Antimicrobial Resistance (AMR) is Critical to the Health System Development and Economic Growth

In Resource-Limited Countries:

Time for Tackling AMR with the “ONE HEALTH” Approach

8th Annual Conference of the Ethiopian Public Health Laboratory Association (EPHLA) February 20 - 21, 2016, Global Hotel

Addis Ababa, Ethiopia

Wubshet Mamo, DVM, PhDClinical Associate Professor of Global Health

Global Health Department, School of Public HealthUniversity of Washington, USA

This presentation is based on the presenter’s expertise and experience, does not reflect any official point of view. It represents the views of the presenter for the purposes of the 8th Annual Conference of EPHLA, February 20-21, 2016, Global Hotel, Addis Ababa, Ethiopia.

Disclaimer

Global Health & Global Challenge

Use of Antimicrobial Agents & Antimicrobial Resistance (AMR)

Cornerstones in the Fight Against AMR One Health Approach: The Integration of Human, Animal and Environmental Health

One Health Approach and AMR

Emerging and Re-emerging Infectious Diseases

Why One Health Approach?

Benefits of a One Health Approach in Tackling AMR

Outline

Global Health & Global Challenge

Global Health Security Agenda (GHSA): To accelerate toward a world safe & secure from infectious disease threats.

1- Prevent avoidable epidemics 2- Detect threats early and 3- Respond rapidly and effectively

1)- Prevent Avoidable Epidemics (including naturally occurring outbreaks and intentional or accidental releases)

by preventing the emergence and spread of AMR organisms by preventing emerging zoonotic diseases and strengthening international regulatory frameworks governing food safety

The global health challenge: An interconnected world is increasing the opportunities for human, animal and zoonotic diseases to emerge and spread globally.

GHSA

Today’s health security threats arise from at least 5 sources (Ref: GHSA):

1) the emergence and spread of new microbes

2) the rise of drug-resistant pathogens (including antimicrobial resistance)

3) the globalization of travel and food supply

4) the acceleration of biological science capabilities and the risk that these capabilities may cause the inadvertent or intentional release of pathogen

5) continued concerns about terrorist acquisition, development and use of biological agents.

The Global Challenge

The introduction of antimicrobial agents (antibiotics) was a break through health intervention that helped save millions of lives around the world Any use of antimicrobials will select for resistance Resistance to anti microbes (AMR) is a natural phenomenon of adaptation of microorganisms in the presence of antimicrobial agents The emergence of resistance in microbes can be precipitated most obviously by underuse/overuse of antimicrobials

However, resistance to antimicrobial drugs increase mortality and morbidity from infectious diseases

Alexander Fleming’s Nobel Prize acceptance speech, is often cited- “it is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them…there is the danger that the ignorant man may easily under-dose himself and, by exposing his microbes to nonlethal quantities of the drug, make them resistant” [Nobel Lecture, December 11, 1945].

Use of Antimicrobial Agents & AntimicrobialResistance (AMR)

Its amplification and spread of AMR is promoted through the improper utilization of antimicrobial agents, the use of fake and counterfeit medicines, poor prescribing habits and non-compliance to prescribed treatments Human/animal infected with an antimicrobial-resistant pathogen remain infectious for longer periods of time, increasing the opportunity for resistant infection to be spread to others AMR presents an ever-increasing global public health threat that involves major microbial pathogens and antimicrobial drugs

Use of Antimicrobial Agents & AntimicrobialResistance (AMR)

Zoonotic AMR (i.e. resistance transmissible between animals and humans) is a public health concern

In low-income countries AMR frequently occurs in microorganisms that are likely to be transmitted in the community such as organisms causing pneumonia, diarrheal diseases, Tuberculosis, sexually transmitted diseases, meningococcal infection and malaria

AMR is adding profound costs to healthcare. AMR is a serious threat to the public health system and economic growth of countries in particular countries with poor economy.

It is serious that the increase in the prevalence of drug-resistant pathogens is occurring at a time when the development of new antimicrobial agents is slowing AMR may lead to facing potentially untreatable infections

AMR in livestock reduces the effectiveness of drugs targeted at treating infection in animals AMR has profound impacts on animal health and production. It means that essential veterinary drugs may no longer be available for the treatment of animal diseases Resistant bacteria and resistant genes do not recognize geographical, species or ecologic borders. AMR can spread within countries and from one country to another in an increasingly globalized world (Ref: WHO)

Use of Antimicrobial Agents & AntimicrobialResistance (AMR)

Use of Antimicrobial Agents & AntimicrobialResistance (AMR)

AMR can spread through our food chain Antimicrobial agents are widely used in aquaculture and livestock production Antimicrobial agents are used in crop culture-more specifically antifungicides

Key Facts About 500,000 human death per year related to AMR (FAO)

Drug-resistant infections will cost the world 10 million extra deaths a year and up to $100 trillion by 2050, if the global increase is not stopped (UK, D. Cameron, 2014) The reduction in population and the morbidity impact would also reduce the level of world GDP by between 2% and 3.5% by 2050 (RAND and KPMG)

27 different antimicrobial classes used in animals (FAO)

No standardized data available on the global use of antimicrobials in livestock (FAO)

Only 42 countries have a system to collect data on the use of antimicrobials in livestock (OIE) The world population expected to exceed 9.6 billion by 2050. Increased demand for animal proteins, intensifying animal production means additional challenges in disease management and higher potential for increased antimicrobial resistance.

