Strategic and Technical Advisory Group on antimicrobial resistance (STAG-AMR) Report of eighth meeting 29 June 2017 Via teleconference 1
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Background In November 2016 members of the STAG-AMR met in Geneva to advise on priority activities to tackle antimicrobial resistance. They were informed about the high level meeting on AMR at the United Nations General Assembly held on 21 September 2016 and, taking its outcome into account, made recommendations on the global action plan on antimicrobial resistance. Since then, the ad-hoc Interagency Coordination Group (IACG) on antimicrobial resistance was formed; its first face to face meeting was convened on 2-3 May 2017 in New York. Later that month, the seventieth meeting of the World Health Assembly (WHA) was held in Geneva. The Member States of WHO have elected Dr Tedros Adhanom Ghebreyesus as the new Director General of WHO: his five-year term began on 1 July 2017. Championing the One Health approach, Dr Tedros expressed his commitment to addressing AMR as a global health priority. Furthermore, there was a very active discussion on antimicrobial resistance during the WHA in which over sixty Member States participated. The discussion centred around a report on progress in the implementation of the Global Action plan, Member States achievements and challenges faced by them in addressing AMR, the development of the stewardship framework, and the resolution on sepsis. On 29 June 2017, WHO organised the 8 th meeting of STAG-AMR via teleconference. For one third of all members of the STAG, including the Chair, their four-year appointment has come to an end. Dr Sprenger took this opportunity to thank the outgoing members for their strong commitment and invaluable contributions, which informed and guided the work on AMR since the group was established. The next meeting of the STAG will see seven new members appointed by the Director- General based on their technical expertise and with consideration given to geographical representation and gender balance. The renewed STAG-AMR will select a new Chair at its next meeting planned for late 2017. Apart from the WHO staff, the teleconference was attended by the members of STAG-AMR and Dr Arjon van Hengel, Scientific Officer in the Research & Innovation DG of the European Commission, who was an observer. Declarations of interest In advance of the meeting in November 2016, the AMR Secretariat at WHO reviewed the completed declaration of interests provided by the members of the STAG-AMR against the scope & purpose and the agenda of the meeting. A summary of relevant interests can be found in the meeting report of the seventh meeting of the STAG-AMR. In addition, prior to the teleconference in June 2017 members of the group were requested to inform the WHO AMR Secretariat of any conflict of interest that might have arisen from activities taken in the period between November 2016 and June 2017. As no conflict of interest was identified, all members of the STAG were allowed to participate in the meeting. 3
Review of the actions taken by WHO to implement the recommendations of the 7 th STAG-AMR Prior to the meeting, the advisory members were provided with a short document, which lists recommendations made by the 7 th STAG along with actions, activities and initiatives taken by the WHO to implement them (please see the appendix). Update on the implementation of the Global Action Plan Looking at the time period from the last meeting of STAG in November 2016 until present, Dr Sprenger spoke about several recent key accomplishments made by the WHO in the area of combating antimicrobial resistance. They included recently released results of the country selfassessment questionnaire on development of the National Action Plan (NAP) and the publication of a new version of the Essential Medicines List. Among the most important guiding documents were Integrated Surveillance of Antimicrobial Resistance in Foodborne Bacteria: Application of a One Health Approach and the New WHO Guidelines on Core Components of IPC Programmes at the National and Acute Health Care Facility Level. The Global Framework for Development & Stewardship Framework to combat antimicrobial resistance. Draft Roadmap was released ahead of the World Health Assembly in May 2017. Currently, the WHO Guideline for use in food animals of antimicrobials important for human medicine is in preparation. Dr Sprenger praised the outcome of the 2nd High-Level Technical Meeting on Surveillance of Antimicrobial Resistance (AMR) for Local and Global Action, which was held in Stockholm on 27-28 April 2017. He also mentioned two other important technical consultations of which one was on the value of vaccines in avoidance of AMR and the other one was on health workforce education and AMR control. Members of the STAG enthusiastically welcomed those developments and offered suggestions on how the work on the human-animal interface and vaccines can be advanced further in collaboration with external partners and the private sector. WHO staff restated their continuous support to lowincome countries, particularly those where health systems are weak and the burden of AMR is high. Global Framework for Development & Stewardship to combat antimicrobial resistance. Draft Roadmap. Sarah Paulin presented the recently published Global Framework for Development & Stewardship to combat antimicrobial