Info Service on Health Issues (May14/06)
Geneva, 28 May (Mirza Alas and Chee Yoke Ling) – Governments at the recent World Health Assembly have committed to a higher level of action to combat antibiotic resistance that is an increasing public health threat across the world.
On 24 May, a resolution was approved by health ministers on “Combating antimicrobial resistance, including antibiotic resistance” after an important exchange of country positions and one amendment put forward by Mexico with regard to conflict of interests.
(According to footnote 1 of the resolution, “Antimicrobial resistance refers to the loss of effectiveness of any ant-infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines. Antibiotic resistance refers only to resistance to medicines in bacteria.” The draft resolution had first been considered by the WHA Executive Board following the procedures of decision-making in the WHO.)
The Sixty-seventh session of the World Health Assembly (WHA) took place in Geneva from 19 to 24 May with six days of intense discussions on a large list of global public health topics. More than 20 resolutions on public health issues of global importance were adopted and according to Dr. Margaret Chan, WHO’s Director-General in an official press release, “This has been an intense Health Assembly, with a record-breaking number of agenda items, documents and resolutions, and nearly 3,500 registered delegates.”
India supported the antimicrobial resistance (AMR) resolution subject to the understanding that its concerns would be included in the proposed global plan of action. These included financial access of developing countries patients to new antibiotics, news ways of funding research and development based on the delinkage principle in the context of developing countries, and the special needs of developing countries and their capacity building to take on relevant activities. India’s proposal was in lieu of making changes in the resolution text itself which was its first preference. The United Kingdom in its statement also acknowledged the legitimate concern of developing countries on access to antibiotics, and the importance of support for technical capacities and affordable drugs.
All Member States agreed on the importance and magnitude of antimicrobial resistance and broad support was heard in the statements made by all delegations on the paramount need to take action. Both developing and developed countries agreed that this is of global magnitude and urged the WHO to develop the action plan and for Member States to build up their own national plans.
Developing countries stressed on the urgency of the problem but also on the importance of ensuring access to new antibiotics for developing countries and the mobilization of resources so that they can implement action plans and surveillance.
Antimicrobial resistance is also addressed by the United Nations Food and Agriculture Organization (FAO) and the Organización Mundial de Sanidad Animal (OIE – World Organization for Animal Health). On 30 April WHO launched its report “Antimicrobial resistance: global report on surveillance 2014”. This is the organization’s first global report on antibiotic resistance with data from 114 countries. It revealed serious, worldwide threat to public health posed by antibiotic resistance.
Below are the highlights of several country statements that supported the resolution. (A new civil society coalition, the Antibiotic Resistance Coalition, also made a statement presented by one of its founding members, Health Action International.)
Lebanon said that extensive use and misuse of antimicrobials in human and animal health has resulted in AMR which now constitutes a serious threat to health and global health security. It noted that the 2001 WHO Global Strategy for the Containment of AMR has not been realized and expressed strong support for the strategy and next steps. It stressed the need for strong commitment from member states, international organizations and the food industry. Particularly, Lebanon highlighted that self-medication and over-the-counter use of antibiotics is widespread in developing countries and needs more attention.
China stressed on how the WHO and Member States have conducted a series of work on fighting AMR but the situation remains daunting. It also emphasized the need for rational clinical use and stressed that in the case of China, supervision of marketing and a surveillance network has been established. It also placed emphasis on the need to examine the role of animal husbandry and the food industry on this issue and the importance on raising awareness among medical institutions and health workers on rational use. In supporting the resolution China said that we need to take action to conduct multi country, multi channel, multi-sectorial cooperation.
Singapore said that AMR is a global problem of large magnitude, requiring a global solution. It said further that the WHO Global Surveillance Report 2014 on AMR released just before the WHA was a good sign, adding that the United Kingdom and Sweden had done a lot in terms of putting the AMR on the global agenda.
Thailand appreciated the international cooperation and collaboration amongst WHO, FAO and OIE and strongly supported the resolution. It said that the size of the problem is big and global collective action is needed, and stressed that both human health and agricultural sectors have to be addressed. Irrational and overuse of antimicrobial in agriculture is a matter of serious concern, said Thailand, adding that human antimicrobials used in agriculture can lead to reservoir of resistant bacteria. It stressed that the management of AMR needs strong political support and also called for new antibiotics and rational use of them. It asked the WHO to develop a global action plan.
Qatar reiterated that the threat of AMR is great and the issue of lack of new medicines to combat AMR. It also noted the need to have policy guidance, monitoring and research.
Mexico recognized the need to strengthen measures on AMR and noted how AMR is the main cause of health problems that have major impacts on the economy. It emphasized the need to deal with AMR at the global level respecting specificities at each level and called for new strategies and new models to deal with use of antibiotics.
