D1-Rottingten-the global response to antimicrobial resistance in the context of COVID-19

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The global response to
antimicrobial resistance
Lessons learned from Covid19
John-Arne Røttingen, Ambassador for Global Health
The global response to antimicrobial resistance, in the context of COVID-19
WMA scientific session 2021
8.10.21
COVID-19 cases and deaths – a pandemic
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COVID-19 has a devastating
impact on the world
ACT-A was created to save
lives and the economy
• accelerate development of tests,
treatments & vaccines
• ensure equitable access globally
ACT-Accelerator’s core focus:
>4.7
million
Reported
deaths
WHO; Sep 9, 2021
>9
trillion
Cum. US$ loss on
global output by
’25
IMF; October 2020
Working with Governments, industry, CSO & development system for impact
>230
million
Reported cases
WHO; Sep 9, 2021
© The Economist
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Global vaccine coverage
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Coronavirus chart: see how your country compares | Free to read |
Financial Times (ft.com)
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AMR
Holmes et al. (2015) The Lancet. doi:10.1016/S0140-6736(15)00473-0
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AMR – A Global Collective Problem
Eili Y Klein et al. BMJ Glob Health 2019;4:e001315
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Drug
Resistance
Index (DRI)
for each country
compared with
its per capita
antibiotic use in
defined daily
doses (DDDs) per
1000 individuals
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.
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Orphanage in Bamako, Mali
ESBL colonized 100% of the children and 63%,
of the adult staff studied.
Tandéet al. Emerg Infect Dis. 2009 Mar;15(3):472-4.
Mumhibili hospital, Tanzania Tanzania
The paediatric mortality rate from Gram-negative
infections were more than 40 %. Antibiotic
resistance were a significant risk factor for a fatal
outcome
Blomberg et al. BMC Infect Dis. 2007 May 22;7:43.
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Children with suspected
pneumonia receiving
antibiotics
United Nations Children’s Fund (UNICEF) June 2012
© UNICEF/UNI172461/Bindra
Sustainable effectiveness of antibiotics – a
«bath tub problem»
– a common pool resource
The Global Health System
– Four functions
Global
Public
Goods
(GPGs)
Managing
Externalities
Solidarity/
Assistance
Leadership/
stewardship
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AMR –
Interconnectedness
of policies
Innovation of
Antimicrobials
Conservation
of
Antimicrobial
Effectiveness
Universal
Access to
Antimicrobials
and
Prevention
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Global Public Goods
(GPGs)
Managing
Externalities
Solidarity/
Assistance
Surveillanceand
Accountability
Policy framework
for Sustainable
Access to Effective
Antimicrobials Responsible use
Infection
prevention
Universal Access
Innovation and R&D
(Knowledge Base)
need
demand
supply
One Health
Human
Health
Animal
Health
Surveillance and Monitoring
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V.
Collective
action
IV.
Collaborative
decisions
III.
Coordination
II.
Communication
I.
Common norms, principles
and goals
Surveillance Policies
Requiring International Collaboration
Sharing of surveillance data globally
International collection and analysis
Improving national / regional lab capacity
V.
Collective
action
IV.
Collaborative
decisions
III.
Coordination
II.
Communication
I.
Common norms, principles
and goals
Infection Control and Access Policies
Requiring International Collaboration
Sharing of evidence concerning
effective interventions
Financing for implementation of
infection control interventions
Donors and governments prioritize
access to effective antimicrobials
Ensuring global affordability of antimicrobials
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V.
Collective
action
IV.
Collaborative
decisions
III.
Coordination
II.
Communication
I.
Common norms, principles
and goals
Responsible Use Policies
Requiring International Collaboration
Sharing of evidence concerning
best practices for responsible use
Common standards for marketing of antibiotics
Restricting specific classes to human use
Reduction in use as growth promotion
“Controlled drug regime”
Quality assurance combatting
counterfeits and substandards
Sales tax / AB consumption tax
V.
Collective
action
IV.
Collaborative
decisions
III.
