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• Saúde debate 44 (126) 16 Nov 2020Jul-Sep 2020 •
https://doi.org/10.1590/0103-1104202012602 copy
ANTIMICROBIAL RESISTANCE: FORMULATION OF THE RESPONSE IN THE GLOBAL HEALTH
CONTEXT
Rafael Almeida da Silva
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
http://orcid.org/0000-0002-5049-9124
Beatriz Nascimento Lins de Oliveira
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
http://orcid.org/0000-0002-2397-5244
Luiza Pinheiro Alves da Silva
Universidade Federal de Minas Gerais (UFMG) – Belo Horizonte (MG), Brasil.
http://orcid.org/0000-0002-3740-2973
Maria Auxiliadora Oliveira
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
http://orcid.org/0000-0003-2400-536X
Gabriela Costa Chaves
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
http://orcid.org/0000-0002-8347-6164
About the authors
* ABSTRACT
* Text
* Introduction
* Methodology
* Results and discussion
* Conclusions
* References
* Publication Dates
* History
ABSTRACT
Antimicrobial Resistance (AMR) has proved to be a major public health problem at
the global level. This paper examined the formulation of the response to AMR
negotiated through the World Health Organization (WHO) by its Member States.
Related WHO reports and resolutions from 1998 to 2019 were analysed. The
findings indicate that, from 2014 on, more robust conditions were established
for approval of a Global Action Plan on AMR, encompassing the concept of One
Health and involving other international entities (FAO, OIE, WTO and Unep).
Content analysis and various analytical frameworks, considering two economic
sectors (the livestock and pharmaceutical industries), proved relevant to
illustrating the complexity of the issue, reinforcing its global importance and
acknowledging the extent of antibiotic use in animals and the gaps in
technological innovation. As the WHO is not only an important agent for
mobilizing the response to AMR at the global level, but – despite a context of
de-funding – has guaranteed a budget for action in this area, it is concluded
that the public health perspective should prevail in the response to AMR.
KEYWORDS
Global health; Drug resistance, microbial; One Health; Livestock industry;
Orphan drug production
INTRODUCTION
Antimicrobial Resistance (AMR) is currently considered to be a major global
public health problem. It is estimated that approximately four million people
acquire health care-related infections annually in the European Union (EU) and
that some 37,000 die as a result of resistant infections acquired in hospital
environments. Most (67.6%) of these deaths are caused by
multi-antibiotic-resistant bacteria11 European Center for Disease Prevention and
Control. Antimicrobial Resistance and Health Care associated infection programme
[internet]. [União Europeia]: ECDC; [acesso em 2020 set 18]. Disponível em:
https://ecdc.europa.eu/en.
https://ecdc.europa.eu/en... .
The World Health Organization (WHO) describes AMR as the ability of
microorganisms (bacteria, fungi, viruses, and parasites) to change when exposed
to antimicrobial drugs and to resist such drugs, leaving them ineffective22
World Health Organization. Antimicrobial Resistance fact sheets- What is
antimicrobial resistance? [internet]. [Genebra]: WHO. [acesso em 2017 set 10].
Disponível em: https://www.who.int/features/qa/75/en/.
https://www.who.int/features/qa/75/en/... . Often, however, the term is
exemplified by the case of antibiotics used in bacterial infections.
AMR occurs as a result of the natural interaction among microorganisms in the
environment33 Munita JM, Arias CA. Mechanisms of Antibiotic Resistance. In:
Virulence Mechanisms of Bacterial Pathogens. Microbiol Spectr. 2016;
4(2):481-511., but its increasing incidence may result from a series factors,
such as high consumption and improper use of antimicrobial drugs; populations’
lack of information; overuse of antimicrobial drugs in agriculture and livestock
production; and environmental pollution caused by discharge of pharmaceutical
waste into soil or water. The problem is aggravated by a lack or insufficiency
of regulation; a lack of oversight of antimicrobial drug consumption by
government institutions; and a lack of innovative antimicrobial drugs as a
result of low investment in Research and Development (R&D)44 Kaae S, Malaj A,
Hoxha I. Antibiotic knowledge, attitudes and behaviours of Albanian health care
professionals and patients-a qualitative interview study. J Pharm Policy Pract.
2017; 10(1):13.
5 Pavyde E, Veikutis V, Maciuliene A, et al. Public Knowledge, Beliefs and
Behavior on Antibiotic Use and Self- Medication in Lithuania. Int J Environ Res
Public Health. 2015; 2(6):7002-7016.
6 Michael CA, Dominey-Howe D, Labbate M. The antimicrobial resistance crisis:
causes, consequences, and management. Frontiers in public health. 2014; 2:145.
7 Roca I, Akova M, Baquero F, et al. The global threat of antimicrobial
resistance: science for intervention. New microbes and new infections. 2015;
6:22-29.
8 Brasil. Decreto-lei nº 8448, de 6 de maio de 2015. Regulação da Fiscalização
dos Produtos de Uso Veterinário [internet]. Diário Oficial da União. 6 Maio
2015. [acesso em 2017 nov 15]. Disponível em: http://www.planalto.gov.br/.
http://www.planalto.gov.br/... -99 Davis MA, Hancock DD, Besser TE.
Multiresistant clones of Salmonella enterica: The importance of dissemination.
The Journal of laboratory and clinical medicine. 2002; 140(3):135-141..
Improper and excessive use of antimicrobial drugs in agriculture and livestock
contributes to increasing incidence of AMR in humans. These medicine are used in
the livestock industry to treat and prevent infections, as well as to promote
animal growth, bringing selective pressure to bear on microorganisms to become
resistant. Transmission to humans can occur directly, by contact, or indirectly,
on consuming food products and from pollution caused by agricultural biological
waste77 Roca I, Akova M, Baquero F, et al. The global threat of antimicrobial
resistance: science for intervention. New microbes and new infections. 2015;
6:22-29..
Despite the seriousness of AMR, few new antibiotics have been developed in the
past 40 years. Traditional market incentives have not been – and are unlikely to
be – able to bridge this gap in innovation, especially in a context where use of
these medicines is being restricted1010 United Nations. Report of the United
Nations Secretary-General's High-Level Panel on Access to medicine [internet].
