PACCARB Meeting Part 12: One Health & Antibiotic Resistance

PACCARB Meeting Part 12: One Health & Antibiotic Resistance


>>Jay’s comments as an introduction are very good. So we appreciate it.
But let’s get started, I will take nine minutes to give an introduction to this topic.
Probably a little different way to look at it but coalesces your ideas how to think about
that and then drill down into more specific strategies as well bring our panelists involved.
For me it’s because we have a lot of infectious disease docs around the table, to think about
this in terms of three epidemiologic transitions. So I will quickly go through ten thousand
years as I start ten thousand years ago, the first transition really was with the advent
of farming. And that was a new social order.
People became sedentary, they worked and lived in communities exposure experiences took place,
diseases spread rapidly and there was domestication of animals and the big influx that point in
time of zoonotic diseases that represents the first major transition.
The second really was with the advent of penicillin, the other antibiotics that came forward, vaccines,
and diagnostics and the sophistication of medicine human and veterinary medicine in
terms of a second transition and people thought at that point in time infectious disease because
of steep decline were a thing of the past. That was a little premature as we know.
But this was an important transition and we’re reminded the importance of antibiotics in
improving our lives in animals and human health so as we talk resistance, we’re also reminded
of what it means to us. So we’re in the midst of a lot of people think
the third epidemiologic transition. That took place probably plus or minus 25
or 30 years ago. Characterized by what we see in this slide,
new group of emerging re-emerging diseases, three quarters of which human infections are
zoonotic, ecological disruptions, population increases in animal and people, shift to urbanization
and what some believe is perfect analogy or analogy of the perfect microbial storm.
So the events ta that converge are genetic and biological.
Social political and economical, environmental physical and certainly ecological factors
that all are drivers that are in place now to create the perfect microbial storm and
in the center of the storm emerges new emerging and re-emerging diseases not only in people
but in animals and in plants. So it’s a whole new era, if you will, as we
move forward. Kate Jones did an article in nature published
in nature a few years ago looking at 335 emerging infectious diseases and she tracked those
by decades. This is a slide that look at the trend line
of new emerging and re-emerging infections. And you can see how they’re going up this
decade is not here but the trend line continues, the 1980s were representative of HIV.
And new infections compromised individuals and a slide on the left really is a look at
new emerging infections which she believes 21% are characterized of as new diseases based
on resistance. So she believes that 21% new emerging diseases
have come about because of disease resistance. One thing to think about, this is a very difficult
vexing complex problem. And in the terms coming out of the business
community, it’s very much a wicked problem. And a wicked problem is a business term.
Wicked problems are characterized being complex and tangled, unprecedented, they’re difficult
to define, no yes and no answers to their solutions.
And most importantly, that unique and past experiences are not always helpful as we move
forward. So I would characterize antimicrobial resistance
very much as wicked problem, difficult vexing and fulfills different requirements of a wicked
problem as we move forward. The other thing to think about metaphorically
is Shakespeare’s Mcbeth, I always like the version of the three witches, churning around
this wonderful brew, if if you will. And we really are in the 21st century mixing
bowl. So if you think of what’s drone throne into
this big pot of animals, people and antibiotics and all the kinds of things that connect our
world, and spill out into the environment, double double toil and trouble.
So in that 21st century pot if you will, 7 1/2 billion people moving to 9 billion by
middle of the century, 35 to 40 billion animals and that’s an estimate increase by 50% to
actually meet the growing demand of protein from animal sources.
315 million-tons of meat produced, that’s quite an enterprise, $1.1 trillion output.
And fastest growing group of populations in the world are slums where a billion people
unfortunately reside and 2 billion people with within 20 years is what is going to happen.
So rapidly changing environments, polluted, and antibiotics are thrown into this mixing
bowl in ways that we have never seen before. So kind of think about that metaphorically
as we move forward. In global animal health, so the global risk,
if you will, or the disease burden is undetermined. But in the developing world and some of the
developing world estimated 20% loss due to disease and in the underdeveloped or developing
world it’s at least 40% or higher depending when you count paracytic disease, et cetera.
So think of $1.4 trillion industry that’s impacted and while the use of antibiotics
is so important then to this group. Trade regulations are estimated at any point
in time to keep 30% of animal and animal products out of the export market.
So diseases are important, treatment of those diseases, if you think antibiotics are not
going to continue, in these populations, that’s not true.
I checked with RAMANAN this importanting, this is a paper some think underestimated
but he was a co-author talking about 63,000-tons of use of antibiotics in animaling a could
canture and we — animal agriculture, that may move to over 100,000-tons so picture the
big 21st century mixing bowl and what continues to be thrown in to that mixing bowl.
The antibiotic use worries me both as group of animals and developing world where intensified
production systems and global marketplace is going to drive animal production and antibiotic
use and that will be southeast Asia, China and India.
So here is the perfect microbial storm. If you can think of a better scenario, to
put people’s animals and changing environment together here it is.
And I will tell you that environment also has changing agriculture so agriculture is
moving closer to the communities in ways that we have never seen before and great mixing
bowl continues in unprecedented ways. We have already changed permanently 50% of
our environment not for the better. So Randy singer talked about, I think the
environment is a much more critical issue we’ll discover in this process as we move
forward. So this vexing complex difficult problem I
think we turn to a real wise person and Albert Einstein said, we cannot solve our problems
with the same thinking we use when we created them.
