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International priorities for antimicrobial resistance: a need for consensus, collaboration, & coordination Oslo 10 May 2016 Antimicrobial Resistance Why react? The thoughtless person playing with penicillin is morally responsible for the death of the man from penicillin-resistant organism. I hope this evil can be averted. Alexander Fleming 1945 Drug-resistant infections are a challenge on the scale of climate change. Jeremy Farrar 2016 Antimicrobial resistance is a slow-motion tsunami. It is a global crisis that must be managed with the utmost urgency. Margaret Chan 2016 Our philosophy We are an independent global charitable foundation, dedicated to improving health. Good health makes life better. We want to improve health for everyone by helping great ideas to thrive. Science and research expand knowledge by testing and investigating ideas. This new understanding can be applied to health and change medicine, behaviour and society. That’s why we support thousands of curious, passionate people all over the world to explore great ideas, at every step of the way from discovery to impact. What we do We fund health-related research, across the world. We pursue new understandings of the body, disease, or the environment we live in, ideas about how to change medicine, culture or even the world. We support thousands of curious, passionate people all over the world to explore great ideas, at every step of the way from discovery to impact. Where we do it: our active funding UK £2,300m Europe & Central Asia £113m North America £77m India: £156m Latin America & the Caribbean £10m Sub-Saharan Africa £225m South-east Asia & Pacific £92m How we work Investments: We are funded from a private endowment – the assets stand at around £18 billion To improve health, we have spent (and plan to spend): 1936 2005 2015 2020 £11 BILLION £6 BILLION £5 BILLION Our strategic approach. Describes our philosophy and establishes a framework that sets out our modes of working and gives us the flexibility to set new priorities over time Our framework Advancing ideas We support great ideas and inspired thinking Seizing opportunities We bring ideas together to make a difference Driving reform We change ways of working so more ideas can flourish What’s new? We have developed a strategic approach, instead of a plan. This: • builds on our last plan, but has no fixed time frame • give us the flexibility to set new priorities over time • seeks to reach out to new audiences and partners • allows us to be directive and purposeful when the time is right Seizing opportunities We bring ideas together to make a big difference We identify times when our concerted intervention can accelerate progress towards better health. We identify a critical need and set ambitious goals. We connect experts from different disciplines, build partnerships, and lead advocacy, policy development, communications and public engagement. We do this by providing focused, intensive support that creates a step change over five to ten years. Wellcome funding since 2004 Distribution by pathogen type and stage of development Other Basic Preclinical Clinical Human £247.4m Bacteria Vector control Parasites Viruses Cross-species £15.8m £5m Multiple Animal Fungi 0 20 40 60 80 100 120 140 Enviroment £1.7m £0.4m Total Awarded (£m) Significant investment in translational research for therapeutics in a smaller number of projects compared to basic science. Notably there has been little support for diagnostic development and very little in public engagement. DRI Wellcome strategic priority Wellcome strategy development 1) Identify how Wellcome can improve health outcomes and deliver on an agenda that promotes Access, Conservation and Innovation of medicines. 2) To identify the opportunities where Wellcome can have an additional significant impact beyond current efforts and activities to address the threat of DRI. Scope • All Infectious diseases focus on NTDs: bacterial, viral, fungal, parasitic and inclusive of HIV, TB and malaria • One Health: humans, animals, environment AMR areas for action New interventions and tools innovative therapeutics & diagnostics, medicines quality assurance, experimental medicine/clinical trials Stewardship optimising use Surveillance access to and use of surveillance data Communication public awareness Education behaviour change Prevention vaccines, infection prevention and control Policy regulation and facilitating utilisation of evidence Research agenda to support all of the above People and Skills developing thinkers and doers to promote ideas and actions Equipping the world to address the threat of drug resistant infection Opportunities Improving Treatment Enabling Policy •Improve and promote scientific understanding of drug •Proactively drive evidence-based policy interventions, resistance working to align stakeholders to integrate emerging •Practical diagnostic tools for DRI evidence and implement policy actions, along with developing tools to measure impact of interventions •chemical matter for antibacterial discovery •Work with others to highlight the value of antibiotics for •Understand and overcome barriers to drug penetration public health, combined with mechanisms to ensure access and efflux avoidance for Gram-negative bacteria to essential medicines to those who need them most •Conduct key proof-of-concept studies for non-traditional therapies. Validate combination therapy for treatment of systemic bacterial infections •Improve models for PK/PD studies and accelerate PK/PD studies in humans Halt AMR •Optimise drug use •Share data, materials, and knowledge across disciplines and between sectors Education