Wilton Park: Workshop Report

Photo: © Charlotte Kesl / World Bank

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Innovations to reduce the use of antimicrobials in food-producing animals in LMICs WORKSHOP REPORT WILTON PARK | 11 – 13 APRIL 2018

Contents

Executive Summary

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1 Introduction

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1.1 The Workshop

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2 Summary of Discussions

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2.1 Context-specific Innovation in Vaccines and Alternatives to Antimicrobials

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2.2 Improved Education and Training

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2.3 The Power of Social Sciences and Beyond

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2.4 Partnerships and Collaboration across Borders and Disciplines

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2.5 Impact of Gender in Farming

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2.6 Improved Frameworks for Stewardship and Regulation

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2.7 Systems of Diagnostics and Surveillance

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2.8 Priority Areas for Support

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3 Conclusions

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4 Future Outlook

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5 Annex A: Species-specific key priorities

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6 About the Sponsors

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The views and opinions expressed in this publication are solely those of the workshop attendees. They do not purport to reflect the opinions or views of the International Development Research Centre (IDRC), the Canadian Government, the UK Department of Health and Social Care (UK DHSC), the UK Government or Wilton Park.

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Message from Nick Adkin, Deputy Director - Global Health Security at the UK Department of Health and Social Care (UK DHSC) and Santiago Alba-Corral, Interim Director - Agriculture and Environment at the International Development Research Centre (IDRC) This workshop, jointly hosted by UK DHSC and IDRC at Wilton Park in the UK, was born out of the very real need to gather evidence on the global threat of antimicrobial resistance (AMR). We wanted to do this in a way that would not only inform future research agendas, but also facilitate understanding of how to build successful partnerships to better coordinate global research, development and funding calls.

Nick Adkin

The insights and lessons gained by convening 63 experts from the global North and South – experts from across academia, industry and the public and private sectors, with a particular focus on emerging and developing economies – are already being applied.

Lessons have directly informed the technical scope of the recently launched CAD$ 27.9M program, Innovative Veterinary Solutions for Antimicrobial Resistance (InnoVet-AMR), an exciting new partnership between our two organizations.

We are excited to see how the opportunities and support for synthesis, synergy and collaboration that are hard-wired into this initiative play out in developing innovative solutions to reduce the risk that AMR in food-animal production systems poses to global health and food security.

Santiago Alba-Corral

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Executive Summary Antimicrobial resistance (AMR) is recognised as a global threat which disproportionately affects people in low and middle-income countries (LMIC’s). If not addressed, AMR will impede progress towards achieving the Sustainable Development Goals related to improving health outcomes, food security, economic growth and environmental health.

Research and development of innovative solutions to reduce the non-prudent use of antimicrobials in food-producing animals as well as improving global collaboration transcending disciplines and sectors have been identified as important areas of action in tackling the complex challenge of AMR. In response to the growing concern of AMR, the Global Antimicrobial Resistance Innovation Fund (GAMRIF) in the UK Department of Health and Social Care (UK DHSC) and Canada’s International Development Research Centre (IDRC) held a 2-day workshop on alternative solutions to reduce the use of antimicrobials in food-producing animals in LMICs. The workshop, held at Wilton Park on 11-13 April 2018, brought together 63 experts from 22 countries and 28 nationalities across the world from the public and private sector. The objectives were to (1) identify research gaps on AMR in food-producing animals in LMICs to inform future research calls, (2) understand AMR research capacities in animal health globally and in LMICs and what constitutes successful partnerships and (3) generate awareness and information to direct future research in animal health.

Discussions around context-specific innovation in vaccines and alternatives to antimicrobials highlighted the importance of context when considering the applicability, cost-effectiveness and sustainability of interventions to reduce

antimicrobial use. The focus of interventions should be on reducing the non-prudent antimicrobial use, rather than general use, as antimicrobials play an important role in reducing the burden of disease and access to them remains an issue in LMIC’s.

Improved education and training were considered crucial for the successful implementation of improved disease control strategies for food-producing animals in LMICs. There is a need for effective programs encompassing, amongst others, husbandry practices, production systems, vaccination awareness, disease treatment decision-making and prudent antimicrobial use. Mobile technology was identified as an ideal conduit in this regard.

The power of the social sciences (and beyond) were identified as vital in ensuring that contextspecific interventions, developed for local realities, are applicable, adopted and effective.

