Comprehen-sive review of WHO GAP on AMR reflects many civil society concerns

From the start of the year, there have been civil society calls for WHO to conduct a Five-Year Review of the Global Action Plan on AMR as promised in the Tripartite’s Monitoring and Evaluation framework. These calls were made before the WHO’s Executive Board meeting in January 2021 and also as part of ARC’s briefing for the World Health Assembly in May 2021. The WHO did, in the end, conduct an evaluation of its work on the Global Action Plan on AMR and included voices from the Antibiotic Resistance Coalition in a consultation on July 26, 2021. The findings of the WHO Comprehensive Review of the Global Action Plan (GAP) on AMR (Main report) and Annexes have become available on the organization’s website.

The Comprehensive Review looked back at the successes, challenges, and gaps in the implementation of the GAP on AMR since its adoption in 2015 and provides lessons and recommendations to improve the implementation of the GAP on AMR. While noting the lack of a shared understanding of what would constitute success, the Review used data from the Tripartite AMR Country Self-Assessment Survey (TrACSS) as implementation scores for four out of the five Strategic Objectives. By these measures, the most significant improvements were in the multi-sector and One Health working arrangements and National Action Plans on AMR. However, little change was reported for key NAP components, specifically infection prevention and control in human health and optimizing antimicrobial use in animal health.

Overall the Comprehensive Review noted that the WHO GAP on AMR suffered from an unclear definition of outcomes, a lack of a detailed workplan unlike other Tripartite organizations like the FAO, the need for a prioritization tool, and a “more practical M&E framework with clearer indicators and targets which are actively tracked and reported on.” The evaluation pointed out that while the GAP had raised awareness of AMR, “this has largely not been translated into increased financial resources available to the AMR response, not least because there is no clear purposive plan of action.”

However, the Global Leaders Group recently put out priorities on these issues though the GLG failed to clear “on a number of issues including how the priorities and plans to monitor progress towards them fits with the GAP AMR and its M&E framework.” Civil society had raised concerns over the GLG’s process in arriving at its key performance indicators, without public input, transparency, or connection to the Tripartite’s M&E Framework. The Comprehensive Review observed that “indeed, the priorities document simply gives titles of key performance indicators without defining them in detail or explaining how data on them will be collected and reported or whether baseline data exists or not.”

The Comprehensive Review reflected gaps in how the WHO GAP on AMR took a truly One Health approach, noting its exclusion of “important areas, such as plant health, food production, food safey and the environment.” Importantly, it repeatedly noted that respondents, which certainly included members of the Antibiotic Resistance Coalition, had called for greater inclusion of UNEP, “for example by expanding the Tripartite to become a Quadripartite.” Slow progress on the AMR governance structures, the lack of coordination across structures, the neglect of other multilaterals and UN agencies, and the neglect of the contribution of civil society also received mention.

On issues of innovation, access and stewardship, the Comprehensive Review also flagged concerns. Civil society has noted the focus on excess, but less so ensuring access to appropriate antibiotics; the risk of WHO losing its normative lead on equitable access to an industry-funded AMR Action Fund; and the multiple missed opportunities by the WHO’s Division on AMR (e.g., WHA report on the unstable supply of benzathine penicillin G, high-price barriers to accessing liposomal amphotericin B for mucormycosis). The progress to expand the work of the Global Antimicrobial Resistance and Use Surveillance System (GLASS) is a notable bright spot in WHO’s work on AMR. In addition, important initiatives from GARDP (a product development partnership working to bring antibiotics to market) to the priority list of pathogens, antibiotic pipeline analyses, and target product profiles for antibiotics and diagnostics also have advanced progress to bring new medicines and diagnostic tools to market. The Review also noted how civil society might be engaged in promoting bottom-up innovation in access and stewardship initiatives, both in the healthcare delivery system and at the community level. Particularly troubling, the Comprehensive Review concluded that “relatively little had been done” on making the economic case for sustainable investment (GAP Strategic Objective 5). The report observed that: “While some organizations have done work on the economic case globally, this has not been used to advocate for or track global resources available to respond to AMR or to provide guidance and support for countries in terms of identifying resources available to their national action plan.” The “only very partially funded” Multi-Partner Trust Fund was a case in point.

