Speech by CMO at the Launch of National Intersectoral AMR Consultative Committee

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Speech by Chief Medical Officer on Launch of  National Intersectoral AMR Consultative Committee at European Antibiotic Awareness Day

Good morning

I would like to thank the RCPI and the National Clinical Programme for HCAIs for the invitation to speak to you this morning on the occasion of European Antibiotic Awareness Day, in the beautiful historic surroundings of the Royal College of Physicians.

In particular, I welcome the opportunity to speak to you as Chief Medical Officer together with my colleague, Mr Martin Blake, Chief Veterinary Officer, to describe our plans for a ‘One Health’ approach to future intersectoral working between our respective Departments. This approach has been endorsed by the Ministers for Health and for Agriculture, Food and the Marine.  It will reinforce and build on our joint efforts to date in tackling AMR, as part of our two Departments’ wider commitment to Intersectoral working under the Healthy Ireland framework.

Over the course of the next few minutes I would like to share some reflections on the problem of AMR and our journey to date in tackling the problem.

AMR is not a mystery, nor is it a new problem.  To quote the warning words of Alexander Fleming himself, the discoverer of penicillin, at his Nobel Prize lecture in 1945:

“There is the danger that the ignorant man may easily under dose himself and by exposing his microbes to non-lethal quantities of the drug, make them resistant.”

Today we know that the emergence of AMR is a real and growing public health crisis. It is a natural biological phenomenon, but significantly driven by the misuse and overuse of antibiotics, poor infection control and hygiene practices.  The problem is further compounded by international trade and travel. Increasingly we are seeing the emergence and spread of resistant bugs within and between countries, against a background of a dwindling supply of effective antibiotics as resistance develops to frontline drugs and with few agents in the pharma Research and Development pipelines.

It is over two decades since the WHO (1994) identified AMR as “an alarming crisis calling for urgent measures”.  Over that period, the problem has grown inexorably.

Almost seventy years after Fleming’s warning, we are in danger of entering what Dr Margaret Chan, Director General of the WHO, on a recent visit to Dublin has termed the “post antibiotic era”.

This is an era in which the developments of modern medicine which all of us take for granted are at risk – an era in which the dramatic falls in morbidity and mortality from infectious diseases we have witnessed are reversed and simple infections once again become killer diseases;

an era in which medical procedures such as neonatal care, hip and joint replacements, organ transplants and cancer therapies become impossibly dangerous because of the risks of associated infections which we cannot treat effectively.

We must act now.

A great deal has already been done.  The control of HCAIs and AMR has been a policy priority for the Department of Health and the health system for almost two decades and it continues to be one of the patient safety priorities for the National Service Plan of the HSE.

The first national MRSA guidelines were published as far back as 1995. The SARI Strategy (Strategy for the Control of Antimicrobial Resistance in Ireland), which many of you in the audience were involved in developing and implementing, was launched in 2001.

The successor to the SARI Committee, the RICP/HSE National Clinical Programme for HCAIs, and the organiser of today’s event, was established in 2011. At the same time the HCAI Clinical Advisory Group was established here in the RCPI.

It is not possible in the time available to mention all the actions and developments that have been put in place across our system over the years to strengthen our arrangements for the control and prevention of HCAIs and AMR, under the leadership of SARI and latterly the Clinical Programme and the Clinical Advisory Group. These developments are testament to the expertise and personal commitment of those involved, many of you in the audience here today.

They span education and training, awareness-raising, the development of evidence-based guidelines, hand hygiene and infection control practices.

To highlight a few:

As a system, we have improved our surveillance of AMR infections and clarified our governance arrangements for the prevention and control of HCAIs and AMR.

The implementation and monitoring against the HIQA National Standards for the Prevention and Control of HCAIs provide us with an important benchmark and assurance of progress.

As referred to previously, reporting of key performance indicators for HCAIs and AMR form part of the regular monitoring process of the National Service Plan in place between the Department and HSE

Working together with the Colleges, the Clinical Programme has developed several excellent tools and guidelines to support prudent prescribing of antibiotics and infection prevention and control. These include, for example:  the ‘Start Smart and then Focus’ antimicrobial bundle in hospital care; primary care antibiotic prescribing guidelines on the website www.antibioticprescribing.ie and surgical site infection bundles.

