INTRODUCTION: AMR Belongs in the Pandemic Instrument

In the wake of COVID-19, the World Health Organization established an Intergovernmental Negotiating Body to negotiate a new instrument for pandemic prevention, preparedness, and response. This special issue of the Journal of Law, Medicine & Ethics brings together multidisciplinary scholarship to address the question of whether antimicrobial resistance should be included in this new instrument. Drawing from disciplines including law, anthropology, history, public health, public policy, economics, and veterinary medicine, this special issue explores the inclusion of AMR within the Pandemic Instrument from three perspectives: first, through the lens of global AMR governance, second, from the perspective of technical governance challenges and opportunities affecting the global ability to address AMR and future pandemics, and third, from the perspective of pandemic instrument mechanisms for strengthening global AMR governance. Each paper makes a concrete recommendation with respect to the importance of including AMR within the scope of the pandemic instrument

Government policy interventions to reduce human antimicrobial use: protocol for a systematic review and meta-analysis

Background: Antimicrobial resistance (AMR) is a recognized threat to global public health. Increasing AMR and a dry pipeline of novel antimicrobial drugs have put AMR in the international spotlight. One strategy to combat AMR is to reduce antimicrobial drug consumption. Governments around the world have been experimenting with different policy interventions, such as regulating where antimicrobials can be sold, restricting the use of last-resort antimicrobials, funding AMR stewardship programs, and launching public awareness campaigns. To inform future action, governments should have access to synthesized data on the effectiveness of large-scale AMR interventions. This planned systematic review will (1) identify and describe previously evaluated government policy interventions to reduce human antimicrobial use and (2) estimate the effectiveness of these different strategies. Methods: An electronic search strategy has been developed in consultation with two research librarians. Seven databases (MEDLINE, CINAHL, EMBASE, CENTRAL, PAIS Index, Web of Science, and PubMed excluding MEDLINE) will be searched, and additional studies will be identified using several gray literature search strategies. To be included, a study must (1) clearly describe the government policy and (2) use a rigorous design to quantitatively measure the impact of the policy on human antibiotic use. The intervention of interest is any policy intervention enacted by a government or government agency in any country to change human antimicrobial use. Two independent reviewers will screen for eligibility using criteria defined a priori. Data will be extracted with Covidence software using a customized extraction form. If sufficient data exists, a meta-analysis by intervention type will be conducted as part of the effectiveness review. However, if there are too few studies or if the interventions are too heterogeneous, data will be tabulated and a narrative synthesis strategy will be used. Discussion This evidence synthesis is intended for use by policymakers, public health practitioners, and researchers to inform future government policies aiming to address antimicrobial resistance. This review will also identify gaps in the evidence about the effectiveness of different policy interventions to inform future research priorities. Systematic review registration PROSPERO CRD42017067514. Electronic supplementary material The online version of this article (10.1186/s13643-017-0640-2) contains supplementary material, which is available to authorized users

Developing an approach to assessing the political feasibility of global collective action and an international agreement on antimicrobial resistance

Background: Antimicrobial resistance (AMR) is a global issue. International trade, travel, agricultural practices, and environmental contamination all make it possible for resistant microbes to cross national borders. Global collective action is needed in the form of an international agreement or other mechanism that brings states together at the negotiation table and commits them to adopt or implement policies to limit the spread of resistant microorganisms. This article describes an approach to assessing whether political and stakeholder interests can align to commit to tackling AMR. Methods: Two dimensions affecting political feasibility were selected and compared across 82 countries: 1) states’ global influence and 2) self-interest in addressing AMR. World Bank GDP ranking was used as a proxy for global influence, while human antibiotic consumption (10-year percent change) was used as a proxy for self-interest in addressing AMR. We used these data to outline a typology of four country archetypes, and discuss how these archetypes can be used to understand whether a proposed agreement may have sufficient support to be politically feasible. Results: Four types of countries exist within our proposed typology: 1) wealthy countries who have the expertise and financial resources to push for global collective action on AMR, 2) wealthy countries who need to act on AMR, 3) countries who require external assistance to act on AMR, and 4) neutral countries who may support action where applicable. Any international agreement will require substantial support from countries of the first type to lead global action, and from countries of the second type who have large increasing antimicrobial consumption levels. A large number of barriers exist that could derail efforts towards global collective action on AMR; issues of capacity, infrastructure, regulation, and stakeholder interests will need to be addressed in coordination with other actors to achieve an agreement on AMR. Conclusions: Achieving a global agreement on access, conservation, and innovation – the three pillars of AMR – will not be easy. However, smaller core groups of interested Initiator and Pivotal Countries could develop policy and resolve many issues. If highly influential countries take the lead, agreements could then be scaled up to achieve global action. Electronic supplementary material The online version of this article (doi:10.1186/s41256-016-0020-9) contains supplementary material, which is available to authorized users

A Pandemic Instrument Can Start Turning Collective Problems into Collective Solutions by Governing the Common-Pool Resource of Antimicrobial Effectiveness

To address the complex challenge of global antimicrobial resistance (AMR), a pandemic treaty should include mechanisms that 1) equitably address the access gap for antimicrobials, diagnostic technologies, and alternative therapies; 2) equitably conserve antimicrobials to sustain effectiveness and access across time and space; 3) equitably finance the investment, discovery, development, and distribution of new technologies; and 4) equitably finance and establish greater upstream and midstream infection prevention measures globally. Biodiversity, climate, and nuclear governance offer lessons for addressing these challenges

Social, cultural and economic aspects of antimicrobial resistance.

