1. Losing Antibiotics Losing lives Losing economies
Jørgen Schlundt
Michael Fam Chair Professor
Director NTU Food Technology Centre
Nanyang Technological University

2. 1,000 Major disease burden Major Deaths Burden
The world: 700,000 deaths per year
from antibiotic resistant bacteria

3. 3 Switzerland Traffic Fatalities 2013 : 269
Switzerland: 800 deaths per year
from antibiotic resistant bacteria
Switzerland Traffic Fatalities 2013 : 269

4. Die from previously harmless infections
United Nations 21 September 2016
agreed on a resolution
warning of a potential post-antibiotic era
where many will – again
Die from previously harmless infections

5. (Note: annual global deaths from cancer: 7-8 million)
Annual deaths from antimicrobial resistant bacteria
Deaths per year
10 million
2050
700000
If left to continue at present pace, we will see a return to the pre-antibiotic era within the next years
(Note: annual global deaths from cancer: 7-8 million)

6. Where do we (mostly) use our antibiotics?
Sick humans
15-25%
Sick animals
To grow healthy animals faster 50-70%
(Estimated figures from USA)

7. The need for an evidence base
“The effect of antimicrobial resistance policies seems variable … absence of progress partly due to an insufficient evidence base to inform policy makers about the effectiveness, generalisability, and cost-effectiveness of initiatives”
From Paper 4 in the Lancet series:
Antimicrobials; access and sustainable effectiveness
18 November 2015
DOI:

8. A number of (simple) steps to take
Document use of antibiotics and occurrence of resistance
Regulate all use of antibiotics
Block Vet’s right to make a profit from dealing drugs
Do the same for medical doctors
Reduce stupid use of antibiotics significantly

9. New veterinary medicinal regulation adopted in 1995
Banning routine prophylactic usage and limiting Vet’s profit from the sale of drugs (which was close to 50% of a standard Vets total net income)
New veterinary medicinal regulation adopted in 1995
Profit on
therapeutics
reduced
In 1995 a law was passed, which banned the routine prophylactic usage of antimicrobials in animals, and which limited the veterinarians profit from the direct sale of drugs. This immediately led to a 40% drop in therapeutic drug use. However with time the effects of this intervention have been lost, and we are now back at the same level of therapeutic drug use as in 1994, taking into account the increased production of food animals in the same time period.
Reduced the total usage of prescribed veterinary medicine by 30-40% from one year to the next

10. Effects on productivity of the Stop for Antimicrobial Growth Promoters
(NTA = Non-Therapeutic Antimicrobials)

11. Lessons about resistant foodborne zoonoses from 10 years surveillance (DK)
Close association between animal use and AMR.
Close association between AMR in the food supply and AMR in foodborne human infections/commensals:
AMRhuman ≈ x*AMRfood/animals + y*AMRimport + z*AMRtravel
Significant impact of imported food and travel
Growing use of antimicrobials in animal (incl. fish) production
Antimicrobial growth promotion only banned in EU
Vet profit only restricted in Scandinavia

12. Old-fashioned quantitative limits
Import control
Old-fashioned quantitative limits 12

13. Another Old Approach based on ‘Mutual Recognition Agreement’
MRAs can be time bound and depend upon agreements on ‘equivalence’ of the measures in place at a specific time.
MRA’s are negotiated between two or more countries and as such become part of a broader negotiation.
AMR is not static but constantly developing as more scientific evidence emerges so need for regular update
MRA’s will not necessary cover testing of all inputs that go into the exported product

14. Alternative approach based on ‘National treatment principle’ works for bacteria, can also work for AMR:
A criterion based on assessment of risk
(remember WTO SPS agreement):
“Members may introduce measures resulting in a higher level of health protection than international standards, if there is a scientific justification …”
Thus, countries are allowed to block import of products if based on an assessment of risk such imports results in a significantly increased health risk

15. HOW? The short version:
From a batch of poultry x samples are analysed.
The estimated relative risk of the batch is compared to the base-line risk in the country in question
If the relative risk is substantially higher the batch is rejected

16. Determination of the Baseline
Survey data from all products that the risk assessment include
Represent total exposure from products and thereby also total cases from products included

17. Example (but from real life
Example (but from real life!) relationship between Campylobacter load (cfu/g) and mean probability of illness
0, , c + 0, c2 + 0, c3 + 0, c4 - 0, c5 + 0, c6
R2 = 0,
P_ill =
Polynomial fit

18. This is a risk-based Microbiological Criterion:
A risk assessment is carried out for each individual batch
Rejection/acceptance directly linked to risk
Rejected lots should pose a significantly higher risk than average
Rejection/acceptance is not based on specific number of positive and negative samples
Judgment of relative risk estimate is a risk management decision

19. Advantages And: it works!
Judgment is based on risk/output
Flexible
Cut-off level may be adjusted to the current situation
Decision left to Risk manager, but transparent and based on assessment of risk
And: it works!

20. Case by Case from

21. What we know we can do:
Total antimicrobial consumption can be reduced without compromising productivity
Specific drugs can be almost or entirely removed
This will lead to reduction in resistance
Still a lack of data quantifying the livestock (including fish) contribution to global AMR
New risk-based quantitative criteria can enable future trade restrictions based on ‘national treatment’