Public Engagement •Develop the skills and expertise to address the scientific challenges in microbiology, chemistry, pharmacology, medicine and epidemiology •Support research to better understand impactful communications AMR Call for Action A world equipped to address the threat of drug resistant infection To contain antibiotic resistance, we need to create incentives—for patients, doctors, hospitals, [food producers,] drug companies—to act in ways that slow the depletion of antibiotic effectiveness. - Ramanan Laxminarayan Goals 1. Maintain effectiveness of existing treatments (stop the increase of drug resistance) 2. Regain effectiveness of treatment where drug resistance has happened AMR a complex problem with multiple drivers AMR global strategic aims Key priorities to avert or delay a post-antibiotic era1 • Prioritise access for children and neonates • Encourage innovation in markets and medicine and repurposing of existing instruments • Balance universal access with effective oversight and investment in basic public health • Advocate for multisectoral attention and inclusive public health practices 1. Lancet 2016; 387: 10014. 188-198 AMR international priority Gaps in international collaboration2 • Surveillance • Infection Control • Universal Access • Responsible use in human beings • Responsible use in animals • Innovation 2. Lancet 2016; 387: 10014, 296-307 AMR international priority Gaps in international collaboration1 research needs • Surveillance sampling, data harmonization, analysis • Infection Control implementation studies, innovative tools • Universal Access technologies suitable for global access • Responsible use in human beings improved clinical guidelines • Responsible use in animals therapeutic use only • Innovation new tools, new products, new approaches 1. Lancet 2016; 387: 296-307 Dx workshop • Optimising patient treatment and antibiotic use • Avoiding unnecessary antibiotic use • Identifying high-risk patients • Improving drug development AMR immediate international priority There is an urgent need to develop better local understanding of antibiotic use and resistance levels, in human and animal medicine • Surveillance systems Surveillance and monitoring are essential to provide a clear picture of local situations and to assess the impact of interventions; expanded data are required on both antibiotic usage and resistance (in humans and animals). • Targets Quantitative data will enable policymakers to track progress over time, increase accountability and set targets to motivate changes in behaviour. • Labelling Labelling has a potentially important role to play in establishing the ‘protected’ status of antibiotics, supporting tracking mechanisms, and ensuring drug quality. • Education Community-level education is necessary to ensure that all people, ranging from parents of ill children to farmers, understand what antibiotics can do and cannot do and why minimizing use is in the interest of all. AMR immediate global health priority Public health & food production systems need to be adjusted to optimise antibiotic use • Public health Consistent with the Sustainable Development Goals, emphasis should be placed on improved sanitation and access to clean water, and in promotion of public health measures such as good hand hygiene practices and enhanced infection prevention and control in hospitals; such moves would address antimicrobial resistance as well as deliver direct public health benefits. • Development assistance International development agencies need to integrate antimicrobial resistance prevention as a core aspect of their work. • Education Healthcare worker education and professional development should have a stronger emphasis on antibiotic stewardship. • Economics Financial incentives that link rewards to volumes of antibiotic sales need to be eliminated. • Guiding use Enhanced ‘gating’ of antibiotics is required, so more use is routed through informed healthcare professionals and over-the-counter use is minimised, with due consideration for the need to enhance access to antibiotics in many countries of the global South. AMR immediate cross-sector priority Antibiotic use in agriculture must be reduced, without compromising the food system’s capacity to meet increasing global demand • Growth promoters Use of antibiotics for growth promotion and disease prevention should be replaced by improved animal husbandry practices. • Insurance Innovative insurance schemes should be developed to mitigate the risk of income loss among producers during this transition. • Food production Food production systems should do more to limit consumer exposure to drug-resistant microbes (e.g. through increased use of surface cleansing). • Alternatives Alternative treatments and husbandry practices should be investigated to support reduced antibiotic use in agriculture. Opportunities Near-term priorities with long-term outputs Important needs requiring near-term efforts for delivering outputs in the long- term • Therapeutics • Diagnostic tools • Clinical trial networks • Regulatory frameworks • Fiscal frameworks Opportunities Horizon-scanning Long-term scientific opportunities with transformational opportunity • Host-pathogen interaction • Microbiome • Alternative therapies • Transmission dynamics • Environment AMR international action requirements A world equipped to address the threat of drug resistant infection Consensus general agreement Collaboration working together Coordination effectively organizing different activities to enable them to work together Cooperation assistance, sharing and willingly fulfilling requests Drug Resistant Infection strategy development Tim Jinks PhD [email protected]