1 Center for Disease Dynamic, Economics & Policy, Washington DC

The UN High-Level Meeting on Antimicrobial Resistance: A Historical Opportunity to Ensure Sustainable Access to Effective Antimicrobials

Ramanan Laxminarayan1,2,3, Carlos F. Amábile-Cuevas4, Otto Cars5, Timothy Evans6, David Heymann7, Steven Hoffman8, Alison Holmes9, Marc Mendelson10, Devi Sridhar11, Mark Woolhouse11, John-Arne Rottingen12,13,14

2 Princeton Environmental Institute, Princeton University, USA

3 Public Health Foundation of India, India

4 Fundación Lusara para la Investigación Científica, Mexico

5 ReACT, Uppsala University, Sweden

6 The World Bank, Washington

7 The Center for Global Health Security, Chatham House, London

8 University of Ottawa, Canada

9 Imperial College, UK

10 University of Cape Town, South Africa

11 University of Edinburgh, UK

12 Norwegian Institute of Public Health, Oslo

13 Institute of Health and Society, University of Oslo

14 Harvard T.H. Chan School of Public Health, USA

Introduction

Global access to effective antimicrobials is under serious threat1. Antimicrobial resistance is a global challenge akin to climate change and the impact of resistance is increasingly visible in all countries regardless of income level. An estimated 700,000 deaths worldwide including 214,000 neonatal sepsis deaths are attributable to resistant bacterial pathogens each year2. Notably, insufficient access and delays in access to antibiotics cause more deaths than antibiotic resistance.2 The key is to promote universal provision of antimicrobials while ensuring continued effectiveness. The UN General Assembly High-Level Meeting of Heads of State will discuss the SAEA agenda this September 2016. Such an unprecedented opportunity may not present itself again in the foreseeable future and it is essential that the meeting achieve more than a mere call to action. The meeting must provide direction and leadership on developing realistic goals, stimulate political will, mobilize resources, and agree on an accountability mechanism for global collective action.

Providing sustainable access to effective antimicrobials (SAEA) is a prerequisite for achieving several of the SDGs3 and requires global collective action, both among countries and among sectors within and across in countries that deal with health, agriculture, environment, animal husbandry and trade4. The elements of effective country-level action on tackling antimicrobial resistance are described in the World Health Organization’s Global Action Plan on Antimicrobial Resistance, which has been ratified by the World Health Assembly and is supported by the Food and Agricultural Organization and the Organization for Animal Health (OIE). Yet, AMR transcends the capabilities of these organizations and requires the involvement of UNICEF, UNDP, UNEP, UNESCO and the World Bank; and other multilateral agencies as part of a globally coordinated plan.

We believe that the UNGA HL meeting should establish a UN High-Level Coordinating Mechanism on Antimicrobial Resistance (HLCM) with the following core functions that are similar to those performed by UNAIDS when it was first established in 1996.

1. Advocacy: Raise awareness about the current challenges with lack of access to antibiotics and drug resistance.

A global campaign to change attitudes and norms towards antibiotics to enable healthcare and veterinary professionals, and the public understand the significant value and potential side-effects of antibiotics should be a primary goal.

2. Monitoring and Evaluation: Establish, monitor and report on global and national enforceable targets for antimicrobial access, appropriate use, policies implemented, and resistance rates in human, agricultural, veterinary and environmental sectors.

The HLCM should achieve consensus on strategies and targets across the animal and human health sectors. These would include interventions proposed by the WHO Global Action Plan, and add others that would move towards sustainable access to antimicrobials7. The HLCM should agree on targets to reduce the global burden of deaths avertable by effective antimicrobials, and reduction of inappropriate consumption of antimicrobials in human and/or animal sectors.