Mexico proposed an amendment to the second paragraph, sub-paragraph six of the resolution (OP2.6) which was adding at the end the phrase: ‘taking into account the need to manage possible conflicts of interest’.
(OP2.6 refers to “a multisectoral approach to inform the drafting of the global action plan, by consulting Member States as well as other relevant stakeholders, especially other multilateral stakeholders, such as FAO and OIE; …”
Engagement with “non-state actors” was one of the important issues addressed at the WHA where conflict of interest in the relationship between industry and WHO has been raised by several Member States and civil society organizations.)
Malaysia stressed on the need for awareness and action at the highest level, and the need for concrete action including sanitation and hygiene, use of vaccines when possible, innovation in service delivery as well as health promotion and communication programmes to change the present culture on anti-microbials use.
India noted the emergence of new AMR mechanisms and how this is making it difficult or impossible to treat certain infections. It also expressed support for the global action plan which should be developed in close collaboration with all relevant partners and stakeholders, while avoiding conflict of interests.
In stressing that AMR has been a priority for India, it also said that the South East Asia Regional strategy on prevention and containment of AMR and the Jaipur Declaration of Health Ministers of the region on AMR are the guiding principles for building capacity to combat AMR.
India said further that the prevention of transmission of infectious disease gains new urgency in the face of resistance to chemotherapy for tuberculosis, HIV and hepatitis. A fresh and strong initiative around infection control in healthcare settings is, therefore, urgent.
It strongly believes that ways to ensure financial accessibility of people to new antibiotics have to be better addressed in the global action plan; otherwise new antibiotics may be prohibitive for patients in developing countries, similar to the situation for second and third line antiretroviral drugs. New ways of funding research and development based on delinkage principle need to be explored in the context of the developing world, India emphasized. It added that the challenge of AMR adds weight to the proposed R&D Treaty and supporting transfer of technologies to ensure access to medicines for low income countries.
India also stressed the need to address the specific needs of developing countries and their capacity building to undertake the relevant activities. It is important to help mobilize financial and technical resources to support the developing countries and their special needs for strengthening national laboratory based surveillance capacities; as well as forging networks to produce comparable data and inform evidence-based treatment guidelines.
Its understanding is that the proposed global plan of action would take into account these concerns paving the way for an effective global action on containment of AMR. Subject to this understanding, India supported the draft resolution.
Ghana spoke on behalf of the African Region (AFRO) and underlined that the growing prevalence of AMR poses challenges and threats to health security especially for countries with low surveillance and laboratory capacity. It emphasized that AMR threatens the security of public health control particularly for TB, malaria and HIV control. Ghana also pointed out that a number of countries have developed national action plans on AMR and urged Member States that do not have action plans to develop them.
Also, it reiterated the need for regulations to ensure new innovations for new antibiotics and the importance of collaboration between policy makers, academia and industry to develop new antimicrobials. It said that field epidemiology and laboratory programmes in Africa are being developed.
AFRO is convinced that coordinated efforts are necessary and encouraged the WHO to lead and support action plans in both human and animal health, adding that hygiene, infection control and rational drug use are crucial. Ghana emphasized the need for the global action plan to take into consideration the specific needs of developing countries, as well as access to new antibiotics and diagnosis. It supported the resolution as amended by Mexico.
South Africa supported the statement made by Ghana and the resolution. It pointed out that control and adherence to antibiotics are key interventions. South Africa underlined the particular challenges for developing countries on the optimization of surveillance systems, within countries, but in particular in those countries where those systems do not exist. It emphasized the need for investments in those systems and that the agricultural sector must be addressed.
The Philippines supported the adoption of the draft resolution which will expedite and strengthen the implementation of national, regional and global evidence-based actions on AMR. It talked about implementation of its national policy and plan to control AMR and noted that AMR surveillance in the Western Pacific is a major development to handle AMR. It stressed its commitment to continue leading the surveillance for the western Pacific region together with the WHO.
Tanzania aligned with Ghana’s statement on behalf of AFRO and supported the global action plan as well as for the work of the WHO strategic and technical advisory group (STAG). It expressed concern about losing the first line antibiotic which is having impacts on treatment length, stressing that a major challenge is irrational prescribing and irrational use. Tanzania also urged the WHO secretariat to address the specific needs of developing countries and ensure access to new antibiotics and diagnostics.
Indonesia acknowledged the global efforts that have been taken to address AMR and shared information on its national efforts. It fully realized the importance of novel antibiotics and diagnostics in health care settings for addressing AMR and recognized that in order to address AMR many challenges need to be overcome such as finance and infrastructure issues.
Turkey pointed out that AMR is location specific and that it is necessary to understand regional dynamics, sharing information on its national and Central Asia efforts. It also supported the amendment proposed by Mexico.