The role of civil society within the Global Action Plan on AMR was also raised in the report. Antibiotic Resistance Coalition members had noted the value of holding dialogues between WHO experts and civil society organizations on priority issues in AMR and the need for safe spaces for civil society and LMICs to voice their perspectives. The Comprehensive Review explained these concerns further: “We recognize the need for WHO to conduct this in a way that involves all stakeholders, but as in other areas where significant financial conflict of interest exists, we hope that WHO can go the extra mile in creating separate, safe space for the voices from LMICs and civil society to share their inputs.” ARC members also called for involving civil society in the process of establishing indicators for monitoring and benchmarks for accountability as well as enlisting civil society in campaigns to effect behavior change and greater financing of AMR efforts.

NRDC, US PIRG and partners challenge the U.S. EPA’s approval of streptomycin on citrus trees

NRDC, US PIRG and their partners have filed a lawsuit to halt the U.S. Environmental Protection Agency (EPA) from allowing the spraying of streptomycin, an antibiotic classified by the World Health Organization as critically important for human medicine, on citrus crops. Streptomycin is an aminoglycoside antibiotic used in the treatment of tuberculosis. The petition asks the Court to reverse the EPA’s decision, made before the Trump Administration left office, to permit the use of streptomycin on citrus on two grounds: 1) that the “Agency failed to ensure that the use of streptomycin would not cause unreasonable harm to human health or the environment and 2) that the “EPA violated the Endangered Species Act by failing to consult with the U.S. Fish and Wildlife Service or the National Marine Fisheries Service to insure EPA’s action will not jeopardize any listed species or destroy or adversely modify any of their critical habitats.” The citrus crop, particularly in the U.S. state of Florida, has suffered from a devastating bacterial disease, known as huanglongbing, carried by the Asian citrus psyllid. Citrus growers have applied streptomycin as well as oxytetracycline through aerial spraying to rid the crop of Candidatus “Liberibacter asiaticus,” the responsible bacterial species, with limited effectiveness. Alternative approaches have emerged such as traps that control the Asian citrus psyllid, cover crops, and other non-antibiotic therapies.

This work builds upon earlier efforts by U.S. public interest groups, including a Keep Antibiotics Working coalition petition in 2019 to deny then an emergency exemption requested by the Florida Department of Agriculture and Consumer Services that would have allowed streptomycin’s use as a pesticide against citrus greening. The exemption at that time sought permission to spray up to 780,000 pounds or 353,000 kilograms of streptomycin sulfate, an aminoglycoside antibiotic, on the citrus crop. The streptomycin use alone is 54 times the quantity of aminoglycoside-class antibiotics used in human medicine in the United States.

Alliance to Save our Antibiotics webinar on Soil Assoc. Certified Farms' antibiotic use

In early March, the Alliance to Save Our Antibiotics held a webinar on “Farm Antibiotic Use and Husbandry: Better Understanding through Data.” As farms in the U.K. have seen a 48% reduction in tonnes of antibiotics sold in 2019 compared to 2014, the Alliance to Save Our Antibiotics wanted to document that it was possible to reduce antibiotic use in these settings even further. Towards these ends, a survey was organized over a year-long period from 2018 to 2019 and sent to Soil Association Organic-certified organic farms. The convenience survey engaged over 200 farms that raised dairy cattle, beef cattle, sheep, pigs, and poultry. Overall, Soil Association-certified farms had four times lower the UK average, and farms with pigs had 77 times lower antibiotic use than the UK average. The Alliance’s full report will be published later. A recording of the webinar is also available here.

ARC members write to U.S. National Institute of Food and Agriculture

In a recent letter, fourteen member and colleague organizations of the Keep Antibiotics Working coalition wrote to the National Institute of Food and Agriculture - United States Department of Agriculture. In this letter, the group asks that the agency prioritize funding for research that reduces antibiotic use. They noted that recent awards for tackling AMR all aimed to mitigate the spread of AMR, after it had already developed. This is in contrast with an approach that would prevent antibiotic overuse. Furthermore, the group also called on the Agriculture and Food Research Initiative (AFRI) to “prioritize research applications that identify practices that reduce the need for antibiotics over projects that attempt to improve antibiotic stewardship once animals are already ill.”

