On June 21, 2022, the South Centre and the ReAct Network organized a webinar to analyze how a potential new international instrument on pandemic preparedness, prevention and response could offer opportunities for a more robust global response to the crisis of Antimicrobial Resistance (AMR). The webinar featured the participation of the Minister of Health of Zambia, H.E. Sylvia Masebo; the Minister of Health of Ghana, H.E. Kwaku Agyeman Manu; the Director of Technical Coordination, Ministry of Health Ghana, Dr. Martha Gyansa-Lutterodt; and the Director of Health Service Quality, Ministry of Health Indonesia, Dr. Kalsum Komaryani.
The Executive Director of the South Centre, Prof. Carlos Correa, and the Founder of ReAct, Prof. Otto Cars, provided the introductory remarks and urged for more political leadership to accelerate actions on AMR. The webinar also had two key presentations on AMR featuring the negotiations for a pandemic instrument by Dr. Viviana Muñoz from the South Centre and Ms. Mengying Ren from ReAct.
The recording of the webinar is available at https://www.youtube.com/watch?v=UdBZlbRcYTI.
Prof. Carlos Correa opened the webinar by welcoming the panelists and the participants. Correa explained that AMR is one of the significant challenges humanity faces, which is particularly concerning for developing countries as they need to strengthen health systems, access to water and sanitation and improve infrastructure and health workforce. The South Centre has worked over the years to create awareness among governments and with civil society to advance response to AMR. There is a significant opportunity right now through the forthcoming negotiation of an instrument on pandemic preparedness and response. The legal character of this instrument is still unknown. It opens an opportunity for developing countries to articulate their needs and seek that their conditions and interests are reflected in the new instrument. Developing countries must actively participate and engage in the process.
Prof. Otto Cars emphasized that we now have better global estimates about the burden of AMR and mortality. The Lancet publication of the GRAM study indicates that 1.27 million people are dying, and most of these deaths are concentrated in the Global South, which is a matter of great concern. In some cases, these mortality figures have overtaken the mortality from malaria and HIV/AIDS. This burden is particularly affecting children, especially prematurely born children with higher resistance levels in cases of sepsis, with an enormous mortality from these infections. An option is to include AMR in the discussions of a pandemic instrument. AMR is a pandemic since bacteria spread globally. AMR is an increasing threat to all health systems and a challenge for the global development agenda and the fulfillment of the SDGs. Antibiotics are not only essential for the treatment of common infections in the community and hospitals but also as for treating the bacterial complications that follow from virus infections, as observed during the 1918 pandemic with “the Spanish flu” and also with the “swine flu.” Many of the complications and mortality were caused by bacterial infections. The global governance mechanisms so far have not been able to deliver on their commitments. Even though the UN political declaration on AMR included those commitments, they are yet to be fulfilled.
Regarding options to include AMR in the proposed pandemic instrument, there is a need to move beyond the focus only on viral infections and include all relevant health threats that have pandemic potential. Some objectives are common to AMR and pandemic preparedness, such as global surveillance and early detection, infection prevention and control, increased research and development and sustainable access to the countermeasures, including vaccines, antibiotics, and diagnostics.
Prof. Roma Chilengi read a statement on behalf of Sylvia Masebo, Minister of Health of Zambia. Zambia, in implementing the AMR national action plan has established a national public health institute to coordinate AMR activities. The media has played a critical role in raising awareness. The collaboration of journalists yielded positive results in increasing information dissemination and awareness through radio, television, print media, and online platforms.
With the support from the Fleming Fund, Zambia has undertaken several activities to build up capacity and strengthen surveillance of AMR, including training in the detection and characterization of food-borne pathogens and AMR testing. There is also continuous monitoring of antimicrobial residues in products such as honey for export markets. Activities to promote the rational use of drugs have increased, including strengthening legislation on licensing and enforcement of strict standards, and developing an electronic health surveillance database. As part of these efforts, training has been provided to equip veterinary with the knowledge and skills in biosafety and biosecurity needed to ensure animal health security in the spirit of One Health, and efforts are on the way also to have more integrated surveillance.
Furthermore, Zambia is currently working towards phasing out non-therapeutic antibiotic use in food animals. With support from ReAct Africa, Zambia has drafted an antimicrobial stewardship policy and implementation framework, which is already being piloted in four government hospitals and one private hospital. All these efforts align with regional and global aspirations for universal health coverage and to implement sustainable development goals, ensuring that actions to address AMR include human, animal, and environmental sectors. Fellow health ministers and leaders are urged to raise awareness and be AMR champions.
National Action Plan (NAP) implementation has not been without challenges, the most encountered being insufficient coordination, inadequate local funding across sections and lack of staff dedicated to coordinate and spearhead implementation of the National Action Plan. Emerging and re-emerging diseases provide an opportunity to accelerate global action against AMR, leveraging synergies that exist. The COVID-19 pandemic offers a unique opportunity to address AMR, a multifaceted “silent pandemic” that threatens the existence of humankind, animal welfare and food security, among others. The proposed international instrument on pandemic preparedness and response aims at protecting the world from future infectious diseases. Effective management and treatment of these infectious diseases is key to achieving this objective. The fact that AMR is a threat to effective treatment, answers the question as to whether it should be included in this instrument or not. This will not only ensure it is a priority but attract sustainable funding especially at country level.
