Antimicrobial resistance from a global perspective. Along with clean water, sanitation, and vaccines, antimicrobials were responsible for the vast improvements in health and life expectancy over the past century. However, those important gains are at risk, due to the widespread misuse, and overuse of this life-saving drugs. At the same time, many people, especially in low and middle-income countries, are still struggling to gain access to high-quality antimicrobials to treat infections. Antimicrobial Resistance or AMR is a global issue. The lack of action in one country can undermine progress in another. Therefore, responding to AMR is a global responsibility, relying on accountability and solidarity among countries. This presentation will give you an overview of how a global momentum to address AMR was built up, and how the World Health Organization and partners are working on bringing about change. AMR is recognized as one of the greatest threats to human health worldwide. Antimicrobial resistant microbes can be found in people, animals, food, and the environment. They can spread between people and animals, from person to person, from country to country. Poor infection control, inadequate sanitary conditions, and inappropriate food handling encourages spread of antimicrobial resistance. In May 2016, a review on AMR was published in which it is estimated that unless action is taken, the death toll from AMR could increase the 10 million lives each year by 2050. This means that every three seconds a person will die because of a resistant infection. In economic terms, it means that every year, an economy the size of the United Kingdom will be removed from the global economic output. In 2014, WHO published a global report on the surveillance of antimicrobial resistance. Based on data obtained from 129 member states around the world, the most important findings of the report revealed very high rates of resistance observed in all WHO regions, highlighting the global nature of the problem. That we're still many gaps in knowledge and information on pathogens that are of major public health importance, and that key tools to tackle AMR, for example, surveillance systems, do not exist in many countries. In 2015, WHO published another report providing a global overview of the capacity of countries to respond to the threat of AMR. The most important findings of this report include widespread over-the-counter sales of antimicrobial medicines, even in some countries that have a policy in place. Lacking standard treatment guidelines, lacking infection prevention and control programs, low public awareness, and in addition, the report highlighted the issue of weak linkages between relevant sectors, low levels of coordination and leadership, and it only 25 percent of the 133 countries that provided information for the report, have a comprehensive action plan for AMR in place. So, let us look at the broader context of AMR. Antimicrobials are non-renewable resources, and the current benefits of antimicrobials must be balanced against their use leading to resistance. Such services as major surgeries, cancer treatments, and treatment of pneumonia will be compromised, endangering all the progress made in modern medicine, and undermining the function of health systems as we know them. Increasing expectations and demands of patients, due to the ethical dilemma of access versus excess; where some populations like access to vital antimicrobials, easy access in other populations due to excessive use, and misuse of these precious medicines. Financial incentives that link medicine sales with health provider revenues should be abandoned. If current practices are continued, the societal impact of our actions will compromise the right of future generations, to effective treatment options. So, let's look at the specific challenges for low and middle-income countries, and why they are particularly at risk. Low and middle-income countries usually have a high burden of infectious diseases, a large proportion of which could be caused by resistant pathogens. This burden is maintained through poor infection prevention and control practices and a generally low quality of care. There often is weak control of prescription or enforcement of legislation against over-the-counter sales, as well as the issues of access versus excess. There may be issues with quality of drugs and diagnostics including counterfeit sub-standard medicines. Generally, there is a low service delivery capacity including diagnostic support by laboratories. All these factors considered, the achievement of several sustainable development goals will depend upon access to, and availability of affordable antimicrobials that work. Mortality and morbidity in vulnerable populations of newborns, children, and women will escalate if AMR is not effectively contained. In this sense, AMR should be considered a development issue, that must be addressed accordingly throughout the world. While there's currently only limited reliable knowledge about the availability of antimicrobial medicines including antibiotics around the world, it is generally accepted that the current antibiotic consumption is highest, in high-income countries. But the growth in antibiotic consumption is highest in low and middle-income countries. In Europe, primary care accounts for 80-90 percent of all antibiotic prescriptions. Mostly, for respiratory tract infections. Antibiotics are also widely utilized in other sectors, for instance, approximately 80 percent of antibiotics in the United States, are consumed at agriculture, farming, and aquaculture. Antimicrobial resistance is a complex problem that affects all of society and is driven by many interconnected factors. Single isolated interventions have shown to have limited impact. Coordinated action is required to minimize the emergence and spread of antimicrobial resistance. Although there are many activities, campaigns, policies, and protocols around the world, these need to be coordinated to avoid duplication of work, and important gaps unattended. AMR has been known to be an important health issue for several decades, but as a slow developing threat, it was often overshadowed by more acute and visible health issues such as SARS, evident influenza, and Ebola. However, the unprecedented momentum around antimicrobial resistance that we witness around the globe today, can be largely accredited to a very successful World Health Day in 2011. The day did not only draw attention again to the issue of antimicrobial resistance, but managed effectively to instill a sense of urgency, and severity through the campaign slogan "No action today, no cure tomorrow". Later that same year, all 53 member states of the WHO European region, adopted a regional strategic action plan on antibiotic resistance. As awareness continued to grow, the Global Action Plan on Antimicrobial Resistance was adopted by the World Health Assembly in 2015. Later that year, AMR also appeared high on the G7 Agenda, ensuring support of these powerful countries. In 2016, AMR was discussed during the United Nations General Assembly as only the fourth health issue ever to be discussed at this high level. In 2017, AMR is high on the agenda of the G20 meeting which will further strengthen AMR on the global health agenda and affirm WHO's leadership in addressing AMR globally. The goal of the Global Action Plan on Antimicrobial Resistance is to ensure for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality assured, used in a responsible way, and accessible to all who need them. The action plan has five strategic objectives: improving awareness and understanding, which includes education of human and animal health professionals. Strengthening knowledge in evidence-based, which includes strengthening national AMR surveillance systems. Reduce incidence of infection which includes implementing infection prevention and control programs, as well as vaccination programs. Optimize use of antimicrobial medicines which includes measuring the use of antimicrobials. Develop the economic case for sustainable development that takes account of the needs of all countries and increase investment in new medicines, diagnostic tools, vaccines, and other interventions. WHO is working closely with FAO and OIE and One Health Approach to promote best practices to avoid the emergence and spread of antimicrobial resistance, including optimal use of antimicrobials, in both humans and animals. The global action plan contains a framework for action which tabulates the action step member states, the Secretariat, and international and national partners need to take in order to attain the goal and meet the objectives of the global action plan. By committing to the global action plan, all countries were urged to have a national aim or action plan in place by May 2017. Although not all countries were able to reach this goal within two years, most countries are developing their national action plans and many activities have been launched all over the world. At the national level, WHO support governments national action plan development, implementation, and monitoring. WHO's work at a technical level involves strengthening the health workforce by building capacity for infection prevention and control, Antimicrobial Stewardship Antimicrobial Resistance and use surveillance, and by supportive importers to detect them report resistant pathogens. Next to supporting countries individually, important work is being done at the global level. In the next slides, a few key areas are highlighted. WHO and partners have been building resistance surveillance networks to stimulate and strengthen national surveillance systems. Examples of such resistance networks include, ReLARVA in the Americas and the CAESAR Network in Central Asia and the East European part of the European region. The European Center for Disease Prevention and Control, ECDC, Manages regional networks on AMR, Antimicrobial use, and healthcare associated infections for countries of the European Union. In October 2015, WHO launched a global Antimicrobial Resistance Surveillance System or GLASS to foster standardized AMR surveillance globally. Surveillance of Antimicrobial use and resistance is important for building the evidence base for national policy making, advocacy, implementing interventions, and monitoring their effect. Prevention is better than cure. High vaccine coverage and effective infection prevention and control measures, prevent infections that otherwise would require treatment and therefore help preserve Antimicrobials. Improved management of the use of Antimicrobials in food animals, particularly reducing those critically important for human medicine, is an important step towards preserving the benefits of Antimicrobials for people. WHO has ranked Antimicrobials according to their relative importance in human medicine in order to help clinicians, regulatory agencies, policymakers, and other stakeholders to preserve the effectiveness of currently available Antimicrobials. Essential medicines are those that satisfy the priority healthcare needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage forms, with short quality and adequate information, and at a price the individual and the community can afford. The newest edition of the Essential Medicines List will give due attention to resistance patterns with the attempt to reduce and contain resistance for high priority antimicrobial medicines, and to avoid empiric use of Antimicrobials with widespread resistance. WHO was asked by member states to develop a global priority pathogens list antibiotic-resistant bacteria, to help prioritize research and development of new and effective antibiotic treatments. It should be noted that Micobacterium tuberculosis, the bacteria responsible for human TB was not included in the scope of the prioritization of previously unrecognized health threats, because there is already consensus that TB is a top priority for R&D for new antibiotics. The most critical group of all includes multidrug-resistant bacteria that pose a particular threat in hospitals, nursing homes, and among patients whose care requires devices such as ventilators and blood catheters. They can cause severe and often deadly infections such as bloodstream infections and pneumonia. These bacteria have become resistant to a large number of antibiotics, including carbapenems and third-generation cephalosporins, and while more on these vital, more is needed to solve the problem. To address resistance, there must also be better prevention of infections and appropriate use of existing Antimicrobials in humans and animals, as well as rational use of new Antimircobials that may be developed in the future. The first objective of the Global Action Plan on AMR, is to improve awareness and understanding of Antimicrobial resistance through effective communication, education, and training. To help achieve this objective, WHO launched the antibiotic's handle with care campaign. First World Antibiotic Awareness Week in November 2015, working closely with FAO and OIE. The Awareness Week has been well-received and campaigns have been launched around the world during the week. The campaign includes call for action for all levels of society including health professionals. WHO and many technical partners support capacity-building of healthcare professionals, including frontline clinicians, epidemiologists, and microbiologists to improve patient care. Their efforts also helped to build AMR surveillance to gain an overview of the resistance patterns to support treatment decisions. Healthcare professionals need to become antimicrobial stewards, who consider not only the individual effect of prescribing medicines, but also realize the societal impact of the chosen treatment. This is why clinicians are such an important part of the solution and the reason why they are targeted by campaigns and capacity building interventions. National action plans on AMR often involve reforms of educational curricula for under and post-graduate health care professionals. Licensing requirements and other interventions aimed with clinicians. Multifaceted comprehensive interventions to reduce the over use of antimicrobial medicines, have been found to be effective and better than single initiatives. Globally, there's consensus that intervention should encompass the enforcement of the policy of prohibiting the over-the-counter sales of Antimicrobials. The use of antimicrobial stewardship programs, participation of clinicians in audits, utilization of rapid point of care tests, the promotion of the late Antimicrobial medicines prescribing strategies, enhancement of communication skills with patients, and enhance professional collaboration and interdisciplinary teams. Everybody has a role to play to help control Antimicrobial resistance or in other words, nobody is exempt from the problem nor from playing a part in the solution. Thank you for your attention.
