Addressing a global crisis17/10/16
Dilip Nathwani OBE and Tracey Guise, of the British Society for Antimicrobial Chemotherapy [BSAC], detail one society’s diverse response to the UN’s global AMR action plan.
Global healthcare professionals issued a collective sigh of relief when, on 21 September 2016, 193 UN members signed up to a declaration to fight antibiotic-resistant infections at a meeting of the UN General Assembly.1 These healthcare professionals – working individually, locally within healthcare teams, through professional organisations and collaboratively with industry, government, economic and public stakeholders – have sought to raise the profile of antibiotic resistance and its catastrophic effect on the health of nations for over two decades.
Their voices were not wasted; neither was the story of antimicrobial resistance (AMR) nor efforts to tackle it overlooked. Indeed, ahead of this historic declaration, the catastrophic consequences posed by AMR had been addressed at the highest political levels for over a decade. In 2013 the publication of the World Health Organization Strategic Action Plan on AMR2 was supported by no less than 14 global, regional and national strategies across all continents.
Governments had already begun introducing legislative changes to tackle the problem at global and national levels – changes such as the Generating Antibiotics Incentives Now (GAIN) Act in the US, which provides accelerated approval processes for antibiotic development, and in India the amendment of the Drugs and Cosmetics Act 1940 to prohibit the direct sale of antibiotics to the public.
However, AMR was running the risk of becoming an old news crisis as ever more parties entered the field to call for solutions. The evidence base that AMR is a global epidemic was clear, and since 2013 AMR has been situated alongside climate change on the Global Risk Register. The world was learning of the projected devastating impact that AMR could have.
The AMR Review reports that AMR will be directly responsible for over ten million deaths by 2050, more deaths than from cancer, diabetes, road traffic accidents and cholera combined. The final report by Jim O’Neill’s group has been instrumental in capturing the key global issues and potential solutions to fighting AMR.3 This evidence base will inform our future direction.
The UN declaration has, according to a commentary published in New Scientist,4 provided ‘a once in a generation opportunity’ to address the crisis of AMR. Moreover, it provides an unparalleled opportunity and catalyst for change; after all, this is only the fourth time in its 70-year history that the UN has confronted a major health threat. In doing so, and overnight, the magnitude of the crisis of AMR was acknowledged and placed alongside HIV and Ebola due to the gravity of the threat it poses.
What next? Member nations now have two years to report back on their action plans and co-ordinate efforts to ensure the opportunity presented is not squandered. The declaration offers us no less challenge than before, nor does it offer solutions. It does, however, provide a floodlit political stage on which all stakeholders – professional, political, regulatory, economic and public – can demonstrate their collective commitment and capabilities.
Moving forward, we must adopt the proposed ‘one health’ approach to AMR.4 This approach (defined as the collaborative effort of multiple disciplines – working locally, nationally and globally – to attain optimal health for people, animals and our environment) recognises that the health of all three is connected to the health of animals and the environment.
AMR has clear links to each of these domains, of which we here concentrate on human health. For meaningful actions and outcomes we must translate policies into practices that lead to improvements in drug research and development, infection prevention and control practices, antibiotic prescribing practices, and both professional and public education. This cannot be done alone. Globally, we must harness the resources we already have, identify what we still lack and work alongside governments and key stakeholders to deliver against their targets and achieve the changes that are needed.
One readily available resource is the professional medical charity sector – there is a myriad of global organisations that can offer practicable, low-cost solutions. The Centre for Disease Dynamics, Economics and Policy, in collaboration with six leading organisations, held a forum titled ‘Sustainable Access to Effective Antibiotics’5 ahead of the UN General Assembly. One output was the establishment of CARA (Conscience of Antibiotic Resistance Accountability)6 to provide a powerful alliance to support implementation of the UN declaration and hold governments to account. One partner in this alliance is the British Society for Antimicrobial Chemotherapy (BSAC), which, through the expertise and dedication of its professional members, can offer significant national and international contributions and solutions to tackling AMR (Fig. 1).
BSAC exemplifies what is already developed and available in the fight against AMR and has a broad portfolio of activities, has funded over £4.1m (~€4.8m) in research, operates national programmes to measure antibiotic resistance,7 and has developed software to measure8 how many antibiotics are prescribed and the quality of the prescription so as to help improve prescribing and patient outcomes. BSAC’s chair in public engagement, Professor Laura Piddock of the University of Birmingham, also serves as director of Antibiotic Action,9 a low-cost, high-impact initiative that has over the past five years successfully engaged with professional and public stakeholders to stimulate interest and efforts in antimicrobial drug discovery research and development through a global network of 145 Antibiotic Action champions. The initiative also secured the establishment of the All Parliamentary Group on Antibiotics (APPG),10 ensuring the topic remains high on the UK political agenda.