resistance. Draft Roadmap. Developed in collaboration with FAO and OIE, the framework supports the development, control, distribution and appropriate use of new antimicrobial medicines, diagnostic tools, vaccines and other interventions while preserving existing antimicrobial medicines and promoting affordable access to all antimicrobial medicines and diagnostic tools, taking into account the needs of all countries and in line with the GAP on AMR. The Member States Consultation, to which FAO and OIE have also been invited, is planned for 9-10 November 2017. The framework is expected to be revised and expanded in the next couple of years. Members of the STAG stressed the need to address the shortage of currently available antibiotics and their sustainability in the future. They recommended that focusing too much on prescription only for antibiotics was not realistic in areas where physicians are largely unavailable, as this would put a risk on constraining access. The STAG also encouraged a stronger tripartite collaboration on the country level and further progression of work in the areas of food safety and environment. 4
Monitoring and Evaluation (M&E) Framework Dr Liz Tayler updated the STAG on progress in Monitoring and Evaluation Framework (M&E). First presented to the STAG in November 2016, the Framework was broadened to a tripartite approach in the first half of 2017. The expert consultation on outcome indicators was held in the WHO headquarters last June and attended by two members of the STAG. The group discussed ways to effectively monitor and evaluate implementation and outputs as well as outcomes and goals. The tripartite online consultation will take place in the summer months. In addition there will be work in collaboration with FAO and OIE to refine the country self-assessment questionnaire, which will be repeated over the next year. STAG reiterated the importance of developing systems to obtain outcome metrics and process metrics. Furthermore, the group articulated the need for a clearer picture of the funding gaps in implementing AMR activities in developing countries as this would be useful for targeting specific donors. WHO Ranking of antimicrobials according to their importance in human medicine: the WHO CIA List Dr Awa Aidara-Kane presented the 5 th revision of WHO ranking of antimicrobials according to their importance in human medicine drawing on the WHO CIA List and Guideline Development Process. Since 2005, WHO regularly publishes and updates the ranking, as recommended in a series of regular expert meetings with FAO and OIE. Furthermore, Dr Aidara-Kane elaborated on the WHO Guideline for use of medically important antimicrobials in food producing animals and explained the process of guideline development. She also briefly mentioned a brand new AGISAR guidance on Integrated surveillance of AMR in foodborne bacteria: application of a One Health Approach. All the documents address the fourth strategic objective of the Global Action Plan, which calls for optimization of the use of antimicrobial medicines in human and animal health. Members of the STAG were very pleased to see those developments and expressed their support for the extensive work conducted by the WHO Department of Food Safety and Zoonoses. Update on the ad-hoc Interagency Coordination Group (IACG) on AMR Dr Hajime Inoue, the ADG/Special Representative of DG on antimicrobial resistance, briefed the STAG on the composition, method of work and objectives of the ad-hoc Interagency Coordination Group (IACG) on AMR. He was pleased to see two members of the STAG involved in the IACG. Having elaborated on the IACG s first meeting in New York on 2-3 May 2017, Dr Inoue mentioned an upcoming teleconference and the next face-to-face meeting planned for 16-17 October in Paris in the OIE headquarters. The group is expected to report back to the Secretary-General at the seventythird session of the UN General Assembly, which runs from September 2018 to September 2019. Professor Dame Sally Davies, a member of the IACG, expressed her appreciation for the creation of the group, which has not only brought together representatives from a wide range of agencies and organisations, but also provided an all-inclusive venue where experts in human health, animal health, agriculture and environment can exchange their ideas and work together to develop innovative 5
solutions. Prevention and control of AMR is complex. Therefore, it requires an appropriate global response which includes a One Health approach and strong cross-sectoral collaboration. Prof. Davies stressed that in order to tackle the problem of antimicrobial resistance, it is necessary to ensure that prevention and control efforts are taken up as quickly and effectively as possible. Concluding remarks Dr Sprenger concluded the meeting by thanking the outgoing members of the STAG for their firm commitment and considerable input offered during the three years of their work. He praised Professor Dame Sally Davis for her incredible dedication and continuous efforts to raise awareness of antimicrobial resistance and inspire positive change on many fronts of the fight against antimicrobial resistance. 6