So this means a different level of thinking, different construct and that construct for
me is One Health. And One Health being the collaborative effort
of multiple disciplines, working locally, nationally, globally to obtain optimal health
in humans and animal in an environment and do it siloed individuals but look at that
as a collective as we move ahead. So another way to think about that is
in essence for every action there’s equal
and opposite reaction. So because of our intricately connected world
today you cannot impact these domains specifically without changing the others.
So think about that. You cannot impact these domains and this includes
antibiotics without impacting the other. So for every action there’s a reaction.
And that is a good way to think about One Health as as we move forward.
Randy we selected the same slide out of — to look at this but this is the road map for
One Health and antimicrobial resistance. There’s horizontal an vertical transmission.
We go address species through environment, through water, multiple settings in human
hospitals community health outpatient, et cetera.
Advancing on my own but not on yours. So there’s the interconnectivity of the dynamics
of One Health and this is the road map for One Health.
So just look at all the connectivity, if you will, of antimicrobial resistance and organisms
being passed back and forth. To close, One Health I think really talks
about how to address the wicked problem, a vexing difficult problem as we move ahead.
We’re past solutions, to contemporary problems, work as well, that’s for sure.
A changing mind set, the interconnectivity of One Health, new emphasis on prevention,
we heard that going around the table. And shifts in thinking and acts moving upstream
with an emphasis on prevention. I think lastly we need to think of One Health
in terms of a new value proposition. That value proposition is we need to convince
potential users that are particular product or service in this case a concept, will add
value or solve a problem better than contemporary actions and status quo.
So we’ll end with this. And it really talks about — what are the
benefits then of One Health? And that approach?
We live in this exquisitely interconnected horizontally integrated world that’s the vexing
difficult wicked problem but our systems, our processes and our organizations are vertically
orient and siloed. So it shouldn’t surprise us that when we have
these difficult broad problems that to be able to move out of the silos into a different
level of thinking is going to be critical to us.
Improving environmental and animal health is actually a public health strategy.
If these domains are connected that is a public health strategy and we need to think in those
terms. If you focus on a single domain, you only
solve a third of the problem. It will continue.
So this is a process that brings veterinarians, physicians ecologist economists together promotes
interoperability and interdisciplinarity. This is the last slide that I have.
This is the five year plan for the UK. This is h the front page of that five year
plan. Looking at my thing.
This is the five year plan, it says which you probably can’t read on the end, this basically
is in line with aims of global One Health approach, spanning people animals in the — and
agriculture in a wilder environment and it is assigned by chief medical officer and chief
veterinary officer. So these are the two signatures that actually
have authored this plan. That’s a strategy we need to think about as
we go forward. So I’m going stop there.
This is way I hope for you to think about this concept, the value proposition is needed,
and while this wicked problem has to be attacked by a different strategy, I hope this is the
concept that we will use. So let’s turn to a group of panelists here
and get their perspective on One Health from their point of view.
And also talk about three questions they were given those questions are why the concept
of One Health is necessary in the future of PACCARB and the national action plan, what
it will take to adopt strategies aorganizations and government and what are the barriers to
adopting One Health as part of the national action plan and how do you suggest we actually
focus on those. So with that in mind, I want to turn to our
colleagues who are some of whom are on the this council and we can give them an opportunity
to answer those questions. So Randy, I have you first, and Peter, you
want to go first? Dr. Davies from university of Minnesota, who
does a lot of work in swine and pork industry.>>Michael, do you want to is that right
>>Out of Kansas state university and expertise in the beef industry and the cattle industry
in terms of>>Thank you, Dr. King.
I took the property of addressing this through illustrating how we can interact and the importance
of it through some — in place and we can build off of towards One Health so to put
it in perspective, can quality and calves are 19% of totaling a churl sales in this
country and milk is 9% of total sales. We’re substantial component of this, there
are about 619,000 beef cattle farms, about 43,000 dairy farms licensed to sell milk each
averaging 214 cows so there’s a very broad footprint with needs for interaction between
veterinarians and producers and different agencies.
So I want to talk about some of our existing beef industry health commitments and dairy
health commitments that fit in exactly to what we’re doing and I think support what
we’re after with One Health. Our beef quality assurance program is serve
as a platform for interaction within the beef industry starting back in the 1970s and today
addresses residues, car cause quality, animal handling and also is poised to and starts
to address the use of antibiotics and relationship between the net veterinarian and the client.
Another example that folds into One Health is the beef industry safety council.
BSCO as we call it was created to address e. coli 017 H 7 and addresses the other S
techs as well and addresses multiple food potential food borne pathogens related to
beef. This has become a platform and example of
an industry coming together in a non-competitive way to address something that is about the
health of our consumers which is foremost on the mind of the industry.
The national cattle and beef association consistent are long term focus can on this and I serve
as chair of a task force specifically addressing antimicrobial resistance, again looking at
the impact of what we do in relation to our consumer as well as the health of our animals.
The dairy industry has — as the dairy beef quality assurance program, the national dairy
farm program, and just released in 2016 their residue prevention manual which focus on antimicrobial
stewardship, these platforms are there and moving and serve as examples of where we can
support private entities moving forward. American association of bovine practitioners
is a demonstration of our wrestling with this issue, there’s the practice guidelines that
are there, the ABC state BMAs also, here is a shining example of a veterinary organization
which is created a platform ideal for One Health.
