Dutch antibiotic resistance policy A One Health Approach Ministry of Health, Welfare and Sport Ministry of Economic Affairs Ministry of Infrastructure and the Environment AMR Media Seminar 16 – 11- 2015

Background (1) Doing relatively well in health care Focus on veterinary measures since 2008 Political will Self-regulation Transparency Independent monitoring and benchmarking Enforcement A short history of the development of policy on antibiotic resistance in NL: NL is doing relatively well in health care; There is relatively little use of antibiotics And there is relatively little spread of resistance On the other hand, NL used to be on the other side (a ‘red country’ so to say) of the graphs when it comes to the use of antibiotics in the veterinary sector. This in an important sector in NL. Starting in 2008, the focus had been on measures in the veterinary sector Against the background of discussion on the risk of animal farming for public health 2009 Q-fever outbreak, General discussion on intensive livestock farming in a densily populated country like NL And discussion on ESBL in poultry - following a person who died and seemed to have the same type of ESBL as was found on chicken meat. This even led to a small dip in the sales of chicken meat Political will = not only the government but also all parties in the parliament were in favor of measures in the veterinary sector - Sda: In 2010 an independent body, the Netherlands Veterinary Medicines Authority (SDa), was established for monitoring and benchmarking the use of antibiotics at the level of herd and veterinarian, for supervising the follow-up of recommendations for reduction of use, and for quality control of the data recording systems AMR-NL@minvws.nl

Results: 58% reduction in 2014 This graph shows that drastic reduction of the use of antibiotics in the general animal husbandry sector is hard – but possible. Use of antibiotics in animal husbandry has dropped with 58% compared to 2009. Also the use of criticaly important antibiotics has dropped. In the Netherlands we use less than 0,5 kg 3e en 4e generation cefalosporines in the 4 most important animal husbandry sectors. The use of fluorochinolons has reduced 25% in these sectors. Our efforts have been succesfull. We have a reduction of antibiotic resistance in our livestock animals!! AMR-NL@minvws.nl

The Dutch One Health approach We have a 5 year national action plan recently published as a letter to parliament (dated June 24, 2015) this letter is translated and available with more information (like the fact sheet which is also provided in hard copy today) in English on our website – reference/link is given at the end of this presentation The One Health approach in NL addresses all domains where human health is threatened by antibiotic resistant Bacteria The Dutch approach is characterized by clear goals and specific actions. AMR-NL@minvws.nl

Healthcare avoidable healthcare-associated infections will be reduced by 50% incorrectly prescribed antibiotics across the entire healthcare chain reduced by at least 50% reduction in the emergence and spread of multiresistant bacteria in healthcare becomes visible infections and deaths due to antibiotic resistance in the Netherlands will remain at the current level or decrease possibilities for effective treatment of patients with infections with resistant bacteria will not reduce any further This slide shows what specific goals and clear actions in our National action plan looks like for the health care domain All stakeholders in health care and public health have committed to a joint agenda to take concrete measures against increasing antibiotic resistance. The parties involved have set themselves 5 very ambitious goals, to be realised in the next 5 years (2015-2019). Their view – and we agree on this- is that these goals can only be met if we focus on creating regional networks in which the health care organizations, GP’s etc. work on screening patiënts, sharing data and taking shared responsability for reducing the use of antibiotics as well as taking all measures necessary to reduce emerging and spread of multi resistant bacteria. AMR-NL@minvws.nl

Animals Actions to further decrease use of all critical antibiotics Actions to combat and prevent carbepenem resistance in livestock Develop new policy, focus on prevention As mentioned before, there is already a 58% reduction of the use of antibiotics compared to 2009. The goal is to achieve a 70% reduction by the end of 2015. In 2016 new measures will be developed, focussing on prevention. Healthy animals don’t need antibiotics. What can be done to increase the health and well being of livestock.

Goal: prevent exposure to resistent bacteria in food Through: Research on transmission of resistant bacteria through food Improved food hygiene Consumer education and information on food hygiene

Environment Environment plays a role in the spread of (residues of) antibiotics and resistant bacteria However little is known about these processes and attribution of these aspects to the overal problem of antibiotic resistance Focus is on research to gain more knowledge and to define the scope of the problem (eg we measure samples of wastewater from hospitals) Development of action plan with evidence-based measures (by the end 2016)

Development new antibiotics and resistance In this graph you can see new antibiotics developed over time, like the well known penecilin, followed by resistance observed to these antibiotics When the antibiotics that we currently use to treat infections don’t work anymore because of antibiotic resistance, we need new classes of antibiotics, or other treatment options. It is evident that there are not enough new treatment in development. That is why we need to invest in the research and developement of new antibiotics and alternative therapies. In The Netherlands we have seen that there are several promising technologies and research initiatives, but that the cooperation can be improved to make the research more efficient. The Ministry of Health wants to facilitate and support the closer cooperation of Dutch stakeholders in this field. Once national research initiatives are better aligned and coordinated, we can also build stronger international collaborations. We fund research on new antibiotics and alternative therapies through the Netherlands Organisation for Health Research and Developement. The research program also aims to stimulate other innovations to tackle antibiotic resistance, such as prevention of infections. The Netherlands also participates in international research initiatives such as the Joint Programming Initiative AMR, and the IMI projects DRIVE-AB and COMBACTE.

