Landmark Asian workshop on AMR organized by South Centre and TWN

The antimicrobial resistance (AMR) crisis is affecting many Asian countries seriously.  There has been progress in the last few years in recognizing this crisis.  But for most countries the battle is only at the beginning stage, much more needs to be done, and several problems of  implementing national plans need to be overcome if real progress on the ground is to be made.

This picture of the situation emerged at a South-east Asian regional workshop on AMR attended by 60 participants, including policy makers from 10 countries, as well as representatives of civil society, scientists and regional AMR focal points of the World Health Organization and the Food and Agriculture Organization.

The workshop, held in Penang (Malaysia) on 26-28 March 2018, was co-organised by the South Centre and the Third World Network, with the support of the Fleming Fund.  The policy makers were from Indonesia, Thailand, Malaysia, the Philippines, Myanmar, Vietnam, Cambodia, Laos, China and India. NGOs from most of these countries, as well as Australia, also attended.

It was a landmark meeting for several reasons.  Firstly, high-level policy and technical experts, most of them being focal points or coordinators of their national AMR committees, took part.   Secondly, the government officials were AMR experts from both the human health and animal sectors, which is quite rare as usually international AMR meetings involve officials from only one sector or the other.   The workshop thus lived up to the concept of a One Health approach.

Thirdly, civil society groups involved in AMR or general health issues were also represented, enabling dialogues to take place between the governmental and non-governmental sectors.  It was recognized that actions by both are crucial to generate public awareness and mobilise public support for AMR actions.   Fourthly, the workshop provided the most up-to-date information on global and regional developments (provided by experts, including from the WHO, FAO and South Centre) as well as the state of policies and actions at national level.

The workshop was opened by Dato Dr Chong Chee Keong, Director of Disease Control of Malaysia’s Health Ministry, who stressed the importance of Asian countries to join the global fight against AMR.  Malaysia is taking the challenge seriously, as seen in the recent launch of the national action plan  by the Ministers of Health and Agriculture.

Martin Khor, Executive Director of the South Centre, presented a comprehensive analysis of why developing countries are being affected the most from the AMR crisis and must join in the global effort to address it.  However their interests and challenges while doing so should be recognized so that they can effectively implement their national plans.

The countries need international cooperation in funding and technical equipment to set up the institutions and coordinating mechanisms to undertake the required actions, including surveillance, diagnosis, infection control, regulation of prescription, dispensing, marketing of antimicrobials to ensure rational use of drugs, as well as actions to phase out antimicrobial use as growth promoters in animals and in aquaculture, and to keep antibiotics out of the environment.  Khor said that affordable access to existing and new antibiotics, and encouraging the de-linkage models of innovation, which were highlighted in the UN General Assembly Declaration on AMR, should also be components of international cooperation.

In a session on the AMR situation in Asia, the AMR regional focal persons for WHO (Dr Socorro Escalante, WHO-WPRO and Prof Tjandra Yoga Aditama, WHO-SEARO) and the AMR regional focal person for FAO (Dr Katinka de Balogh) presented on the state of the AMR problem in the human health and the animal sectors, and the roles played by their organisations.  Beverley Snell (HAI, Asia-Pacific) gave a review of the AMR national action plans submitted by Asian countries and the status of implementation.

On the session on international action and processes, Dr Viviana Munoz of the South Centre gave an update on the origins and progress of the Inter-Agency Coordination Group established by the UN General Assembly.  Dr Socorro presented on the WHO’s global surveillance system (GLASS) and its most recent implementation report.  Adam Tregidga explained the role of the Fleming Fund, an initiative of the United Kingdom’s Department of Health, in supporting the developing countries’ activities on AMR.

A highlight of the workshop was a session on the need for a One Health Approach to AMR.  Dr Peter Collignon, Director of ACT Pathology at Canberra Hospital (Australia) spoke of the AMR situation in the human health, animal, aquaculture and environment sectors and their interconnectedness.

He also gave a presentation on the WHO Guidelines on the Use of Medically Important Antimicrobials in Food Producing Animals, which had been published in November 2017. Dr Collignon was the Chair of the Guidelines Development Group that produced the guidelines after a rigorous process.  There was a lot of interest in the guidelines, as seen from the many questions and comments to Dr Collignon in this session and in the breakout groups.

In the session on actions at the national level, the lead speaker Dr Christopher Lee (National Head of Infectious Disease Service, Malaysian Health Ministry) gave a lively and frank account of the process that a country needs to initiate in order to set up a coordinating body involving all relevant Ministries (especially health and agriculture) to implement AMR policy measures.

Viviana Munoz (South Centre) explained the importance of affordable access to antibiotics, and an appropriate system to encourage innovation that produces new antibiotics.  Lim Kah Poh (Malaysian Pharmaceutical Society) spoke on the marketing practices used in promoting antibiotics and the need for regulation, while Beverley Snell (HAI, Asia-Pacific) presented on obstacles that need to be overcome if rational use of antibiotics is to be achieved.