Surveillance of bacterial resistance Strengthen the implementation of a national action plan (“a One Health approach”) to address AMR Strengthen surveillance of resistance (building integrated regional-African network), understanding the evolution of resistance and the mode of transmission

Accurate data collection, timely and accurate reporting of AMR results to national and multinational reporting systems Building the capacity of clinical and reference laboratories to confirm drug- resistant , perform susceptibility testing, PT; concerted global efforts ex. ASM (improved microbiology service), ASLM (improved lab service quality), CDC , etc Adaption of new diagnostic technologies (including P-O-C diagnostics to enable rapid/reliable identification of viral and bacterial infections Strengthen capacity to Prevent, Detect and Respond (PDR) to emerging infectious disease threats- public health emergency preparedness Promoting a One Health approach to policies and practices

Cornerstones in the Fight Against AMR

Better regulation and better education of the public, clinicians/prescribers and veterinarians in the appropriate use of antimicrobials Update/implement existing infection prevention and control programs/ policies and/or practices Promoting research on AMR Promote safe practices in livestock production Building international capacity to tackle AMR more efficiently Promote the appropriate and responsible use of antimicrobials in all settings Strong medicine regulatory capacity (incl in the African region), to prevent circulation of substandard/counterfeit antimicrobials Improved supply chain (medicine, reagents, etc) Promote health management approaches that recognize the links between animals, humans and ecosystems Promote health management approaches that recognize the links between animals, humans and ecosystems Collaborative efforts across the human health (human medicine), animal health (veterinary medicine) and environment sector implementing, cross-sector actions in line with the One Health approach

Cornerstones in the Fight Against AMR

One Health Approach- The Integration of Human, Animal and Environmental Health

Background Since the 1800s, scientists have noted the similarity in disease processes among animals and humans However, the human and animal medicine were practiced separately until the 20th century Given the interconnected interests of those working across several sectors, including human health, veterinary medicine and the environment, a ‘One Health’ Initiative to improve the health of humans and animals has been developed Human health is inextricably linked to animal health and production One Health break down the traditional silos between animal health and human health since human, animal and environmental health are so interrelated The integrative effort of multiple disciplines working locally, nationally, and globally to attain optimal health for people, animals, and the environment (AVMA)

EnvironmentONE HEALTH

Human Health

Animal Health

As microbes that cause illness in animals become resistant to treatments, they also become resistant to similar treatments used in treating humans The drugs used to treat Animals and humans contain similar active ingredients (APIs) One Health includes this aspect of the interlinked health of animals, humans and the ecosystems in which they live, and strengthening of collaboration among the responsible sectors.

One Health Approach and AMR

The One Health Initiative is considered to be an important framework for addressing several issues threatening health, including AMR.

One Health approach will advance efforts to reduce the emergence and spread of AMR strains Using a One Health approach improves outbreak responses

Example, the Ministry of Agriculture typically deals with livestock health and disease issues, while the Ministry of Health manages human health affairs; the Ministry of the Environment manages conservation of natural resources. On the health services level, physicians and other human health care providers not often coordinate activities with veterinarians or other animal health professionals including livestock agriculture or vector control experts.

Humans and animals are often susceptible to the same disease causing pathogens, including AMR pathogens There are about 1,415 microbes that are known to infect humans, of which about 61% come from animals (PBMID 11516376)

Approximately 60% of all human infectious diseases recognized so far, and about 75% of emerging infectious diseases that have affected people over the past three decades, have originated from animals (WHO)

In the past 30 years, more than 30 new infectious diseases have emerged (WHO)

The contact between human & wild animal habitats increases, introducing the risk of exposure to new viruses, bacteria and other disease-causing pathogens

Key Facts

One Health Approach and AMR…………..cont’d

Emerging and Re-emerging Infectious Diseases

Ref: Uiversiteit Utrecht

Antimicrobials (ex. Antibiotics) are used in many settings- clinical medicine, communities, animal husbandry /aquaculture, horticulture Antimicrobial use in livestock compounds the AMR problem Antimicrobial use in livestock is considered to be the primary cause of resistance developing in some pathogens that infect humans AMR threatens the effectiveness of successful treatment of infections in human and animals. Tackling AMR requires a range of interventions and multidisciplinary teams approach. Single approach does not work. Therefore, it needs an integrated approach considering human, and animal health, and the environment- a One Health Approach

Why a One Health Approach?

= ONE HEALTH

An important framework for addressing several issues threatening health, including AMR A holistic approach to address complex challenges that threaten human and animal health, food security, poverty and the environments where diseases flourish (FAO) enhances close cooperation and collaboration between physicians, veterinarians, other scientific health and environmental professionals to ensuring a robust response to the threat of AMR Early detection of threat and timely, effective or rapid response Better/improved/more effective disease control and/or biosecurity measures (often related to infectious disease) Improvement in human or animal health or well-being Economic benefit/increase in economic efficiency, eg. A cost-sharing initiative between medical and veterinary vaccination campaigns, in Chad Ecosystem benefit, resilience, wildlife conservation Higher quality or larger quantity of information & data and improved knowledge or skills

Benefits of a One Health Approach in Tackling AMR

Ref: OIE, Hasler et al. 2014

Global acceptance: It is the collaborative effort of multiple disciplines – working locally, nationally and globally - to attain optimal health of humans, animals and our environment For the first time, the governing bodies of FAO, WHO and OIE have adopted resolutions on AMR in the same year (2015), and all three resolutions have stressed the importance of the "One Health" collaboration, approach to combat AMR One Health approach is considered as a common, worldwide approach only can bring about a long-lasting change in the AMR situation (G7-Germany, 2015)

Benefits of a One Health Approach …………cnt’d

Millions AMR-associated human death every year, can be controlled

& prevented!

A shared responsibility!

Thank you for your attention!