Furthermore, the social sciences should be included in every step of approaches to tackle disease in order to understand the key drivers of adoption, including factors of success and failure of past interventions, to better inform future efforts. Beyond the social sciences, an integrated and multidisciplinary approach using a One Health lens was considered important in investigating the impact of AMR in foodproducing animals in LMICs. Addressing the challenge of AMR in livestock and aquaculture is a complex and global issue and as such, global collaboration in the form of both partnerships and collaboration across borders and disciplines is required. While the importance of North-South partnerships was recognised, participants expressed the need for regionally-led partnerships in the Global South to generate locally-driven solutions. Partnerships that are

Innovations to reduce the use of antimicrobials in food-producing animals in LMICs | Page 4

multidisciplinary, adopt a comprehensive approach and are informed by consultation with local stakeholders were highlighted as an ideal model.

The impact of gender in farming and the role of gender in AMR reductions strategies, was highlighted as both an important, but overlooked consideration. To improve the outcome of interventions aimed at reducing non-prudent antimicrobial use, there is a need to better understand the role of different genders in the animal husbandry process. The evidence suggests women often hold the knowledge of animal and family health and prioritise spending on this, as well as being responsible for animal sanitation and feeding. As such, targeting female farmers in LMICs is key, as they are often the best advocates for change in practices.

While recognizing that medicine access is limited in certain contexts, antibiotics are often readily available without prescription, professional advice and at a low cost, indicating the need for improved frameworks for stewardship and regulation. Within this broad theme, participants highlighted three important areas. (1) The need for political support and buy in that would result in locally-relevant, long-term strategies with guaranteed financial support, (2). the need for harmonisation of the drug registration and licensing process across countries to facilitate more agile and rapid deployment of interventions such as vaccines and alternatives and (3) lack of regulation has led to the fact that, in some LMICs, at least 60% of medications are substandard or falsified (SF) and there are few effective mechanisms for the consumer to differentiate between authentic and SF medicines.

Understanding the contribution of SF medicines in AMR requires further research.

There was clear consensus among participants on the need for more evidence to help inform research priorities, interventions and policy.

Systems of diagnostics and surveillance that

generate standardised, reliable, in-depth and local baseline data on both antimicrobial use (AMU) and AMR in different production systems is required. In addition, specific disease diagnosis is a challenge and to enable a more targeted disease management pathway, low-cost pen-side or farm-level diagnostics are required.

Following two days of intensive discussion each participant was asked to prioritize, from their point of view, the most critical area for support to reduce non-prudent use of antimicrobials in foodproducing animals in LMICs. (1) New/improved vaccines and delivery systems, (2) the need for a comprehensive disease prevention and management and (3) novel therapeutic and prophylactic products as well as the need for local data and surveillance were highly prioritized.

Building on the key messages of collective action, multi-faceted approaches, sustainable interventions and partnerships, the UK DHSC (through GAMRIF) and IDRC announced a fouryear, CA $27.9 million partnership (16.4 million GBP) to fund research on Innovative Veterinary Solutions for Antimicrobial Resistance (InnoVetAMR). This program will draw on the strengths of both organizations to focus on developing new and/or improved vaccines and delivery systems and novel therapeutic and prophylactic alternative products to reduce the non-prudent use of antimicrobials in LMIC poultry, swine and aquaculture systems. A Call for Proposals was launched on June 25, 2018 with a portfolio of projects set to commence in 2019.

This partnership is one of many possible outcomes from the findings of this workshop.

Stakeholders and funding organizations should feel encouraged and empowered to pursue complementary partnerships in other key areas, such as surveillance and diagnostics, farming best practices, farmer education and training and innovation uptake. It is only with a robust and comprehensive body of work that the threat that

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AMR poses to human, animal and environmental health can be substantially addressed.

1 Introduction

In 2016, the UN General Assembly recognized antimicrobial resistance (AMR) as a global threat which disproportionately impacts people in lowand middle-income countries (LMICs). According to the World Health Organization (WHO), if AMR is not addressed, the world will be at risk of not achieving many of the Sustainable Development Goals, particularly those focused on improving health outcomes, food security, economic growth

and reducing environmental degradation. The international community was called upon to rise to the complex challenge of AMR and take urgent action. This action included further research and development of innovative solutions to reduce the non-prudent therapeutic use and prevent the non-therapeutic use of antimicrobials in foodproducing animals, as well as to improve global collaboration transcending disciplines and sectors.

Š Brian Sokol

â—„ "Mama" Gestelina Hambo, 44,

and her husband Juma Hambo, 45, work together to milk one of their dairy goats in Kunke Village, Morogoro Region of Tanzania.

