1. Introduction
Antimicrobial Resistance (AMR) is now recognized as a global public health threat that is spreading at a faster pace than ever, outpacing the solutions. WHO has shown its concern about AMR and main contributing factors and has requested concrete response to curb the situation through adoption of a number of resolutions at the World Health Assembly and Regional Committees. Studies from around the world – although limited – have shown significant socio-economic burden on the countries, regardless their development levels. Obviously the impact on vulnerable health systems and populations in resource-limited states would be catastrophic and could hinder developmental programmes including MDGs. The situation becomes more sophisticated where the excess or inappropriate use of antimicrobials in animal husbandry may contribute to the risks to human and environmental health in particular in Low- and Low Middle Income Countries (LICs and LMICs).
WHO has established and activated the Strategic & Technical Advisory Group on AMR (STAG-AMR) and the WHO AMR Global Task Force since 2011. These committees have identified the most crucial actions that have to be taken in response to the AMR threat. EMRO is an active member of the Global Task Force and participates in the AMR-STAG meetings to bring the regional context to the decisions.
The 2014 Antimicrobial Resistance Global Report on Surveillance showed that the largest gaps in the obtained surveillance data were seen in Africa, the Middle East and EUR Member States outside the EU. Accordingly, only 11/21 (52%) of the countries of the Region returned surveillance data (the lowest participation rate) . This could be partially due to lack of a robust AMR/ABR surveillance system, presence of other pressing priorities due to emergency situation in some countries or lack of awareness among the decision makers on the importance of AMR.
National data on E. coli resistance to third-generation cephalosporins were obtained from 4 countries of the Region with Overall reported range of resistant proportion from 22-63% (2-94% in Regional publications). National information on E. coli resistance to fluoroquinolones were received from 4 countries of the EMR with a 21-63% resistance (0-91% in Regional Publications)1. Available national data on resistance of Klebsiella pneumonia to third generation cephalosporins has consistently shown high resistance rates (22-50%) in our Region whilst the resistance to carbapenems have been reported from 0 to 54%. The Global report on Surveillance has also portrayed the antibacterial resistance among other bacteria in the Region in the range of 0-93% (national data and publications all together) over the following combinations:
Staphylococcus aureus resistance to beta-lactam antibacterial drugs (methicillin, methicillin-resistant S. aureus [MRSA]), Streptococcus pneumoniae: resistance or non-susceptibility to penicillin (or both), Non-typhoid Salmonella (NTS) resistance to fluoroquinolones, Shigella species resistance to fluoroquinolones and Neisseria gonorrhoeae decreased susceptibility to third-generation cephalosporins.
These types of ABR have a significant public health impact worldwide because they are common aetiologies for hospital or community-acquired infections, or both.
Recognizing the existing threat of the AMR, the Eastern Mediterranean Regional Office of WHO (EMRO) has included the subject in the public health priorities in the Region. EMRO has also taken several steps to bring the subject on top of the public health agenda of its Member States and will continue advocating and supporting national policies, strategies and plans for protecting its Member States.
2. Context
Resolutions WHA39.27 and WHA47.13 on the rational use of drugs, WHA51.17 on emerging and other communicable diseases: antimicrobial resistance, WHA54.14 on global health security, WHA58.27 on improving the containment of antimicrobial resistance, WHA60.16 on progress in the rational use of medicines and WHA66.22 on follow up of the report of the Consultative Expert Working Group on Research and Development: Financing and Coordination, and Regional Committees’ resolutions EM/RC49/R.10 on antimicrobial resistance and rational use of antimicrobial agents and EM/RC60/R.1 on Annual report of the Regional Director for 2012 and progress reports all have highlighted the emergence of the resistance and the necessity for a collaborative response at all levels.
Since the RC60 in 2013 several achievements have been made that necessitate updating Member States and continued advocacy for curbing AMR.
- During 13-14 November 2013 the consultative meeting on AMR with the title “AMR: from policies to action” the Regional Strategic Action Points were devised and shared with the Member States. Those mainly look into producing evidence for informed policies and plans as the first step (Annex II). This forum will be a good opportunity for tracking the implementation of those recommendations by the countries.
- On 30 April 2014 the first ever “Antimicrobial resistance: global report on surveillance” was published by WHO. The Report portrays the magnitude of AMR and the current state of surveillance globally. Very high rates of resistance in bacteria that cause common health-care associated and community-acquired infections, significant gaps in surveillance, under-reporting of MDR-TB, artemisinin resistance in malaria and increasing levels of transmitted anti-HIV drug resistance are the highlights.