This is the Wisconsin B Marks food armor program, a group of veterinarians these men and women
developed this based off testify principle that includes identifying the drugs, putting
in place protocols, veterinary oversight and they are certified, there’s outside auditing,
where this is — was based on residues, we’re working together to look at this also for
stewardship and is the perfect type of platform to bring in that concept of everything we
do matters for our animals and for our consumers. So my last slide is what is stewardship, this
is the perfect platform for considering both human and animal health and what we do and
the first consideration is is there a non-antibiotic alternative which will appropriately prevent
and control or treat this disease challenge. We talk today about prevention and that’s
— I agree that’s integral to everything we do, if not is there antibiotic demonstrated
safe and effective for this purpose? And while using that under veterinary oversight
we assure the use of this antibiotic is shown to be safe and effective.
While asking that first question again. So it’s a cycle.
And I think that cycle is perfectly constructed for laying alongside each other the importance
of both human and animal health and the way we address things.
Thank you.>>Thanks so much, you see a million farms
and ranches and the complexity into stewardship programs and how to go about that.
Thank you, Michael. Dr. Davies.>>Good morning, again.
I work close which the pig industry, have done so for about 30 years, wanting for the
wicked problem of talking about One Health in three minutes in the pig industry.
I’ll touch on a few things. Scope of the industry, pork is the most consumed
meat internationally U.S. is a major producer and major exporter.
We have a large number of jobs 24 billion in sales, about a quarter is exported currently.
Appoint people that don’t tell — our number of pigs we have got in the U.S. is 67 million.
About the same number in the U.S. in 1920, the population increased but the productivity
is four fold so the amount of meat produced from that inventory has increased a lot.
In the One Health context an environment footprint that issue of efficiency and productivity
is something that is part of the picture. The other thing having come here in 1991 is
phenomenal change in the structure an operations of the industry in the last 30 years.
What has driven those things in the free market economy is largely again these drivers of
economic sufficiency so a lot of changes that happened in the operation and industry have
been driven by those goals but part of that efficiency and economics relates to animal
health and productivity so a lot of drivers that we have seen in changing this structure
of the industry, have been towards improving animal health and productivity with I guess
less emphasis perhaps directly on human health or environmental health aspects.
The piece — influence of antibiotics I put here in the last 30 years is incidental because
widely available for 70 odd years but we have had significant structural change in the last
20 to 30 years certainly availability of antibiotics underpins a lot of the environment that we
are working within but hasn’t actually influenced the change that’s gone on, really the change
due to other factors. Again, in a global — One Health concept we
focused on antibiotics and antibiotic resistance but in the broader picture, look at public
health impacts of animal production, we have had substantial and demonstrable progress
in eliminateing what has been the major pathogens over the last centuries being food born parasites
so a tape work parasite of pigs and humans is still probably the major food blood born
pathogen internationally, essentially eliminated from most developed countries through industry
practices, the other worms that we have heard of over the years, parasites toxoplasma were
major zoonotic diseases now reduced to negligible or minimal risk in developed countries.
There’s residual risk and that is largely tied to animals with outdoor access.
I’m not stating that because I think animals are having a bad outdoor access is not a good
thing but just really the point that if we’re going to any changing of systems in an ecological
sense, it’s trade offs and we give up one and gain another thing.
The other thing they think is noticeable in the data is there’s a marked reduction since
1996 in carcass contamination and measured zoonotic food borne diseases measured by food
net so not all come back to prevention piece, not all changes have been in the wrong direction.
Last thing I will touch on is antibiotic redue. That’s part — residue, that’s part of the
One Health concern here, data from the U.S.DA in the 1970s show we had extremely embarrasing
high levels of residues in the market, hogs the data recently from 2014 show those residues
have been reduced to extremely low levels and that’s come about largely through for
quality assurance prodicer education industry maturity and export market discipline.
So even though we often hear things going in the wrong direction there’s measurable
benefits that have been seen in the last few years.
Probably out of a little bit of time here so might just skip to the last point here.
We have change in all changing structure operation we have changed the disease profile of the
industry and a lot in bacterial disease. I put the point really that antibiotics will
still be necessary for animal health even in the best situations.
I think the challenge is to to going forward as Mike said to suggested yesterday is identifying
removing all the uses that we have are that are not bringing benefit, bringing risk but
still wanting to preserve things that are most beneficial to animal health and food
safety. Thank you.
Dr. Singer university of Minnesota. Key researcher in the pork industry.>>Thank you.
I I want to go last because I’m going to build off what the other two have said, not because
I think poultry is less important obviously. I won’t use slides for this quick presentation.
I have a slide set for the environmental piece. So to start when we stay poultry production
we’re really talking different types of production, we have got broiler chickens, turkeys we have
egg layer chickens so you — each have their own challenges and their own dilemmas when
we try to manage health. One Health is a critical component of all
poultry production. We think about the infectious diseases that
affect burden how they get into a domestic poultry production most noteworthy avian influenza,
might enter production, via wild birds an reps animal and human health threat.
So the environment plays a key parole in the health of poultry production.
There are bacteria poultry that also can be transmitted to humans via food, the environment
and obviously any antibiotic use in poultry production has potential to impact antibiotic
resistance in these bacteria. Because of that, judicious use is a key component of poultry
production, the American association of avian pathologist known as AAAP has guidelines on
its website to advise how to maintain proper health and use antibiotics appropriately and
all poultry production. That’s organized veterinary groups within
the commodity groups whether represents broiler veterinarians turkey veterinarians handling
the table egg layer production. So what I want to conclude with is a what
I think is a key example of a significant One Health initiative within the poultry sector,
it’s the development of a public private partnership with USDA AFIS on quantitative antibiotic
usage data on farm. So the different commodity groups we’re talking
broiler, turkey and table egg production. A reporting quantitative antibiotic use estimates
by drug, by indication, route, dose, duration. The broiler industry is already begun this
survey effort. It covers the December 31, 2015 to start and
conducted every six months and the turkey and layer surveys are about ready to go live.
