The response to the antibiotic crisis: policy matters

Policy matters for the reduction of antibiotic consumption. I will give you some examples on why I conclude so confidently. We know that antibiotics are available over the counter and on the internet. And that a prescription is not always necessary. This is absence of policy. And this is one reason why we have seen resistant infections emerging worldwide over the last decades. Here’s an example from Europe where resistant E. coli infections increased from below 5% of patients in 2001 to above 10% in 2012. The year after these numbers were launched, Dame Sally Davies acted decisively. She wanted to put AMR on the National risk register. Right up there together with international terrorism and climate change.

And when the British chief medical officer speaks, people listen. AMR was now on the political agenda. The World Health Organisation launched the global action plan to combat AMR the following year. Shortly after the USA released their action plans. As did my country Norway and others. Today almost 100 nations have developed their national action plans on AMR. Isn’t that great? But what is an action plan? Let me use the Norwegian one as an example on how it works. The government has decided that the number of activities should be implemented throughout the health care services in the country. They can do that to reduce the burden on the health care services and the public health.

Naturally they expect voluntary compliance, like we have seen also for all the relevant infections. If you know what I mean. For the AMR action plan, the government and municipals were strengthened on organisational sectors. And national steering group was established. Regional competence centres and county governors were scaled up. For the general population information campaigns were launched. An adult immunisation programme was designed. Not unlike the one we were lining up for against COVID 19 in 2021. There were also efforts to get more suitable pack sizes on antibiotics. And prescription validity times were introduced. The primary health care services peer reviewing of prescription practises were introduced. And electronic prescription support was developed. A prescriber gets pop up windows warnings when prescribing antibiotics.

Are you really sure you want to prescribe this product? I bet some are irritated to see that pop up every time they prescribe antibiotics. Now they can also compare own practises with that of others in the same or different regions. Within the specialist health care services, antibiotic stewardship groups were put in place. Both to offer support and guidance. But also to follow up practises in general. In nursing homes and similar municipal institutions surveillance programmes were put in place. And regional competence centres assist institutions in routines related to infectious disease control and prevention. Dentists are also included by their specialised dental committee. This is the framework of the activities on the human medicine side.

There are similar activities implemented within veterinary services. And in the food production industry and other areas. But, do they work? The government aimed at reducing the 2012 level of systemic antibiotics with 30% by the end of 2020. These are the grey bars. It worked well the first years, as we can see this red line set the target. The blue bars indicate the use of typical airway antibiotics. They should be reduced by 20% by 2020. That target was reached after only a couple of years into the action plan. But what about 2020? It was the year of the big pandemic, if you still remember. If we look at wholesale antibiotics to pharmacies around the country.

And compare month by month to 2019. The increase in March 2020 was obvious. This was the month of the lockdown. But pharmacies did not buy equally much antibiotics for the rest of 2020. Were they hoarding? The prescription database can show what was sold to patients. The peak in March does not appear here. And the prescriptions were reduced also the rest of the year. So it appears that the national AMR action plan for Norway did succeed in reducing prescription of antibiotics. But also, that it got help from the COVID 19 pandemic. What may future action plans include? There are numerous other actions that can be taken if policymakers want. Here are some that paved the way for resistome studies.

We still need better data on how many are carrying AMR strains. And what is really the burden of AMR disease. Can we benefit from infection prevention and control routines that are well in place throughout society after the pandemic? How can we use this valuable momentum of hand hygiene and cough etiquette to prevent AMR? How does international travel influence? And what new health care services will the future bring that will rely on more antibiotics? Finally, issues on One-health remain to be clarified. One-health is how humans, animals, and environment share the same microbes. How much antibiotics are used in animals and in agriculture? How common is spread between animals and to and from people? Which agents are those of concern?

And are rural areas at the same risk as urban areas? Is One-health issues the same in polar areas as in tropical or tempered zones? Does water and sewer represent special challenges? There are numerous activities to follow up if we are to fully understand and combat AMR.