection control, 5) Promote vaccination against bacterial infections; 6) Strengthen the national infrastructures and international efforts”.

The Actions of China in Antimicrobial-Resistance Containment. Since 2011 China has embarked on an ambitious program for “rational antibiotic use”, reports Professor Yonghong Xiao of the Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases. What is striking is that the same levels of antibiotic drug resistance are found in all regions and settings even though the regions are widely different in terms of socio-economic development, neglected – element in proper antibiotics usage.

A middle-income country model national AMR Plan: South Africa. A very comprehensive model program on AMR control has been put together by the Republic of South Africa, described by Professor Marc Mendelson and Ms Malebona Precious Matsoso in South Africa, the report highlights reinforcement of infection prevention and control within health care structures, and comprises just about all the recommended features, including flu vaccination to decrease superfluous use of antibiotics in the flu season. The South African Strategy Framework features: “Optimization of surveillance and early detection of AMR with a watch on: 1) Antimicrobial resistance patterns; 2) Antimicrobial consumption; , 3) Antimicrobial drug quality; 4) Medication errors.” Overall the RSA program is a model of the kind for a middle income country.

Actions to Face AMR/ABR-Prescription Control in Human Health. Professor Céline Pulcini, of France’s Nancy University Hospital, and WAAR’s General Secretary, a pioneer innovator in her field, discusses what is called antibiotic stewardship. The paper describes the main measures that could be implemented and discuss the potential limitations and barriers to implementation of those restrictive antibiotic stewardship strategies.

The Role of Sanitation in the Development and Spread of AMR. The article from Professor Timothy Walsh, UK Cardiff University and Professor Antoine Andremont, is set to challenge many perceived notions on AMR Control. One sentence for example says: The link between sanitation, or lack thereof, and antimicrobial resistance (AMR) is primarily to do with two factors: the level of antibiotic resistant bacteria in a person’s gut, and 2, the level of AMR in the environment”.

Diagnostic Solutions Critical to Limit Antimicrobial Resistance Development. Time has come for more investments and more expenditures in diagnostics, in every way, postulate Dr Catharina Boehme (Foundation for Innovative Diagnostics), Mark Kessel, and Professor Ilona Kickbush: Accurate, precise, diagnostic tools ought to be considered as crucial as medicines, the necessary companion. Too many doctors in well to do countries bypass precise diagnostic to put patients on antibiotics indiscriminately. Too many LMIC hospitals systematically give ‘a shot of antibiotics’ to a patient coming up with diarrhoea, for example, in regions where parasitic and viral pathogens causing diarrhea are widespread.

Infection Prevention and Control – Patient Safety a Key Objective for AMR Control. Is Patient Safety important for AMR Control says USAID team with Professor Rashad Massoud (with Danika Barry, Sonali Vaid, Samson M. Haumba, Nokuthula Mdluli Kuhlase). According to USAID ‘patient safety’, starting with the prevention and control of infection in health care settings, is a crucial component of any AMR control program, internationally and nationally. This article takes us through the USAID outstanding effort in this area and their partnering with low income countries, in this case Zambia.

Multidrug Resistant Tuberculosis monitoring in India.“Systematic surveillance for TB drug resistance is the best way to document its presence and has been very difficult to establish in most of the high burden countries, the major obstacle to the expansion of routine surveillance activities has been the lack of laboratory capacity needed to detect resistance.” writes Assistant Director General of the TB program for the Indian government Department of Health, Dr Kuldeep Singh Sachdeva, (with Dr S. Anand and Dr Ranjani Ramachandran of the WHO-India).

HIV Resistance to Antiretrovirals another key issue of AMR Management. ​From South Africa, Professor Gary Maartens, Head of Clinical Pharmacology, University of Cape Town, South Africa; Professor Lyn Morris, HIV Virology laboratories at the National Institute for Communicable Diseases, Dr Gillian Hunt, senior research scientist, Centre for HIV and STI and Professor François Venter, Wits Reproductive Health and HIV Institute (RHI) review the management of HIV resistance in a high burden country. With over 6 million persons living with HIV, South Africa has, on record, the highest number of patients to whom the country offers antiretroviral treatment. The RSA is truly a model country today considering that it is not a high resource country, and that it also has, historically, a high load of tuberculosis.

From civil society’s input, other than WAAAR, we have two contributions: CDDEP director Hellen Gelband, reports on the Center for Disease Dynamics, Economics & Policy partnership with LMIC : “The Partnership operates to bring a set of new voices to the antibiotic resistance issue and to establishing local capacity to develop and help to implement evidence-based policies in eight LMICs from Africa and Asia”, while our WAAAR collaborator, Dr Abdul Ghafur explains his Mumbai Declaration initiative, an India wide coalition which has been extremely effective, in that it convinced authorities to stop over the counter sales of medicines.

Just before  the European Médicines Agency  organized the first ever seminar on the Therapeutic use of bacteriophages (June 8th, 2015), which I attended,  I had sollicited two articles on the issue:

Phagoburn: an EU Research program. Professor Patrick Jault, French Military Health Services, and Jérôme Gabard, CEO of Pherecydes Pharma, gives us an account of a specific clinical research “Phagoburn”, funded by the European Union, on the use of viruses specific to bacteria (phages) to combat bacterial infection so dangerous on burn wounds, the type of research which might well open our arsenal to treat antibiotic resistant infections.

Phage therapy: Could viruses help resolve the worldwide antibiotic crisis?The article from Professor Daniel de Vos and Dr Jean-Paul Pirnay, both with the Belgian Military Hospital research, gives a background on ‘phages’ as therapy and stresses the epistemological hurdles in its acceptance for mainstream medicine. Phage therapies could be part of a ‘patient-centered’ highly individualised medicine of the future.

Costs and benefits of antimicrobial use in livestock. Could Animal Husbandry Do Without Antibiotics?  Aude Teillant, researcher at Princeton’s Environmental Institute, discusses the costs and benefits of antimicrobial use in livestock. She is co-author of the OECD just released first study on global consumption of antibiotics in food producing industries.

What are law makers waiting for? In 2006 the EU banned AGPs (Antibiotic Growth Promoters), the US FDA only ‘recommends it’.