[Nova York]; [2016]. [acesso em 2018 set 20]. Disponível em:
http://apps.who.int/medicinedocs/en/m/abstract/Js23068en/.
http://apps.who.int/medicinedocs/en/m/ab... .
At the international level, in 2015, the WHO Member States adopted the Global
Action Plan on Antimicrobial Resistance (Resolution WHA68.7) at the World Health
Assembly (WHA)1111 World Health Organization. Draft global action plan on
antimicrobial resistance [internet]. [Genebra]: WHO; [2015]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . This plan was based on the One Health
concept, which assumes that human, animal and environmental health are
interrelated and proposes that different fields of knowledge integrate with each
other to address health problems1212 Boqvist S, Soderqvist K, Vagsholm I. Food
safety challenges and One Health within Europe. Acta Veterinaria Scandinavica.
2018, 60(1):1-13.,1313 Ministério da Saúde. Resistência antimicrobiana: enfoque
multilateral e resposta brasileira. In: Saúde e Política Externa: os 20 anos da
Assessoria de Assuntos Internacionais de Saúde (1998-2018). [internet].
[Brasília, DF]: MS; [2018]. [acesso em 2020 maio 20]. Disponível em:
www.saude.gov.br.
www.saude.gov.br... .
Given the complexity and multi-causality of AMR, responses to it involve
regulatory networks at various stages in the chain of antimicrobial drug
production, use and trade, with implications for various economic sectors, such
as the livestock and pharmaceutical industries. Considering the multiple
dimensions of the response required by AMR, as well as the different actors in
society and the economy directly involved and affected, this paper examines the
formulation of the AMR response negotiated at the WHO by its Member States. Its
working assumption is that the fronts on which it is considered important to
take action to tackle AMR have broadened over the years, posing the need to
involve other multilateral bodies and actors.
METHODOLOGY
This study falls within the policy analysis field, because it acknowledges the
role of proposal formulation in a multilateral arena such as the WHO. The WHO
belongs to the United Nations (UN) system and is characteristically
member-driven, that is, directed by the decisions of its Member States. By
negotiating and approving resolutions in the WHA, the Member States mandate the
work of the WHO and agree on country guidelines on the various issues
negotiated1414 World Health Organization. Governance [internet]. [Genebra]: WHO;
[data desconhecida]. [acesso em 2019 jan 20]. Disponível em:
https://www.who.int/about/governance.
https://www.who.int/about/governance... . Although the resolutions approved in
the WHA are not binding, they do have the potential to guide policies, plans and
programmes at the national level.
The reports and resolutions approved are important sources for examining the
main arguments agreed among the countries on the subject of AMR. In this study,
these arguments are themselves considered to constitute formulations of
responses to AMR, which can in turn influence the formulation of national-level
responses. In addition to reports and resolutions, this study examined other
documents (chart 1), such as WHO budgets, spanning the 22-year period from 1998
to 2019.
Thumbnail
Chart 1
List of documents examined
The study used a triangulation among multiple theoretical frames of reference,
including the policy cycle concept proposed by Howlett & Ramesh (2009) (as in
Mattos et al.)4545 Mattos RA, Baptista, TWF. Caminhos para análise das políticas
de saúde. Porto Alegre: Rede UNIDA; 2015., involving five distinct phases:
agenda setting, policy formulation, decision process, policy implementation and
policy evaluation. Although related to national-level policymaking, some of
these phases – formulation and implementation – can be of use in analysing the
role of international processes and, subsequently, their influence on policy
formulation at the national level. Accordingly, this study is considered to be
an endeavour to recognise the international dimension in national-level public
policymaking.
The global health governance proposal described by Frenk & Moon4646 Frenk J,
Moon S. Governance challenges in global health. New England Journal of Medicine.
2013; 368(10):936-942. is considered in analysing the architecture established
in the process conducted at the WHO on the issue in question. The analysis of
the institutional dimension offered by Sell4747 Sell SK. The quest for global
governance in intellectual property and public health: Structural, discursive,
and institutional dimensions. Temp. L. Rev. 2004; 77:363. also proved relevant
to appraising issues of global governance (chart 2).
Thumbnail
Chart 2
The institutional dimension as proposed by Sell and the global health functions
as proposed by Frenk & Moon
The document analysis, based on the proposal by Minayo et al.4848 Minayo CSM,
Deslandes FS, Gomes R. Pesquisa social: Teoria, método e criatividade.
Petrópolis: Vozes; 2009., at first considered three categories (general aspects
of AMR, pharmaceutical innovation and agriculture and livestock). After reading
the documents, the categories were reorganised, making the results easier to
interpret and synthesise. These were: formulation of the response to AMR; the
new formulation of the response to AMR and developments from it; and global
health system governance and functions applied to the case of AMR.
As the analysis was based on documents that were the outcome of negotiations,
the study is recognised to be limited as regards any possibility of identifying
tensions among countries on sensitive aspects of the subject over the course of
the negotiating process. The ‘formulation process’ was considered to be the
development, over time, of content included in the AMR response, as well as the
involvement of other multilateral institutions.
RESULTS AND DISCUSSION
FORMULATION OF THE RESPONSE TO TACKLE AMR
The period from 1998 to 2013 was identified to be when the response to AMR was
formulated in the WHO: when the issue was acknowledged to be a public health
problem and discussions were held on the action to be taken to deal with the
problem. It was possible to organise this period into the three distinct phases
described below (figure 1).
Thumbnail
Figure 1
Timeline of AMR response formulation
*Biennial budget.
**International-level response.
World Health Organization (WHO), World Animal Health Organization (OIE), United
Nations Food and Agriculture Organization (FAO), United Nations Organization
(UN), United Nations Environment Programme (Unep). Global Antibiotic Research
and Development Partnership (GARDP), List of antibiotics by level of resistance
(AWare Classification).
PERIOD FROM 1998 TO 2001: THE PROBLEM RECOGNITION AND FIRST FORMULATION OF THE
RESPONSE TO AMR
AMR appeared on the WHO agenda for the first time in 1998, when discussion of a
Report1515 World Health Organization. Report of regional interest adopted by the
fifty-first World Health Assembly [internet]. [Genebra]: WHO; [1998]. [acesso em
2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... resulted in the approval of Resolution
WHA51.171616 World Health Organization. Resolution and decision of fifty-first
Assembly [internet]. [Genebra]: WHO; [1998]. [acesso em 2017 ago 10]. Disponível
em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . In the two-year period 1998-1999, the
organisation approved a specific budget of about US$23 million for this
issue1717 World Health Organization. Financial Report and Audited Financial
Statements for the period 1 January 1998- 31 December 1999. [internet].