One of the main focuses of BSAC’s current activity is
multi-professional education on antimicrobial prescribing and stewardship. This activity has a local, national and international focus and aims to use innovative and cost-effective e-learning methods to complement traditional educational methods with the underlying ethos of high-quality, peer-reviewed, up-to-date and globally relevant educational resources that are free at the point of access. An example of this includes BSAC’s partnership with Scotland’s University of Dundee and FutureLearn to deliver the first open access global educational course on antimicrobial stewardship,11 providing access to free education on prescribing to global health economies. In 12 months the course attracted almost 30,000 learners (Fig. 2), adding to the work the society is doing via the British High Commission Science and Innovation Office12 with local colleagues in India,13 Russia14 and Africa15 to develop educational frameworks for multi-professional antimicrobial stewardship education.
To support a more interactive forum for learning, these educational initiatives will be embedded into a modern, innovative virtual learning platform dedicated to AMR education.
The society has a longstanding reputation for developing good quality, pragmatic, evidence-based guidelines, but has also recognised the need to implement core practice more effectively within the ‘real-world healthcare setting’. Led by Professor Peter Davey, a previous president, BSAC is at the forefront of embracing the use of improvement and social science in the context of AMR. The society was also a partner in the EU Innovative Medicines Initiative project DRIVE-AB, a multidisciplinary, pan-European project looking for new economic models for antibiotic development.16 One key output has been the publication of a report on quality indicators and quantity metrics of antibiotic use in both hospital and outpatient settings.17
Global health requires the rapid acquisition and dissemination of high quality news in relation to AMR. BSAC actively supports the Centre for Infectious Disease Research and Policy18 in its ambition of making current information widely available to educate and inform healthcare providers, public health professionals, business leaders, students, opinion leaders, policy makers, the media, and other national and international stakeholders.
BSAC is just one of many such professional bodies in the infection management arena. Through such societies there is a wealth of resources and opportunity to tackle the problem of AMR and improve patient care and outcomes. The inability of human and capital resources to unite in a common goal – either through lack of awareness, leadership, co-ordination, desire or ambition to adapt and adopt – has led to wasted and often lost opportunities. We must ensure this is not now the case. New methods are needed to align the work of professional organisations from diverse geographical and resource settings with that of health administrations, government organisations supporting health and innovation, and other stakeholders to accelerate the pace of change and meet the challenges of the global AMR agenda. BSAC believes that harnessing professional engagement through global societies has a significant role in our ability to provide the cohesive response we need.
In light of this, and if asked if we can improve the health of nations by addressing the crisis of AMR, we should strongly argue that by pooling our resources and by working collectively and in synchronicity we will use this powerful opportunity to the full and – to quote Barack Obama’s 2008 presidential campaign slogan – respond, ‘Yes we can’.
1 Draft political declaration of the high-level meeting of the General Assembly on antimicrobial resistance: http://www.un.org/pga/71/wp-content/uploads/sites/40/2016/09/DGACM_GAEAD_ESCAB-AMR-Draft-Political-Declaration-1616108E.pdf
2 WHO Global Action Plan on Antimicrobial Resistance: http://www.who.int/antimicrobial-resistance/publications/global-action-plan/en/
3 Tackling Drug-Resistance Infections Globally: Final report and recommendations. The Review on Antimicrobial Resistance: https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf
4 World war on superbugs can only be won by a UN-led global effort. Commentary, New Scientist. Dilip Nathwani, Ramanan Laxminarayan, 22 September 2016: https://www.newscientist.com/article/2106929-world-war-on-superbugs-can-only-be-won-by-a-un-led-global-effort/?utm_
5 Antibiotic resistance is the quintessential One Health issue. Trans R Soc Trop Med Hyg (2016) doi: 10.1093/trstmh/trw048
6 Forum on Sustainable Access to Effective Antibiotics: http://www.forumonantibiotics.org/video
7 BSAC Resistance Surveillance Programme http://www.bsacsurv.org
8 National Point Prevalence Survey System: http://nas-pps.com/
9 Antibiotic Action: http://antibiotic-action.com
10 All Parliamentary Group on Antibiotics http://appg-on-antibiotics.com/
11 Massive Open Online Course on Antimicrobial Stewardship: https://www.futurelearn.com/courses/antimicrobial-stewardship
12 British High Commission Science and Innovation Office: https://www.gov.uk/government/world/organisations/uk-science-and-innovation-network
13 India: http://bsac.org.uk/meetings/antimicrobial-stewardship-in-hospitals-improving-outcomes-through-better-education-and-implementation-of-
14 Russia: http://bsac.org.uk/uk-russia-roundtable-discussion-antimicrobial-resistance-amr-dialogue-between-sectors
15 Africa: http://ican-ams.com
16 EU Innovative Medicines Initiative DRIVE-AB project: http://drive-ab.eu/
17 The Conscience of Antibiotic Resistance Accountability: http://www.forumonantibiotics.org/alliance/
18 Quality Indicators and Quantity Metrics of Antibiotic Use. DRIVE_AB: http://drive-ab.eu/wp-content/uploads/2014/09/WP1A_Final-QMs-QIs_final.pdf
19 BSAC Podcast – Centre for Infectious Diseases Research and Policy: http://www.cidrap.umn.edu/asp/meet-the-experts/asp-podcast-aug-2016
Dilip Nathwani OBE, President
Tracey Guise, CEO
British Society for Antimicrobial Chemotherapy
+44 (0)121 236 1988