“Antimicrobial resistance (AMR): dialogue between sectors”
17-18 December 2015, Smolensk & Moscow, Russia
The RT set up two key objectives:
1.Russian, UK and other European approaches to tackling AMR: national and global action plans.
2.Improve a coordinated approach between health and livestock sectors on the effective use of antibiotics (AB) in Russia and UK/other European countries.
·The key UK and Russian stakeholders supported the RT concept: British Society of Antimicrobial Chemotherapy (BSAC), Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (IACMAC), DoH, RF Ministry of Health, PHE, DEFRA, BIS, FCO, as well as WHO European Office in Copenhagen and EU Delegation to Russia.
· The Russian partners that hosted the first session in Smolensk were the Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (IACMAC, Russian) and Institute of Antimicrobial Chemotherapy (IAC) of Smolensk State Medical University (SSMU). The second session was held at the UK Residence in Moscow. About 60 people attended and contributed to discussion from Russian medical universities and research institutes, innovation hub Skolkovo& Skoltech, Official state agencies and bodies.
· The Russian Minister’s SPAD on AMR Professor Lyalya Gabbasova delivered a talk at the event. The Head and Deputy Head of the Social Policy Committee at the Russian Federal Council participated in Smolensk and Moscow sessions and expressed their support.The overview and analysis of the situation in Russia were given by Russian experts from IAC of SSMU and IACMAC.
· The following UK Professors and experts delivered presentations:
o Prof Dilip Nathwani (President, British Society for Antimicrobial Chemotherapy (BSAC) – Co-Chairman of RT
o Prof John Watson (Deputy Chief Medical Officer, England (DCMO), Department of Health, UK)
o Prof Peter Borriello (CEO of the Veterinary Medicines Directorate, DEFRA, UK)
o Prof Neil Woodford (Head, AMRHAI Reference Unit, PHE)
o Dr Susan Hopkins (Consultant in Infectious Diseases & Microbiology, Royal Free London NHS Foundation Trust, Healthcare Epidemiologist, Public Health England, Honorary Senior Lecturer, University College London)
o Dr E. David McIntosh (Honorary Clinical Senior Lecturer, Imperial College, London UK)
o Mr Tim Mepham (AZ)
o Prof Shabbir Simjee (Elanco)
·Russian speakers:
o Prof Roman Kozlov - (Chief Specialists on Clinical Microbiology and AMR, RF Ministry of Health, President of IACMAC) – Co-Chairman of the RT
o Professor Lyalya Gabbasova(Special Adviser to the RF Minister of Health)
oDr Andrey V. Dehnich (Deputy director, Institute of Antimicrobial Chemotherapy of Smolensk State Medical University)
oDr Michael Eidelstein (Head of Microbiological Laboratories, Institute of Antimicrobial Chemotherapy of Smolensk State Medical University)
o Dr Vladimir Bulatov (GSK Russia Country Medical Director) Dr Kamil Saytkulov (Head GR, Moscow office)
o Dr Svetlana Ratchina (IACMAC)
·The WHO approach was presented by Dr Danilo Lo Fo Wong, (Program Manager Control of AMR, Communicable Diseases, Health Security, and Environment World Health Organization Regional Office for Europe, WHO)
·UK International pharma companies supported the RT and delivered presentations on industry initiatives to tackle AMR in medicine and veterinary: AstraZeneca, GSK, ELANCO, Pfizer.
·At the end of the meeting all the participants were invited to send key points that they deemed a priority to take forward. Below is a synthesis and summary of these key points and of the discussions. This narrative is by no means all inclusive but aims to highlight the emphasis placed by those attending the round-table discussion. The intention of these key points is that they will inform, in addition to a much wider consultations process, the development of proposed Russian Federation AMR Strategy & Action Plan.
1. Vision and Strategy
To ensure a common understanding of the issues across all species and sectors it is fundamental to agree on the definitions of all the commonly used terms.
AMR control activities must be underpinned by a “One Health approach” . This approach should reflect a true integrated approach that engages and has buy in from all the relevant stakeholders at the outset.
Prevention of infections, including the vital role of vaccines, new approaches to diagnosis including point of care diagnostics, better use of existing diagnostics, strong surveillance and stewardship, active R&D including new drug discovery, through regional, national and international collaboration are essential components of the AMR strategy.
The UK’s new strategy, with a focus on implementation and measuring progress., represents a step change in the determination to make a difference within the UK. The WHO’s Global Action Pan for AMR should be seen as an opportunity to do the same around the world. The effectiveness of the strategy will require collaboration across a wide range of government departments, professional groups, agriculturalists, veterinarians, healthcare administrators, public and media engagement.
Ensuring political ownership and commitment at the highest level is key to the success of the strategy. Presenting the case to policy-makers and gaining their political and financial support are critical to the success of the strategy. This round table discussion is a part of this overall process.
There is a strong case for setting up a national oversight body such as a Task Force or equivalent to co-ordinate the implementation of the Russian strategy and action plan.
