In June 2016, EPHA attended the Public Health 2016 conference in Toronto which, among many other topics, discussed antimicrobial resistance (AMR) in a satellite symposium. How can AMR be framed as an urgent public health issue that will engage the entire public health community? The questions raised in Canada are equally valid in the EU.
Bad Bugs, No Drugs
At this session, Dr Allison McGeer (Mount Sinai Hospital, U of Toronto) recalled the dilemma that, under the current business model, antibiotics are not an attractive investment proposition for manufacturers given that, unlike drugs for cancer and chronic diseases, people will not take them regularly for the rest of their lives. But despite the gaping hole in the development pipeline and growing international concerns about the health and economic burden of AMR, only 20% of Canadian healthcare professionals view it as a problem, probably because the country has been relatively well protected so far.
However, this is a delusion since the best time to act and invest in prevention is when the situation is not critical. McGeer noted that tackling AMR is intimately tied to public health yet the public health community tends to regard it as a problem created in hospitals and does not engage as much as it should. This must be changed for a number of reasons, among them the following:
- AMR represents a significant and immediate threat to the health of communities
- It is a vital opportunity to leverage primary prevention alongside secondary prevention
- It presents a major environmental food and water safety risk, increased by the use of industrial chemicals, which calls for a coordinated One Health response
- Public health expertise is critical for both surveillance and action; and
- Future generations will live longer and healthier lives if action is taken now
McGeer noted there are few mechanisms for coordinating many different groups, but public health professionals have the expertise and the capacity to do it.
Antimicrobial Stewardship
To this, Dr Gerald Evans (Queen’s U, Kingston) added that it is vital to think about the purposes for which antibiotics are being used in humans and animals. Drug safety, effectiveness, and resistance are three key areas to consider. He stated that antibiotics must be viewed as a shared resource, analogous to developing and maintaining good roads: too many potholes will damage the car, which is very costly. The indirect cost of resistance must also be considered, in addition to the fact that inappropriate antibiotic therapy is by itself a risk factor for mortality.
He noted that in Canada as in Europe, there are big differences in prescribing rates between different areas. Often higher use of antibiotics is linked to socioeconomic status and age. Doctors must take into account the long-term population consequences and consider multi-faceted interventions. He also explained that while awareness campaigns can successfully reduce the use of antibiotics, they may not have an immediate effect on the occurrence of AMR, which is why they have to be repeated continuously. Some practices used to reduce AMR include the following:
- Rewarding GPs with bonuses to reduce antibiotics prescriptions (UK)
- Ensuring vaccinations, including against influenza (North America)
- Removing medical devices from the body when not required
- Exercising good hand hygiene, stepping up infection prevention and control
- Ensuring appropriate clinical diagnosis of infections
- Treating patients not lab results: not all infections require antibiotics and health professionals should consult experts (e.g. clinical microbiologists, infectious disease specialists) if unsure
- Practising personal antimicrobial stewardship: stop them as early as possible and consider alternatives
The session highlighted some of the difficulties in coordinating all the different things that need to be in place for public health perspective, from surveillance and infection control to broader political consensus around policies and setting targets for the reduction of infections and prudent use in different settings. Only by working together, filling knowledge gaps, reflecting on the complexity of the system, and not blaming each other can AMR be challenged successfully, whether in Canada, in Europe or globally.
