Consultation on a draft Global action plan to address antimicrobial resistance The questionnaire is divided into four sections. The questions are broadly framed and intended to give you the opportunity to enter into some depth and explain your organization's viewpoint. While only questions marked with * are mandatory, we would appreciate answers to as many as possible. Where a choice of answer needs to be selected please highlight your answer. Before answering the questions, please refer to our list of supporting documents. http://www.who.int/drugresistance/amr-consultation/en/index.html About you 1. Name of individual respondent* (deleted) 2. Email address* (preference for official email addresses): (deleted) 3. Are you authorised to represent your organization or interest group?* YES 4. Organization Name: Fédération Européenne pour la Santé Animale et la Sécurité Sanitaire () 5. Address of the organization 149 Rue de Bercy 75012 Paris France 6. Organization website: www.fesass.eu 7. Country: European Union 8. Type of Organization* Government department, ministry or agency Development or aid agency, foundation, trust or other funding authority International developmental organization Academic institution Civil society Private sector X Other non-governmental organization (NGO) 1
gathers farmers animal health services and organisations in European member States. Its members are national or regional technical organisation which work with farmers, private veterinarian and States veterinarian services. Some of them have also analysis laboratories. All of them work in partnership with public authorities for public and animal health. All are fully involved in the prevention, the surveillance and the fight against antimicrobial resistances. is a European stakeholders organisation recognized by European Authorities (Commission, EFSA, Members States) and OIE. Other (please specify) 9. Main sectors of interest Animal health and welfare, Agriculture or food Communication, education and community 10. Would you like to be added to our mailing list to receive updates on the development of the global action plan?* YES General questions 1. From the perspective of your organization, what are the most important areas of concern in AMR: - prudent use auf antimicrobials by patients and animal owners - extending the life span of antimicrobial medicines - support research (for new antibiotic discovery, alternative treatments and to improve diagnostics quality) - encourage stronger international cooperation 2. Is your organization currently involved in work related to AMR? YES If Yes, how? At European level, as stakeholders representative, in the work of European authorities, in the general awareness and members information. is also member of EPRUMA platform. At national or regional level our members organisations advise livestock farmers, i.e. owners of cattle, pig, sheep, poultry and fish in diagnostics and prevention of diseases as well as in case of treatment problems. When they have laboratories, they realize analysis with modern 2
techniques (like MALDI-TOF) and give recommendations to the practitioners for targeted antimicrobial treatment of 1 st and second choice. Generally our members are associated to national programmes against AMR and can support research activities in this field. Questions about the draft global action plan outline document Before the WHA resolution was adopted, two WHO AMR Strategic Technical Advisory Group (STAG) meetings were held in anticipation, which included members plus a large number of representatives from other organizations. These meetings identified key issues, concerns and led to the development of a draft outline. As this consultation progresses and stakeholder meetings are held, the secretariat will harvest and incorporate the input into the draft global action plan. 1. How would you rate your understanding of WHO s intention in the development of a global action plan to address AMR? Good Additional comments --- 2. From the perspective of your organization, are the major issues relating to AMR outlined in the draft global action plan? YES, because it is general. If No, what additional issues need to be addressed?--- Questions on the Building blocks described in the draft outline. You will notice, the global action plan has been constructed around building blocks in recognition that different countries will have different starting points. In this situation, countries can choose building blocks to concentrate upon. Each building block specified has been identified as a key area where specific attention, planning and work are needed to achieve progress in addressing AMR. Through questions in this section, we would like to hear your opinions on these building blocks in more detail. I. Building block-1: Increasing awareness and understanding about AMR and of the actions and changes needed The main issue is the prudent use of antimicrobials by humans and animal owners i.e. livestock and pet owners. Medical and veterinary stewardship is essential. Use antimicrobials to attack the causes of the diseases not the symptons. 3
Clarify and simplify the term antimicrobial resistance to be understood by the general public. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? Promotion of knowledge the knowledge must go to the user, not the user to the knowledge. The pharmaceutical industry should print the rules of prudent use on drug packages and user information as simple as possible: e.g. strong indication for targeted use against bacterial infection; no underdosing; no shortening of the treatment period; no using without specific prescription; withdrawal times for meat, eggs and milk should be strictly observed. International organisations should implement an information portal on prudent use of antimicrobials, advantages and disadvantages medicine as well as individual hygiene and disease prevention. States should implement hygiene education at schools and for adults. Resistance containment strategies must be implemented in the medical and veterinary practice. Medical and veterinary distributer organisations should establish mandatory training for their members. It would be interesting to deliver only adequate quantity to satisfy treatment s needs It is also necessary to ensure that the general public is aware of the mandatory prescription of veterinary medicinal products and in particular those intended for food-producing animals for human consumption to ensure the safety of food chain. Physicians, veterinarians and pharmacists must give much more mandatory information to the users of antimicrobials on the rules they have to comply. A way to stimulate the farmer s awareness could be to build an indicator and to develop data recording which makes the comparison between an average antimicrobial consumption and the consumption of his farm possible. c) What steps have already been taken to address this priority? (please provide references where possible) In each state there are exemplary projects; national administrations should inform international organizations (like WHO) accordingly. However, there must always be a binding agreement upon the objectives. 4