Brazil, Bahrain, Libya, Qatar and Vietnam also spoke in support of the resolution.
Most of the developed countries that spoke emphasized the global nature of the problem, the need for a global action plan and the importance of the WHO in guiding the process.
Australia noted the impact of AMR on all countries and said that it has committed resources to contain microbial resistance, stressing that it is time to move from advocacy to action.
Norway called for the global action plan to be received in the next WHA and for the implementation of this action plan. Norway offered the possibility of co-hosting a meeting to discuss cooperation on actions to implement the global action plan on AMR.
Greece on behalf of the European Union stressed the growing public health threat of AMR, and emphasized the crucial role of the WHO in monitoring and surveillance of AMR and its effects for human health. The EU highlighted the need for global action and leadership on AMR of the WHO and the need for a One Health approach, involving human, animal, environment and agriculture. Adding that a multisectorial approach is needed, it said that there is an integrated action plan in the EU on these lines which supports the development of a global action plan.
Sweden also called for an inter-sectoral approach and said that AMR is a threat for low, middle and high income countries. It emphasized the important leadership role of the WHO in the global action plan and also urged Member States to support the development of a Global Action Plan, facilitated by the WHO Secretariat. Sweden announced that it will co-host an expert meeting on surveillance with WHO which will build on the WHO Global Surveillance Report 2014. It also expressed its support for the resolution as amended by Mexico.
The UK underlined how the cross regional support for the resolution demonstrated that is not only a developed or developing country issue but a global problem. The UK recognized the legitimate concern of developing countries on access to antibiotics and said that technical capacities as well as affordable drugs must be supported. (This was a reference to the statement by India). It approved the resolution with the amendment by Mexico.
The Russian Federation speaking on behalf of the CIS (Commonwealth of Independent States – comprising Russia, Belarus, Ukraine and several former Soviet Republics) underscored the need for a comprehensive approach for AMR with veterinary, agriculture and human medicine sectors. Dealing with AMR needs comprehensive action and measures within the healthcare system, including boosting access to laboratory research on AMR; monitoring antibiotic resistance research on key microorganisms, quality control; reducing the unnecessary consumption of antibiotics.
The United States supported the action plan with stakeholders and multisectoral action (human and animal health). It also supported innovative collaboration especially public private partnerships. It underlined the importance of surveillance and said further that the US, the EU and the Trans Atlantic Task Force is a model to follow for shared information and joint research. It also agreed with Mexico’s amendment.
Japan called attention to the way AMR often spreads through hospital-acquired infections and the need for more efforts to address this.
The Netherlands urged Member States to “Act Now and Together” and noted the challenges faced in recent years, in both human and animal health and how they cannot be solved by countries on their own. It pointed out the need for actions at the national level, but equally, the importance of cooperation at regional and at global level. The Netherlands will be co-sponsoring a meeting with the WHO in June this year and supported the resolution with the amendment by Mexico.
Germany shared information on its national actions stressing that AMR does not stop at national borders. Accordingly, Germany supported the need for a global action plan, adding that the international leadership of the WHO is extremely important in this regard. It also emphasized that current practices of selling antibiotics in many countries need to be addressed.
Spain, France, Canada and the Republic of Korea also spoke in support
of the resolution.
It further suggested that the Director General be asked to consider a comprehensive Framework Convention as a core component of the Global Action, and that Member States commit to the development and implementation of specific, measurable and realistic targets for the reduction of antibiotic resistance. The Coalition also urged the Assembly to consider the following recommendations in the resolution and Global Plan of Action:
The Coalition statement also pledged that global civil society is prepared to assume its role as a partner in the development and implementation of a comprehensive Global Action Plan that makes certain the threat of a post-antibiotic period does not become a reality.
NGO statements were also made by Medecins Sans Frontieres and Medicus Mundi International.
In the conclusion of the agenda item, the WHO Secretariat representative Dr. Keiji Fukuda summarised that there has been a large number of speakers and interventions from many countries with each highlighting the importance of AMR. The way forward is to work collectively and develop a global action plan. The action plan needs to a cross all sectors, has Member State voices and capture principles from the One Health approach.
Fukuda emphasized the need to close the gap using research and innovation and the need to highlight prevention. He also acknowledge that in order to have a successful global action plan the specific needs of developing countries such as capacity building have to be considered. There must be a balance of the different realities, but also common guidelines. He sad further that political will, technical support and funding are essential. Other pathogens apart from bacteria must also be addressed.
He then read the amendment proposed by Mexico in paragraph 6.2 as follows: “to apply a multisectoral approach to inform the drafting of the global action plan, by consulting Member States as well as other relevant stakeholders, taking into account the need to avoid conflict of interest…”
The resolution with the amendment was accordingly approved.