Two sessions were held on national AMR policies and experiences in the human health sector.  Presentations were made by Harry Parathon (Chair of AMR Committee, Indonesia), Suraya Amir Husin (Malaysian Health Ministry), Htay Htay Tin (General Secretary, National AMR Committee, Myanmar), Li Dachuan (National Health Commission, China), Nov Vandarith (Cambodian Health Ministry), Somphone Soulaphy (Laos’ Health Ministry), Nithima Sumpradit (AMR Focal Point, Thai Health Ministry), Sunil Gupta (Indian Health Ministry), Cao Hung Thai (Vietnam’s Health Ministry), Nina Isabelle Tolentino (Philippine Department of Health).

This was followed by two sessions on AMR national policies in the animal and food sector.  Speakers included Riana Arief (Director, CIVAS, Indonesia), Rozanah Asmah Abd Samad (Malaysian Dept. of Veterinary Services), Adela Contreras (Bureau of Animal Industry, Agriculture Department, Philippines), Sasi Jaroenpoj (AMR containment section, Dept. of Livestock Development, Thailand), Le Thi Hue (Veterinary Dept., Vietnam), Min Thein Maw (Veterinary Dept., Myanmar), Sun Jing (Peking Union Medical College, China), and Chea Rortana (National Animal Health and Production Research Institute, Cambodia).

The Experiences of Civil Society on AMR were then discussed, with speakers from national groups from Indonesia, Malaysia, India, Thailand as well as international or regional groups Third World Network, Antibiotic Resistance Coalition, ReAct-Asia and HAI-AP.

Four breakout groups were organized with participants discussing the state of AMR plans and coordination in their countries, the challenges of implementing activities and control measures, and what support is required to enable speedier progress.

From the reports of the breakout groups and from the earlier country presentations, the following main points can be drawn:

• There has been quite a lot of progress in making a start in combatting AMR, with countries already formulating their national action plans and having a national AMR committee. However, while some countries have incorporated both the health and agriculture/animal sectors in their AMR committees, others have only the health ministry.
• While the health ministries have embarked on a number of activities such as surveillance and infection control, the agriculture/livestock sector in many countries have still to catch up with regards to actions.
• One encouraging sign is that Indonesia has banned the use of antibiotics as growth promoters in livestock since January 2018, whereas Vietnam imposed a similar ban a few years ago and in Thailand there has been a ban on antibiotic use as growth promoters in chickens since 2006.
• In most countries, little work has been done on the environmental component of the spread of AMR. This is an area requiring much more work.
• While plans and guidelines have been formulated in a number of areas, implementation in most countries is still inadequate. This is because of various factors, depending on the country concerned.  The factors include that there is lack of priority and lack of political interest or will;  lack of financial and human resources;  too few equipment needed for diagnostic work;   lack of champions and of a systematic stewardship program at national or local level.
• There is still inadequate understanding of the AMR issue in the animal sector in many countries. The WHO guidelines on antibiotic use in animals is a useful and important reference as it takes a human health perspective.  This should be supplemented by guidelines jointly issued by WHO, FAO and OIE, so as to involve all the relevant international organisations.
• To increase the speed of implementation and of progress, a fund or funds to help developing countries to coordinate their AMR actions and to build their technical and organisational capacity should be made available with sufficient resources.

Feedback from participants through a final session (and through evaluation forms that they filled up) was that they found the workshop very useful for enabling the sharing of experiences and best practices, and the coming together of participants from different sectors (human, animal and food; government and non-government) and countries. Many of the participants also flagged the importance of focusing attention on the animal sector including following the example of Vietnam and Indonesia in banning of the use of antibiotics as growth promoters for animals.  Participants also would like discussions on AMR and the  environment.

Among some of the follow-up actions that the participants would like from the South Centre and TWN are to organise workshops on a regular/annual basis to take stock of countries’ progress;  to form a “Community of Practice” (CoP) or an Asian coalition on AMR; and to come up with an Asian Action Plan.

Educational materials were produced for the workshop.  These include six dossiers (compilation of useful articles) on general AMR issues;  International Processes and Guidelines to Control AMR; Antibiotic Resistance: The role of agriculture and food animals; and Colistin Resistance and mcr-1 gene.   Two books were also produced:  When Medicines Don’t Work Anymore (by Martin Khor) and Revenge of the Killer Germs (a reprint of a CAP book first produced in 1996).

In the concluding session, South Centre director Martin Khor said the organisers were interested in publishing a book of the workshop presentations.  A report of the proceedings of the workshop will be produced.  Updated versions of the dossiers will also be produced.  He said that a workshop on AMR in Asia will also be organized in 2019, with a focus on South Asian countries.