ReAct members join WHO's Strategic and Technical Advisory Group for Antimicrobial Resistance

The Strategic and Technical Advisory Group for Antimicrobial resistance (STAG-AMR) is the principal advisory group to the World Health Organization (WHO) on antimicrobial resistance. When the WHO reorganized its organizational structure creating a new AMR Division, the previous STAG was dissolved and the terms of reference were revised. In the new terms of reference, the priorities are defined by the Inter-Agency Coordination Group on AMR’s (IACG) report to the United Nations Secretary-General in April 2019 and feedback from Member States when the AMR Resolution was adopted at the 72nd WHA in May 2019. The newly defined STAG-AMR is being chaired by Professor Gunnar Kahlmeter, a clinical microbiologist from Sweden. Two members from ReAct, Dr Sujith Chandy (ReAct-Asia Pacific) and Otridah Kapona (ReAct-Africa) have become members of the STAG. The STAG’s members largely have a human health background with no individuals working primarily on food systems. Nevertheless, it includes Dr.Tim Walsh, who has worked on the global illegal trade of colistin in agriculture. The STAG-AMR also includes a patient advocate. The STAG will have its first introductory meeting on March 4, which will be used to brainstorm the agenda for the STAG-AMR. The first official meeting is planned for June 2021.

Healthcare Without Harm's new infographic and call for case studies

Healthcare without Harm has produced a new infographic to summarize the impact of antimicrobial resistance both in Europe and globally. The infographic highlights that AMR already causes more than 30,000 deaths per year in the EU/EEA and that the main drivers of AMR are: 1) animal use; 2) human use; and 3) environmental pollution. For a separate project to identify solutions for preventing/removing pharmaceuticals in hospital wastewater, Healthcare without Harm is asking that stakeholders provide case studies for any initiatives within European hospitals to remove pharmaceutical residues from wastewater, or to prevent them from entering wastewater. If you are aware of related projects implemented in a European hospital, please contact Jean-Yves Stenuick (jean-yves.stenuick@hcwh.org) by March 15, 2021.

U.S. food groups criticize the One Health Certified label

A coalition of U.S. civil society members, including Consumer Reports, NRDC, and U.S. PIRG, has launched a new campaign to continue highlighting the issues with the One Health certified label. Groups first began raising the alarm on this label back in 2020. In the press release, the groups are raising the concern that the label is a “greenwashing and humane washing scheme.” The One Health Certified label is developed by industry groups through a U.S. Department of Agriculture auditing program (Process Verified Program). These verification programs are designed voluntarily by companies for marketing purposes. Consumer Reports ranked the label with its second-poorest rating as the OHC standards reflect current industry practices rather than novel stewardship approaches to antibiotic use, animal welfare, and environmental impact. The groups have published a detailed critique of the label alongside a consensus statement from the coalition’s partners. In the latest podcast episode of Superbugs Unplugged, Matthew Wellington (U.S. PIRG) featured Maryn McKenna, a journalist who has long tracked AMR, and also highlighted the issue with this One Health label.

ARC members keep watch and call for action on AMR during the WHO Executive Board meeting

This January, the World Health Organization’s Executive Board met to discuss progress on antimicrobial resistance among other agenda items for its 148th session. The report, “Antimicrobial Resistance - Report by the Director General” (EB148/11), highlighted accomplishments across the five strategic objectives of the WHO’s Global Action Plan and Global Coordination and Tripartite Partnership. It also noted challenges in the context of COVID-19; the multisectoral work and the One Health approach; access to quality diagnostics and antimicrobials; sustaining political commitment; and lack of financial and technical resources. The report also asks that Member States accelerate implementation of National Action Plans (NAPs), building linkage with plans and financing for UHC and primary health care, and addressing health security challenges, including the COVID-19 response. Furthermore, it called for health ministries to support efforts to ensure the Codex Code of Practice to Minimize and Contain Foodborne AMR reflects public health values. A link to the recording of the WHO EB’s discussions is available.