2. Surveillance of AMR
High quality reference microbiology must be used to underpin surveillance of AMR, giving critical information about resistant strains, their resistance genes and any mobile genetic elements and setting national problems into international context.
Whole genome sequencing offers potential to revolutionise how surveillance of resistance is delivered and could reduce the scale of phenotypic testing required.
Russian, UK and other relevant institutions should closely work together to support WHO capacity building activities in surveillance. There is scope to share UK/Russian IT capability to develop business analytical tools and ‘dashboards’ for analysing AMR data effectively and simply.
Developing collaborations through focused research [e.g PhD programmes] is suggested as a pragmatic means of developing the relationships that facilitate broader and larger collaborations.
3. Antimicrobial Stewardship
Reduce the need for antibiotics through improved water, sanitation, and immunization. Improving coverage for existing vaccines and adding new ones, improving access to clean water and sewerage systems, and ensuring a safe and healthful food supply all reduce the need for antibiotics, thereby reducing antibiotic resistance rates.
Better infection prevention and antibiotic stewardship programmes reduce infection rates. Surveillance of resistance and hospital-acquired infections gives clinicians administrators information for management and policy decisions.
Antimicrobial stewardship programmes should be mandatory and will require clinical leadership and organisational leadership support combined with clinical professional and organisational accountability. Use of metrics/indicators for prescribing can support local improvement and scrutiny.
Where possible, the antimicrobial stewardship should be delivered through a multi-professional team approach and aligned to the infection prevention/control, risk management or patient safety components of the organisation; The role of the clinical pharmacist or senior trained nurse in stewardship is an important opportunity. The constitution and operational model of the stewardship programme should be flexible and reflect local needs, cultures and resources.
Surveillance of the quantity and quality of antimicrobial use in primary, secondary and tertiary care is a fundamental component of stewardship programmes. These should be linked to surveillance of resistance at a national and healthcare facility level. Use of paper based or electronic point prevalence surveys is a key tool to audit the quality of antibiotic use. Simple tools, validated across the healthcare facilities, are available and could be adapted to measure consumption.
Systems to feedback data to healthcare systems and clinicians is an important component of surveillance and key to clinician engagement
Use of social, behavioural and improvement science methods in implementating effective and sustainable stewardship and infection prevention practices are worthy of pursuing.
Change incentives that encourage antibiotic overuse and misuse to incentives that encourage antibiotic stewardship.
Eliminating economic incentives, for example through de-linking of financial revenue and amount of antibiotic use, that encourage the overuse of antibiotics all along the supply chain—in hospitals, in communities, and in agriculture—can conserve antibiotic effectiveness.
Regulation to stop the use of over the counter and non-prescription use of antimicrobials
Educational programmes to support health professionals and the public in prudent use of prescribing of antimicrobials should be in place. Participation in educational programmes that support better prescribing should be encouraged as a core part of healthcare staff contiuing professional development. These educational programmes can take on a variety of formats. The use of e-learning educational programmes is a cost-effective means of delivering mass training.
4. Drug and Vaccine Discovery
Governments across the globe need to act on how they can commit to a sustainable market for antibiotics. For example, innovation in R&D in development of new antibiotics will be driven if it is seen as commercially viable
Urgent action is need by individual governments for new reimbursement approaches (i.e. Insurance type reimbursement models) to signal a change in address the current thin Pipeline.
Mitigate risk for both developers of the new products and health systems through innovative reimbursement schemes and globally harmonized regulatory standards;
To encourage and support greater commitment to discovery and development of innovative new antibacterials pharmaceutical companies need appropriate incentives: These include :
Partnerships to discover and develop new antibiotics- such a model could include supporting and sharing research and development experience/“know how” between biotechs, academia, SMEs, governments, regulators and health care professionals
Continued investments in a range of innovative antibiotics and vaccines with supporting and diagnostics ; dedicated anti-bacterial/vaccine R&D teams would provide greater focus
5. Veterinary Practice
Irrespective of differing evidence of the risk of antibiotic use and resistance emergence in people or animals, antibiotics should be treated as a precious commodity.
Antibiotics in food producing animals should be restricted to use for disease prevention and control and the experience in the EU of banning antibiotics for growth promotion should be used to reconsider such use in other countries.
Antimicrobial Consumption : Total sales of active antibiotic ingredient should be collected for both veterinary use and for human use by all countries. For example, the EU system for veterinary antibiotic sales is a good model
Antimicrobial surveillance : Establishment of an AMR infra-structure that encompasses a veterinary microbiologist with expertise in AMR who can provide sustainable leadership in this area, a national veterinary microbiology laboratory that supports the formulation of a governmental funded national AMR monitoring program
Stewardship: Formulation of national guidelines for prudent use and which encompass generic “good practice” and provide specific details for swine, cattle and sheep and perhaps over time acqua-culture
Educational outreach in the veterinary sector on responsible use of antibiotics in veterinary medicine.
Dilip Nathwani
Roman Kozlov
22/01/2016