Coordination
II.
Communication
I.
Common norms, principles
and goals
Innovation Policies
Requiring International Collaboration
Financing and performing the necessary R&D;
supporting new business models for delinkage
Financing market entry rewards,
Global/multi-country “pull” incentives
Increasing Frequency of Epidemics caused by
Wildlife Zoonoses (excluding Influenza) and
Reported Influenza Spillover Events (log-normal scale)
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Source: Metabiota
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Log10
transformation
of the y-axis
COVID-19
Event Severity:
Number of reported deaths
Event Severity:
Number of reported deaths
Trend: frequency and severity
Post Covid-19 reforms: Global governance for health
• Global Health Threats Council/Board
• Global Health Threats Fund/Financing Facility
• Pandemic Preparedness Partnership & Pandemic Radar (G7)
• ACT-A 2.0 – platform for medical countermeasures
• Strengthening the International Health Regulations
• Pandemic treaty – Framework convention
Plugging Four Major Global Gaps
Recommendations of the G20 HLIP on
Financing the Global Commons for PPR
1 Globally networked surveillance and research: to prevent and detect
emerging infectious diseases
2 Resilient national systems: to strengthen a critical foundation for
global pandemic preparedness and response
3 Supply of medical countermeasures and tools: to radically shorten
the response time to a pandemic and deliver equitable global
access
4 Global governance: to ensure the system is tightly coordinated,
properly funded and with clear accountability for outcomes
Global health security –
Pandemic Preparedness and Antimicrobial Effectiveness
– as Global Public Goods
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Five types of Global Public Goods
• Dependent on total aggregate efforts
• Efforts to reduce unnecessary use of antimicrobials in human and animal health sectors
• Prevention efforts within environment and food safety to reduce zoonotic spillovers and prevention
efforts to control infections
• Dependent on the weakest link
• Surveillance and alert systems to detect emerging pathogens and infectious outbreaks – as well as
evolution of antimicrobial resistance
• Dependent on coordination
• Common norms, standards and interoperative systems to share information and data
• Dependent on single best effort
• Development and warm base capacity for production of medical countermeasures like vaccines,
therapeutics, diagnostics and other technologies – both relevant for epidemics as well as endemic
infections
• Dependent on joint regulations to prohibit/ban activity that pose risks
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Commonalities –
PPR and AMR
• The zoonosis aspect and the need for a One
Health approach
• The need for improved global surveillance for both
viral and bacterial infections
• The need for a health-needs driven research and
development model
• Increasing transparency and strengthening of
global pharmaceutical supply chains
• Ensuring equitable, affordable and timely access
to health products and prevention efforts
• And ensuring Stewardship – access without excess
ReAct briefing paper
US$ 18.1 billion contributions forACT-A
received (as of 3 September 2021)
Note: all financial commitments can be accessed at https://www.who.int/publications/m/item/access-to-covid-19-tools-tracker.
1. US$ 18.1 billion include $470m contributed by the Diagnostics Consortium to procure automatedand manual molecular tests for LMICs, and exclude pledges to Gavi for vaccine delivery as Gavi vaccinedelivery costs arenot reflectedin theStrategy
& Budget for 2021 2. Contributions <US$ 12m, and including $470m contributed by the Diagnostics Consortium to procure automatedand manual molecular tests for LMICs 3. Including $2.7b of the new USG commitment of US$ 3.5 billion to the
Global Fund – The precise composition of grantsunder C19RM2021 will be determined by recipient countries and reported once funding requests areapproved 4. COVAX AMC being fully funded for 2021, additional contributions to COVAX AMC do
not reduce ACT-A funding gapfor 2021.
