Can the Application of the International Health Regulations to Antimicrobial Resistance Events Help to Preserve Antimicrobials? AMR 1, abstract N° 406 Didier Wernli, Thomas Haustein, John Conly, Stephan Harbarth Service prévention et contrôle de l‘infection Hôpitaux Universitaires de Genève

Background (1) 2 Legal framework for international efforts to contain the risk from public health threats that may spread between countries scope not limited to a list of diseases, but covering “illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans” Adopted by WHA in 2005, entered into force states parties + WHO as “hub”.

Background (2) 3 States Parties to develop certain minimum core public health capacities States Parties to notify WHO of significant public health events At the request of a State Party, WHO shall collaborate in the response […] by providing technical guidance and assistance (Art. 13.3).

Background (3) – Notification 4 All events which may constitute a public health emergency of international concern (PHEIC) within its territory (≥2 x yes to the following questions)  Is the public health impact of the event serious?  Is the event unusual or unexpected?  Is there a significant risk of international spread?  Is there a significant risk of international travel or trade restrictions? DG to determine whether event constitutes a PHEIC [this has happened once so far: H1N1 2009].

Are AMR events notifiable under the IHR? 5. Example: International spread of “new” types of resistance carbapenem-resistant Enterobacteriaceae

6. CRITERIONPROCONTRA 1.Is the public health impact of the event serious ?  The spread of CRE has a high potential for future impact on public health.  Treatment failure associated with AMR is one of the “circumstances that contribute to high public health impact” listed in Annex 2.  Not an immediate threat to public health; short-term impact difficult to quantify.  Impact concentrated on a minority group, (hospitalized patients.)  Low potential to cause visible community epidemics compared to infections such as influenza, cholera or polio. 2.Is the event unusual or unexpected?  Novel resistance mechanisms, particularly pan-resistance are by definition unusual and unexpected.  Selection of resistant pathogens is an expected consequence of the use of antimicrobials. 3.Is there any significant risk of international spread?  Clear epidemiological links and cross border movement of individuals colonised or infected with CRE  The international spread of CRE is slow compared to the acute risk to public health caused by respiratory viruses. 4.Is there any significant risk of international travel or trade restrictions?  In 2008/2009 Russia refused imports of pork and poultry products based on the presence of antibiotic residues; similar reaction to presence of CRE in food items possible?  In reality, no case of trade restrictions and no travel restrictions due to CRE so far.

Are AMR events notifiable under the IHR? 7 At least 3 of the 4 criteria could be affirmed If they could, should they?.

Why should the IHR be applied to the global AMR threat? 8 AMR requires a coordinated international response. “wake-up call” to strengthen global AMR surveillance and response early warning system: allow early implementation of screening measures and prevent the establishment of new resistant strains societal investment in core surveillance and response capacities at different levels by setting minimum standards.

Outlook 9 IHR ultimately “owned” by the States Parties WHO to provide leadership on the role of the IHR for combating AMR Many practical obstacles for realizing the full potential of the IHR Window of opportunity for an open debate about the applicability of the IHR to AMR..

Thank you! 10. PLoS Med Apr;8(4):e