Communication Communication strategy taregetd towards: General public – a special edition of a famous comic book in NL and Belgium, is distributed to all GP’s, for patients and their children to read. I have a hard copy for you here today. Professionals in healthcare (Boards of) directors / administrators (=bestuurders)

10 million deaths attributable to AMR every year in 2050 Amr is an international problem, resistant bacteria do stop at national borders. Therefore our national action plan specifically addresses international cooperation. The Netherlands want to play an active role by putting and keeping AMR on the agenda, and where possible come to further agreements on measures The Review on Antimicrobial Resistance, Chaired by Jim O’Neill. December 2014

International cooperation Less (spread of) antibiotic resistance by: Higher efficiency Share best practices Through: Implementation WHO Global Action Plan Global Health Security Agenda AMR Action Package EU (Presidency) International cooperation contributes to reducing AMR because international agreements on measures make that they are more efficient; it does not work if one or a few countries take drastic measures while others do not act Furthermore we see international cooperation as an opportunity to share best practices. We all can learn from activities and challenges in other countries. We financially support the implementation of the WHO Global Action Plan We play an active role as one of the leading countries in the Global Health Security Agenda Actiion Package on AMR. Moreover; we organise the next GHSA annual meeting in the Netherlands in 2016 AMR is one of our priorities for the Dutch EU presidency starting in january 2016. We organise a ministerial meeting for ministers of both Health and Agriculture in February in Amsterdam. This is a unique combined One Health ministerial meeting at this level. Our overal goal is to take EU action one step further

EU presidency One health leadership Solid national Action Plans Commit to EU Action Legislate prudent use of antibiotics in animals in the interest of public health A next step in the development of new antibiotics The five goals of the AMR Ministerial conference are: 1. One health leadership Health Ministers should coordinate a One Health approach to AMR in cooperation with Ministers of Agriculture and Environment. This means: to urge upon Ministers to take measures from the public health perspective in all domains; healthcare, animals, food safety and the environment. National action plans should be developed in cooperation with relevant stakeholders in public and private sectors and preferably signed by all responsible ministers. Member States (MS) should have a national action plan based on a One Health approach by mid 2017, as stated in the WHO Global Action Plan adopted during the World Health Assembly in May 2016. 2. Solid national Action Plans Based on the EU decision on cross border health threats; MS have to present to the Health Security Committee (HSC) their national action plan with measurable targets before mid 2017, and hold each other accountable via the HSC. MS use assessment tools (country-to-country assessment, ECDC assessment, surveillance data presented to ECDC) to demonstrate to the HSC progress in implementation and contribution to the EU targets in the EU Action Plan. 3. Commit to EU Action Action within the EU MS ask the Commission to develop a new EU Action Plan, with firm goals[1]: Antibiotic resistance of bacteria in humans and animals in the EU decreases in the next five years The differences between MS, in use of antibiotics in both human and animal health, decrease in the next five years , whereas also member states with a relatively low use should try to further pursue prudent use of antibiotics. Healthcare Associated Infections in the EU decrease in the next five years Specify biosecurity (infection prevention) measures in animal husbandry by prioritizing the adoption of a delegating  act under the Animal Health Law Concrete actions to reach these goals are suggested to the Commission by the MS (we will provide an annex) MS politically commit to the new EU Action Plan by adoption in the both the Health and Agriculture and Fisheries Councils  Action outside the EU MS commit to putting AMR on the agenda of the UN general Assembly in September 2016 Commit to contribute to implementing WHO GAP AMR and FAO AMR resolutions, including phasing out of use of antibiotics for animal growth promotion and reduction in nontherapeutic use of antimicrobial medicines in animals[2]  4. Legislate prudent use of antibiotics in animals in the interest of public health Ban on the use of last resort drugs in animals In livestock, susceptibility testing has to be mandatory before using antibiotics which are of critical importance to human health  Both require implementation through the veterinary medical products legislation  5. A next step in the development of new antibiotics Putting in place a strategic expert commission to define a yearly prioritized r&d agenda in 2016, based on an analysis of gaps in EU research on new antibiotics and alternatives for antibiotics presented during the conference on 10th February 2016 [1] Discussion point: possible quantification of these goals [2] This point is already agreed; but needs to be emphasized

Further information/references Website: http://www.government.nl/topics/antibiotic-resistance Fact Sheet: https://www.government.nl/topics/antibiotic-resistance/documents/leaflets/2015/09/22/tackling-antibiotic-resistance National Action Plan: http://www.government.nl/documents/parliamentarydocuments/ Health Council advisory report Antibiotics in food animal production and resistant bacteria in humans : http://www.gezondheidsraad.nl/sites/default/files/201116E_Antibiotica_in_food_animal.pdf AMR-NL@minvws.nl