- On 24 May 2014, the World Health Assembly adopted the resolution WHA67.25 on Antimicrobial Resistance in its 67th session. In this resolution WHO DG has been requested to draft a Global Action Plan (GAP) to combat antimicrobial resistance including antibiotic resistance, which addresses the need to ensure that all countries, especially low- and middle-income countries, have the capacity to combat antimicrobial resistance. WHO is in the process of developing the GAP based on the advice from AMR-STAG and in recognition that different countries are at different levels of AMR programme development. Therefore the GAP is planned to be built on a “six building block” configuration so that countries with different situation could fit into a proper “block” (Please see Annex I: List of GAP Building Blocks). It is expected that the draft is widely circulated before presentation to the EB135. One of the aims of this side event is to inform the Member States on the process and to listen to their first hand comments.
- The report on AMR Country Situation Analysis is being prepared and will be published before the 68th Health Assembly. Data from the EMR will be available for discussion in the plenary session.
3. Objectives
- Advocacy on the importance and urgency of collective response to the AMR through orientation/updating the Member States during the RC61
- To obtain political attention of the Member States to the AMR GAP through presenting the concepts of the AMR GAP and to invite their engagement in the process
- To list major challenges of the Member States in meeting the requirements for implementation of AMR containment programs.
4. Methods
The meeting will present the following to the participants and questions will be answered by renowned experts in a following plenary session. It is expected that representatives from animal health sector and FAO also attend this side meeting.
- The scope of the AMR problem (presentation from the global report with a focus on the situation in the Region and results of the regional Country Situation Analysis)
- The steps taken and their outcomes in pipeline
- The Global Action Plan (contents and what is expected from the Member States).
5. Materials
A CD-ROM containing the following documents will be distributed to the audience:
- Antimicrobial Resistance: Global report on Surveillance, 2014 summary
- Antimicrobial Resistance: Global report on Surveillance, 2014 Full Report
- Relevant RC and WHA Resolutions
- Report of the AMR Consultative meeting (AMR: from policies to action) in November 2013
- Basic Antimicrobial resistance materials published in 2001
- Policy Package to Combat Antimicrobial Resistance, published during the WHD 2011
Limited number of available recent publications listed above will also be distributed.
Annex I
List of Global Action Plan (GAP) Building Blocks
1 Increasing awareness, insight, education and engagement about AMR and of the actions and changes needed
2 Identifying the most important approaches for preventing development of infections and the steps needed to move beyond guidance to more effective implementation of such approaches
3 Optimizing the use of existing antimicrobials for human and animal health and in agriculture
4 Identifying and closing critical gaps in knowledge needed to address AMR
5 Developing an innovative and sustainable approach to develop and distribute critical products and technologies needed to address AMR
6 Assessing the long term economic, developmental and social costs and implications of AMR as a basis for sustainable investment and action
Annex II
Recommendations of the Consultative meeting on antimicrobial resistance for countries in the Eastern Mediterranean Region: “AMR: from policies to action”
Sharm el Sheikh, Egypt
12–14 November 2013
To Member States
1. Establish or revise inclusive intra- and intersectoral coordination mechanisms/focal points for AMR containment, consisting of the human health, animal health, food and agriculture sectors, in order to plan and monitor implementation of comprehensive national plans.
2. Map institutions that are performing AMR surveillance at the country level for the initiation of a regional collaborative platform.
3. Identify competent hospitals for providing surveillance information on AMR and hospital-acquired infection.
4. Map stakeholders in AMR containment at the country level and develop a management plan for engagement of stakeholders.
5. Map existing laws and regulations on the use of antimicrobials and the status of their enforcement.
6. Organize social mobilization and information campaigns on high priority areas for the appropriate use of antimicrobials, such as with upper respiratory infections.
7. Optimize existing programmes and capacities to expand or initiate AMR containment activities.
To FAO/OIE/WHO
8. Establish a regional multisectoral AMR coordination mechanism for steering AMR activities at the regional level, including the definition of priority areas for action.
9. Pursue policy dialogue with countries for in-depth analysis to foster AMR containment activities.
10. Establish a mechanism to strengthen capacities for collecting and sharing surveillance data at regional level.
11. Coordinate on the development of standardized protocols for use by countries for mapping the situation of AMR.
12. Develop an AMR research agenda for the Region and map regional research capacities on AMR.
13. Support pilot studies in the Region to assess the impact of the withdrawal of certain antimicrobial molecules used as growth promoters on animal production.
14. Develop tools for social mobilization and information campaigns.
15. WHO should identify partners in humanitarian assistance and ensure the alignment of AMR activities with regional plans.
16. Support countries in the assessment of regulatory practices in the Region to inform the development of a comprehensive regulatory framework to foster the optimal use of antimicrobials in humans, animals and agriculture.
