WHO global strategy to contain
antimicrobial resistance:
prioritisation of interventions
ICIUM 2004
K.A.Holloway
Essential Drugs and Medicines Policy
WHO Geneva
WHO Global strategy
Identifies 67 interventions targeted at
different groups
•
•
•
•
•
•
•
Prescribers and dispensers
Patients and the general public
Hospitals
Governments and health systems
Pharmaceutical industry
Non-human uses of antimicrobials
International aspects
WHO, Dept. Essential Drugs and Medicines Policy
2
Prioritising interventions
• Multidisciplinary groups at country / regional level
– done in EMRO & SEARO and with Nepal officials
– group members agreed 32 interventions for prioritisation &
scored (0,1,2) each intervention for feasibility & importance
– interventions were plotted on a graph & compared
• Three specialist expert groups at WHO/HQ level
– experts sat in specialist groups for (1) prescribers &
dispensers (2) hospitals & (3) government & health systems
– each group prioritised interventions for their target groups
– comparison was done of different expert groups’ priorities
to identify interventions common to different target groups
WHO, Dept. Essential Drugs and Medicines Policy
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32 interventions to contain AMR prioritised in regions
A. Patients &
the public
(1) Education on appropriate use, (2) Education on hygiene,
(3) Discourage self medication
B. Prescribers
& dispensers
(1) Train, (2) Guidelines & formularies, (3) Monitor & supervise,
(4) Regulate professionals, (5) Educate prescribers about promotion
C. Health
systems
(1) DTCs, (2) Infection control committees, (3) Antimicrobial guidelines,
Surveillance of (4) antimicrobial use, & (5) resistance with Lab. Network
D. Government (1) National AMR task force with budget, (2) Drug policies e.g. EDL,
(3) Drug outlet registration, (4)Antimicrobials by Px-only, (5)Dispensing
& regulation
of antimiocrobials by licensed staff only, (6) QA system, (7) Drug
licensing to include resistance data, (8) UG & PG training on AMR,
(10) Access to evidence-based drug info, (11) Cut perverse economic
incentives for rational use of drugs, (12) Monitor & supervise drug
promotion, (13) Monitor and link AMR & drug use data
E. Pharmaceut- (1) Incentives for industry to do R&D, (2) Monitor & supervise drug
promotion, (3) Production according to GMP standards
ical industry
F. Non-human
use
(1) Surveillance of resistance & use, (2) Phase-out growth promoters,
(3) Educate farmers and vets
WHO, Dept. Essential Drugs and Medicines Policy
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Prioritization of interventions by the 11 members
of EMRO antimicrobial resistance task force
25
Feasible and relevant
Importance
20
11
2
15
4
4
5
12
3
1
1
6
3 3
2 1
9 4 3
5
1
5
3
1
2
8
2
1
3
2
7
2
10
10
Key: group targeted by interventions
A
B
C
D
E
Not feasible or relevant
5
F
0
0
5
patients, families, communities
prescribers and dispensers
health systems
govt. policies, strategies, regulations
pharmaceutical industry
non-human antimicrobial use
10
Feasibility
15
20
25
5
Prioritization of interventions by 7 staff members
of SEARO
15
14
1
13
1
3 4
12
2
34
5
5
7
1
Importance
12
11
1
1 4
3
9
8
6
Key: group targeted by interventions
A
B
5
C
D
Not feasible or relevant
3
2
E
1
F
0
0
1
2
3
4
5
Feasible and relevant
6
4
2 2
2
9
11
7
1
2
10
10
0
32
38
3
5
6
7
patients, families, communities
prescribers and dispensers
health systems
govt. policies, strategies, regulations
pharmaceutical industry
non-human antimicrobial use
8
9
10
11
12
13
14
15
Feasibility
WHO, Dept. Essential Drugs and Medicines Policy
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Prioritization of interventions by 15 health
officials in Nepal
3
25
2
5
Importance
10
20
3
1
311 13
1
4
1
12
2
4
5
1
6
2
3
3
5
4 3 2
2
8
1 1
2
9
Feasible and relevant
7
15
Key: group targeted by interventions
A
B
C
D
E
patients, families, communities
prescribers and dispensers
health systems
govt. policies, strategies, regulations
pharmaceutical industry
F non-human antimicrobial use
Not feasible or relevant
0
0
10
15
20
25
Feasibility
WHO, Dept. Essential Drugs and Medicines Policy
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WHO/HQ priorities (1)
Fundamental interventions
1 Make containment of AMR a national priority including:
 creation of a national task force,
 allocation of resources to implement interventions to contain
antimicrobial resistance,
 development of indicators to monitor and evaluate the impact of an
antimicrobial resistance strategy.