[Genebra]: WHO; [1998]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
That Resolution mentioned that using antimicrobial drugs in humans or animals,
whatever the amount or purpose, fostered selective pressure on bacteria to
become resistant to such medicines, which favours the spread of AMR1616 World
Health Organization. Resolution and decision of fifty-first Assembly [internet].
[Genebra]: WHO; [1998]. [acesso em 2017 ago 10]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . Responsibility for the problem was
acknowledged to lie with both human and veterinary medicine, because medicines
are also used in animal production and agriculture1515 World Health
Organization. Report of regional interest adopted by the fifty-first World
Health Assembly [internet]. [Genebra]: WHO; [1998]. [acesso em 2017 ago 17].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . It was recommended that governments develop
strategies to reduce antibiotic consumption in humans and in animal
production1515 World Health Organization. Report of regional interest adopted by
the fifty-first World Health Assembly [internet]. [Genebra]: WHO; [1998].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,1616 World Health Organization. Resolution
and decision of fifty-first Assembly [internet]. [Genebra]: WHO; [1998]. [acesso
em 2017 ago 10]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
One possible reason why the subject entered onto the WHO agenda in 1998 was
that, in that year, the European Union (EU) had embarked on a process of
reviewing of its community rules on the use of antibiotics in animal
production4949 Castanon JIR. History of the use of antibiotic as growth
promoters in European poultry feeds. Poultry Science. 2007; 86(11):2466-2471..
Castanon4949 Castanon JIR. History of the use of antibiotic as growth promoters
in European poultry feeds. Poultry Science. 2007; 86(11):2466-2471. reported
that Sweden was the first European country to ban the use of antibiotic growth
promoters, and its entry into the EU in 1995 brought the issue into the bloc’s
discussions. Also in 1995, Germany and Denmark banned certain therapeutic
classes of antibiotic for animal use, further helping to raise the issue within
the EU. In the late 1990s, EU rules were altered to tighten restrictions on the
use of antibiotics as animal growth promoters4949 Castanon JIR. History of the
use of antibiotic as growth promoters in European poultry feeds. Poultry
Science. 2007; 86(11):2466-2471..
As regards innovation, the Resolution asserted that antimicrobial drug-resistant
infections are made harder to treat by the lack of effective agents for some
cases and by the prohibitive prices of new generation antimicrobial drugs1515
World Health Organization. Report of regional interest adopted by the
fifty-first World Health Assembly [internet]. [Genebra]: WHO; [1998]. [acesso em
2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . Many countries were unable to afford
innovative medicines, while existing antimicrobial drugs were being prescribed
irrationally. The solutions proposed included strengthening patent laws. That
Resolution made no provision for recommendations to countries as regards the
innovation gap. It merely recommended that the WHO collaborate in knowledge
sharing among the public sector, academia and industry, and encourage promotion
of R&D in the area1717 World Health Organization. Financial Report and Audited
Financial Statements for the period 1 January 1998- 31 December 1999.
[internet]. [Genebra]: WHO; [1998]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
In 2001, the WHO published the Global Strategy for Containment of Antimicrobial
Resistance (WHO/CDS/CSR/DRS/2001.2)1818 World Health Organization. Global
strategy for containment of antimicrobial resistance [internet]. [Genebra]: WHO;
[2001]. [acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... , proposing a series of interventions to
retard the emergence and reduce the dissemination of microorganisms resistant to
antimicrobial drugs.
With regard to animal production, the document addressed the relation between
the food production system and the spread of AMR. World population growth had
driven mounting demand for foods from animal sources and, in order to meet that
need, animal production had shifted to an intensive model, thus creating an
environment favourable to the spread of infectious diseases among animals. This,
in turn, led to antibiotics’ being used to treat and prevent diseases and also
to promote animal growth1818 World Health Organization. Global strategy for
containment of antimicrobial resistance [internet]. [Genebra]: WHO; [2001].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
The WHO recognised the relationship between antibiotic use in animal production
and AMR in humans in the light of evidence that antibiotic-resistant bacterial
strains had appeared in humans after antibiotics were introduced into production
of foods from animal sources. France, Germany, Ireland, the Netherlands, Russia
and other countries had reported that certain strains had become less
susceptible to antibiotics after their use was permitted in animal
production1818 World Health Organization. Global strategy for containment of
antimicrobial resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
Recognising that AMR is a complex, multifactor problem, the 2001 document1818
World Health Organization. Global strategy for containment of antimicrobial
resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago 17].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... outlined an inter-sector strategy resting on
collaboration among various sectors of society (doctors, veterinary doctors,
pharmacists and other health professionals, agricultural and livestock
producers, the pharmaceutical industry, civil society, governments and other
interested parties)1818 World Health Organization. Global strategy for
containment of antimicrobial resistance [internet]. [Genebra]: WHO; [2001].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . That document also proposed legislation to
control the consumption of antibiotics in animal production; for instance,
making veterinary prescription mandatory for the dispensing of antibiotics1818
World Health Organization. Global strategy for containment of antimicrobial
resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago 17].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
Regarding technological innovation, the 2001 document repeated that the risk of
there being no effective therapies in coming years resulted from a gap to
innovate in antimicrobial drugs. The gap was justified by the lengthy, expensive
R&D activities involved and by the fact that restrictions on the use of new
medicines, indicated as the therapeutic option of last resort, could have
adverse impact on sales. The document acknowledged that firms should recover
their R&D expenditures and gain profit from the product. Accordingly, new
antimicrobial drugs and vaccines should be developed in order to avert the
future impact of resistance, but that incentives were necessary for private R&D
in this field1818 World Health Organization. Global strategy for containment of
antimicrobial resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
The Global Strategy of 20011818 World Health Organization. Global strategy for
containment of antimicrobial resistance [internet]. [Genebra]: WHO; [2001].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... warned of the existence of biases in
cost-effectiveness studies, which favoured new antimicrobial agents, because
older ones unprotected by patents were not attractive, and that studies of the
cost or clinical impact of AMR were lacking. Added to this, access to new
medicines was unequal, because it was limited in less-developed countries, and
solutions were required for resource-limited settings. Greater interaction among
industry, government and academia was cited as one possible solution in this
context1818 World Health Organization. Global strategy for containment of
antimicrobial resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
It proposed that international research and cooperation networks be set up to
work on harmonizing regulatory requirements, and specifically mentioned
interaction with industry through innovative incentives for investment in
antimicrobial drug R&D. The suggestions mentioned included a regulatory fast
track or application of a policy similar to that in place for orphan diseases;
time-limited exclusivity; and appropriate patent protection. Action to combat
AMR should be taken at the global level, framed by the concept of “global public
goods for health”1818 World Health Organization. Global strategy for containment
of antimicrobial resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017
ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... , and coordinated in such a way as to avoid
duplicating efforts. It was also suggested to establish an international
database of funding sources for research in the field, thus creating a single
gateway for projects, developing new programmes and strengthening existing
ones1818 World Health Organization. Global strategy for containment of
antimicrobial resistance [internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
PERIOD FROM 2002 TO 2005: LITTLE DISCUSSION ON THE ISSUE
Between 2002 and 2004, the topic of AMR was not addressed at the WHA, probably
in view of the 2001 Global Strategy and the expectation that Member States would
be drawing up their own action plans. In 2005, AMR was mentioned again at the
WHA, but matters relating to antibiotic use in agriculture and livestock
production were not discussed2020 World Health Organization. Report of regional
interest adopted by the fifty-eight Assembly [internet]. [Genebra]: WHO; [2005].
[acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,2121 World Health Organization. Resolution
and decision of fifty-eight Assembly [internet]. [Genebra]: WHO; [2005]. [acesso
em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
On innovation, Report A58/142020 World Health Organization. Report of regional
interest adopted by the fifty-eight Assembly [internet]. [Genebra]: WHO; [2005].
[acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... once again stressed the high prices of
antimicrobial drugs when launched onto the market and proposed solutions to the
problem, such as prices being lowered by the industry and using generic
alternatives. Nonetheless, Resolution WHA58.272121 World Health Organization.
Resolution and decision of fifty-eight Assembly [internet]. [Genebra]: WHO;
[2005]. [acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... of the same year contained no action in this
respect.
The mention of competition with generic medicines to address high prices marked
a shift from solutions put forward in previous documents, which had pointed to
reinforcing the intellectual property system. That shift in orientation is
likely to have reflected the process – underway in the WHO as well – on the
subject of public health, innovation and intellectual property, triggered
chiefly by the approval in 2003 of Resolution WHA56.275050 World Health
Organization. Resolution and decision of fifty - sixth Assembly [internet].
[Genebra]: WHO; 2003. [acesso em 2019 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... , which set up the Commission on Intellectual
Property Rights, Innovation and Public Health (CIPIH)5050 World Health
Organization. Resolution and decision of fifty - sixth Assembly [internet].
[Genebra]: WHO; 2003. [acesso em 2019 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
PERIOD FROM 2006 TO 2013: LITTLE VISIBILITY FOR AMR ON THE WORLD HEALTH ASSEMBLY
AGENDA
Few documents on the subject of AMR were found to have been issued in the WHO
from 2006 to 2013. Meanwhile, between 2003 and 2012, the subject of public
health, innovation and intellectual property gained prominence in the wake of
developments from the 2006 CIPIH report5151 World Health Organization. Report of
the Commission on Intellectual Property Rights, Innovation and Public Health
[internet]. [Genebra]: WHO; [2016]. [acesso em 2019 jan 10]. Disponível em:
https://www.who.int/intellectualproperty/report/en/.
https://www.who.int/intellectualproperty... and approval in 2008 of the Global
Strategy and Plan of Action on Public Health, Innovation and Intellectual
Property5252 World Health Organization. The Global Strategy and Plan of Action
on Public Health, Innovation and Intellectual Property [internet]. [Genebra]:
WHO; [2008]. [acesso em 2019 jan 10]. Disponível em:
https://www.who.int/phi/implementation/phi_globstat_action/en/.
https://www.who.int/phi/implementation/p... and the 2012 report of the
Consultative Expert Working Group on R&D: Financing and Coordination (CEWG)5353
World Health Organization. Research and Development. Report of the Expert
Working group [internet]. [Genebra]: WHO; [2010]. [acesso em 2019 jan 10].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,5454 World Health Organization. Consultative
Expert Working group on Research and Development: Financing and Coordination
[internet]. [Genebra]: WHO; [2012]. [acesso em 2019 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . The latter sought proposals of new funding
sources and innovative funding mechanisms to encourage R&D to meet health needs
that affected developing countries disproportionately.
In the eight years during which the issue of AMR was not addressed explicitly at
WHA meetings, advances were observed in implementation of a global strategy for
AMR, such as the development of integrated epidemiological surveillance systems
on the African continent and in Latin American countries and the implementation
of strategies to address the problem in regions including the Eastern
Mediterranean, Southeast Asia, the EU and the Western Pacific5050 World Health
Organization. Resolution and decision of fifty - sixth Assembly [internet].
[Genebra]: WHO; 2003. [acesso em 2019 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
Although the Plan of Action on AMR approved in 2001 was in place, the WHO
considered it not to have been widely accepted by countries5050 World Health
Organization. Resolution and decision of fifty - sixth Assembly [internet].
[Genebra]: WHO; 2003. [acesso em 2019 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . In 2014, of the 92 Member States present,
only 29 had developed national strategies, 20% of them developing countries.
Accordingly, in 2013, the WHO Director-General set up a strategic and technical
consultative committee on AMR, which met for the first time that same year and
concluded that it was necessary to renew and expand the global strategy to
contain AMR5050 World Health Organization. Resolution and decision of fifty -
sixth Assembly [internet]. [Genebra]: WHO; 2003. [acesso em 2019 maio 20].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,5151 World Health Organization. Report of
the Commission on Intellectual Property Rights, Innovation and Public Health
[internet]. [Genebra]: WHO; [2016]. [acesso em 2019 jan 10]. Disponível em:
https://www.who.int/intellectualproperty/report/en/.
https://www.who.int/intellectualproperty... .