So the industry recognizes the importance of a One Health approach, it’s actively working
to to collect on farm antibiotic usage data to allow us to assess how antibiotic use practices
are changing with changing regulations, changing interest by the consumer.
And I think I’ll conclude with that.>>Thank you.>>Thanks very much.
I don’t want to exclude rich and Liz who also have a lot of expertise in these areas, we
just kind of for time but if there’s east anything you want to add.>>I’ll sigh this very quickly, this is Liz
WAGSTROM, the importance of the quality assurance programs cannot be underestimated and the
involvement — evolved — how they evolved over time to now where we’re with the pork
we have usage, sit through an hour of education, you have your certification.
The people on the farm now need to take tests, the packing plants are requiring audits on
farm for stern very objective points that can be auditable.
So the transition from a sit through an hour lecture and you got your certification card
to now where you have records examination and true third party auditing, I think really
helps enforce the importance of those issues.>>Thanks, Liz.
So we’re now going to shift lens and look through the lens of public health and we have
asked Dr. Jim Hughes to join us, Dr. Hughes is a physician, he was in charge of the infectious
disease center at CDC and currently Emory and global health and I have known Dr. Hughes
for a long time and he has a really good perspective. Jim, thank you for being here.>>Thanks very much, Lonny.
I appreciate the invitation to join you and say a few words.
I have no financial conflicts to discloses. I’m going to remind you of the problem which
is already been very well delineated. Mention some of the challenges and then close
with some discussion of some of the opportunities that I think you have.
The problem. Almost 25 years ago the institute of medicine
now the national academy of medicine put together an expert committee that issued this consensus
report, the committee was chaired by Nobel laureate Dr. Joshua letterberg co-chaired
by Dr. Bob Shope. Important report provided a definition of
emerging infection. Here it is.
New re-emerging or drug resistant infections whose incidence in humans increased within
the past two decades or whose incidence threatens to increase in the near future so this group
appreciated this problem 25 years ago. The IOM revisited this issue with another
consensus or expert committee co-chaired again by Dr. Letterberg assisted by Dr. Peggy hamberg
before she moveed to FDA. Also an important report, interesting quote
from robust public health system in its science capacity practice an through its collaborations
with clinical and veterinary medicine academia, industry, and other public health — public
and private partners is the best defense against antimicrobial threat.
It’s gratifying to sit here with you and recognize the interdiscipline — interdisciplinary representation
that this group has. I don’t need to remind you of the scope of
the human problem over 2 million illnesses per year, 23,000 deaths, 55 to 70 billion
in direct and indirect costs. The two IOM expert committees identified factors
contributing to disease emergence an reemergence, the first committee 6 on the left, the second
committee validated the six and added 7 more. If you think about ones that contribute to
this problem of antimicrobial resistance that we’re focusing on, arguably they include at
least those highlighted in yellow on this slide.
But at the end of the day, the crux of the problem starts with microbial adaptation and
change. In thinking about these factors, you might
also reflect upon the fact that in today’s world most if not all of them seem to be operating
in favor of the microbes. In is a figure from from CDC that illustrates
the complex multi-facetted nature of the problem Dr. King nicely layed out.
The human silos on the right, the animal silo is on the left.
There are clearly opportunities going forward as we break out of these silos to learn lessens
from each other. There are plenty of challenges and plenty
of opportunitiesna can be capitalized upon more effectively by interdisciplinary collaboration
of. The environmental dimension of the promise
actually underemphasized that slide. Now, the One Health concept, Dr. King has
laid this out, the human arena, the animal arena which includes domestic animals and
wildlife, I point out, wildlife is really not been discussed but as you move into the
environmental arena more vigorously you will want to think about that.
Then the ecosystem and environmental dimension there the lower right.
From thinking common ground between medical and veterinary communities you can develop
a long list of issues that are of interest to both groups.
The ones that are particularly germane to the problem of antimicrobial resistance are
highlighted here in yellow. The microbes are telling us that the One Health
approach makes sense. And there are two examples that are familiar
to you. The identification and emergence of beta lactamase
is reported back in 2010, pan resistance except to doxycylcine and — most of this are sustains
genes on plasmids, transmissible many associated with medical tourism and rapid geographic
spread. A follow-up to that study looked at the environmental
dimension of the problem. 171 surface water and 50 tap water samples
collected in new deli, the MDM 1 gene was found in 30% surface water, 4% tap water samples
and the gene was found in 11 species bacteria which had not.
Been previously encountered environmentally. More recently, I’m sure you’re all well aware
of this, problem, the identification of MCR 1 and its conveying the resistance to COLISBINnd
presence for the first time of this resistance on a plasmid.
Known as rapid spread and there’s clearly animal human dimension to this problem.
So now to begin to wind down, the national action plan familiar to all of you, I would
like to emphasize the antibiotic stewardship and strengthening of One Health surveillance
capacity approaches in the U.S., and abroad. So addressing the barriers, I think it’s time
to get beyond playing games, something rich alluded to in his comments this morning.
