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A Critical Missing Link in National Action Plans on Antimicrobial Resistance Graziella Iossaa & Piran CL Whiteb

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A Critical Missing Link in National Action Plans on Antimicrobial Resistance Graziella Iossaa & Piran CL Whiteb PerspectivesPerspectives The natural environment: a critical missing link in national action plans on antimicrobial resistance Graziella Iossaa & Piran CL Whiteb Antimicrobial resistance, that is, the environment in contributing to antimi- antimicrobial use in livestock and the ability of a microorganism to stop an crobial resistance, we call for greater in- selection of resistance in humans is antimicrobial from working against it, is tegration of the natural environment in difficult to establish, there is evidence one of the most important global health existing and new national action plans, of an association.8 Resistant bacteria challenges. Antimicrobial resistance is so that we can maximize our chances of of animal origin can be transmitted to projected to become the leading cause of finding holistic and sustainable solutions humans directly via food or indirectly death worldwide, claiming an estimated to this global health threat. via the natural environment. More- 10 million lives a year by 2050, primarily over, wastewater treatment plants, ma- in low- and middle-income countries.1 Resistance in the nure from farm animals and spill-over In 2015, the World Health Assembly ad- from the pharmaceutical production opted a global action plan on antimicro- environment industry contribute to an environmen- bial resistance underpinned by the One tal reservoir of resistance.7 The natural Antimicrobial resistance develops Health approach.2 One Health seeks to environment should therefore be a key in, and is maintained and transmit- improve health and well-being through consideration in understanding and ted across humans, animals and the the integrated management of disease developing strategies to control anti- natural environment. Resistance is risks at the interface between humans, microbial resistance, as acknowledged an ancient and naturally occurring animals and the natural environment. through the One Health approach.9 phenomenon, but anthropogenic an- Efforts are based on closer collabora- tibiotic use since the 1930s has been tion among individual disciplines and National action plans linked to the increasing occurrence a cross-sectoral approach to research, of antimicrobial-resistant micro- One of the key guiding principles surveillance and response.3 The natural organisms, particularly bacteria.5,6 of the national plans is to use a One or biophysical environment here in- The natural environment presents a Health approach and multisectoral cludes all living (biotic) and non-living transmission route and a reservoir for coordination. This principle gives the (abiotic) factors affecting the survival of resistant microorganisms and plays a various collaborating organizations all organisms, including humans, at the significant role in the development of, equal status and emphasizes a sense individual, population, community or and response to, antimicrobial resis- of ownership of the plan.4 As of May ecosystem level. In this context, an eco- tance.7 Antimicrobial use in the live- 2018, 56 Member States (29.0%) out system refers to a community of plants, stock industry is driving the selection of 194 have published national action animals and microorganisms that live, of resistant bacteria in farm animals, plans, of which 21 have been published feed, reproduce and interact within the and while the causal link between since 2015. same area or environment. Antimicro- bial resistance connects human health to the health of ecosystems and the natural Box 1. The national action plans on antimicrobial resistance considered in our analysis, environment. With the global action by WHO Region plan on antimicrobial resistance, Mem- African Region ber States agreed to develop individual United Republic of Tanzania (2017) national action plans on antimicrobial resistance by May 2017.2,4 Here we pres- Region of Americas ent an analysis of the extent to which the Barbados (2017) and Canada (2017) national action plans developed after Eastern Mediterranean Region 2015 have been successful in integrating Oman (2017) the natural environment within a One European Region Health approach. We found that the Denmark (2017) and Sweden (2016) action plans feature human and animal South-East Asia Region health prominently, but that most do Bangladesh (2017), India (2017), Indonesia (2017), Maldives (2017), Nepal (2016), Sri Lanka not specifically incorporate the natural (2017), Thailand (2016) and Timor-Leste (2017) environment, and hence fall short of Western Pacific Region achieving a genuine One Health ap- China (2016), Japan (2016), Mongolia (2017) and New Zealand (2017) proach. Given the key role