REFORMULATION OF THE AMR RESPONSE AND RELATED DEVELOPMENTS
PERIOD FROM 2014 TO 2019: FORMULATION OF THE AMR RESPONSE AND AN IMPLEMETATION
PLAN.
In 2014, AMR returned to the WHO agenda in more robust form and with a view to
engaging other global actors. Report A67/392424 World Health Organization.
Report of Sixty-Seventh World Health Assembly. [internet]. [Genebra]: WHO;
[2014]. [acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... and Resolution WHA67.252525 World Health
Organization. Resolution and decision of Sixty-Seventh World Health Assembly
[internet]. [Genebra]: WHO; [2014]. [acesso em 2017 ago 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... were approved
Two changes proposed in 2014 stand out in relation to the plan approved in 2001.
The first was the adoption of the One Health concept as a guiding principle for
formulation of a global plan of action on AMR. The WHO regarded the concept as
allowing a coherent, comprehensive and integrated approach at the global,
regional and national levels, involving different actors and sectors, such as
human and veterinary medicine, agriculture, environment and consumers.
The second change was the establishment of a Global Task Force on Antimicrobial
Resistance based on tripartite collaboration among the United Nations Food and
Agriculture Organization (FAO), the World Animal Health Organization (OIE) and
the WHO2424 World Health Organization. Report of Sixty-Seventh World Health
Assembly. [internet]. [Genebra]: WHO; [2014]. [acesso em 2017 ago 17].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,2525 World Health Organization. Resolution
and decision of Sixty-Seventh World Health Assembly [internet]. [Genebra]: WHO;
[2014]. [acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
In that context, the WHO Director-General called for a Global Plan to be drawn
up to assist the Assembly with its decisions and assure that all countries,
especially developing countries, were able to respond to AMR2424 World Health
Organization. Report of Sixty-Seventh World Health Assembly. [internet].
[Genebra]: WHO; [2014]. [acesso em 2017 ago 17]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,2525 World Health Organization. Resolution
and decision of Sixty-Seventh World Health Assembly [internet]. [Genebra]: WHO;
[2014]. [acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . That document was then drafted in
collaboration among the three organisations mentioned earlier.
The draft approved in 20142626 World Health Organization. Draft global action
plan on antimicrobial resistance. [Internet]. [Genebra]: WHO; [2014]. [acesso em
2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... outlined the priority areas for AMR response
action, with quantifiable targets and goals and implementation plans specifying
roles and responsibilities of the actors involved. It also provided for
indicators to enable progress to be monitored, measured and replicated.
The 2014 Report (A67/39)2424 World Health Organization. Report of Sixty-Seventh
World Health Assembly. [internet]. [Genebra]: WHO; [2014]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... broadened its view of the innovation problem
to include the lack of innovation in diagnostics. The report mentioned the
insufficiency of investment in R&D for AMR-related technologies, whether
preventive (vaccines), treatment-related (antimicrobial drugs) or diagnostic. It
stressed the need for incentives for innovation in the field, associated with
sustainable new models to support R&D in the long term and recommended that the
WHO partner with industry. That year’s Resolution (WHA67.25)2525 World Health
Organization. Resolution and decision of Sixty-Seventh World Health Assembly
[internet]. [Genebra]: WHO; [2014]. [acesso em 2017 ago 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... cited limited development of new
antimicrobial agents, and mentioned the CEWG Report and the R&D Observatory. It
recommended that countries encourage new collaborative and financing models for
innovation. The need to finance R&D and Innovation (RD&I) in this field was
mentioned both in recommendations to the countries and in the WHO mandate2525
World Health Organization. Resolution and decision of Sixty-Seventh World Health
Assembly [internet]. [Genebra]: WHO; [2014]. [acesso em 2017 ago 20]. Disponível
em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
This gap in technological innovation is a central item in discussions of AMR.
Beginning in 2003, the issue of public health, innovation and intellectual
property began to gain prominence in the WHO, and arguments and actions relating
to this public health issue can be seen as included into documents issued from
2014 onwards.
In 2015, the 68th WHA reaffirmed the importance of the tripartite collaboration
(WHO/FAO/OIE) and mentioned the institutions’ common interest in tackling
AMR3232 World Health Organization. Report of sixty-eight World Health Assembly
[internet]. [Genebra]: WHO; [2015]. [acesso em 2017 ago 2017]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . That year the Tripartite developed a new
Global Action Plan on AMR1111 World Health Organization. Draft global action
plan on antimicrobial resistance [internet]. [Genebra]: WHO; [2015]. [acesso em
2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... and a meeting was convened with the
Secretary-General to hold a high-level meeting on AMR in 20163333 World Health
Organization. Resolution and decision of sixty-eight Assembly [internet].
[Genebra]: WHO; [2015]. [acesso em 2017 ago 2017]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
The Resolution approved that same year (WHA68.7) requested all Member States to
adapt the Global Action Plan on AMR to their national priorities. It also
stipulated that, by the 70th WHA, in 2017, all country plans should be aligned
with the WHO plan1111 World Health Organization. Draft global action plan on
antimicrobial resistance [internet]. [Genebra]: WHO; [2015]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... and with the standards and guidelines laid
down by other international bodies, such as the Codex Alimentarius Commission,
FAO and OIE3333 World Health Organization. Resolution and decision of
sixty-eight Assembly [internet]. [Genebra]: WHO; [2015]. [acesso em 2017 ago
2017]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
In 2016, the WHO published Report A70/123535 World Health Organization. Global
action plan on antimicrobial resistance. Options for establishing a global
development and stewardship framework to support the development, control,
distribution and appropriate use of new antimicrobial medicines, diagnostic
tools, vaccines and other interventions [internet]. [Genebra]: WHO; [2016].
[acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... , as well as a Global Framework for
Development and Stewardship to Combat Antimicrobial Resistance, produced jointly
by the WHO, FAO and OIE. The Framework pointed to the need to support the
development, control, distribution and appropriate use of new antimicrobial
drugs, diagnostic tools, vaccines and other interventions, with a view to
promoting affordable access to existing and new antimicrobial medicines and
diagnostic tools, taking into account the needs of all countries and in line
with the Global Action Plan on Antimicrobial Resistance3535 World Health
Organization. Global action plan on antimicrobial resistance. Options for
establishing a global development and stewardship framework to support the
development, control, distribution and appropriate use of new antimicrobial
medicines, diagnostic tools, vaccines and other interventions [internet].