Countries where legislation, regulatory surveillance and monitoring systems on the use of antimicrobials and the prevention and control of AMR, are weak or inadequate are 1

disproportionately impacted by the increase of infectious disease outbreaks and loss in livestock productivity1. Livestock provide food and income for roughly 1.4 billion farmers globally, including

FAO (Food and Agriculture Organization of the United Nations). The FAO action plan on antimicrobial resistance 2016 – 2020.

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800 million poor livestock keepers. As the global demand for protein increases, many emerging economies are intensifying their livestock and aquaculture productions. Antimicrobials play a critical role in the welfare and treatment of diseases in humans and animals. However, in animal production, antimicrobials are used both therapeutically (to treat and prevent disease) and non-therapeutically (to promote growth). With the global consumption of antimicrobials for foodproducing animals on the rise, coupled with the threat of transmission of AMR from animals to humans, it is critical that antimicrobials are used appropriately and only when needed.

To protect human and animal health and welfare, as well as ensuring food safety, the responsible and prudent use of antimicrobials will ensure that current (and future) antimicrobials are preserved and remain effective. Recently, an updated version of the WHO list2 of clinically important antimicrobials was published, as a step towards improving the management of antimicrobial use in food-producing animals and to further reduce the use of antimicrobials that are critical for human health. In parallel to this effort, it is essential to further develop alternative strategies which can reduce the dependence on antimicrobial use and help tackle the rise of AMR3.

In 2015, on the request of several countries and organizations, the World Organisation for Animal Health (OIE) assembled an ad hoc group to prioritise diseases and pathogens for which vaccines could significantly reduce antimicrobial use in swine, poultry and aquaculture animals4.

Furthermore, in 2017, the Pew Charitable Trusts published a comprehensive overview of different approaches to alternatives to antibiotics in animal agriculture, which can help reduce the

inappropriate use of antimicrobials and enable infection prevention via other means5.

1.1 The Workshop In response to the call to action by the UN General Assembly and building on recent publications, the Global Antimicrobial Resistance Innovation Fund (GAMRIF) in the UK Department of Health and Social Care (UK DHSC) and Canada’s International Development Research Centre (IDRC) organized a two-day workshop on alternative solutions to reduce the use of antimicrobials in food-producing animals in LMICs. Through the LMIC lens, the program focused on critical topics related to the reduction of the non-prudent use of therapeutic antimicrobials and prevention of the nontherapeutic use of antimicrobials. The workshop was organized in collaboration with Wilton Park on 11-13 April 2018, with the following objectives: ►

►

►

Gathering evidence to identify the research gaps on AMR in food-producing animals in LMICs, which could inform the scope of potential future research calls; Collecting evidence on AMR research capacities globally and in LMICs and understanding what constitutes successful partnerships; Raising awareness and providing information for the sector to help direct future research.

This workshop brought together 63 experts from 22 countries and 28 nationalities across the global South and North from academia, industry and other key stakeholders across the public and private sector. With the focus on emerging and developing economies, the participants identified

WHO. Critically important antimicrobials for human medicine, 6th revision, 2018.

Tackling Drug-resistant Infections Globally: Final Recommendations. The Review on Antimicrobial Resistance, Jim O’Neill, May 2016.

4 OIE (World Organisation for Animal Health). Report of the meeting of the OIE ad hoc group on prioritisation of diseases for which vaccines could reduce antimicrobial use in animals. Paris, April 2015.

5 The Pew Charitable Trusts. Alternatives to Antibiotics in Animal Agriculture. Washington, D.C., July 2017.

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and prioritised key issues and innovative solutions to reduce the non-prudent use of antimicrobials in livestock production and aquaculture. The workshop additionally sought to understand how to build effective and successful partnerships to better coordinate global research, development and future funding calls.

The United Kingdom’s Chief Medical Officer, Prof.

Dame Sally Davies and the President of IDRC, Dr.

Jean Lebel, jointly opened the workshop by launching the Innovative Veterinary Solutions for AMR (InnoVet-AMR) program– a new partnership between GAMRIF and IDRC to fund research for the development of vaccines and alternatives to antibiotics to reduce the non-prudent use of antimicrobials in livestock and aquaculture operations in LMICs. The findings of this workshop were used to further develop the scope of the partnership.

◄ A technician nets a Nile tilapia (Oreochromis niloticus) at an aquaculture facility

©FAO | Valerio Crespi

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2 Summary of Discussions

This section provides a synthesis of the key points that were raised and discussed over the two days.

