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The new UK Five Year Antimicrobial Resistance Strategy is published today. Its cross-government approach reflects growing international interest in Antimicrobial Resistance as an economic as well as health concern.
The new UK Five Year Antimicrobial Resistance Strategy indicates the cross-government and cross-sector approach needed to address one of today's greatest public health issues: the increasing resistance of microorganisms - including bacteria and viruses - to the drugs that are used against them.
The strategy was originally expected to be published in early 2013, following a consultation on a draft version issued in October 2012. However, cross-government consensus takes time, and its later publication has provided an opportunity to address the points raised in the Chief Medical Officer's Annual Report, published in March 2013. The development of the strategy has been led by the Department of Health and the Department for Environment, Food and Rural Affairs (DEFRA), in collaboration with the devolved administrations, the Department for Business, Innovation and Skills (BIS), the Ministry of Defence and others. More than 130 organisations - including RUSI - contributed during the consultation process.
The Imperatives to Tackle AMR
AMR has long touched the edges of a number of defence and security issues including immigration policy and border screening, where the challenge is how to prevent the spread of drug-resistant tuberculosis, gonorrhoea and other diseases into and around the UK by leisure and business travellers returning home, as well as from those seeking immigration. AMR also affects the management of international aid to refugee camps (more than 90 per cent of the cases of dysentery in some camps can be resistant to the two most common frontline drugs) and the response to pandemic flu, which would become even more serious if the flu strain involved was drug-resistant.
In the UK, the Department of Health has considered how AMR affects existing National Risk Assessment emergency scenarios and has agreed to consider how it affects UK security interests more widely for the next National Security Risk Assessment (NSRA) in 2014. The NSRA is summarised in the UK's National Security Strategy and this, in turn, informs the classified National Risk Assessment and its public version, the National Risk Register.
The economic impact of AMR is being felt across the globe, ensuring that the efforts of those beyond the healthcare community will be engaged to address it. It was a major focus of the World Economic Forum Global Risks 2013 report published in February. In 2009, the European Centre for Disease Control (ECDC) estimated that AMR costs the EU approximately €1.5 billion in healthcare expenses and lost productivity each year, while the cost to the US is estimated to between $21 billion and $34 billion. Rightly or wrongly, such figures are grabbing political attention and driving international action, more so than the fact that 25,000 Europeans, just under 100,000 Americans and around 80,000 Chinese die each year as a direct consequence of a drug-resistant infections. At the time of the 11 September 2001 attacks on the World Trade Center in New York, in which just under 3000 people lost their lives, more than 6000 Americans died annually from MRSA caught in hospitals, yet the issue received little interest outside of specialist medical circles. It would be more than a decade before the 2011 World Health Day was dedicated to AMR and the topic began to push its way slowly up the political agenda.
Developing a Strategy that Transcends the Health Sector
One of the key challenges of the new UK strategy is to communicate the significance of AMR to all the government departments, pharmaceutical companies, hospitals, doctors, vets, patients, farmers, border officials and scientists whose combined efforts are needed to stop the increase in resistance seen over the last 50 years. If the economic impact helps to drive this message through, it is as valid an approach as any other, though efforts to reduce antibiotic use must not be discredited as NHS cost-cutting.
Developing a strategy that takes into account the opinions of all of the key stakeholders, which requires their buy-in and acceptance, their seal of approval and - most importantly - their ongoing support and willingness to implement it, was never going to be easy. In places, the published version seems less robust and less hard-hitting than the draft circulated at the end of last year, for example that version not only suggested that veterinary sales of antibiotics should be reduced but also set out by how much. The softer approach may, however, be the only way to achieve the consensus needed get the strategy out. A distinct advantage it now contains is the strong roadmap towards implementation, in particular with targets set for a High Level Steering Group, which will report regularly throughout the five-year life of the strategy.
This is particularly significant as the next few years will be a crucial period in which the world will win or lose the fight to retain the efficacy of antimicrobial drugs in general and antibiotics in particular. Some diseases, such as gonorrhoea, will become impossible to treat without them.
Since the introduction of penicillin into common medical practice in the 1940s, science has fought a delicate balancing act between exploiting the life-saving power of the drugs and guarding against the evolutionary processes that result in their widespread use encouraging the emergence of resistant organisms. We have, in fact, fallen into the exact trap that the discoverer of penicillin, Alexander Fleming, predicted and warned against in his 1945 Nobel Prize acceptance speech. Having failed to heed Fleming's warnings, we now need to make sure we take more notice of the conclusion of the World Economic Forum Report 2013, which recognises: 'We will never stay ahead of the [AMR] mutation curve. A test of our resilience is how far behind it we allow ourselves to fall.'
This recognition - along with a determined effort on all parts to implement the new strategy through the Action Plan that will follow it later this year - will go some way to ensuring that the challenge of AMR is met. The value of economic drivers to push the strategy through has historical precedent: in addition to predicting AMR, Alexander Fleming also acknowledged the role played by the economic climate of his day in bringing penicillin into widespread use, when 'the second world war enabled large scale production [to] go ahead as it would never have done in times of peace'.
Resistance means that new antibiotics have a relatively short useful lifespan. This in turn means that pharmaceutical companies have little chance of a return on investment in their development, and so do not invest. As a result, it is likely to be left to governments and the public sector to take the lead role in ensuring AMR does not change the landscape of twenty-first century medicine as significantly as the discovery of antibiotics did in the middle of the twentieth. AMR needs leaders and champions, who will spread the message and fight its corner to keep it at the top of the political agenda. Most importantly, those champions need a message to spread and this strategy provides it. Implementing it may well prove harder, but at least now we can start.
Group Captain Andrew Green, Defence Consultant Advisor in Communicable Diseases at the Royal Centre for Defence Medicine will be giving a Members' Lecture at RUSI in November to mark European Antibiotic Awareness Day
 Jennifer Cole, 'Antimicrobial resistance, infection control and planning for pandemics: The importance of knowledge transfer in healthcare resilience and emergency planning', Journal of Business Continuity and Emergency Planning (Vol. 6, No. 2, Autumn/Winter 2012-2013) pp 122-123
 ECDC/EMEA Joint Technical Report The bacterial challenge: time to react, last accessed 10 July 2013
 Spellberg, B., Blaser, M., Guidos, R. J., et al. Combating Antimicrobial Resistance: Policy Recommendations to Save Lives. In Clinical Infectious Diseases: an Official Publication of the Infectious Diseases Society of America, 2011, 52:S397-428.
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