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Going global on resistance

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IN a report on antimicrobial resistance published last December, the O'Neill Commission took a tough line on the use of antibiotics in agriculture, calling, among other things, for global targets to reduce antibiotic use in food production to an agreed level per kilogram of livestock and fish, along with restrictions on the use in animals of antibiotics considered important in human medicine (VR, December 12, 2015, vol 177, p 580). The commission, chaired by economist Jim O'Neill, was established by the UK's Prime Minister, David Cameron, in 2014, to examine the economic issues surrounding antimicrobial resistance and the development of new drugs, after the Prime Minister had warned that, if things go on as they are, antibiotic resistance could result in the world being ‘cast back into the dark ages of medicine where treatable infections and injuries could kill once again’ (VR, July 12, 2014, vol 175, p 30). Its report on the use of antimicrobials in agriculture formed part of a series of reports it has produced over the past 18 months, building up to its final report and recommendations, which was published this week (see pp 515-516 of this issue). The review has been primarily concerned with ensuring that effective antibiotics continue to be available to treat infections in people and other topics considered in the series have included improving the ‘pipeline’ for new antibiotics, managing supply, infection control and prevention, alternatives to antibiotics, improved diagnostics and better surveillance for antimicrobial resistance in people and animals. These, along with the use of antimicrobials in agriculture, are all discussed in the final report.1

The final report also takes a firm line on the use of antimicrobials in animals. Reducing the ‘extensive and unnecessary use of antibiotics in agriculture’ is, for example, one of four interventions highlighted in a foreword by Lord O'Neill as being particularly important, along with the need for a global awareness campaign to make everyone aware of the problem of resistance, the need to stimulate the development of new drugs to replace the drugs that are no longer working and the need for rapid diagnostic tests. He also argues that ‘we need to make much faster progress on banning or restricting the use in animals of antibiotics that are vital for human health’. At the same time, the report acknowledges that ‘there are clearly circumstances where antibiotics are required in agriculture and aquaculture’ and that ‘their proper use can maintain animal health and welfare as well as food security’ and, while it makes no bones about the need to reduce the ‘vast’ quantities of antibiotics that are used in livestock, the commission seems to take a slightly more pragmatic line on setting global targets than it did in its report in December. Specifically, it recognises that there will not be a ‘one size fits all’ target and recommends that targets should be set by individual countries, enabling governments to have the flexibility to decide how they will achieve lower levels of use. Its preference would still be for targets to be calculated on a mg/kg basis for livestock and fish, but it now suggests that another option might be to measure usage on the basis of a defined daily dose.

The proposals on target setting proved contentious when put forward by the commission in December, and it will be interesting to see if they turn out to be any less so in this amended form.

The extent of the challenge involved in regulating antimicrobial use in animals worldwide has been illustrated by an evaluation of animal health systems undertaken by the World Organisation for Animal Health (OIE). This found that, of 130 countries evaluated, 110, mainly developing and emerging countries, did not have relevant legislation governing the importation, manufacture, distribution and use of veterinary medicines, including antibiotics, and that, in some cases, there was no legislation at all.2 In this respect, comments in the report about providing support to help build regulatory, veterinary and laboratory and surveillance capacity in developing countries are helpful. The report also calls for greater transparency on antimicrobial use in agriculture, and for producers, retailers and regulators to agree standards for responsible use. It notes that recent months have seen a series of announcements from companies, including retailers, wholesale producers and fast food chains, of antibiotic reduction targets for their supply chains, driven largely by consumer pressure but also by pressure from investors. It suggests that pressure from investors and long-term asset holders could play a crucial role in changing behaviours in the future.

On improving the supply of new antibiotics, the commission recommends that countries should review how they buy and price antibiotics, to reward innovative new drugs without encouraging unnecessary use. It further suggests that a group of countries such as the G20 should get together and provide a reward for the development of new products after they are approved for use. These ‘market entry awards’, of about $1 billion each, would be given to the developers of successful new drugs, subject to conditions to ensure that ‘they are not over-marketed and yet are available to patients who need them wherever they live’. This kind of approach might help stimulate the development of new antibiotics for use in people, but is unlikely to result in new products for use in animals.

The O'Neill report adds to a growing number of reports on the need to tackle antimicrobial resistance that have been produced in recent years, at national, European and global levels. Having been commissioned by the Prime Minister, it is likely to have a significant influence in the UK. How influential it proves to be beyond these shores remains to be seen but, ultimately, it will be its international impact that will count. For a review that was set up to look at the economic issues surrounding resistance and the development of new drugs it seems to focus quite heavily on reducing the use of antibiotics in animals but in one respect it is absolutely right: it is only through action at a global level that the problem of antibiotic resistance will be addressed.

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