While many transversal themes emerged, seven overarching

priority

themes

were

identified

covering innovation, education, social sciences, collaboration, gender, regulation and surveillance, which are presented in further detail below. To understand how the situation differed among species, participants further identified speciesspecific needs and/or challenges covering swine, poultry, aquaculture and ruminants which are captured in Annex A. Finally, at the end of the workshop, participants prioritised key areas for support which will reduce the non-prudent use of

With many farm systems in LMICs rapidly growing from small-holder farms to medium- and largescale intensive operations, ensuring the sustainability of specific interventions is a challenge. To further ensure sustainability, interventions should also be accompanied by complementary best farming practices, diagnostics and surveillance. While new and improved interventions are needed, the participants fully recognised that access to antibiotics (smallholders, in particular) in LMICs remains an issue for farmers. It is crucial that this dichotomy is considered when developing and implementing interventions for LMICs.

antimicrobials in food-producing animals in LMICs (Figure 1).

2.1.1 Vaccines

2.1 Context-specific Innovation in Vaccines and Alternatives to Antimicrobials New vaccines and administration systems, as well as novel therapeutics and prophylactics, are needed to reduce the non-prudent use of antimicrobials in farming systems in LMICs. Participants stressed that products must be context-specific to ensure applicability in LMICs, which should be factored in early in the development process. Equally, local frameworks that evaluate the cost-effectiveness of proven interventions in specific regions, are required.

While certain interventions may work in one region, unless trialled on the ground and adjusted accordingly to the local needs and realities, they are unlikely to be as effective in other regions.

Vaccines have significant potential to reduce antimicrobial use in animals. Improvements to address the need of LMICs farmers include thermostability; addressing local disease strains; production of maternal antibodies; and developing appropriate and simple administration mechanisms for specific contexts. For example, oral vaccines are preferable over injected vaccines in livestock due to ease of administration. In particular multivalent vaccines that increase the efficiency and reduce the cost for the farmer are needed. The ease of use and safety of administration of new and improved vaccines are other key characteristics which must be considered at the outset of development. Lastly, successful development and use of these products also requires improved vaccine uptake, coupled with solutions to current market challenges which sees few incentives for private sector investment and limited public funding.

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Š IDRC | Bartay

challenges faced with vaccine development, the development of alternatives to antimicrobials must likewise be context-specific. Key characteristics of these interventions, such as applicability, ease of use and administration, should be considered early in the development.

There is a clear need to further understand the effectiveness of these alternative approaches as part of a comprehensive strategy to reduce the non-prudent use of antimicrobials. Probiotics, as replacement for growth promoters, was highlighted as an example owing to the important role they could play in LMICs. However, further research is required to understand the mechanisms of antimicrobials as growth promoters to enable the development of better alternatives. Moreover, there is a need for improved understanding of the incentives (or lack thereof) not to use antimicrobials as growth promoters, with the added knowledge of methods that maintain or boost animal productivity. For the effective development and deployment of alternatives to antimicrobials, the participants emphasized that the regulatory and commercialization processes must be better defined and fit for purpose.

2.2 Improved Education and Training

â–˛ A vaccine for Contagious Bovine Pleuropneumonia, Contavax, must be kept frozen, a problem in many areas due to the lack of refrigeration.

2.1.2 Alternatives to antimicrobials Innovative alternatives to antimicrobials were considered part of a larger solution to tackling AMR in livestock and aquaculture. Similar to the

Successful implementation of improved disease control strategies for food producing animals in LMICs, including the appropriate use of existing antimicrobials, effective vaccines or alternatives to antimicrobials, has been limited to date. There is a need to develop more effective programs which encompass delivering education and training of the importance of disease control strategies to farmers, para-professionals and veterinarians at the local level in LMICs. Providing examples that reduced antimicrobial use will not have a negative impact, will ensure buy-in from stakeholders and build trust in new supply chains and advisory networks.

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Programs that focus on improving general biosecurity, cleanliness and husbandry practices could have a drastic impact on reducing the transmission and emergence of AMR, animal welfare, productivity and profitability of farm enterprises in LMICs. Production systems designed to promote healthy animals, by considering housing, flow of animals and feeding for example, will facilitate reduced non-prudent therapeutic use of antimicrobials due to lower disease incidence. This would additionally enable developing, deploying and demonstrating the use of vaccines and alternatives to antimicrobials where they are most needed. Further educating farmers in LMICs on the relationship between vaccines and disease prevention – why vaccines are effective and how they differ from conventional drugs – is needed to overcome false impressions that vaccines are only used once disease is present. This impression can be created

as a result of the response of the international community in way of vaccine deployment during epidemics.