There’s a lot of progress here, more room to improve this but moving towards more trust
and transparency. Important to respond to and leverage executive
order the strategy and PACCARBCAS recommendation, develop shared commitment to antibiotic stewardship,
evident yesterday, shared commitment to develop better data on usage and resistance in various
settings. Development and implementation of a collaborative
research agenda. I would like to emphasize this point urge
you and think about this going forward. Wouldn’t it be recognize if there were a interdisciplinary
group convened that included human health animal health and environmental health, experts
to work on development of a collaborative research agenda that might be a vehicle to
stimulate more funding streams. Then finally, a shared commitment to communication
and collaboration, with professional societies, private and public sector partners and the
public. And then the last slide, some possible elements
to think about that might be part of a collaborative research agenda.
Assessment of stewardship approaches in human and animal settings, better quantitation of
the relationship between agricultural use and resistance in humans, assessment of the
possible role of food and community transmission resistant bugs CRE, ESPL, MRSA a CDIFF comes
to mind. And then finally, environmental risk assessments
of resistant organisms and antibiotic residues. Soil, water, human, animal waste, ma environments,
come to mind. I didn’t put companion animals on there, but
that might be another area to think about so let me stop there, thanks very muchtor
the opportunity to be here.>>Thanks very much, we’ll hold questions
to the end. So that was a good segue to Dr. Singer and
going have Randy talk a little bit about this environmental domain.>>Thank you, I’m going to try to address
the environment using three questions you posed, try the stay addressed on that.
Starting with environmental health. I they in itself is a challenge to define,
we often see and centric deaf in this case environmental factors that affect human health.
There are others who would use more environmental focus for a definition which might be impact
on sustainn ‘t diversity within the environment. Regardless how you define it clearsly intimately
tied to activity that involves humans
all related to this aspect of health. Unfortunately the environment importance in
One Health, it’s important in antibiotic resistance was dramatically understated in the national
action plan hopefully we can address its importance. D on slides animal agriculture waste water
treatment plant, aqua culture, I don’t show crop and orchard production, companion animal,
et. They occur naturally in the microbes and through
mutation and they can be transfer to others that can become pathogens So I it is a complex
arrangement and that’s why we have diagrams like this we call confuse grams because it’s
hard to make sense of all these complex relationships. I prefer this graphic, very simple one put
out in 2013, in part because of the directionality of the arrows.
We see clearly the inner relationship of humans an animals with the environment, problem I
have had with the CDC graph earlier the arrows point the human pop ration and never leave
it. This is an ecological problem where everything
is interrelate are sod a graphic works well to understand and see very simply how important
the flow of antibiotic resistance and antibiotics can be in the environment.
So what barriers might we see to adopting to the environment?
We have antibiotic resistance bacteria, gene antibiotics and the environment, and we can
find them wherever we look. Quantities might be low but they’re there.
So in my opinion, a barrier is this question of so what?
What is the negative health outcome of finding antibiotic resistance bacteria genes or antibiotic
and metabolites in the environment? Because of our uncertainty about the role
that they play on health, whether it’s human health animal health, et cetera, there’s inertia,
until we understand better what that health impact is, we don’t take action.
So I think that a clear research program needs to be looking at how that environmental observation
translates into health outcomes. Without that piece there will be that barrier.
To start to understand the challenge of barriers with was through an approach known as the
systematic review. So recently Miami group completed a formal
systematic review of the literature. And in this process we had a very specific
objective. Summarize the evidence of studies, assessing
the dissemination of antibiotic resistance back toreia, and antibiotic resistant genes
from sources into the environment. So you do a very formal literature search,
review the articles in a very formal systematic way.
Asking for us, the primary question, are environmental levels of rearesistant bacteria and resistance
genes higher in close proximity to or downstream from known or suspected sources compared to
areas distant from or upstream from these sources.
Where are these inputs coming from in to the environment, how important are they, and how
do we gin to attribute that relative importance? And the conclusions the study reached.
So an example why again this is so challenging and reps in my opinion another barrier.
Let’s assume that this is your area where you’re studying and you’re focused in our
study on this dairy that and the role it has on antibiotic resistance making its way into
the water way. So you do your study and that is your source
of interest. Also putting antibiotics into that environment,
a classic example of confounding bias and epidemiology, a competing source so any effort
you now make to try to attribute the observed levels in environment back to a source, and
again in is not about blame, this is about where do you target your interventions and
where do you target your limited resources, without an understanding of this complexity
and this diversity of sources that impact the environment you will always make inaccurate
conclusions and therefore allocate resources inappropriately.
So this is another barrier really trying to understand ecology of resistance.
There are other data gaps and concerns that come.
What are quantities of that being used and how much is excreted into the environment.
Relative to that, what is the fate and transport of these bacteria, these genes an these antibiotic
metabolites. They all work differently, they may persist
in different environments for different amounts of time.
What is efficacy of waste management systems for being able to control inputs to the environment.
And finally, once they are in the environment, what is the environmentsal selection of resistance
and role of horizontal gene transfer? Do the metabolites that make their way into
the environment we finds at low levels are they exerting a biological effect on the bacteria
in the environment? So there’s a lot of data gaps we have that
we need to address to really understand this environmental health One Health piece.