The WHO Watch, organized by the People’s Health Movement, monitored the proceedings of the WHO EB and prepared comments on the various agenda items, including AMR. ReAct released two briefings for the Executive Board, one on the agenda of the WHO EB and the other analyzing results from the Tripartite AMR Country Self-Assessment Survey (TrACSS), collaboration of the Tripartite agencies in curbing antimicrobial use in food production, and opportunities to advance the WHO GAP on AMR. The first briefing highlighted the need to complement the creation of the One Health Global Leadership Group on AMR (GLG) with progress on the Independent Evidence Panel and the Multi-stakeholder Partnership Platform. the lack of financing for implementing NAPs, the value of establishing a new global R&D financing and coordination entity for antibiotics, and the need to develop rules-based global governance for AMR.

With feedback from ARC members, the ReAct Strategic Policy Program’s policy briefing on the WHO EB discussion of AMR called attention to key areas in which the WHO Global Action Plan should ensure greater accountability. Drawing on analysis of the TrACSS survey, the policy briefing flagged that over twenty fewer countries participated in this Country Self-Assessment survey, how ten countries had slid backwards in recent years from financing their NAPs, and how the AMR report to the WHO EB made no mention of the promised five-year review of the WHO Global Action Plan. The policy briefing also noted the failure of the Tripartite collaboration to embrace the WHO’s 2017 Guidelines on Use of Medically Important Antimicrobials in Food-Producing Animals. Not addressing the use of antimicrobials important to human medicine in food production jeopardizes the progress that might be made in adopting the AwaRe classification of antibiotics as part of national essential medicine lists. The campaign also called attention to the promised, five-year review of the WHO Global Action Plan; the shortfall in financing the UN Multi-Partner Trust Fund on AMR; and contrast between the World Bank’s projection of economic losses of $3.4 trillion a year by 2030 and the paltry $13M raised to date by the Multi-Partner Trust Fund on AMR.

ReAct distributed its findings as part of policy briefing and social media campaign through ReAct, ARC, the People’s Health Movement WHO Watch, social media, Geneva missions, and targeted Facebook and Twitter ads. The messages in the social media campaign carried the unifying refrain, “Are we #NAPpingOvertheGAP?” and called for greater support of the work of countries on AMR. The social media resources are still live and can be used to continue to raise awareness for action on the Global Action Plan.

The South Centre partners with FAO and UNEP to organize webinar on One Health and AMR

In early January, the South Centre, the Food and Agriculture Organization of the UN (FAO) and the UN Environment Program organized a joint webinar “Advancing the One Health response to Antimicrobial Resistance (AMR).” The presenters came from intergovernmental agencies and governments and represented the various facets of One Health. The presentations were targeted to Member States which are represented in Geneva and those stakeholders that cover health, agriculture, environment, and the Sustainable Development Goals. Dr Carlos Correa, South Centre, gave the opening remarks emphasizing the importance of One Health and the need to continue highlighting AMR as a critical issue. The various agencies all commented on the work they were doing on AMR, noting the relevant SDG indicators for their work. The participating countries shared their experiences with working in One Health and the challenges on cross sectoral collaboration.

The FAO noted that they are developing a new Action Plan on AMR 2021 to 2025. In this plan, one of the new objectives in the Action Plan will be strengthening governance and allocating resources to accelerate and sustain progress. Separately, the World Organisation for Animal Health’s (OIE) animal standards are in the process of being revised after the Codex task force on AMR meets in October 2021. The OIE is also keen on collecting more granular antibiotic use data at a farm-level and by species. The World Health Organization also presented on how the human health sector can work better with other sectors to address AMR. UNEP noted that their approach to tackling AMR builds on their history of regulating chemicals/pharmaceuticals in the environment. UNEP sees a goal for providing incentive structures for development of green and sustainable pharmaceutical drugs for human and veterinary uses, including through procurement and innovation (R&D).

AMR as a health systems issue highlighted in Project Syndicate op-ed

In a new op-ed, Professor Otto Cars, Senior Advisor to ReAct-Action on Antibiotic Resistance, with Patricia Gelli at the World Bank, wrote about the “Silent Pandemic of Antibiotic Resistance.” In this piece, they note that while the antimicrobial resistance framing has been used by organizations like the WHO to “facilitate programmatic synergy and efficiency,” it ignores key elements that make antibiotic resistance unique. Countries have contributed relatively weak political support for the implementation of National Action Plans on AMR. Furthermore, they call for investing in R&D to spur novel antibiotic development, while delinking these incentives from volume-based sales. By quantifying the health and economic costs, they argue that such evidence would help convince governments to finance these efforts in bringing new drugs to market. The writers highlight the example of the African Union, which has recently made progress towards taking a health-systems approach in equitably providing access to antibiotics. By working collaboratively on COVID-19, the African Union has paved the way with key investments in digital surveillance and next-generation sequencing tools. These tools, in turn, might support surveillance efforts against antibiotic resistance, building upon the regional endorsement this past September of working together on AMR.

