Nils Daulaire

International cooperation to improve access to and sustain effectiveness of antimicrobials

Securing access to effective antimicrobials is one of the greatest challenges today. Until now, efforts to address this issue have been isolated and uncoordinated, with little focus on sustainable and international solutions. Global collective action is necessary to improve access to life-saving antimicrobials, conserving them, and ensuring continued innovation. Access, conservation, and innovation are beneficial when achieved independently, but much more effective and sustainable if implemented in concert within and across countries. WHO alone will not be able to drive these actions. It will require a multisector response (including the health, agriculture, and veterinary sectors), global coordination, and financing mechanisms with sufficient mandates, authority, resources, and power. Fortunately, securing access to effective antimicrobials has finally gained a place on the global political agenda, and we call on policy makers to develop, endorse, and finance new global institutional arrangements that can ensure robust implementation and bold collective action.

Universal Access to Effective Antibiotics is Essential for Tackling Antibiotic Resistance

Universal access to effective antimicrobials is essential to the realization of the right to health. At present, 5.7 million people die from treatable infections each year because they lack this access. Yet, community-based diagnosis and appropriate treatment for many of the leading causes of avoidable infectious deaths has been shown to be feasible and effective, demonstrating that strategies to reach the under-served need to receive high priority. This is a necessary part of a broad strategy to assure the long-term benefits of antimicrobials and to combat antimicrobial resistance, both because the lack of systematic and rigorous efforts to assure effective coverage increases the likelihood of antimicrobial resistance, and because global efforts aimed at antimicrobial stewardship and innovation cannot succeed without explicitly addressing the needs of the under-served. Elements of this strategy will include clear evidence-based treatment protocols, a robust international framework and locally tailored regulations, active engagement with communities and local health providers, strong attention to program management and cost considerations, a focus on the end user, and robust surveillance and response to emerging resistance patterns. Only by balancing the needs of universal access with stewardship and innovation, and assuring that they are mutually reinforcing can a global strategy hope to effectively address antimicrobial resistance.

Strategies for achieving global collective action on antimicrobial resistance

Abstract Global governance and market failures mean that it is not possible to ensure access to antimicrobial medicines of sustainable effectiveness. Many people work to overcome these failures, but their institutions and initiatives are insufficiently coordinated, led and financed. Options for promoting global collective action on antimicrobial access and effectiveness include building institutions, crafting incentives and mobilizing interests. No single option is sufficient to tackle all the challenges associated with antimicrobial resistance. Promising institutional options include monitored milestones and an inter-agency task force. A global pooled fund could be used to craft incentives and a special representative nominated as an interest mobilizer. There are three policy components to the problem of antimicrobials – ensuring access, conservation and innovation. To address all three components, the right mix of options needs to be matched with an effective forum and may need to be supported by an international legal framework.

A better future for women and children

Over the past century the risk of maternal and infant death and of injury associated with childbirth has decreased substantially in developed countries. Sadly the benefits of these advances are not accessible to all throughout the world. Why does one woman die every minute from complications related to pregnancy and childbirth? 99% of such deaths occur in developing countries and the reasons are basic. Women haemorrhage to death; they do not have access to antibiotics to prevent infection; or they do not have the option of a caesarean section. Why do nearly 10 million children die each year before their fifth birthday (more than the number of adults who die from AIDS malaria and tuberculosis combined) if most of these deaths are preventable? Why when contraception is cheap and effective do 200 million women still have an unmet need for family planning? (excerpt)

Refugees in the eastern Mediterranean region

2476 www.thelancet.com Vol 386 December 19/26, 2015 3 Pareek M, Baussano I, Abubakar I, Dye C, Lalvani A. Evaluation of immigrant tuberculosis screening in industrialized countries. Emerg Infect Dis 2012; 18: 1422–29. 4 Tebruegge M, Ritz N, Koetz K, et al. Availability and use of molecular microbiological and immunological tests for the diagnosis of tuberculosis in Europe. PLoS One 2014; 9: e99129. 5 Basu Roy R, Sotgiu G, Altet-Gómez N. Identifying predictors of interferon-gamma release assay results in pediatric latent tuberculosis: a protective role of bacillus Calmette-Guerin? A pTB-NET collaborative study. Am J Respir Crit Care Med 2012; 186: 378–84. 6 Borrell S, Español M, Orcau A, et al. Tuberculosis transmission patterns among Spanish-born and foreign-born populations in the city of Barcelona. Clin Microbiol Infect 2010; 16: 568–74. 7 Abubakar I, Laundy MT, French CE, Shingadia D. Epidemiology and treatment outcome of childhood tuberculosis in England and Wales: 1999–2006. Arch Dis Child 2008; 93: 1017–21. opted to simply modify their original guidelines they developed before the migration crisis. Some countries are exclusively aiming to identify adults with active tuberculosis, arguing that this screening will restrict transmission within refugee centres and to the resident population. However, this strategy neglects addressing the reservoir of tuberculosis that is latent tuberculosis infection. Epidemiological evidence shows that progression of latent tuberculosis infection to active tuberculosis usually occurs within the fi rst 2 years of arrival and that children have the highest risk for progression. Recognition of tuberculosis symptoms needs to be integrated into immediate health assessments of refugees, including children and adolescents. Long-term assimilation of arrivals into health-care systems should include screening for both latent and active tuberculosis, as well as training primary and emergency treatment service in vigilance for and recognition of tuberculosis symptoms in this vulnerable population.