What will it take to adopt a One Health strategy? We need a clear definition of objectives to
guide research and interventions many studies gout and observe but we need a very clear
definition and understanding of why we’re doing it and what we will do with that information
once we obtain it. So attention to the design of monitoring system
is critical. We don’t want a system that just goes out
haphazardly and picks up samples, detects resistance or antibiotics, that doesn’t help
anyone. We need a very clear focus on the design of
that system, we need interdisciplinary teams, that doesn’t mean you put an epidemiologist
and microbiologist and call it good. We need interdisciplinary teams that go beyond
the sciences — interdisciplinary teams that go beyond the physical sciences and when it
comes to the antibiotic piece we’re not including chemists enough, soil scientists, there’s
a lot going on in the environment that is going to require these strong teams.
I probably — we have talked about it all day yesterday and today, it’s the funding
issue. Studying the environment is not going to be
inexpensive. So to do this correctly, especially with the
country the size of the United States, this is going to require us a serious investment
but I still hope that the environment does become an area of focus, both within any program
that relates to CAARB and our council here addressing how to look at the environment,
understand its role in the spread of antibiotic resistance.
Thank you.>>Thank you very much.
So is Dr. Clifford on the phone?>>Yes, I am.>>We’re pleased to have Dr. John Clifford
on the phone. So Dr. Clifford, recently just finished his
term as the deputy administrator for veterinary services at AFIS U.S.DA, in that role for
some time. In that role you also as chief veterinary
officer to the OIE in Paris, the world animal health association.
So with John’s background and experience, he’s still working in AFIS veterinary services
and area of trade. So Dr. Clifford will talk what about we heard
and working group 5 was this international relationship and concern about growth health
and One Health. Dr. Clifford.>>Dr. King, thank you and Dr. Blaser and
committee, I want to thank you all for the tremendous work you have done and also in
my new role as chief advisor, I will be the delegate for the United States for the OIE.
You see a tissue being aggressively consumed by pathogenic bacteria.
This is why we need a One Health approach to addressing antimicrobial resistance.
Next slide please, furthermore AMR is not just bacteria but viruses, they don’t know
global boundaries. And recognize borders, we have seen this in
many, many cases around the world that requires global effort.
Next slide, please. The global level the OIE or world organization
for animal health, the world health organization, the food and agriculture organization forge
adtry par tide alliance tie dress AMR, these organizes have agreed to work together in
their respective areas of responsibility to tackle this priority area.
Next slide please, these three organizations are going to focus on many issues of which
to raise awareness, strengthen national infrastructure, encourage appropriate policy and legislation,
to support surveillance and promote research and development as well as improve infection
prevention and control. Next slide, please.
I’m going to focus now on my — on the OIE specifically.
The OIE is actively working in many of these area, it’s raising awareness by developing
standards which advocate for prudent responsible use of antimicrobial agents.
We have a co-chapter on the responsible improvement andious of antimicrobial agents in veterinary
medicine which gives member countries that basic background and considerations on applying
antibiotics while reducing the emergence — emergency spread of antimicrobial resistance bacteria.
It’s recommendations include ensuring the rational use, complying with the ethical obligation
to keep animals in good health, reducing transfer of resistant organisms between animals and
humans an to the environment. Maintaining the efficacy, protecting consumer
health by ensuring safe food. The co-chapter on risk analysis for antimicrobial
resistance as arising from use of antimicrobial agents in animals provides objective assessment
and managing human and animal health risk associated with resistance.
The methodology follows basic established risk analysis of processes.
Through the application of what we refer to as the PACCARBDS tool which is performance
of veterinary services in countries, it’s helping to identify gaps including developing
relevant legislation on antibiotic distribution and use.
Most member countries assess by OIE do not have meaningful legislation to ensure appropriate
measures for manufacturing importing and distributing antimicrobial agents.
Such agents are widely available with no restrictions in these countries.
Next slide, please. The oIE developed two chapters on surveillance.
Harmonizing the national antimicrobial sense surveillance and monitoring programs, this
chapter provides member countries with the guidance and criteria on development of national
antimicrobial resistance surveillance and monitoring programs.
The second, is monitoring of the quantities and usage patterns of antimicrobial agents
used in food production animals. This chapter encourages member countries to
develop collect quantitative species class type of use and route of administration.
This past fall, the OIE sent its first data call for antimicrobial use to establish a
baseline across member countries. In its collecting information on the use and
circulation of antimicrobials in animals, compiling such information into a database,
this information will help better control the quality and effectiveness of products
in use. Next slide.
There’s significant challenges and barriers to progressing the effort against AMR and
the greatest of which is a lack of ledges lakes in most member country.
Legislation is practically non-existent. Political will and commitment to establish
meaningful legislation, political will, sustainability of funds and implement such legislation as
well as global will and commitment. And in closing with regard to the United States
and our commitment I think it’s important for people to recognize that this type of
effort needs to continually be educating our appropriators.
And when we talk about our appropriators from the human health and animal health, I think
it’s well stated about how we have a united front.
That goes to to funding as well. Funding for the human side funded through
one committee and for the animal health side funded through another committee.
All those — both of those committees had different priorities and needs for the funding
levels that they have been given. That’s why I think it’s critically important
in our country that we have a totally united front with regards to all aspects of the One
Health initiative. Thank you.>>Thanks very much, John.
Appreciate that. I’m glad you continue with the OI in your
new role. So we heard from our commodity groups and
animal agriculture from from public health environmental health, from John Clifford in
terms of global health and now turn to our last group to look at USG in One Health and
the activities that are taking place in our critical agencies.
So we’re pleased to have Dr. Bern net Dunham, changing roles, Dr. Dunham was the director
of the center for veterinary medicine at FDA and is moving her One Health site to academia.