Although often considered only a medical problem, antimicrobial resistance is an evolutionary challenge accelerated by social, cultural and economic factors that lead to the misuse, overuse and abuse of life-saving antimicrobial medicines. The antimicrobial resistance challenge is compounded by inadequate attention to disease prevention and response, global circulation of people and products, differences in industry and market regulations across countries, and a fragile pipeline of new antibiotics and their alternatives. While the discovery of new antimicrobials will provide temporary solutions, sustainable success requires rigorous social science research that explores the drivers of antimicrobial resistance. These solutions should promote balance between equitable access to, conservation of, and innovation for antimicrobials, adapted to local conditions across the globe

Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

There is increasing concern globally about the enormity of the threats posed by antimicrobial resistance (AMR) to human, animal, plant and environmental health. A proliferation of international, national and institutional reports on the problems posed by AMR and the need for antibiotic stewardship have galvanised attention on the global stage. However, the AMR community increasingly laments a lack of action, often identified as an ‘implementation gap’. At a policy level, the design of internationally salient solutions that are able to address AMR’s interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward. This multidisciplinary paper responds by asking two basic questions: (A) Is a universal approach to AMR policy and antibiotic stewardship possible? (B) If yes, what hallmarks characterise ‘good’ antibiotic policy? Our multistage analysis revealed four central challenges facing current international antibiotic policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we propose three hallmarks that can support robust international antibiotic policy. Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. We describe these hallmarks and propose their consideration should aid the design and evaluation of international antibiotic policies with maximal benefit at both local and international scale

International Law and Antimicrobial Resistance:Learning from Fifteen Years Implementing the International Health Regulations

Although few international laws govern global health, there has been widespread discussion of the need for a global legal instrument to mitigate the ‘One Health’ threat posed by antimicrobial resistance (AMR). This chapter presents lessons learnt from the implementation of the International Health Regulations (2005) (IHRs) to inform debates about the potentials and pitfalls of international legal instruments for governing the global antimicrobial commons. Concretely, the chapter analyses the experiences of the World Health Organization (WHO) in IHR implementation through analysis of reports from the WHO archives, covering the years 2006-2021. Special attention is paid to the extent to which the IHRs incentivize action, institutionalize accountability, and activate interest groups. The analysis shows that IHR implementation suffers from lack of sustained action by WHO member states, lack of enforcement mechanisms, combined with an imbalance with respect to which interest groups are activated. The chapter concludes that the IHR is not suitable as an international legal framework for dealing with AMR. It argues that dispute resolution procedures with clear measures for enforcement and responsibilities need to be built into the global AMR governance regime and suggest that international trade regulation might have some relevant building blocks to draw from.</p

Mapping educational opportunities for healthcare workers on antimicrobial resistance and stewardship around the world

Background: Antimicrobial resistance is an important global issue facing society. Healthcare workers need to be engaged in solving this problem, as advocates for rational antimicrobial use, stewards of sustainable effectiveness, and educators of their patients. To fulfill this role, healthcare workers need access to training and educational resources on antimicrobial resistance. Methods: To better understand the resources available to healthcare workers, we undertook a global environmental scan of educational programs and resources targeting healthcare workers on the topic of antimicrobial resistance and antimicrobial stewardship. Programs were identified through contact with key experts, web searching, and academic literature searching. We summarized programs in tabular form, including participating organizations, region, and intended audience. We developed a coding system to classify programs by program type and participating organization type, assigning multiple codes as necessary and creating summary charts for program types, organization types, and intended audience to illustrate the breadth of available resources. Results: We identified 94 educational initiatives related to antimicrobial resistance and antimicrobial stewardship, which represent a diverse array of programs including courses, workshops, conferences, guidelines, public outreach materials, and online-resource websites. These resources were developed by a combination of government bodies, professional societies, universities, non-profit and community organizations, hospitals and healthcare centers, and insurance companies and industry. Most programs either targeted healthcare workers collectively or specifically targeted physicians. A smaller number of programs were aimed at other healthcare worker groups including pharmacists, nurses, midwives, and healthcare students. Conclusions: Our environmental scan shows that there are many organizations working to develop and share educational resources for healthcare workers on antimicrobial resistance and antimicrobial stewardship. Governments, hospitals, and professional societies appear to be driving action on this front, sometimes working with other types of organizations. A broad range of resources have been made freely available; however, we have noted several opportunities for action, including increased engagement with students, improvements to pre-service education, recognition of antimicrobial resistance courses as continuing medical education, and better platforms for resource-sharing online

Probing popular and political discourse on antimicrobial resistance in China

Abstract Background Antimicrobial resistance (AMR) is an increasing threat to global public health that is largely exacerbated by the overuse and misuse of antimicrobial medicines. As the largest antimicrobials producer and user in the world, China has a critical role to play in combatting AMR. By examining Chinese news articles and policy statements, we aim to provide an authentic understanding of public discourse in China on AMR. Methods A search was conducted using two of the most comprehensive digital libraries for Chinese news media documents. Chinese policy documents were retrieved from official Chinese government websites. Records from June 2016 to May 2017 were included. Grounded theory was used to analyze included records, and we followed an iterative thematic synthesis process to categorize the key themes of each document. Results Across 64 news articles, most articles delivered general knowledge about AMR and debunked AMR-related myths, explored the implications of AMR-relevant policies, and discussed the misuse of antimicrobials in the agricultural sector. All policy documents provided guidance for healthcare workers, encouraging them to better manage antimicrobial prescriptions and usage. Conclusions While the Chinese media actively educates the public on strategies for AMR prevention, certain news articles risk misleading readers by downplaying the hazards of domestic AMR issues. Further, although several national policies are geared towards combatting AMR, the government faces difficult challenges in overcoming public misconceptions regarding antimicrobial use. Records from the regional level should also be examined to further explore China’s public discourse on AMR