2 Designate or develop reference microbiology laboratory
facilities to co-ordinate effective, epidemiologically-sound,
surveillance of AMR among common pathogens in the
community, hospitals and other health care facilities
WHO, Dept. Essential Drugs and Medicines Policy
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WHO/HQ priorities (2)
High Priority Interventions
1 Patient education on preventing infection (immunization,
vector control, use of bed-nets, etc.) and reducing transmission of infection (hand-washing, food hygiene, etc.)
2 Prescriber and dispenser (including drug sellers) education
on appropriate antimicrobial use, containment of AMR,
disease prevention and infection control
3 Targeted UG & PG education for all health workers & vets
on accurate diagnosis & management of common infections
4 Develop, update and use STGs & treatment algorithms
5 Infection Control Programmes in hospitals
WHO, Dept. Essential Drugs and Medicines Policy
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WHO/HQ priorities (3)
High Priority Interventions
6 Good quality diagnostic laboratories that provide:• microbiology lab. services appropriate to the level of hospital
• appropriate diagnostic tests, bacterial identification, antimicrobial
susceptibility tests of key pathogens with relevant timely reporting
7 Limiting availability of antimicrobials to prescriptiononly status, except in special circumstances where they
may be dispensed on the advice of a trained health care
professional
8 Ensuring only antimicrobials meeting international
standards of quality, safety & efficacy are granted
marketing authorisation
WHO, Dept. Essential Drugs and Medicines Policy
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Problems with prioritisation
• People prioritised according to their
specialities and expertise
• agricultural interventions were not prioritised
in the exercise in Geneva
• the prioritisation of which interventions are
most important and feasible was based on
opinion and not evidence of which there is very
little
WHO, Dept. Essential Drugs and Medicines Policy
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Conclusions (1)
Five interventions deemed important &
feasible by all groups
• training prescribers and dispensers and using
guidelines and formularies
• establishing infection control committees and
guidelines for antimicrobial use
• developing national drug policies, essential drug lists
and standard treatment guidelines
• ensuring undergraduate and post graduate training on
antimicrobial resistance
• ensuring that drugs are produced according to GMP
standards and are of adequate quality
WHO, Dept. Essential Drugs and Medicines Policy
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Conclusions (2)
• A national task force with budget is needed to
carry out & coordinate the 5 interventions
• There is a need to evaluate all interventions for
their effectiveness & cost-effectiveness in
containing antimicrobial resistance
• In order to evaluate interventions, it is
necessary to do linked surveillance of
antimicrobial resistance and use
WHO, Dept. Essential Drugs and Medicines Policy
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Key lessons, policy implications and
future research
Key lessons
• There is expert consensus that a national task force and national public
reference lab are regarded as fundamental to containing AMR
• There is widely differing opinion and a profound lack of evidence
concerning which strategies to contain AMR should have highest priority
Policy implications
• Lack of evidence for prioritising interventions to contain AMR hampers
the development of coordinated national approaches to containing AMR
Future research
• Rigorous evaluation of interventions to contain AMR must be conducted
in order to identify which strategise are most cost-effective
• Sustainable, reliable and affordable surveillance systems need to be
researched and developed in order that interventions can be evaluated.
WHO, Dept. Essential Drugs and Medicines Policy
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