Treatment decision by farmers in LMICs are often made based on the advice of pharmaceutical salespeople, due to limited access of knowledgeable local advisors. To tackle AMR, and the wider disease burden, there is a strong need for unbiased advice. New methods for awarenessraising and education of farmers on the prudent use of antimicrobials, as well as reporting of their use, are required. For example, mobile technologies make an ideal conduit as they provide an easy means to increase the distribution and penetration of veterinary advice. Especially throughout Africa, the mobile phone revolution has leapt the implementation of traditional “landline” technologies and are used for many aspects of everyday life and business.

◄

WIlliam Muchai, a shop assistant at the Tinganga Farm Shop has taken additional training and is certified to provide clinical services (Nyandarua, Kenya)

© IDRC | Bartay

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2.3 The Power of Social Sciences and Beyond Social sciences have a vital role in tackling AMR in food-producing animals in LMICs (and beyond). In particular, by ensuring that context-specific interventions developed for local realities, are applicable, adopted and effective. They aid understanding of the cultural and behavioural norms that explain, for example, why some solutions are favoured over others or how consumer influence could affect production systems to reduce the use of antimicrobials or to reduce AMR. As such, participants emphasised the importance of considering social science at every step in every approach to tackle diseases. As mentioned previously, successfully implementing disease control interventions for food producing animals in LMICs, has been limited to date. There is an urgent need to further understand the key drivers of adoption, including factors of success and failure of past interventions, to better inform future efforts. Additionally, innovative new approaches that encourage uptake of interventions including biosecurity measures, farming practices and vaccine and other treatment delivery, are also required. Participants suggested that a systematic review, or meta-analysis, should be undertaken of previously performed research on the social and economic factors involved in the uptake and adoption of vaccines, treatments and farming practices. If made accessible and available to all stakeholders, this review could be used to guide future developments.

Beyond the social sciences, an integrated and multidisciplinary approach using a One Health lens was considered important in investigating the impact of AMR in food-producing animals in LMICs. This lens will aid in conceptualizing the economic cost of implementing and using

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interventions, when balanced against the benefits to the animals, consumers and the society.

2.4 Partnerships and Collaboration across Borders and Disciplines Global collaboration and cooperation through partnerships is important – no one group can tackle the challenge of AMR in livestock and aquaculture alone. To ensure the sustainability and continued efficacy of interventions, a One Health approach should be adopted. While the importance of North-South partnerships was recognised, participants expressed a need for regionally-led partnerships in the Global South to generate locally-driven solutions that will be more effective in tackling AMR in food-producing animals. The participants specifically highlighted the need for multidisciplinary Smart Partnerships6.

Taking a comprehensive approach to livestock production, these partnerships utilize both local and global knowledge and expertise, from all disciplines and partners in the supply chain, to address the issue at hand in a logical manner. For the creation of effective disease control strategies which facilitate the prudent use of antimicrobials, key input from local stakeholders (farmers in particular) who understand the reality on the ground should be central in informing these partnerships. Likewise, to encourage working across disciplines, funders should partner with stakeholders to add complementary expertise to maximize the impact of the funded research and interventions.

Participants identified that the AMR community struggles with effective information-sharing and knowledge-exchange at a global level, specifically with respect to key documentation (such as

The concept of Smart Partnerships was used by the Southern African Centre for Infectious Disease Surveillance and is defined as: “partnerships with institutions that can provide specific input and expertise to the program.�

published priority pathogen lists7 by multilateral organisations such as OIE and WHO), studies and reports. A concerted effort to share this knowledge with the wider AMR community in a standardised manner is essential to increase opportunities for collaboration. In general, participants urged that priority lists are produced capturing the perspective of all stakeholders including the LMIC farmer. Furthermore, to complement existing reports such as the WHO list of clinically important antimicrobials8, country or region-specific lists of antimicrobials that should be prioritized for reduction in use in foodproducing animals, are needed.

of modern medicines while female farm-holders primarily have access to traditional medicine.

Participants noted that increasing commercialization and intensification of livestock production can shift the decision making from women to men. As such, targeting female farmers in LMICs is key, as they are often the best advocates for change in practices.

Š Jamesbox | Dreamstime.com

2.5 Impact of Gender in Farming The role of gender in AMR reduction strategies is a particularly important one, but largely overlooked. While research on gender roles in livestock production systems has been undertaken, the evidence is often ignored in veterinary science despite it being crucial for designing effective interventions and education programs.

To improve outcomes of interventions aimed at reducing the non-prudent use of antimicrobials, there is still a need for better understanding of the roles and responsibilities of men and women across different age groups; the motivations of these groups and how motivations affect best practices; who makes decisions about livestock management and whose opinion is valued.