Kwaku Agyeman Manu spoke about the various activities undertaken in Ghana to implement the AMR National Action Plan. This includes ongoing work for increasing and sustaining awareness of AMR in rural and urban areas and media, and training to improve the dissemination of appropriate information on AMR. The veterinary services department has also worked to better determine the use of antimicrobials in animal health and reduce the inappropriate use of antimicrobials. In collaboration with the ministry of food and agriculture and the veterinary services department, farmer field schools have been established aimed at increasing the responsible use of antimicrobials. Farmers undergoing this training are reporting better yield and reduction in production costs. There are significant gaps in implementing actions, mainly because of funding gaps. The new pandemic preparedness and response instrument that is to be negotiated could potentially contribute to support the efforts needed for AMR.
Martha Gyansa-Lutterodt, Ghana, emphasized that AMR remains a very silent pandemic and that COVID-19 has demonstrated why AMR needs to be considered together within the pandemic preparedness agenda. AMR mortality is staggering. Developing countries must make their needs known, especially in the context of the negotiation of binding instruments and what they offer to our countries. Some of the critical issues to be addressed are infection prevention and control, the need for diagnostic tools and technologies. Equity should be critically considered. Research and development are also strategic, and these are cross-cutting issues. Developing countries are urged to add their voice to the negotiations, including on the issue of AMR.
Kalsum Komaryani presented the experience of Indonesia. Indonesia follows the WHO Global Action Plan on AMR and has drafted its AMR National Action Plan. There are six strategies in this plan, including raising awareness, improving research, reducing infection by strengthening infection, prevention, and control (IPC), increasing investment in new treatments and antibiotics, and developing coordination across the ministries in Indonesia.
In terms of governance, Indonesia has a steering committee coordinated by the Ministry of Human Development and Culture. There is also an organizing committee with the chair from the Directorate General of Health Services under the Ministry of Health. Four working groups address resource capacity, surveillance intervention and advocacy. In terms of implementation progress, Indonesia recently enrolled in the WHO GLASS surveillance system, adding some indicators of the AMR program in the NAP by using GLASS data and conducting sentinel surveillance in 20 laboratories across the country. Other activities include infection prevention and control (IPC). Indonesia is also part of the WHO multi-partner trust fund for the implementation of AMR stewardship and IPC in four districts. Currently a study is being conducted by the Ministry of Health on IPC assessment in hospitals using an IPC assessment framework. In terms of increasing investment in R&D, the National Research Board has started investing in new drugs and vaccines.
In 2022 Indonesia will be establishing a task force and conducting a coordination meeting on how to integrate AMR programming into hospital information systems. Indonesia will also organize a side event regarding AMR at the G20 summit.
Linkages between AMR and the ongoing negotiation on the pandemic instrument
Two additional presentations examined opportunities that the negotiations of the pandemic instrument could bring and its possible linkages with AMR.
Viviana Muñoz noted that AMR is part of a global sustainability agenda for all and, therefore, linked to many other global challenges. At the international level, there is guidance and a strengthened role of the quadripartite agencies, but many gaps remain. For example, at the UN level in 2016, there was an agreement to develop a global stewardship and development framework on AMR, covering stewardship to preserve existing antimicrobials, development of new antimicrobials and other tools such as vaccines, and promoting affordable access to a One Health approach; however, those instruments were not developed. The negotiation of a new pandemic instrument at the WHO provides an opportunity to restart the needed process. There is a need for global coordination of AMR context-specific actions, to increase accountability of Member States and stakeholders, and mobilize and sustain investment.
A Special Session of the WHO in December 2021 decided to establish an Intergovernmental Negotiating Body (INB) to draft and negotiate a convention, agreement or other international instrument on pandemic prevention, preparedness, and response. There is now a draft annotated outline as a White Paper that is compiling all suggestions for issues to be covered by the international instrument. Written comments can be provided to the INB Bureau. The second meeting of the INB will take place from 18 July 2022 to 22 July 2022, virtual participation is open, upon request to email@example.com by 12 July 2022.
Mengying Ren provided an update on the status of the discussions on a new pandemic instrument and how several countries have raised AMR as an essential issue to be included in its scope. Some of the discussions are shaped by the experience of the ongoing COVID-19 pandemic, including issues around equitable access to innovations and basic supplies. Equity has been identified as one of the strategic pillars in the current draft. Hopefully, this would help establish clear rules to ensure global equitable access and have this as a central element in discussing the pandemic instrument.
There are significant synergies between the critical considerations for pandemic prevention preparedness and response and AMR. For example, surveillance and rapid testing capacity for early warning of new bacterial mutations and their global spread are needed for both viral pandemics and antibiotic resistance. This would include supporting efforts for increasing laboratory capacity, training staff, and strengthening surveillance and monitoring systems in low- and middle-income countries. Another example is the shortcomings of the current research and development (R&D) model regarding medical countermeasures such as new antibiotics, diagnostics, and vaccines. This would need public sector leadership and require public health needs-driven R&D. For this, there will be a need to promote an end-to-end approach in which all actors and challenges along the entire chain from early-stage research to production and access are connected. In the case of antibiotics, mechanisms for conservation and stewardship and One Health perspective would also need to be considered. Another issue of concern is shortages of antibiotics that cause many disruptions; therefore, the pandemic instrument should promote greater transparency in global pharmaceutical production capacity and global supply chains and support the creation of more regional diversification of active pharmaceutical ingredients (API) production capacity. There is a need to consider antibiotics as global public goods and ensure equitable, affordable, and sustainable access for everyone who needs them.
Prof. Carlos Correa, South Centre, thanked all the speakers in closing the webinar. In summary, there is urgency to address AMR as shown by the new data on burden and mortality. Given that AMR is a silent pandemic it is very legitimate to bring this issue into the pandemic treaty negotiations. There is a need to strengthen global governance and use the opportunity to use the linkages of pandemic preparedness and control with the needed actions for AMR. It is also critical to mobilize funding for developing countries to implement measures to address AMR and to ensure that the voice of developing countries is heard in the discussions.