[Genebra]: WHO; [2016]. [acesso em 2017 ago 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
In 2016, AMR became an issue beyond the health arena with the UN’s approval of
the Political Declaration of the High-Level Meeting of the General Assembly on
Antimicrobial Resistance. The document reaffirmed that the Global Plan of Action
on AMR should be drawn up by the WHO in collaboration with the FAO, OIE and UN,
and represent the commitment of Heads of State and Government to developing a
multi-sector action plan in line with the One Health concept3636 United Nations
Organization. Political Declaration of the High- Level Meeting of General
Assembly on Antimicrobial Resistance [internet]. [Genebra]: UN; [2016]. [acesso
em 2017 set 20]. Disponível em: https://digitallibrary.un.org/record/842813.
https://digitallibrary.un.org/record/842... .
That document mentioned that AMR posed a challenge to attainment of the
Sustainable Development Goals set in Agenda 2030. It also instituted the
Interagency Coordination Group (IACG) on AMR. The Group was co-chaired by the
WHO and the UN Secretariat, with the participation of other institutions of the
UN system, international organisations, civil society and private sector
representatives and experts in a number of AMR-related fields. Its main aim was
to produce a report to assist decision-making on AMR at the 73rd WHA3636 United
Nations Organization. Political Declaration of the High- Level Meeting of
General Assembly on Antimicrobial Resistance [internet]. [Genebra]: UN; [2016].
[acesso em 2017 set 20]. Disponível em:
https://digitallibrary.un.org/record/842813.
https://digitallibrary.un.org/record/842... . In 2019, the Group published the
report ‘No time to wait: securing the future from drug-resistant infections’4444
United Nations. No time to wait: securing the future from drug-resistant
infections. Report to the Secretary - General of the United Nations. [internet].
[Genebra]: UN; [2019]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/.
http://apps.who.int/... .
Unlike previous years, in 2016 and 2017 no Resolution was approved on AMR at the
WHA, because the Global Plan of Action on AMR had been approved in 2015. In
2018, the Tripartite signed a collaboration agreement with the United Nations
Environment Programme (UNEP) (figure 1) to tackle AMR at a multi-sector
(human-animal-environment) interface4040 World Health Organization. Memorandum
of Understanding between The United Nations Food and Agriculture Organization
and The World Organisation for Animal Health and The World Health Organizations.
[internet]. [Genebra]: WHO; [2018]. [acesso em 2020 maio 20]. Disponível em:
https://www.who.int/antimicrobial-resistance/publications/tripartite-work-plan/en/.
https://www.who.int/antimicrobial-resist... .
At each WHA after 2015, countries were updated as to the status of Member
States’ adoption of the Global Action Plan. In 2017, 67 countries had developed
their plans to address the problem3838 World Health Organization. Report of
seventieth World Health Assembly. Antimicrobian Resistance [internet].
[Genebra]: WHO; [2017]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ; by 2019, 117 countries had done so.
However, only half of these – among them Brazil – had set up a multi-sector
committee with representatives of various fields1313 Ministério da Saúde.
Resistência antimicrobiana: enfoque multilateral e resposta brasileira. In:
Saúde e Política Externa: os 20 anos da Assessoria de Assuntos Internacionais de
Saúde (1998-2018). [internet]. [Brasília, DF]: MS; [2018]. [acesso em 2020 maio
20]. Disponível em: www.saude.gov.br.
www.saude.gov.br... . The number of countries still developing their plans
remained at 62 from 20173838 World Health Organization. Report of seventieth
World Health Assembly. Antimicrobian Resistance [internet]. [Genebra]: WHO;
[2017]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... to 20194242 World Health Organization.
Follow-up to the high-level meetings of the United Nations General Assembly on
health-related issues. [internet]. [Genebra]: WHO; [2019]. [acesso em 2020 maio
20]. Disponível em: https://apps.who.int/.
https://apps.who.int/... .
At the 2019 WHA, the countries reaffirmed their commitment to continue
increasing their efforts to adopt the Global Plan of Action on AMR at the
national level4343 World Health Organization. Resolution and decisions of
Seventy-Second World Health Assembly. Antimicrobial resistance. [internet].
[Genebra]: WHO; [2019]. [acesso em 2020 maio 20]. Disponível em:
https://apps.who.int/.
https://apps.who.int/... . The Resolution addressed the question of the rational
use of antibiotics in humans and animals, and mentioned the clinical guidelines
for using antibiotics that are important to human health4343 World Health
Organization. Resolution and decisions of Seventy-Second World Health Assembly.
Antimicrobial resistance. [internet]. [Genebra]: WHO; [2019]. [acesso em 2020
maio 20]. Disponível em: https://apps.who.int/.
https://apps.who.int/... (the ‘AWaRE’ Classification). As regards RD&I, it was
agreed that the countries would support voluntary technology transfer to prevent
and control AMR4343 World Health Organization. Resolution and decisions of
Seventy-Second World Health Assembly. Antimicrobial resistance. [internet].
[Genebra]: WHO; [2019]. [acesso em 2020 maio 20]. Disponível em:
https://apps.who.int/.
https://apps.who.int/... .
Other initiatives led by the WHO during this period included setting up the
Global Antibiotic Research and Development Partnership (GARDP) in 2016,
publication of a list of resistant pathogens and approval of guidelines and best
practices for animal production in 2017 (figure 1 and chart 3).
Thumbnail
Chart 3
Examples of 'global public goods'5555 Drugs for Neglected Diseases Initiative.
Global Antibiotic Research & Development Partnership (GARDP) [internet].
[Genebra]. [acesso em 2019 set 10]. Disponível em:
https://www.dndi.org/achievements/gardp/.
https://www.dndi.org/achievements/gardp/... in the AMR field
The WHO approved specific budgets for AMR for the two-year periods 2016-2017 and
2018-2019 of US$19 million and US$42 million, respectively. What is striking is
that the budget for 2018-2019 is roughly double those approved for 2016-2017 and
1998-1999 (about US$23 million). That fact indicates that, despite the
structural crisis in WHO funding5858 Ventura D, Perez F. Crise e reforma da
organização mundial de saúde. Lua Nova. 2014; 92:45-77., funds were earmarked
for AMR. It also points to greater breadth and commitment in the 2015 plan as
compared with 2001.