Appendix Update on recommendations from the 7 th meeting of the Strategic Technical Advisory Group on Antimicrobial Resistance (STAG-AMR) held on 2-3 November 2016 The WHO Strategic and Technical Advisory Group (STAG) for Antimicrobial Resistance held its seventh meeting in Geneva on 2-3 November 2016. Below is a short summary of how each of the recommendations made by STAG was implemented. STAG recommends that National Action Plans be embedded within national strategic plans and frameworks, including IHR, and that links should be forged, wherever possible, with broader development structures and system strengthening at country level. The strategy for National Action Plan support for the next two years focuses on implementation; that is leveraging existing programmes to deliver results, and the incorporation of key AMR activities into national action plans and budgets. Integration and alignment within planning cycles takes time and there is a risk that momentum will be lost. Therefore, AMR teams in countries are urged to identify and focus on those areas where they can deliver results within the human and financial resources that are currently available. It is important that the teams leverage and build upon existing programmes. The NAP team works closely with the IHR team on the refresh of the Joint External Evaluation (JEE), which will be used to validate the survey responses in the countries that chose to participate in the survey. It is essential to ensure the incorporation and alignment of AMR plans into the health security plans. While the health system strengthening teams within WHO are involved, more work needs to be done to engage the development agencies and banks to incorporate AMR within their current and future system strengthening programmes. STAG encourages WHO to support the scale up of evidence-based interventions, such as infection prevention and control, and access to existing vaccines, within national action plans. Infection, prevention and control: SAVE LIVES: Clean Your Hands 5 May 2017. Fight antibiotic resistance it s in your hands. This year the antibiotic materials are all co-branded with Antibiotics, handle with care to demonstrate unity between antimicrobial resistance and IPC efforts. New WHO Guidelines on Core Components of IPC Programmes at the National and Acute Health Care Facility Level were launched on 15 November 2016. Interim Practical Manual supporting national implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes was published. The manual is intended as a tool for policy-makers and implementers within Ministries of Health working on IPC, particularly in the context of AMR national action plans. 7
Vaccines: WHO Consultation on 31 March 2017 focused on exploring the specifics of potential modelling-based approaches. The meeting marks the first step towards raising awareness of the potential role that vaccines could play in global efforts against AMR. WHO will launch an exercise towards the prioritization of vaccines focusing on their role against AMR and lead the development of a roadmap lying out a global strategy for vaccines against AMR. STAG recommends that WHO facilitates opportunities for countries to share practical experience and concrete advice through communities of practice and links at regional and sub-regional level. STAG also recommends that WHO creates networks of experts to provide support to countries as needed. Communities of practice were established in March 2017 to provide support in key areas where countries are looking for assistance with developing and implementing their AMR national action plans. Feedback from members has identified a range of areas where countries would welcome support. Therefore, a Community of Practice (COP) on Health Workforce AMR Education and Training has been established to allow individuals and representatives of institutions to interact with the aim of strengthening health professional AMR education at the country level. Members also identified a great need for support with intersectoral working/governance and a COP has also been established for this. The AMR Secretariat has spent time looking for guidance and tools on this topic and discussing how best to take this forward. What has become clear is that, while there is an extensive literature around governance, there is little in the way of useful, practical guidance on intersectoral governance for health. To address this issue, the community on Governance aims to develop some initial practical materials, based on group members experiences, to be disseminated to the larger community for feedback. It is anticipated that a third sub-community on Monitoring & Evaluation will be established shortly. WHO run train the trainer workshops in order to build expert capacity in EURO and AFRO regions. Networks of experts are being developed in association with the work streams. STAG recommends that WHO explores means of extending its external engagement and collaboration to embrace a wide range of potential partners, globally and in-country, to include the UN family, NGOs, civil society, academia and private sector. WHO collaborates with FAO and OIE in the following areas: Ad-hoc Interagency Coordination Group (IACG). The group comprises 27 members of which 14 are individual members and 11 are representatives of selected organisations. Those organisations include: FAO, OIE, OECD, UNAIDS, UNEP, UNICEF, WCO, WIPO, WTO, the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO works closely with UNICEF on access to clean water and sanitation. Two agencies jointly launched the WASH FIT tool and mobile app. WHO and the South Centre hosted the 3 rd annual dialogue/consultation on AMR with members of the Antibiotic Resistance Coalition (ARC) and other interested parties. The meeting gave an opportunity to provide updates and exchange views on the IACG, global development and stewardship framework and implementation of the global action plan on antimicrobial resistance. 8