We know Dr. Beth bell, who has been involved in our group for sometime and Dr. Bell also
is in a position where One Health center at CDC is under her purview and Dr. Jane Rooney
in USDA working in their center One Health. So Dr. Dunham, let’s start with you, thanks
for being here.>>Thank you so much.
Thank you Dr. King and Blaser and members of our presidential advisory council.
So the questions you asked, why the concept of One Health necessary to the future success
of the national action plan. One Health is defined as multiple discipline
professions and working locally nationally and globally to achieve optimal health for
humans animals and the environment. One planet and a shared biosphere.
The health of each domain interconnected. The One Health approach to infectious diseases,
recognizes that pathogens and antibiotic resistance arising in one environment can spread and
expand to other environments and compromise health of other individuals in separate (inaudible).
Antibiotic resistance is biologically complex. And the opportunities for microbes to share
genetic material and spread resistance globally are synthesizing the need for global multi-disciplinary
solutions to address CARB challenges and mitigate AM,R.
We can dot no do it aloaning. The council demonstrated how nice to come
in, roll up your sleeves, drop your degrees and egos at that time the door and tack it
will issue. What are the barriers to adopting the One
Health in the AMR plan and how can we suggest on addressing these?
You heard it, isle say again, we have siloed funding, not enough funding.
We have leaders that often fail to think outside the traditional disciplines.
The mission and jurisdiction often sustain silo buyeriers we want to confront.
for some there’s still confusion, various stakeholder engage metrics.
So we need clarify toe define. Perhaps one of the biggest is often data sharing.
Obsolete data systems that make it difficult to access and updated sharing spoils on institutional
habits that are no longer relevant or sincere possible consequences that are no longer valid.
All in the synergy an cooperation that we need.
The government open data initiative is one attempt to foster openness and transparency.
The FDA has been a leader in data sharing on food borne bacteria and released to the
public isolate level data from NARM, 150,000 isolate the past 20 years and soon add the
whole genome sequence data shared in near real time in the future. Global identifier
project is attempting the same for pathogen on a global scale.
We say what will it take to adopt the One Health strategy to be used as a construct
to better understand animal AMR and how to better coordinate activities across the government.
I think we really do have agencies leaders Al all levels to lower the silo walls an open
collaboration and effective multi-disciplinary partnership across our federal agencies, with
the states, local agencies, travel tribal nations private sector organizations, commodity
groups, philanthropic organizations and certainly our international bodies.
We need members of Congress embrace One Health. I will tell you I’m thrilled to see the establishment
of the intera agency One Health program. Rerecently recommended by senator FrankEN.
It’s step forward. Hopefully more can talk and embrace and see
if we can make this happen. And we also need I think a stable representation
that will either be at level of height White House or possibly cabinet secretary level.
The if we really want to assure that we’re going to continue to have key relevant parties
come together under One Health approach. To really address AMR and topics that will
surface, you can see why One Health is the way to go, it brings the best of the best
together. And the silo walls fall down.
We also need to look at all the curriculums that are going on in our medical and veterinary
medical schools as well as schools of public health and the environment.
Because that’s the neuro. And the more that we can bring our future
researchers forward future medical forward is going to help showcase the benefits that
you glean with a One Health umbrella. Sometimes even sharing same lectures and teaming
students up together to have an appreciation how similar and what they bring to each other
to this issue is critical. But I have to give credit because a lot of
the solutions that are sitting in front of you, that you developed, in the national strategy
on CARB already. So if I may, you have already said there should
be a joint educational effort between human veterinary, medical veterinary schools and
schools of public health and environment joint communication efforts in journals and conferences
and Allied health networks. Joint efforts in clinical care through assessment
treatment and prevention which you have heard of for cross species transmission.
Joint cross species, we have to include companion animal, disease surveillance and control efforts
that cross public health. Joint efforts in better understanding cross
species disease transmission through comparative medicine and environmental research.
Joint efforts in development and evaluation of new diagnostics methods medicines and vaccines.
For the prevention and control of diseases across species.
And joint efforts to inform and educate political leaders in the political sector through accurate
media publication. I hope that this group and the enthusiasm
and passion that you have shown in being part of this, in what your report is based on going
forward and your comments today continues because that is how you’re going to sustain
One Health. Thank you so much for the opportunity to join
me this morning.>>Bernadette, thank you very much, appreciate.
Dr. Bell. From perspective from CDC.>>Thank you.
I want to make five points and five points in four mince means I better get on the stick
here. First I want to address the question of why
One Health, I’ll mention on a higher level, going along with some of what Lonnie said
initially, we at CDC identify on average about one new health threat every year.
And tracing the sources of these new health threats infectious disease outbreaks often
lead to an animal bat camel pig, chicken, at CDC we live One Health every day in as
we identify new emerging pathogens. In the area of AR we know that use of antibiotics
is agriculture drive resistance in food born pathogens and this of course is an obvious
area of overlap in addition as already mentioned there is the issue of antibiotic use in animals,
driving resistance on plasmids and most recent relative, example of that being resistance,
this of course was the opportunity for these plasmids to be transferred among species,
provides an additional concern that we have that sort of embodies One Health approach.
Second point I want to make, I think is that there’s been an enormous amount of progress,
I think that for those of us speaking as someone that works as one of the federal agencies
the process of developing the national action plan over a period of whatever the it was
a year and a half or more has at least at the agency level or the staff level meant
people have been working closely together over a long period of time and funding that
is available to us at least somewhat in FY 16 helped with some progress.