GLOBAL HEALTH SYSTEM GOVERNANCE AND FUNCTIONS APPLIED TO THE CASE OF AMR
Drawing on the concept of Global Governance for Health4646 Frenk J, Moon S.
Governance challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942., the document analysis in this study found that the WHO
recognised AMR as a global health problem, because no country alone could
contain its advance, which overrides national borders and involves diverse
sectors of society1818 World Health Organization. Global strategy for
containment of antimicrobial resistance [internet]. [Genebra]: WHO; [2001].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
It is evident that, over the whole course of formulation of the Global Plan of
Action on AMR at the WHO, the issue of international cooperation to support
developing countries and least-developed countries (LDCs) to formulate their
plans to tackle AMR. Inequality among Member States was recognised as an
important issue and, for that reason, international cooperation served as a tool
for supporting LDCs by developing epidemiological surveillance laboratories and
programmes and training personnel1111 World Health Organization. Draft global
action plan on antimicrobial resistance [internet]. [Genebra]: WHO; [2015].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,1818 World Health Organization. Global
strategy for containment of antimicrobial resistance [internet]. [Genebra]: WHO;
[2001]. [acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
Both the 2001 Global Strategy1818 World Health Organization. Global strategy for
containment of antimicrobial resistance [internet]. [Genebra]: WHO; [2001].
[acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... and the 2015 Global Action Plan1818 World
Health Organization. Global strategy for containment of antimicrobial resistance
[internet]. [Genebra]: WHO; [2001]. [acesso em 2017 ago 17]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... reinforced the importance of epidemiological
surveillance as one of the structural components of the response to AMR. It was
recommended that each Member State develop a national system to monitor
antibiotic consumption in humans and animals and the incidence of AMR. Also as
regards epidemiological surveillance, the platform of the Global Antimicrobial
Resistance Surveillance System (Glass) was inaugurated in 2015. This initiative
was designed to collect and analyse country-level information on AMR so as to
produce evidence to guide national, regional and global action to tackle AMR. By
2019, 105 countries claimed to have their own surveillance systems; 67 shared
their findings and 48 input crude data to the GLASS initiative4242 World Health
Organization. Follow-up to the high-level meetings of the United Nations General
Assembly on health-related issues. [internet]. [Genebra]: WHO; [2019]. [acesso
em 2020 maio 20]. Disponível em: https://apps.who.int/.
https://apps.who.int/... .
The Global Plan of Action on AMR, as well as the guidelines and initiatives on
antibiotic use in agriculture and livestock, and research, development and
innovation in new antimicrobial drugs (chart 3), are all regarded as examples of
‘global public goods’4646 Frenk J, Moon S. Governance challenges in global
health. New England Journal of Medicine. 2013; 368(10):936-942. in the AMR
context.
Global health is thus the outcome of the policymaking process in a diversity of
institutional spaces4646 Frenk J, Moon S. Governance challenges in global
health. New England Journal of Medicine. 2013; 368(10):936-942.. Considering the
concept of institutional dimension proposed by Sell4747 Sell SK. The quest for
global governance in intellectual property and public health: Structural,
discursive, and institutional dimensions. Temp. L. Rev. 2004; 77:363., the
document analysis found that a number of multilateral institutions participated
in the process of formulating the plan to tackle AMR, including the WHO, FAO,
OIE, UN, World Trade Organization (WTO) and later the UNEP (figure 2). This
gives greater grounds for claiming that development of the AMR response plan was
the outcome of meshing among organisations with different perspectives.
Thumbnail
Figure 2
Diagram of the institutional dimension of global health in the case of AMR
*The United Nations System comprises specialised agencies and institutional
programmes.
United Nations Environment Programme (Unep), United Nations Food and Agriculture
Organization (FAO), United Nations Organization (UN), World Health Organization
(WHO), World Trade Organization (WTO), World Animal Health Organization (OIE).
Illustrating that interrelationship, it can be seen that three of the four
sub-functions of Stewardship were applied there4646 Frenk J, Moon S. Governance
challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.: cross- sector health advocacy; negotiation and consensus
building; and setting rules to manage the dimensions of health across sectors.
The Resolution of the 68th WHA states that the WHO partnered with the UN in
order to join forces in search of efficient mechanisms with which to implement
the Global Action Plan for all nations, considering the needs of developing
countries3333 World Health Organization. Resolution and decision of sixty-eight
Assembly [internet]. [Genebra]: WHO; [2015]. [acesso em 2017 ago 2017].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . With regard to AMR, the WHO was found to
have collaborated with other multilateral organisations so as to further the
interests of global health in other institutions that were not responsible for
health-related issues, but which could influence the global health field.
As regards negotiating and consensus building on the use of antibiotics in
agriculture and livestock, no mention was found of any ban on the use
antibiotics as growth promoters in animal production, probably because this was
an issue of tension and dissent among countries. At the national level, some
countries took different positions on the issue on the basis of various
arguments. EU countries banned growth promoters as of 20065959 Kahn LW. One
health and the politic of antimicrobial resistance. John Hopkins University
Press; 2016. and recently (2018)6060 European Parliament: veterinary medicine:
another step in fighting antibiotic resistance. [internet]. [acesso em 2020 maio
10]. Disponível em:
https://www.europarl.europa.eu/news/en/headlines/society/20181018STO16580/veterinary-medicines-fighting-antibiotic-resistance.
https://www.europarl.europa.eu/news/en/h... restricted the preventive use of
antibiotics in animal production6060 European Parliament: veterinary medicine:
another step in fighting antibiotic resistance. [internet]. [acesso em 2020 maio
10]. Disponível em:
https://www.europarl.europa.eu/news/en/headlines/society/20181018STO16580/veterinary-medicines-fighting-antibiotic-resistance.
https://www.europarl.europa.eu/news/en/h... . Meanwhile, some developing
countries, such as Brazil, permit the use of growth promoters88 Brasil.
