Global AMR initiatives 2013 -2021

SPEAKER 1: In this step, let us review the global initiatives for AMR since 2013, when WHO issued a call to action with the slogan, “No action today, no cure tomorrow.” In 2015, WHO Member States unanimously approved a global action plan to tackle AMR. The plan is “to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them.”

However, AMR is not only a problem in human health. It’s also a problem in animal health and in our environment. AMR requires collective action, which we now call One Health. In 2015, Member States of the World Health Organisation, WHO, the Food and Agriculture Organisation, FAO, and the World Organisation for Animal Health, OIE, endorsed a global action plan on AMR, which includes five strategic objectives. Taken together, they offer a One Health framework for national action.

The five objectives are to improve awareness and understanding of antimicrobial resistance, strengthen knowledge through surveillance and research, reduce the incidence of infection, optimise the use of antimicrobial agents, and develop the economic case for sustainable investments that take account of the needs of all countries, and increase investments in new medicines, diagnostic tools, vaccines, and other interventions. Now let us look at the second objectives and see what else is being done.

On the 22nd of October 2015, WHO launched the Global Antimicrobial Resistance and Use Surveillance System, GLASS, to support the second initiatives that we just talked about for the action plan, to “strengthen knowledge through surveillance and research,” and to continue filling knowledge gaps, with the aim to inform strategies at all levels. Surveillance is simply data for action. It’s an essential tool to inform policies and infection prevention and control responses. Importantly, it’s the cornerstone for assessing the spread of AMR and to inform and monitor the impact of local, national, and global strategies. This first global collective effort to standardise AMR surveillance was endorsed at the World Health Assembly in 2015.

In 2016, the United Nations convened a High-Level Meeting of the General Assembly on Antimicrobial Resistance. This was only the fourth time that the UN General Assembly considered a global health issue. It speaks to the importance of AMR as both a health and a political priority. At that meeting, Member States affirmed that “antimicrobial resistance challenges the sustainability and effectiveness of the public health response to these and other diseases as well as gains in health and development and the attainment of the 2030 Agenda.” In 2016, Lord Jim O’Neill issued a report to show the world, what if we don’t take any action? What will the world be like in 2050?

Mortality due to AMR, he projected, will increase from 700,000 in 2016, to 10 million a year by the year 2050. The cost, in terms of global loss in productivity, would amount to about $100 trillion.

28 million more people would likely be pushed into poverty due to AMR. And you can see the figure on the left, that in 2050, if we don’t act now, AMR would cost 10 million deaths.

In 2018, WHO launched an integrated multi-sectoral surveillance system based on the Tricycle project, GLASS-One Health.

The Tricycle project aims to implement a simplified, integrated surveillance system for bacterial resistance on a global basis. It has identified extended spectrum beta-lactamase producing E. coli as a common indicator that can be used to detect resistance across human samples, poultry, and water bodies, such as sewage, market runoff, and river sites in urban areas. Beta-lactamase is an enzyme found in some strains of bacteria. An extended spectrum beta-lactamase-producing bacteria cannot be killed by many of the commonly used antibiotics, such as penicillins and some cephalosporins. The protocol for the Tricycle project has been piloted in nine Member States and is being implemented in five others.

WHO continues to support countries in the implementation of GLASS-One Health and a GLASS module has been developed to allow countries to share data of extended spectrum beta-lactamase producing E. coli from the three main sectors.

Now what’s new in the most recent GLASS report, which was issued in 2021? As of 30 of April 2021, 109 countries or territories are enrolled in GLASS. A key new component in GLASS is the inclusion of antimicrobial consumption surveillance at the national level. GLASS is also the data source of the new Sustainable Development Goals AMR indicator. That’s the proportion of bloodstream infections due to E. coli resistant to third generation cephalosporins and methicillin resistant Staph aureus, MRSA.

As of August 2020, more than three million laboratory-confirmed infections were reported by 70 of the 109 countries that enrolled in GLASS. The data showed high rates of resistance among antimicrobials frequently used to treat common bacterial infections. What’s worrying is also that rates of AMR SDG indicators in low and middle income countries are higher than those reported in high income countries. You could see that from the figures on the right hand side. There were also high rates of resistance reported in common pathogens causing urinary tract infections, and also extremely high rates of carbapenem resistance Acinetobacter species, depicting a dire scenario for health care associated infections.

Reporting to GLASS also has been very uneven. If you look at the reports from each country, you could see that the majority of the sites reporting are from Europe and the Americas. Those are higher numbers of sites, much higher than those from Africa and in Asia. And although the Fleming Fund has been supporting a number of countries, it’s shown here in the shaded area, their ability to report to GLASS appears to still be limited and more work needs to be done.

We do have a bit of good news. In January of 2021, WHO published its third edition of the Essential Diagnostics List. Now WHO’s list is a basket full of recommended general and disease-specific in vitro diagnostic tests that should be available in every country. The Director General of WHO said that “Access to quality tests and laboratory services is like having a good radar system that gets you where you need to go. Without it, you are flying blind.” “All countries should pay particular attention to the diagnostic space and use the essential list to promote better health, keep their population safe, and serve the vulnerable.”

These are screenshots taken from the 2021 WHO Essential Diagnostic List, which shows that WHO recommends antimicrobial susceptibility testing to be done on culture isolates in the clinical laboratory. This is especially important for tuberculosis. The list also contains a recommendation for a group A streptococcus antigen test. It could be a laboratory immunoassay or rapid tests being done either in the laboratory or outside of laboratory settings. And this is for streptococcal pharyngitis.