Antibiotics off the Menu Coalition urges Biden Admin to act on antibiotic resistance

In December, several ARC members remarked on the observed increase in antibiotic sales for food animal production in the United States. The new data show that the overall sale of medically important antibiotics increased by three percent from 2018 to 2019. While progress had been seen in the broiler chicken industry, the cattle and swine (pig) production sector have not made similar progress. As such, the Antibiotics Off the Menu Coalition, which includes US PIRG, Consumer Reports, Food Animal Concerns Trust, and the Natural Resources Defense Council, called on restaurant chains to continue with their efforts in curbing the routine use of antimicrobials in food animal production. Furthermore, the Coalition’s statements also urge the new Biden administration to take concrete actions. Among these, the Coalition has called for establishing a national target to reduce medically important livestock antibiotic use 50% by the end of 2023, relative to 2009 levels. In addition, the Coalition has also called for the development of a surveillance system for tracking antibiotic use and resistance at the farm level.

ARC members file petition with USDA to address bacterial foodborne illnesses

In 2011, 1.8 million Americans fell ill with Salmonella and Campylobacter. The Center for Science in the Public’s Interest’s Deputy Director of Regulatory Affairs, Sarah Sorscher, said that “We have seen little progress in actually reducing the number of people getting sick from Salmonella or Campylobacter. A big reason for that is the USDA [United States Department of Agriculture] has yet to take full advantage of the best current technology and science to control foodborne disease from farm to fork.” In response to these inadequacies, CSPI, Consumer Report and allies filed a regulatory petition urging USDA's Food Safety and Inspection Service to improve their food safety standards by establishing a process for USDA to create enforceable standards that target and ultimately eliminate Salmonella types of greatest public health concern and reducing all Salmonella and Campylobacter in poultry. To bring this about, the petition also asks the USDA to require slaughter establishments to adopt and implement vaccinations for live poultry, surveillance on farms for the presence of dangerous bacteria, and other interventions in the food supply chain.

Alliance to Save Our Antibiotics' Expert interview series features ARC member

The Alliance to Save Our Antibiotics has created a series interviewing leading experts in the field of AMR and One Health asking for their take on progress, leadership and challenges. As part of this series, Professor Anthony So of ReAct’s Strategic Policy Program described their work on antimicrobial resistance, from research to policy. The program’s activities span the spectrum of One Health concerns and extend to training the next generation of AMR champions. He noted that the world should recognize the opportunity to address challenges shared by both COVID-19 and AMR, from zoonotic disease transmission and surveillance to infection prevention and control and surge capacity to deliver needed diagnostics, antimicrobials and vaccines. In this interview, Professor So also highlighted where the movement might make the greatest difference in curbing unnecessary antibiotic use in farming and the environment. Developing vaccines to reduce the use of antibiotics in food production, such as in salmon aquaculture in Chile, offer promising opportunities. Much work lies ahead in holding governments accountable, both to financing these priorities and benchmarking measurable change towards these goals. Professor So admonished, “If we hope to have a future free from the fear of untreatable infections, we can now pay to address antimicrobial resistance—or pay much more later.”

EPHA project collects Good Practices on AMR

Hosting the AMR Stakeholder Network, the European Public Health Alliance has put out a call to collect AMR good practices. The AMR Stakeholder Network serves as the largest civil society-led coalition active in the European Union. The good practice should be in line with one of the five areas of the AMR Stakeholder Network’s 2019 Roadmap for Action on Antimicrobial Resistance, which include 1) setting targets and performance indicators; 2) addressing the environmental aspect of AMR; 3) mobilizing resources for national AMR policies; 4) prioritizing prevention of AMR; and 5) increasing collaborations between civil society and policymakers. These case studies are being collected to summarize feasible actions that can strengthen Europe’s AMR “safety net” in the aftermath of the Coronavirus pandemic. The results will also be shared with European decision makers at the end of the process.