We have made some notable progress in reducing rates of resistance.  MRSA rates have fallen by 60% in recent years, although still relatively high compared to some of our Northern European neighbours.  Infections from Clostridium difficile, another useful indicator of overall antibiotic consumption, have also fallen.

But significant challenges remain.

There is an ongoing and worrying upward trend in the national incidence of resistance in many other organisms, particularly in gram negative bacteria such as E coli and Klebsiella pneumoniae. Earlier this week, the latest report from the ECDC on antibiotic resistance in Europe warned that increasing resistance to last-line antibiotics is a continuing concern and this is an area where added vigilance and attention is needed.

Turning to antimicrobial and particularly antibiotic consumption, we know through the ESAC surveillance data reported to the ECDC through the HPSC, that antimicrobial consumption in Ireland is in the moderate to high range.

Over the years we have had a significant focus on antimicrobial consumption in acute settings and in primary care.  Recent survey data has indicated relatively high levels of antimicrobial consumption in community long stay facilities are an area of concern.

Recent survey data has also shown that relatively high proportions of patients, particularly younger parents, are not aware of the importance of using antibiotics wisely.  Earlier this week, Minister Varadkar launched the self-care website www.undertheweather.ie as part of this year’s Public Information Campaign on Antibiotics by the HSE.  The emphasis this year is on public information as a driver for behaviour change and as a support for good prescribing decisions at the prescriber and patient interface.

Of course raising awareness of the importance of prudent antibiotic use is not just an issue for the human health sector.

The prevention of AMR is an Intersectoral issue

As in human medicine, veterinary medicine depends on the availability of safe and effective antibiotics. It is probably surprising for many health professionals to learn that the quantities of antibiotics used in veterinary medicine, particularly in food producing animals, greatly exceed those used in human medicine.

The potential of animal antibiotic consumption as a global driver for AMR and the possible implications of this for human health are of significant concern.

At international level, the requirement for an inter-sectoral approach to address the global problem of AMR is well recognised.

The WHO, FAO and OIE have committed to a tripartite collaboration as part of a ‘One Health’ approach to address AMR. In May this year, the World Health Assembly this year adopted a resolution asking WHO to develop a draft global action plan to combat antimicrobial resistance. The resolution specifically calls on the WHO to collaborate with the FAO and the OIE in a multi-sectoral approach that brings together human health, animal health and agriculture.

The European Union has also been active in recent years in addressing HCAIs and AMR in both human and animal health.

The European Commission published a 5 year action plan against the threat of AMR in 2011 which sets out key areas for action and implementation across the human and animal health sectors.

On the human health side, our national response to AMR has been informed by and broadly in line with international guidance.

Mr Martin Blake, CVO will present the many actions that have been taken over recent years in the animal health sector at both nationals and EU level.

It is reassuring to see how seriously this global public health issue is being taken in the animal health sector and I particularly welcome the personal interest and involvement of the CVO in this area.

Over recent months, I and others in my office have worked with Martin and our counterparts to explore what further actions are needed as part of the national AMR response.  We have jointly prepared a report to both Departments which reviews activities in both sectors to date and also reviewed international developments and advice.

Our conclusion is that a great deal has been achieved in our two areas to date but challenges clearly remain and our two sectors have been acting largely independently of each other.

Tackling AMR is a policy priority for our two Departments and both are committed to working together and supporting the work of our national and international agencies as part of a ‘One Health’ approach.

We have identified the need for the establishment of a National Interdepartmental Consultative Committee on AMR as an essential coordinating mechanism for our ongoing work.  I am delighted that the Ministers have supported this proposal.  This is a manifest recognition at Ministerial level of the serious increasing threat of AMR and of the requirement for a ‘whole of government’ approach to health issues, as articulated in Healthy Ireland (A Framework for Improved Health and Wellbeing).

The Ministers for Health and Agriculture, Food and the Marine are this week writing to the key stakeholders and leaders across the animal and human health sectors to invite them to participate in the Committee.  Thus the Committee will have a clear role and mandate across the two sectors.  It will be chaired by me and by the CVO on an alternating basis.

The proposed terms of reference which will be finalised by the Committee when it meets will be to raise awareness across both sectors and to provide guidance and advice to both Departments in guiding our future actions.

I am greatly encouraged by this development.  I am convinced that this Committee will provide us with an invaluable forum for discussion and advice and I look forward to our continued work together in tackling this critical issue for public health.

Thank you.