Studies show that women often hold the knowledge of the animal (and family) health and prioritise spending on this. They generally are also responsible for sanitation and feeding of the animals. However, although location- and speciesdependent, male farm-holders typically make decisions about purchase, use and administrations

â–˛ Vietnamese woman farmers grade recently harvested shrimps before selling them to processing plants in Bac Lieu city.

WHO. Global priority list of antibiotic-resistant bacteria to guide research, discovery and development of new antibiotics.

OIE (World Organisation for Animal Health). Report of the meeting of the OIE ad hoc group on prioritisation of diseases for which vaccines could reduce antimicrobial use in animals. Paris, April 2015.

8 WHO. Critically important antimicrobials for human medicine, 6th revision, 2018.

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2.6 Improved Frameworks for Stewardship and Regulation While recognizing the issue of limited access of medicines in LMICs, in many places antimicrobials are nevertheless cheap to buy and easy to obtain without a prescription and professional advice on appropriate use. There is a clear need to strengthen the approval and regulation of veterinary medicines, including antimicrobials, in LMICs. Likewise, the enforcement of new and existing policies on the prudent use of antimicrobials, as well as improving practice through antimicrobial stewardship, is essential to tackle AMR in livestock and aquaculture.

2.6.1 Political support and buy-in The participants agreed that a better understanding of the underlying reasons for the weak regulatory infrastructure and enforcement of polices in LMICs is imperative. Critical to any success in changing the regulatory environment to tackle AMR is sustained political support and buy-in, which is heavily linked to awareness of the issues at hand. Added complexities of political instability in many LMICs is most effectively mitigated by long-term strategies and commitments to tackle AMR in livestock and aquaculture, supported by a guaranteed flow of regular funds for delivery. However, to succeed, strategies and methods need to be local solutions based on local realities, with an understanding of who makes the law; who is responsible for enforcing it; and whether they have sufficient capacities to do so. With many LMICs facing challenges around resource capacity, there is a need for a collaborative effort by all stakeholders to develop these strategies, as well as to ensure accountability of implementation and enforcement. Moreover, while it is important to establish new policies and regulations, as well as enforcement methods, leveraging the existing 9

policy and regulatory infrastructure is central. To further understand the landscape, participants identified that a mapping exercises of existing policies and regulations in different regulatory environments would provide an in-depth understanding of how these can be effectively integrated and utilised.

2.6.2 Harmonisation The participants identified the need for harmonisation of the drug registration and licensing processes across countries. Implemented where possible, harmonisation schemes would enable interventions, such as vaccines and alternative products, to reach the market faster and allow for a more agile dissemination of new solutions and greatly benefit farmers, manufacturers and governments. A similar approach has been adopted by the Pan African Veterinary Vaccine Centre (PANVAC), which is an African Union agency established in 2004 in Ethiopia.9 PANVAC provides independent quality control of vaccines produced in or bought into Africa to meet international standards. Through streamlining processes, registration of new drugs in African Union countries through PANVAC offers a faster and cheaper way as only registrations fees are paid in each country, rather than the cost of the preparation of a full dossier.

2.6.3 Substandard and falsified medicines Lack of regulation has led to situations where, in some LMICs, at least 60% of medications are substandard or falsified (SF), including antimicrobials, vaccines and alternative products.

There are few effective mechanisms for the consumer to differentiate between authentic and SF medicines. Further exacerbating this issue is the lack of effective surveillance to monitor the use of

https://aupanvac.org

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medicines and their effectiveness. The main concerns that result in no efficacy, relates to the lack of active pharmaceutical ingredient, presence of poor quality ingredients and limited quality control measures. However, where efficacy is observed in SF medicines, further research is required to understand how they contribute to AMR.

2.7 Systems of Diagnostics and Surveillance 2.7.1 Baseline data A clear consensus among participants was the need for more evidence to help inform research priorities, interventions and policy. However, to underpin this evidence, standardised, reliable, indepth and local data on both antimicrobial use (AMU) and resistance in different production systems is required. Improving the AMR and AMU surveillance to measure the baseline of the situation in LMICs will enable progress, outcomes and impact of interventions to be measured appropriately. To achieve this, a coherent and consistent approach to gathering and comparing data across all countries is needed. Currently, most recorded AMU data is based on sales data.

There is an urgent need to record and report data on the actual use of antimicrobials in LMICs, however doing so faces barriers such as lack of regulatory framework and enforcement as well as minimal coordination between stakeholders alongside limited tools and human resources. It is important to support this data gathering with further understanding of the rationale behind use of antimicrobials by farmers, which again emphasises the importance of integrating social sciences.