STAG recommends that the DG Executive Office engages with not only the WHO AMR Secretariat but also all other relevant areas of the organization s work such as maternal and child health, and health workforce. Aside from the AMR Secretariat, the DG Executive Office engages with: Mother, Newborn, Child and Adolescent Health (MCA) Health Workforce (HWF) The expert consultation on health workforce education & AMR control was convened on 23-24 March 2017. It aimed to outline the needs and define the tools/resources required to ensure that health workers are adequately educated and/or trained for effective antibiotic stewardship to limit AMR. Essential Medicines and Products (EMP) Environment: Water, Sanitation and Hygiene (WASH) Food Safety, Zoonoses and Food-borne Diseases (FOS) Infection, Prevention and Control (IPC) HIV, TB, Malaria and Tropical Diseases (HTM) Reproductive health (particularly in regard to gonorrhoea) The AMR Secretariat holds regular teleconferences with relevant focal points in Regional Offices. The Senior Advisor to the Director-General and Special Representative for Antimicrobial Resistance/ADG and Director AMR hold regular meetings with Directors of technical units in the WHO Headquarters. STAG recommends that WHO convene a group of experts in their respective fields to develop appropriate monitoring indicators that would be applicable at both global and national levels. On 8-9 June 2017 the AMR Secretariat convened a meeting on Monitoring AMR: Outcome & Impact Indicators in WHO headquarters in Geneva. The invited experts, who included experts in animal health and environment from FAO and OIE, broadly supported the approach to monitoring that was presented to STAG in November 2016. The meeting aimed to identify specific outcome measures for GAP objectives 1-4 at country level and propose a core set of global general outcome measures that most countries should be able to use within the next five years. Monitoring of antibiotic resistance was the area of focus; importantly, processes for monitoring resistance in TB, HIV and malaria are already well-established. The group achieved an agreement on a core set of indicators flagging those areas where more work is planned or needed. This includes monitoring education systems, awareness as well as appropriate use and access. In the coming months the framework will be revised and made available for public consultation over the summer. STAG recommends that, when and where appropriate, WHO should support countries to undertake point prevalence surveys to monitor antimicrobial resistance patterns and access to and use of antibiotics. GLASS already collects data on antimicrobial resistance from countries. The first GLASS data call opened in April 2017 (for data from 2016). Results will be reported between late 2017 and January 2018. The AMR Secretariat is working with WHO Collaborating Centres (CCs) on designing special survey studies, which may be piloted sometime in 2018. 9
STAG recommends that, while the broad and complex concerns to be captured by the global development and antimicrobial stewardship framework must be addressed from a holistic and comprehensive perspective at the global level, it is essential that the impact and expectations that will fall on countries are not overlooked, to ensure it is principles based, pragmatic and feasible. Ahead of the 70 th World Health Assembly, WHO Department of Essential Medicines and Health Products (EMP) published the Global Framework for Development & Stewardship to Combat Antimicrobial Resistance. Draft Roadmap. The work is expected to continue throughout 2017 and into 2018. STAG recommends that WHO works with other sectors to agree on principles for the development and sustainable use of antimicrobials that are generally applicable, acknowledging that the pace and mode of application may differ between sectors. There is already a strong tripartite collaboration of the WHO, OIE and FAO within the following areas: Ad-hoc Interagency Coordination Group on Antimicrobial Resistance (IACG) The IACG, which is co-chaired by the Deputy Secretary General and the WHO Director-General, convened its first meeting in New York on 2-3 May 2017. The Secretariat of IACG is located in WHO HQ and comprises staff provided by FAO, IOE and WHO. The overall objective of the IACG is to provide practical guidance for approaches needed to ensure sustained effective global action to address antimicrobial resistance, including options to improve coordination, taking into account the global action plan on antimicrobial resistance. The IACG recognised that AMR is complex and demands a multisectoral approach, and needs a framework for the interventions required. The Stewardship Framework National Action Plans (includes launching a global tripartite database as well as monitoring & evaluation framework) In 2016, WHO, FAO and OIE disseminated a self-assessment questionnaire to monitor countries progress in tackling antimicrobial resistance. The database was launched at the 70 th World Health Assembly, the 85 th OIE General Assembly and the 40 th FAO Conference. 10