for example, global and national goals to be achieved within 2, 5 and 10 years) The implementation of the proposed action is easy to control. However, it will be difficult to observe the development of microbial resistance by a permanent, international monitoring, and thus validate the effectiveness of the measures taken. II. Building block-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 Personal hygiene (e.g. hand, food preparation or travel hygiene) is too often omitted. On one hand because of poverty and poor living conditions and on the other hand due to carelessness as a result of a very good medical care and services with inexpensive antibiotics. Urbanization and the globalization of freight and passenger traffic lead to crowding associated infections in transportation means and at transport hubs. In growing slums, where animals are often kept for subsistence, there is close contact with animals in backyard flocks. In addition, the integration of pets such as dogs, cats, birds and fish in the households offers zoonotic bacterial pathogens new and more frequent opportunities for transmission. The public is far too little conscious that the modern way of life favours (bacterial) infections. There is a substantial need for further research and development for effective vaccines against bacterial pathogens in young animals and against mastitis. As long as these are not available, targeted antimicrobial therapy remains the treatment of choice for successful breeding and a long productive life. There is also a need for research in the field of nutrition and feeding, as well as with a view to plant compounds that strengthen the body's defence. Extensive rearing conditions are to be taken into account, too. The research on genetic selection of resistant animals is also interesting. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? For veterinarian aspects when there are farmers animal health services, they are key stakeholders. For instance they can develop awareness campaigns, training and monitoring in partnership with practitioners and public veterinarian services --- 5
c) What significant work has already been done to address this? (please provide references where possible) Awareness and training sessions on good husbandry practices, prudent use and animal health prevention are already organised for farmers in member states. --- for example, global and national goals to be achieved within 2, 5 and 10 years) --- Exposure level per AM types and following resistance level III. Building block-3: Optimizing the use of existing antimicrobials for human and animal health and in agriculture The main objective is the targeted use of antimicrobials, without promoting false applications and contaminating the environment. The diagnosis is the basis of a targeted treatment. Absolutely necessary are internationally comparable gold standard for the detection of live pathogens and their resistance properties that allow the assessment of microbial resistance for years (decades). For this purpose, a representative monitoring for significant pathogens and their resistance properties should be set up at regional and national level and put together internationally in an appropriate manner and being made publicly available. The investigation should also include long known antimicrobial substances of only low economic interest. The necessary tests are to be financed by the public and must include a neutral recommendation which antibiotic substance for the particular infection and indication is the drug of first, second or third choice. Systemic infections should be treated systemically. To do this, antibiotic substances must be injected. This is associated with higher risks, but it would be a way, in such cases, to avoid contact with the intestinal flora and reduce the residual amounts. There is a considerable research and development need to optimize systemic administration. Since the development of individual electronic identification of animals or collection of body functions such as body temperature, larger animals (pigs, ruminants) can be identified when drinking or eating with their data being collected. Antibiotic substances can be individually administered in a targeted the way at the water and feed dispensers. More research and development is needed in order to optimize the administration technique and minimizing the contamination of the system by antibiotic substances. When given orally, the medicine must be palatable to the animals if it is to be taken voluntarily. 6
a) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? --- b) What steps have already been taken to address this priority? (please provide references where possible) --- for example, global and national goals to be achieved within 2, 5 and 10 years) --- IV. AMR Building block-4: Identifying and closing critical gaps in knowledge needed to address When it comes to human health, we need to appreciate that AMR is a complex issue that is been occurring for millennia and that resistance genes have evolved as part of the natural competition between bacteria, leading to a vast reservoir of possible genes. Sometimes a person or animal can carry certain kinds of bacteria producing certain chemicals against antimicrobials and not be sick. This person or animal can spread these bacteria to others some of these infections are hard to treat and may require different antimicrobials. There are gaps regarding the knowledge about colonization of humans and animals with multidrug-resistant pathogens. This colonization is reversible, however, due to the competition in the bacterial flora that settle in humans and animals, i.e. people and animals can be free of multidrug-resistant pathogens in a short time. This has already been demonstrated in farm animals within a fattening period. The research and development on an active repression of multidrug-resistant pathogens must be strengthened and should especially include hygienic and dietary methods. In the future, there is a great interest in a reduction of such settlements since the colonization with multi-resistant pathogens can be a social and ethical problem. Elderly patients, who were carriers of multidrug-resistant pathogens, have already been refused to return to their retirement homes after a hospital stay. For pets, there is a very close contact with their holder s families, so that multi-resistant bacteria can be transferred by direct contact. With respect to farm animals, it should be assessed whether the existing hygiene measures in food production are sufficient. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? 7
--- c) What steps have already been taken to address this priority? (please provide references where possible) --- for example, global and national goals to be achieved within 2, 5 and 10 years) --- V. Building block-5: Developing an innovative and sustainable approach to develop and distribute critical products and technologies needed to address AMR For example, we cannot say if the human deaths due to AMR are related to the fact that an AM used in an animal led to resistant bacteria transferred to a human. We cannot have a simplistic view of these matters: putting AM into animals does not regularly result in resistant bacteria emerging in the humans via the food chain (from farm to fork). It is necessary to do research and development about AMR in the three main compartments where it occurs: in hospitals, in the general population and livestock. We need to adapt the measures to the reality of the country, without forgetting that often the improper use of AM is due to the lack of other paths and alternatives. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? -- c) What steps have already been taken to address this priority? (please provide references where possible)--- for example, global and national goals to be achieved within 2, 5 and 10 years) --- VI. Building block-6: Assessing the long term economic, developmental and social costs and implications of AMR as a basis for sustainable investment and action 8
b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo?--- c) What steps have already been taken to address this priority? (please provide references where possible)--- for example, global and national goals to be achieved within 2, 5 and 10 years)--- Concluding questions 3. What contribution would your organization be able to make in implementing the global action plan? The members have practical experience and are able to contribute to wide scale action plans against AMR and also to collect data 4. Additional input that you feel would be facilitate development of the GAP.--- 9