Contributions | ACT-A's generous contributors have funded
US$ 18.1 Bn so far, but still has a US$ 16.6 Bn gap for 2021
US$ 16.6 billion funding gap for 2021
(as of 3 September 2021)
Saudi Arabia 1.7%
France 1.7%
Sweden 1.7%
Republic of Korea 1.2%
Japan 6.7%
United States 34.4%
Netherlands 0.9%
Italy 2.7%
Australia 0.7%
Gamers without borders 0.1%
Wellcome Trust 0.4%
Gates Philanthropy Partners 0.7%
UNICEF National Committees 0.6%
New Zealand 0.2%
Germany 14.6%
China 0.6%
United Kingdom 6.3%
Gates Foundation 2.3%
Others 0.9%2
Norway 2.7%
Canada 6.1%
Anonymous Swiss Foundation 0.2%
Spain 1.2%
Reed Hastings and Patty Quillin 0.2%
European Commission 3.3%
Switzerland 2.3%
Denmark 0.1%
Kuwait 0.4%
US$ 18.1
billion
ACT-A budget
as of
September
2020
12.5
Pending
allocations &
cost
adjustments
Contributions to
ACT-A
38.1
18.1
16.0
Funding gap
6.6
6.0
9.5
3.4
0.8
1.1
0.6
3.1
16.6
Therapeutics
Vaccines
Cost adjustments
Diagnostics
HSC
Pending allocation
Funding Gap
Source: Policy Cures. COVID-19 R&D Tracker. Sept 18, 2020. https://www.policycuresresearch.org/covid-19-r-d-tracker
Public, philanthropic & industry funding for
COVID-19 R&D
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Funding for human health AMR R&D
Source: Global AMR R&D Hub. Sept 24, 2020. https://dashboard.globalamrhub.org/reports/investments/overview
DRIVE-AB’s recommended models
Grants
Pipeline Coordinator
Market Entry
Rewards
Basic Science Phase I Phase II Phase III Market
Preclinical
Continuity
payments
Generic market
Tracking & monitoring gaps in financing, production, delivery, trade, supply chain, and
deployment, to support faster & more targeted short-term & longer-term solutions
COVID-19 response of the MLTF/ACT-A
Global Database & Country Dashboards: snapshot
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Most countries are small
Conservation
of the effectiveness of existing
antimicrobial medicines
Access
to effective antimicrobials and
related innovations
Innovation
of new technologies and
solutions for prevention,
detection and treatment
Global commons
dilemma
Negative
externalities
Unrealized positive
externalities
Coordination
problem
Free-rider
problem
Antimicrobial
policy goals
Collective Action
Policy Problems
From Steven Hoffman, extending and building on Hoffman et al. (2015)
WHO Bulletin. doi:10.2471/BLT.15.153171
Prevention
of any kind of infection to
reduce antimicrobial use and
resistance
AMR actions
Prisoner’s
dilemma
Public research funding
ODA for antimicrobials
Fighting counterfeits
Stewarding antimicrobial use
Harmonizing surveillance data globally
Investing in surveillance capacity
Banning manufacturing effluent
Managing animal/farm/human run-off
Scaling-up vaccines
ODA for WaSH and infection prevention
Push mechanisms (e.g., subsidies)
Pull mechanisms (e.g., advance purchasing)
Training for research personnel
Funding for optimized antimicrobials
Use of diagnostics
Stocking narrow-spectrum antimicrobials
Source: Hoffman (2007)
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Global Governance for Health Threats
• Norms and obligations
• Strengthening the International Health Regulations
• Pandemic treaty – Framework convention
• Tools and solutions
• Pandemic Preparedness Partnership & Pandemic Radar (G7)
• ACT-A 2.0 – platform for medical countermeasures
• Financing
• Global Health Threats Fund/Financing Facility
• Oversight and accountability
• Global Health Threats Council/Board
Agricultural
health
Human
health
Animal
health
Conservation Innovation
Infection
Prevention and
Control
Access
Environmental
health
Addressing PPR and AMR requires
multisectoral approach – One Health
Financial mechanisms
Normative framework
(universal, UN/WHO based)
Financial framework
(open, broad coalition)
Core collective
global responsibilities
Core national responsibilities
Oversight mechanisms Compliance mechanisms
Global framework
(PPR and AMR)
With Steven Hoffman and Gian Luca Burci
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