So couple of examples of that, I think are NARMS where we have had excellent collaboration,
a lot of transparency, the data are posted ton websites, and with the FY 16 funding we’re
able to scale up our ability to study and detect antibiotic resistance in Salmonella
using whole genome sequencing. This will be an opportunity to further understand
how antibiotic resistance in Salmonella travels from the farm to meat and people and the what
the relationships are. Leaving AR for a moment I will say that our
— the example of the listeria pilot project that we have been working on at CDC with NIH,
and with FDA USDA has been enormous success over the last three or four years, data are
available real time, they are posted, and we at CDC have been able to demonstrate an
impact on human health in terms of identifying more listeria outbreaks detecting it faster
and basically saving lives. In terms of barriers, I think I’ll just mention
a couple of points here. I think a number of speakers have talked about
the need for additional research. I think that there are some areas that really
we don’t know what is the impact for example of contamination on the environment on human
health. I think it will be difficult to move forward
without answering some of those research questions can.
Second barrier I’ll mention is that the ability to actually — which is also measured the
ability to measure antibiotic use and to track antibiotic use in agriculture is really going
to be completely pivotal to being able to demonstrate impact of some of the One Health
interventions on resistance in both agriculture and human health.
So I really this that this is an important point.
The fourth point I want to make is about there’s discussion about silos, we at CDC, we have
over 150 veterinarians that work at CDC so some ways we live One Health every day.
At CDC. And one thing that we have been trying to
do in the context of the CCARB is to bring some of the lessons from the human health
side to bare oning agriculture side so we have been doing this in number of ways by
sort of highlighting some of the principles of stewardship and showing how some of the
ways that we have been promoting stewardship in human health can actually transfer to veterinary
health. Corporate responsibility which I think is
another area we have had a bit of success on the human health side, there are lesson
there is, tracking as I mentioned which we have been able to show how tracking is data
for action, how powerful it can be and really a pivotal component to this.
And finally, I guess the other thing that we have been trying to do in this area, is
use some of our connections with universities to move some of these areas forward.
So there’s been many discussions here about companion animals and we’re actually hoping
to support some projects in this regard with FY 16-dollars and pick a couple of areas where
are there is a lot of overlap between human and animal medicine and move the field forward.
Final thing I want to say is I think it’s been mentioned a few times here, I think we
don’t want the issue of silos and need for additional collaboration to obscure the need
to move forward in the human health area for example, while addressing some of these issues
of collaboration. I think we don’t want paralysis or the perfect
enemy of the good. So in that general line of thinking, I think
there is a enormous amount that we need to do on the human health side, there’s opportunity
but there’s also a huge amount that needs to be done, I think there’s sometimes a sense
for example with device-related infections that the problem has been solved.
So I just want to urge the committee to continue to keep focus on some areas we can move forward
with prevention and interventions that will have an impact as we improve collaboration.>>Thanks very much.
Our last presenter is Dr. Jane Rooney. She’s also online.
Dr. Joan he wily heads One Health division, he’s not able to be with us so Dr. Rooney
is part of that team and welcome her for her comments.>>Thank you.
Good morning. Thank you for giving USDA the opportunity
to speak on this imperative topic of One Health and its application in combating antibiotic
resistant bacteria. I would like to speak to the three questions
from USDA’s perspective. So the first being the concept of One Health
and the necessity in the future success of the national action plan and the CCARB effort
overall. As many here already stated, the concept of
One Health recognizes the human animal and environmental health are interdependent.
Requiring the multi-sector approach to solve the complex wicked problems at their interface.
Antimicrobial resistance is a complex multi-factorial issue and no one discipline can provide sufficient
scientific information or solutions to resolve the problem alone.
So collaborating across sectors, as everybody mentioned this morning, requires the thinking
and working across those silos, and optimizing resources and efforts while still respecting
the autonomy of the various sectors. Now to speak to the barriers for USDA, in
adopting the the One Health as aspect of this AMR plan.
And how we would suggest that addressing that. Our primary barrier in adopting this multi-sector
approach is AMR plans, is funding. Historically an important limitation in our
ability to fully implement our work on antimicrobial resistance has been lack of dedicated long
term funding. Additional support is needed for implementing
the proposed future activities described in our plan and to ensure the continue weigh
of several activities as well. Continued socializations to one health principles,
with diverse audiences will help to show the value of and gain support for this approach.
Last question, what will it take to adopt a One Health strategy?
We believe the US Government has begun to adopt the strategy for antimicrobial resistance.
Key U.S. agencies have been working together for years and others mentioned the example
of FDA, CDC and USDA. And the strong partnership that we built is
through the national monitoring system or NARs.
That’s occurring for over 20 years. Welcome always do more to strengthen our One
Health partnerships. USDA embraces and uses a One Health multi-agency
approach in its USDA antimicrobial resistance action plan and through the CCARB national
action plan. The USDA submitted a cross agency budget request
to conduct the work outlined in the AMR action and theARB gnashal plan and for FY 17 the
budget request called for $61 million and that’s about a $35 million increase over the
2016 enacted amount that was received. So again I would like to reiterate all of
that what’s been said this morning and the need for us to continue to work together to
make sure we can all view the work needed to solve this complex problem we’re talking
about. Thank you.>>Thanks very much.
That concludes the remarks from five different perspectives.
I’m going to — perspectives. I’ll turn it to Dr. Blaser who will lead a
few minutes of questions and answers.

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