Participants noted that most sick animals, as a first-line approach, will receive antimicrobials for non-specific disease control in doses that may be sub-therapeutic. To enable a more targeted treatment or disease management pathway, development and implementation of low-cost pen-side or farm-level diagnostics, coupled with advice networks to ensure the prudent use of antimicrobial, is required. Specifically, syndromic surveillance and serotype-specific diagnostics, tailored to region-specific disease profiles, is essential. However, cost is often a barrier to specific disease diagnosis, as many farmers in LMICs are unable to afford these tests. There was an emphasis on the inclusion of training at multiple user levels to demonstrate the rationale of using companion diagnostics, as well as how to interpret the results into actionable changes in animal care where required. A greater focus on integrating new communications technology, such as cloud-based solutions using mobile phones, in the diagnosis of disease is essential. Ensuring robust connectivity can improve education and advice for farmers, as well as facilitate improved AMU and AMR monitoring and reporting in LMICs.

2.8 Priority Areas for Support Following two days of intensive discussion on reducing antimicrobial use in food-producing animals in LMICs, each participant was asked to prioritize – from their point of view – the most critical area for support to overcome this challenge (Figure 1). Both new/improved vaccines and delivery systems as well as the need for a holistic disease prevention and management were highly prioritized, followed by novel therapeutic and prophylactic products as well as the need for

2.7.2 Diagnostics As the burden of infectious disease in LMICs is high, specific disease diagnosis is a challenge.

local data and surveillance.

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Figure 1. Priority areas identified for support to reduce antimicrobial use in food-producing animals in LMICs (Produced by the Knowledge Transfer Network)

3 Conclusions

This workshop provided a valuable forum for experts from the global South and North to come together to discuss, understand and challenge the gaps, issues and opportunities of reducing the use of antimicrobials in food-producing animals in LMICs. The whole community must recognise that the challenge of reducing antimicrobial use in foodproducing animals in LMICs is a shared problem requiring a joint effort bringing together all relevant stakeholders. Recognising the importance antimicrobials play for animal health and welfare, reducing the non-prudent therapeutic use and preventing the non-therapeutic use will require a multi-pronged approach. The benefit of new technical innovations, such as vaccines, alternatives to antimicrobials and farm-side diagnostic test, is clear. However, well-thought out training and education, changes to biosecurity management, husbandry and cleanliness should play an important role alongside these innovations, providing a comprehensive approach to disease management and livestock production strategies. To ensure uptake and adoption of sustainable interventions and strategies as well as ensuring that these are context-specific and applicable to the local realties faced by livestock producers in LMICs, it is critical to recognise the importance of social sciences and gender roles.

Without integrating these cross-cutting themes, the risk of wasted effort on developing interventions is high.

To achieve this, research must be put into action.

While developing new vaccines, alternatives to antimicrobials and diagnostics is key, increased understanding of the effect of these interventions on the reduction of antimicrobial use in foodproducing animals in LMICs and their implementation is critical. Likewise, ensuring the existence of an appropriate regulatory environment; enforcement of important policies; and long-term strategies supported by political buy-in will be necessary to implement new (and existing) interventions to reduce the non-prudent use of antimicrobials. Ultimately, to solve the problem, we must understand the problem. With existing gaps in baseline data on AMR and AMU, the real problem at hand remains unknown.

Standardisation, harmonisation and cooperation is required to effectively gather this vital data, to ensure interventions, regulation and policies deliver the desired outcomes. Finally, partnerships and collaboration, transcending borders and disciplines, will be essential for success. It is only with a robust and comprehensive body of work that the threat that AMR poses to human, animal and environmental health can be substantially addressed.

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4 Future Outlook

Building on the key messages of collective action, multi-faceted approaches, sustainable interventions and partnerships, the UK DHSC (through the Global AMR Innovation Fund) and IDRC announced a four-year, CA $27.9 million partnership to fund research on Innovative Veterinary Solutions for Antimicrobial Resistance (InnoVet-AMR). This program of work drew on the strengths of both organizations to focus on developing new and/or improved vaccines and delivery systems and novel therapeutic and prophylactic alternative products to reduce the non-prudent use of antimicrobials in LMIC poultry, swine and aquaculture systems. A Call for Proposals was launched on June 25, 2018 and

While this partnership represents an important investment in reducing AMR by providing innovative alternative solutions to antimicrobials, this is only one response to the complex and integrated research landscape that was revealed in this workshop. Stakeholders and funding organizations should feel encouraged and empowered to pursue complementary partnerships in other key areas, such as surveillance and diagnostics, farming best practices, farmer education and training and innovation uptake. It is only with a robust and comprehensive body of work that the world truly stands a chance at reducing the threat that AMR poses to human, animal and environmental health.

closed September 12, 2018, with a portfolio of projects set to commence in spring 2019.