A global monitoring and review platform is needed to assess progress on goals to improve appropriate use of and access to quality-assured antimicrobials and diagnostics in human, animal and environmental sectors. The platform should track key indicators related to public health, burden of bacterial infections caused by resistant-pathogens, proportion of populations lacking access to antimicrobials (including number of children <5 years dying from pneumonia due to lack of access to antibiotics) as a global indicator, volume of therapeutic and non-therapeutic antimicrobial consumption in human, environmental and animal sectors. Tracking is also needed to measure progress on innovation on vaccines, alternatives to antimicrobials, and the pipeline for new antimicrobials. Support for LMICs is needed to build the relevant capacity for surveillance and data collection. An independent, transparent, expert-led process in which the performance of countries, donors, and non-state actors is analysed, appraised, and reported in order to trigger feedback that could address shortfalls in performance should be part of the global monitoring and review platform.

3. Resource Mobilization: Encourage financial commitments from donors, aid agencies and countries to financing the implementation of global and national level action plans as well of a global coordination and monitoring platform.

Global financing should be targeted to goals that benefit the global public good including a) support HLCM functions; b) enable existing global financing mechanisms such as the Global Fund, GAVI and UNITAID to expand their mandate to assist countries in expanding access to antibiotics, diagnostics and vaccines, c) assist low- and lower-middle-income countries with planning and implementing national action plans including on improving surveillance, pharmaceutical regulation, public health; and d) support a global innovation fund to energize a pipeline of vaccines, diagnostics, alternatives to antimicrobials as well as new antimicrobials in a manner that encourages delinkage and conservation of effectiveness. The HLCM affords the opportunity to expand from the donor-driven model and link the mobilization of financial resources to overall global financing needs that have been proposed for achieving universal health coverage.

4. Multi-Sectoral Domestic Coordination: Support member states to pursue national level, multi-sectoral action involving non-governmental organizations, civil society, and private sector that implement the WHO Global Action Plan alongside national efforts to improve access to effective antimicrobials.

National level multi-sectoral action is critical and should be supported technically by the HLCM. Although targets should be set through the HLCM, country-level strategies should be country-specific rather than centrally mandated. Countries should develop a robust stewardship framework that promotes appropriate use of antimicrobials within the context of the goal of SAEA.

The HLCM structure could select elements from the Framework Convention on Tobacco Control5, the Intergovernmental Panel on Climate Change6, or other specific international agreements/initiatives to solve problems that require global cooperation across various sectors. The HLCM must include UN organizations and key countries representing their regions, civil society, industry and development agencies that, like governments and international organizations, periodically report to the UN Secretary General and to the UNGA on progress achieving SAEA goals.

SAEA is a key development issue and the September UNGA high-level meeting is a rare opportunity to change how we as a global community use the only currently feasible method to treat bacterial infections. It is an opportunity that has been a long time in coming and should not be squandered due to lack of ambition.

References

1. Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance - the need for global solutions. The Lancet Infectious Diseases 2013; 13(12): 1057-98.

2. Laxminarayan R, Matsoso P, Pant S, et al. Access to effective antimicrobials: a worldwide challenge. Lancet 2016; 387(10014): 168-75.

3. Jasovský Da, Littmann J, Zorzet A, Cars O. Antimicrobial Resistance - A Threat to the World’s Sustainable Development. Uppsala University, Sweden: ReACT, 2016.

4. Ardal C, Outterson K, Hoffman SJ, et al. International cooperation to improve access to and sustain effectiveness of antimicrobials. Lancet 2016; 387(10015): 296-307.

5. Heymann DL. What to do about antimicrobial resistance. BMJ 2016; 353: i3087.

6. Woolhouse M, Ward M, van Bunnik B, Farrar J. Antimicrobial resistance in humans, livestock and the wider environment. Philos Trans R Soc Lond B Biol Sci 2015; 370(1670): 20140083.

7. Mendelson M, Rottingen JA, Gopinathan U, et al. Maximising access to achieve appropriate human antimicrobial use in low-income and middle-income countries. Lancet 2016; 387(10014): 188-98.