Patient Safety (4) Antimicrobial Resistance and Infection Prevention Control

8 March, 2019

Patient Safety AND WHAT OF AMR?

Indeed, Dr Tedros is right to remind everyone of the LACK OF PATIENT SAFETY in health structures. What strikes me also is how AMR is all about supporting R&D for new medicines, ignoring the FACR [FACT] that today, even in the EU, the majority of AMR infections are CONTRACTED in Health Structures.

Below my own private comment on the IACG recommendations. Of note, I was ten years on the Patients for Patient Safety Steering Committee with the UK-WHO World Alliance for Patient Safety, later the WHO PS Program, and now I am Vice-President of the WAAAR Alliance www.waaar.org ; garance@waaar.ch ; and, co-Editor in chief, AMR CONTROL (www.amrcontrol.info)

Comments (my own, not voted upon by the board)

I would like to quote Dr. Dominique Monnet (Head, Antimicrobial Resistance & Healthcare-Associated Infections Programme, at the European Centre for Disease Prevention and Control (ECDC): "Without strengthening infection control, putting a new antibiotic on the market will be like pouring fuel on the fire!"

He was speaking at the last meeting of Drive-AB, Brussels, an EU initiative which, like most such initiatives, was looking at new economic models for new antibiotics.

In 2015, in the European Union and Europe, the MAJORITY OF AMR INFECTIONS WERE ACQUIRED IN HEALTH CARE, an estimated 426 000 patients contracted an AMR infection in health care, more than 60% of the total, according to the EU, ECDC surveillance system, published in the Lancet*!

If we had data for the majority of the world with weak or non-existent Infection Prevention and Control (IPC) Systems, the percentage of AMR infections contracted in health systems may well be astounding.

We must beware of placing theory before acting in the real world. In the real world, AMR infections spread as any infectious disease: contagion from one human being to another. With or without intermediary, like the plastic cover on our smart phones. The word is CONTAGION. Via the environment also, via the food chain.

In the IAC recommendations, the necessary IPC comes under the recommendation on Access to antibiotics. So IPC is misrepresented as just a way to reduce the need for antibiotics by reducing the burden of infections, but the fact that AMR Infections spread result from weak IPC even in wealthy countries of the EU is not stated in the IAC.

WHO ADG Dr. Ryan testimony to the WHO Executive Board January 28, was that up to 86% of Ebola cases in Beni, Democratic Republic of Congo (DRC) were contracted in health systems! “Mothers who love their babies come into healthcare... and the child contracts Ebola there!”, he said.

As the epidemic of hard to treat, highly lethal Ebola, started in Beni, it means that if health structures had had strong IPC, there might have been no big epidemic of Ebola. Hard to treat AMR infections outbreaks occur similarly.

We must place IPC on top of the list of recommendations!

The IACG recommendations reflect the search for an “access” compromise, between LMIC fearing the effect of IP Rights on capacity to access new medicines and wealthiest countries advocating for R&D economic models for new antibiotics, but does not reflect the reality of ARM infections outbreaks by the millions for lack of hygiene in care.

It does not follow the GAPARM (the Global Plan of Action voted upon by all Member States) which listed priorities differently when adopted in 2015: (1) Whole-of-society engagement including a onehealth approach (2) Prevention first (3) Access. The order of priorities in the IACG document are not in that order at all.

Presently, most Ministries of Health may have failed to grasp that:

1) implementing IPC can be easy and cheap; 2) it will immediately reduce AMR deaths and illnesses, and preserve the labor force 3) It will be extremely cost effective even if implemented in a ‘light’ cheap version while the more important IPC will bring even more return on investments, for national budgets or a hospital/ health center budget 4) IPC is the most efficient, immediate way to curtail AMR infections and protect against new outbreaks.

So far this has not been understood, judging on the basis of Member States (MS)’s Ministries of Health declarations in the UN General Assembly of 2016 (which I attended, as 6 MS mentioned IPC out of more than a 100), or judging from the different meetings of AMR experts from all WHO regions. At best IPC is mentioned in National Plans, but there is little emphasis, and even less investments, in IPC.

The WHO teams under Dr. Ryan were able to nearly stop Ebola in all places with pre-existing outbreaks with simple IPC training of local staff, (he told me). This is a great lesson for all forces committed to stop AMR infections spread. Basic public information campaign on hygiene and IPC would also be needed.

Addendum:

We just heard (WHO - IACG meeting with Civil Society Monday Feb 25th) the International Union of Food and Agricultural Workers demand that protection from AMR infections for labor, and especially for industrial meat production workers, be included in the IAC and the IUF demands that AMR infections become recognized as occupational diseases. I totally agree.

The issue of IPC in meat production is ignored in the IAC recommendations, yet it is an important issue. It was brought up last year in the Codex Alimentarius’ discussions on AMR in London by former head of AGISAR/ WHO, Awa Aidara Kane.. Fact is: proper IPC in husbandry, not only permits to stop antibiotics for growth promoters, without loss in output, it also allows for much less antibiotic use either for prophylaxis or for treatment. ****

Footnotes:

*www.thelancet.com/infection Nov. 5, 2018 (Cassini, Monnet) http://dx.doi.org/10.1016/S1473-3099(18)30605-4

See also Prs Tim Walsh and P. Collignon on contagion, https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(18)30186-4/fulltext, (with great reservations on the correlation between governance, corruption and AMR)

** India last year adopted a national IPC plan with a subsumed program on antibiotic stewardship, this is the right way to proceed: stewardship, proper use of AB in health systems, is an essential subsumed aspect of IPC. (I say this without commenting on the India plan which, as yet, needs each Indian state to adopt and fund to be effective).

*** Ebola control also benefited from vaccinations. While we need to further vaccine R&D and deployment, it would seem hazardous to imagine that we would have vaccines for each and every disease that emerged to be drug resistant.

**** The International Union of Food, Agricultural, Hotel, Restaurant, Catering, Tobacco and Allied Workers' Associations (IUF).

An excellent book Chickenizing, by Pr. Ellen Silbergeld (John Hopkins University) Makes the link between AMR, industrial meat production and IPC.

See also their website: http://www.iuf.org/w/?q=node/6330

HIFA profile: Garance Fannie Upham is a long time advocate for safety in health care. At present she is Deputy General Secretary, ACdeBMR / WAAAR World Alliance Against Antibiotic Resistance (www.waaar.org) Shortlisted by the EU AMR Prize competition, Chief Editor AMR-Times (English /francais/Arabic) Editor, "AMR Control 2015" and AMR Control 2016 ex-Member, Steering committee, Patients for Patient Safety, Patient Safety Program, World Health Organization (2004-Jan 2014) (www.waaar.org) She is also Treasurer, Member of the St. Com. of G2H2, the Geneva based platform for NGOs (www.g2h2.org) fannie.upham@gmail.com garance@waaar.ch garance AT safeobserver.org