of the natural a School of Life Sciences, Joseph Banks Laboratories, University of Lincoln, Lincoln LN6 7TS, England. b Department of Environment and Geography, University of York, York, England. Correspondence to Graziella Iossa (email: [email protected]). (Submitted: 21 February 2018 – Revised version received: 13 June 2018 – Accepted: 2 July 2018 – Published online: 10 October 2018 ) 858 Bull World Health Organ 2018;96:858–860 | doi: http://dx.doi.org/10.2471/BLT.18.210898 Perspectives Graziella Iossa & Piran CL White National action plans on antimicrobial resistance We analysed the 18 national action plans published in English between Fig. 1. Content analysis of national action plans on antimicrobial resistance published 2015 and October 2017 (Box 1) to de- after 2015 termine the extent to which the plans integrated the natural environment 30.0 within a One Health approach. We used e content analysis10 by constructing a set 25.0 of categories: (i) One Health (inclusion of the term itself, related terms or no ref- 20.0 erence); (ii) human-animal-agriculture y of occurrenc 15.0 (agriculture appeared to be used as synonymous for natural environment; 10.0 inclusion of these keywords was linked to One Health, but with no specific men- erage frequenc 5.0 tion of One Health, related terms or no Av reference); (iii) environment (inclusion 0.0 of the term itself, related terms or no ref- African Region Region of Eastern European South-East Western Pacific Americas Mediterranean Region Asia Region Region erence); and (iv) human-animal health Region (inclusion of the term itself, related One health Human-animal health Human-animal agriculture terms or no reference). The categories Environment Multisectoral also identified the broader context in which those terms were used: in the Note: Content analysis (average frequency of occurrence) of the search terms around One Health, introduction or problem definition of human-animal health, human-animal-agriculture, environment and multisectoral engagement for 18 antimicrobial resistance; in the plans’ national action plans on antimicrobial resistance published after 2015. strategic objectives; in the implementa- tion; and/or in the evaluation process. 14.1 in the text of the action plans. Although most plans have been As we were particularly interested in This was followed by human-animal- drafted by multisectoral coordination multisectoral approaches to tackling an- agriculture, which occurred an aver- teams who acknowledge that One Health timicrobial resistance, we also searched age of 5.1 times, and the environment, guides their approach, the predominance for evidence of the presence or absence which occurred an average of 2.6 times. of topics around human-animal health of such approaches in the national ac- No plans included the terms ecology, and the scarcity of topics around the nat- tion plans. ecologist or ecosystem. Ecosystem ural environment suggests that there are Ten out of 18 action plans followed was mentioned in five plans but the more representatives of human-animal the World Health Organization (WHO) context, for instance “clinical settings health in the coordination teams. The guidelines and identified five objectives represent an ecosystem of high antimi- reason for this could be twofold. First, in line with the global action plan on crobial usage” or “the entire ecosystem we have an increasing understanding of antimicrobial resistance: (i) improve of antimicrobial resistance,” suggests resistance mechanisms in human-animal awareness and understanding of anti- a non-ecological meaning. The term systems, alongside better developed microbial resistance through effective One Health occurred an average of 1.3 surveillance methods, and longer-term communication, education and train- times in the plans and multisectoral collaborations among key agencies, such ing; (ii) strengthen the knowledge and coordination occurred an average of as WHO, the Food and Agriculture Or- evidence base through surveillance and 3.0 times (Fig. 1). Across all plans, with ganization of the United Nations (FAO) research; (iii) reduce the incidence of regards to the context, a One Health and the World Organisation for Animal infection through effective sanitation, approach was occasionally referenced Health (OIE).7,9 Second, the recent his- hygiene and infection prevention mea- in the introductory section and in the tory of the One Health approach has sures; (iv) optimize the use of antimi- definition of antimicrobial resistance as stemmed from the need to confront crobial medicines in human and animal a challenge. Twelve of the 18 plans also emerging infectious diseases outbreaks. health; and (v) develop the economic mentioned a One Health approach in The development of the One Health case for sustainable investment that takes their strategic objectives. However, this approach has therefore so far has been account of the
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