1. Combatting Antimicrobial Drug Resistance Dr Charles Penn Pandemic and Epidemic Diseases Health Security and Environment

2. | RUSI 6 February 2013 2 |2 | Antimicrobial Resistance Impact Challenges Research perspectives

3. | RUSI 6 February 2013 3 |3 | Rising Mortality, Costs We are facing a public health crisis We are facing a public health crisis Increasing incidence of resistance to antimicrobial medicines Few new medicines in the pipeline

4. | RUSI 6 February 2013 4 |4 | % survivors Penicillin Untreated Days Penicillin increased the chance of survival from 10% to 90% Patients with pneumonia and bacteria in the blood Adapted from Austrian et al. Ann. Int. Med 1964; 60, 759

5. | RUSI 6 February 2013 5 |5 | Proportion of MDR among previously treated TB cases, 1994-2010 Combining data from all countries and territories: MDR in previously treated TB cases: 19.8% (95%CI: 14.4-25.1)

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7. 7 |7 | 4 neonatal deaths in a rural hospital, India November 2009 West Bengal E coli septicaemia Treated cefotaxime and amikacin BUT E coli carried NDM-1 gene –Imipenem resistant Infections likely hospital acquired Roy et al. J Antimicrob. Chemother. 2011 v66: 2773

8. | RUSI 6 February 2013 8 |8 | Death of two liver transplant patients USA Both had been treated meropenem Carbapenemase producing K pneumoniae Mathers et al. Transpl. Inf. Dis. 2009 11: 257

9. | RUSI 6 February 2013 9 |9 | Some diseases becoming untreatable (gonorrhea) Resistant to ceftriaxone –Ohnishi et al Emerging Inf Dis 2011 17:148 –MIC 2 ug/ml Resistant gonorrhea strain found in Japan CBC News Posted: Jul 11, 2011 1:38 PM ET Last Updated: Jul 11, 2011 10:17 PM ET External Links Antibiotic susceptibility of gonorrhea, CDC Morbidity and Mortality Weekly Report A strain of gonorrhea is that is resistant to all currently available antibiotics has been identified in Japan. Gonorrhea is a bacterial infection that can be transmitted through oral, genital or anal sex with an infected person. If left untreated, the disease can cause other problems, including sterility and a greater susceptibility to HIV. The newly identified strain of the sexually transmitted infection, called H041, is resistant to the last remaining drugs that treat gonorrhea, known as cephalosporin-class antibiotics, http://www.cbc.ca/news/health/story/2011/07/11/gonorrhea-resistant.html

10. | RUSI 6 February 2013 10 | Impact on multiple sectors of health care Infectious Disease Pneumonia Gonorrhea TB Malaria HIV Etc. Medical Procedures Neonatal care Transplantation Cancer treatment Surgery Etc. Health Security Travel Deployment Conflict & emergencies Refugees IHR

11. | RUSI 6 February 2013 11 | Antimicrobial Resistance: Global Challenges Lack of adequate awareness and understanding Lack of global cohesion and plans Insufficient surveillance information –No cohesion, no reporting standards Inappropriate use of antimicrobial medicines –Human and animal health ("CIA") –Lack of equitable access No new products From Albrich et al EID 2004

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13. | RUSI 6 February 2013 13 | WHO Goal: combat AMR Comprehensive national plans, accountability, civil society engagement Strengthen surveillance and laboratory capacity Access to essential medicines of assured quality Rational use of medicines Enhance infection prevention and control Foster innovation and R&D for new tools

14. | RUSI 6 February 2013 14 | WHO programmes that include AMR Foodborne AMR Patient Safety Infection Control Environmental health Laboratory capacity & capability Medicines –Critically Important Antimicrobials –Regulations, Rational use –Quality and standards Malaria TB HIV STI Cholera Hepatitis Influenza Carmem Pessoa da Silva Johan Struwe Un-Yeong Go Paul Rogers Keiji Fukuda

15. | RUSI 6 February 2013 15 | Research needs: surveillance and burden of disease Global surveillance data –Networks of networks –Common standards for data and reporting Burden of disease –Health –Economic In "real time" –Evidence to support policy –Monitor effectiveness of action

16. | RUSI 6 February 2013 16 | Research needs: evidence to support policy Use of antibiotics in agriculture and animal health, aquaculture –Growth promotion,Prophylaxis –Balancing human health, food supply, economic interests Reviews of existing evidence –Molecular epidemiology and forensics –Economics and burden of disease –Differential products Public and prescriber behaviour

17. | RUSI 6 February 2013 17 | Research needs: innovation, new tools Smarter diagnostic tools –From POC to "molecular forensics" Alternatives –Vaccines, other interventions How to encourage and reward development of new antimicrobial medicines while maintaining controlled and rational use? –New business models?

18. | RUSI 6 February 2013 18 | Prime objective: to continue to treat and cure life threatening infections, everywhere Thailand – SMART antibiotic use Bedaquiline – treatment of MDR-TB

19. | RUSI 6 February 2013 19 | WHO Action (1) There is no "one size fits all" –Comprehensive mapping of gaps, capabilities at a country level –Across 6 point Policy Package (World Health Day 2011) –Initial assessment, short survey, follow up –Methods development and pilots 2012-2013 through RO, CO Supported by Republic of Korea –Support needed for full implementation Essential to enable WHO, RO, CO to develop guidance and plans relevant to different country situations Countries will be better able to identify priority areas for action, leading to more effective interventions.

20. | RUSI 6 February 2013 20 | WHO Action (2) Lack of comprehensive, integrated surveillance –Weak evidence base to support policy and guidance –Inability to adequately quantify and report global burden and trends –Coordinate existing global, regional and national networks E.g. TB, gonorrhea, EU and other regions, WHO CC –Identifying and filling gaps –Agreed reporting standards An integrated global surveillance capability to provide data for action

21. | RUSI 6 February 2013 21 | WHO Action (3) Advocate change in policy and practice –Rational use of medicines Regulation and awareness Animal and human health Equitable access –Clinical care and patient safety Infection prevention and control Evidence based treatment guidelines –Innovation Treatment, "business models" Prevent the development and spread of AMR