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5 Annex A: Species-specific key priorities

During the workshop, participants convened in breakout groups to discuss challenges and opportunities for reducing antimicrobial use in poultry, swine, aquaculture and ruminants. Many transversal themes across all species (Section 2) were discussed, with species-specific messages captured in the table below.

Species

Key species-specific messages

Poultry

►

Lack of understanding about the source and spread of AMR pathogens in poultry.

►

Being a more intensive, low margin sector, poultry farmers in LMICs want to see immediate impacts of interventions, which has limited the understanding of the long-term effects or spread of disease.

►

How will producers move from backyard- to commercial enterprises without the use of antimicrobials?

►

Need for training local poultry supply chain stakeholders in poultry disease management.

►

Optimization of feeding regimes to reflect conditions on the ground.

►

Investigate the development of temporary and portable local manufacturing facilities for antimicrobials, vaccines and alternatives, to allow interventions to be used where they are needed.

►

Potential to move towards the acceleration of cell-based vaccine production, as opposed to a reliance on in-ovo production of vaccines.

Swine

►

Swine production systems are often intensive and designed around the use of antimicrobials leading to non-prudent use.

►

Distinct stages of swine production add to the complexity of the problem – requirements for each stage are different and improved training for farmers and vets on stage-specific challenges is required.

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Species

Key species-specific messages

Aquaculture

►

Contamination and exposure concentration of antimicrobials is a big issue in localized areas or water systems, since animals and humans are utilizing and dependent on the same system.

►

Pharmaceutical residues and other pesticides are an added risk in aquaculture systems, due to risk of direct environmental contamination and with little opportunity to contain the risk.

►

Aquaculture is often a subsistence farming practice in LMICs; AMR is not necessarily a priority issue when ensuring that productivity and survival of the system is more important.

►

Educating farmers of the importance of water quality is important.

►

The applicability of oral vaccines in aquaculture needs to be further understood.

►

There is a need to roll out enhanced training for vets and para-vets on various aquaculture species farmed in LMICs due to an existing knowledge gap.

Ruminants

►

Priority diseases, for which new vaccines and alternatives to antimicrobials are needed,

are

contagious

bovine

pleuropneumonia,

contagious

caprine

pleuropneumonia, East Coast fever and foot-and-mouth disease. ►

Improved epidemiology/ surveillance of bacterial diseases in LMICs at a local level is needed.

►

New genetic editing techniques (e.g. CRISPR) have potential producing diseaseresistant cattle and should be considered in parallel with new vaccines and alternatives to antimicrobials.

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6 About the Sponsors

International Development Research Centre The International Development Research Centre (IDRC), a Canadian Crown corporation, funds research in developing countries to create lasting change on a large scale. Canada’s IDRC supports research that generates local solutions, bringing choice and change to those who need it most in the developing world.

We achieve this by investing in knowledge and innovation, supporting the leaders of the future and by being a partner of choice for the public and private sectors.

UK Department of Health and Social Care The Department for Health and Social Care (DHSC) is the UK Government department which is responsible for helping people to live more independent, healthier lives for longer. The partnership with IDRC is part of DHSC’s Global Antimicrobial Resistance Innovation Fund (GAMRIF). GAMRIF was established to support early-stage, innovative research and development, specifically targeting neglected and underinvested areas in the field of antimicrobial resistance (AMR).

GAMRIF is a £50m Official Development Assistance

investment, which means all projects funded must support research primarily and directly for the benefit of people living in developing countries. The Fund takes a ‘One Health’ approach, seeking to invest in potential solutions to reduce the threat of AMR in humans, animals, fish and the environment.

Wilton Park Wilton Park, established in 1946, convenes around 65 higher level international policy events a year. Wilton Park has a long track record of developing and organizing discussions on themes recommended by partners and is a front-line resource for the UK Foreign and Commonwealth Office and key international partners. It supports strategic foreign policy priorities by engaging key communities of experts in dialogue which addresses and resolves issues of critical importance to global security, prosperity and justice. Wilton Park uses the trust and the global convening power that it has acquired through decades of engagement in various dimensions of foreign affairs.

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Acknowledgements IDRC and DHSC as well as the Wilton Park would like to thank and acknowledge the contribution of the Knowledge Transfer Network (KTN) in the facilitation of the workshop and the analysis of the collected information.

IDRC and DHSC as well as the Wilton Park give a special thank you to all the researchers/participants who participated in the workshop and who provided the valuable ideas that are synthesised in this report.

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