Essential Drugs and Medicines Policy WHO global strategy to contain antimicrobial resistance: prioritisation of interventions ICIUM 2004 K.A.Holloway Essential Drugs and Medicines Policy WHO Geneva

WHO, Dept. Essential Drugs and Medicines Policy WHO Global strategy Identifies 67 interventions targeted at different groups Prescribers and dispensers Patients and the general public Hospitals Governments and health systems Pharmaceutical industry Non-human uses of antimicrobials International aspects WHO, Dept. Essential Drugs and Medicines Policy

Prioritising interventions Multidisciplinary groups at country / regional level done in EMRO & SEARO and with Nepal officials group members agreed 32 interventions for prioritisation & scored (0,1,2) each intervention for feasibility & importance interventions were plotted on a graph & compared Three specialist expert groups at WHO/HQ level experts sat in specialist groups for (1) prescribers & dispensers (2) hospitals & (3) government & health systems each group prioritised interventions for their target groups comparison was done of different expert groups’ priorities to identify interventions common to different target groups WHO, Dept. Essential Drugs and Medicines Policy

32 interventions to contain AMR prioritised in regions WHO, Dept. Essential Drugs and Medicines Policy

Prioritization of interventions by the 11 members of EMRO antimicrobial resistance task force 25 Feasible and relevant 8 4 6 3 2 1 20 4 5 3 3 5 1 3 2 1 3 11 12 9 4 3 1 2 2 2 1 5 15 1 7 Importance 2 10 10 Key: group targeted by interventions A patients, families, communities B prescribers and dispensers Not feasible or relevant C health systems 5 D govt. policies, strategies, regulations E pharmaceutical industry F non-human antimicrobial use 5 10 15 20 25 Feasibility

Prioritization of interventions by 7 staff members of SEARO 15 1 14 1 1 4 3 3 8 13 1 3 3 2 1 2 2 5 12 3 4 3 4 2 2 11 2 5 12 9 6 10 Feasible and relevant 10 9 7 Importance 8 5 1 7 11 Key: group targeted by interventions 6 A patients, families, communities 5 B prescribers and dispensers 4 Not feasible or relevant C health systems 3 D govt. policies, strategies, regulations 2 E pharmaceutical industry 1 F non-human antimicrobial use 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Feasibility WHO, Dept. Essential Drugs and Medicines Policy

Prioritization of interventions by 15 health officials in Nepal 3 4 2 25 3 1 2 3 3 1 1 5 5 1 3 11 13 2 4 4 3 2 8 1 5 1 6 9 20 10 12 2 2 Feasible and relevant 7 Importance 15 Key: group targeted by interventions A patients, families, communities B prescribers and dispensers Not feasible or relevant C health systems D govt. policies, strategies, regulations E pharmaceutical industry F non-human antimicrobial use 10 15 20 25 Feasibility WHO, Dept. Essential Drugs and Medicines Policy

WHO/HQ priorities (1) Fundamental interventions Make containment of AMR a national priority including: creation of a national task force, allocation of resources to implement interventions to contain antimicrobial resistance, development of indicators to monitor and evaluate the impact of an antimicrobial resistance strategy. Designate or develop reference microbiology laboratory facilities to co-ordinate effective, epidemiologically-sound, surveillance of AMR among common pathogens in the community, hospitals and other health care facilities WHO, Dept. Essential Drugs and Medicines Policy

WHO/HQ priorities (2) High Priority Interventions Patient education on preventing infection (immunization, vector control, use of bed-nets, etc.) and reducing trans-mission of infection (hand-washing, food hygiene, etc.) Prescriber and dispenser (including drug sellers) education on appropriate antimicrobial use, containment of AMR, disease prevention and infection control Targeted UG & PG education for all health workers & vets on accurate diagnosis & management of common infections Develop, update and use STGs & treatment algorithms Infection Control Programmes in hospitals WHO, Dept. Essential Drugs and Medicines Policy

WHO/HQ priorities (3) High Priority Interventions Good quality diagnostic laboratories that provide:- microbiology lab. services appropriate to the level of hospital appropriate diagnostic tests, bacterial identification, antimicrobial susceptibility tests of key pathogens with relevant timely reporting Limiting availability of antimicrobials to prescription-only status, except in special circumstances where they may be dispensed on the advice of a trained health care professional Ensuring only antimicrobials meeting international standards of quality, safety & efficacy are granted marketing authorisation WHO, Dept. Essential Drugs and Medicines Policy

Problems with prioritisation People prioritised according to their specialities and expertise agricultural interventions were not prioritised in the exercise in Geneva the prioritisation of which interventions are most important and feasible was based on opinion and not evidence of which there is very little WHO, Dept. Essential Drugs and Medicines Policy

WHO, Dept. Essential Drugs and Medicines Policy Conclusions (1) Five interventions deemed important & feasible by all groups training prescribers and dispensers and using guidelines and formularies establishing infection control committees and guidelines for antimicrobial use developing national drug policies, essential drug lists and standard treatment guidelines ensuring undergraduate and post graduate training on antimicrobial resistance ensuring that drugs are produced according to GMP standards and are of adequate quality WHO, Dept. Essential Drugs and Medicines Policy

WHO, Dept. Essential Drugs and Medicines Policy Conclusions (2) A national task force with budget is needed to carry out & coordinate the 5 interventions There is a need to evaluate all interventions for their effectiveness & cost-effectiveness in containing antimicrobial resistance In order to evaluate interventions, it is necessary to do linked surveillance of antimicrobial resistance and use WHO, Dept. Essential Drugs and Medicines Policy

Key lessons, policy implications and future research There is expert consensus that a national task force and national public reference lab are regarded as fundamental to containing AMR There is widely differing opinion and a profound lack of evidence concerning which strategies to contain AMR should have highest priority Policy implications Lack of evidence for prioritising interventions to contain AMR hampers the development of coordinated national approaches to containing AMR Future research Rigorous evaluation of interventions to contain AMR must be conducted in order to identify which strategise are most cost-effective Sustainable, reliable and affordable surveillance systems need to be researched and developed in order that interventions can be evaluated. WHO, Dept. Essential Drugs and Medicines Policy