Decreto-lei nº 8448, de 6 de maio de 2015. Regulação da Fiscalização dos
Produtos de Uso Veterinário [internet]. Diário Oficial da União. 6 Maio 2015.
[acesso em 2017 nov 15]. Disponível em: http://www.planalto.gov.br/.
http://www.planalto.gov.br/... ,1313 Ministério da Saúde. Resistência
antimicrobiana: enfoque multilateral e resposta brasileira. In: Saúde e Política
Externa: os 20 anos da Assessoria de Assuntos Internacionais de Saúde
(1998-2018). [internet]. [Brasília, DF]: MS; [2018]. [acesso em 2020 maio 20].
Disponível em: www.saude.gov.br.
www.saude.gov.br... .
The 2014 Resolution mentions that the partnership among the WHO, FAO and OIE was
set up to manage conflicts of interest, with a view to support the drafting
Global Action Plan on AMR2525 World Health Organization. Resolution and decision
of Sixty-Seventh World Health Assembly [internet]. [Genebra]: WHO; [2014].
[acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
On the option between ‘banning’ or ‘not banning’ the use of growth promoters,
the IACG reached a compromise in which it recommended that certain antibiotics
classified as critically important to human health should gradually be phased
out4444 United Nations. No time to wait: securing the future from drug-resistant
infections. Report to the Secretary - General of the United Nations. [internet].
[Genebra]: UN; [2019]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/.
http://apps.who.int/... of animal use. The report considered that initiative to
be a first step towards the rational use of antibiotics in animal production4444
United Nations. No time to wait: securing the future from drug-resistant
infections. Report to the Secretary - General of the United Nations. [internet].
[Genebra]: UN; [2019]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/.
http://apps.who.int/... . Accordingly, the establishment of the FAO/WHO/OIE
taskforce is believed to have been fundamental in building consensus on the use
of antibiotics for promoting growth.
In addition to consensus building, the actors are considering settting new rules
or instruments to manage AMR-related issues. The 2016 Report mentioned the legal
status of the standards, guidelines and codes of practice of the Codex
Alimentarius and OIE enjoyed under WTO agreements3434 World Health Organization.
Report of sixty-nine World Health Assembly. Antimicrobial Resistance [internet].
[Genebra]: WHO; [2016]. [acesso em 2017 ago 2017]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .
The Stewardship sub-function ‘setting rules to manage the dimensions of health
across sectors’ is exemplified in the IACG report by the process still under way
among countries with regard to adopting binding and non-binding instruments for
measures on AMR4444 United Nations. No time to wait: securing the future from
drug-resistant infections. Report to the Secretary - General of the United
Nations. [internet]. [Genebra]: UN; [2019]. [acesso em 2020 maio 20]. Disponível
em: http://apps.who.int/.
http://apps.who.int/... .
CONCLUSIONS
This study examined the formulation of the response to AMR in the WHO. The
findings indicate that, although the issue has been on the agenda since 1998,
and a plan to address AMR was approved in 2001, few advances can be seen as
regards adoption by WHO Member States. In 2014, when the One Health concept was
endorsed, conditions were created for adhesion by other international
institutions (FAO, OIE and WTO) and for approval of the Global Plan of Action on
AMR.
Given the complexity and comprehensiveness of the factors relating to AMR, it
was to be expected that design of a global response to the problem would be
immersed in that complexity, particularly because not only do public health
needs affect sensitive economic sectors – the agriculture and livestock and
pharmaceutical industries – but they also reinforce asymmetries among countries.
In that light, it was fundamental to triangulate among multiple analytical
frames of reference so as to permit a broader understanding of the study object,
underscoring its global importance and recognising the dimension of antibiotic
use in animals and the gap in technological innovation.
Besides being an important mobilising agent for the response to AMR at the
global level, the WHO has also assured a budget for actions on this issue even
in a context of defunding. It is thus concluded that the public health
perspective should prevail in the response to AMR. It remains to be analysed how
far-reaching will be national-level adoption of the proposals approved
multilaterally to curtail the spread of AMR and, at the same time, assure that
therapeutic options involving existing and new antimicrobial drugs continue to
be available to those who need them.
* Financial support: Coordenação de Aperfeiçoamento de Pessoal de Nível
Superior (Capes)
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»
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PUBLICATION DATES
* Publication in this collection
16 Nov 2020
* Date of issue
Jul-Sep 2020
HISTORY
* Received
11 Dec 2019
* Accepted
08 June 2020
Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative
Commons Attribution, que permite uso, distribuição e reprodução em qualquer
meio, sem restrições desde que o trabalho original seja corretamente citado
×Close
ABOUT THE AUTHORS
Rafael Almeida da Silva
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
* http://orcid.org/0000-0002-5049-9124
Beatriz Nascimento Lins de Oliveira
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
* http://orcid.org/0000-0002-2397-5244
Luiza Pinheiro Alves da Silva
Universidade Federal de Minas Gerais (UFMG) – Belo Horizonte (MG), Brasil.
* http://orcid.org/0000-0002-3740-2973
Maria Auxiliadora Oliveira
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
* http://orcid.org/0000-0003-2400-536X
Gabriela Costa Chaves
Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca
(Ensp) – Rio de Janeiro (RJ), Brasil. rafaelalmmeida@gmail.com
* http://orcid.org/0000-0002-8347-6164
Collaborators
Silva RA (0000-0002-5049-9124)**Orcid (Open Researcher and Contributor ID).,
Oliveira BNL (0000-0002-2397-5244)**Orcid (Open Researcher and Contributor ID).,
Silva LPA (0000-0002-3740-2973)**Orcid (Open Researcher and Contributor ID).,
Oliveira MA (0000-0003-2400-536X)**Orcid (Open Researcher and Contributor ID).,
Chaves GC (0000-0002-8347-6164)**Orcid (Open Researcher and Contributor ID).
contributed equally to preparing the manuscript.
*
Orcid (Open Researcher and Contributor ID).
Conflict of interest: non-existent
×Close
FIGURES | TABLES
* Figures (2)
* Tables (3)
Thumbnail
Figure 1
Timeline of AMR response formulation
*Biennial budget.
**International-level response.
World Health Organization (WHO), World Animal Health Organization (OIE), United
Nations Food and Agriculture Organization (FAO), United Nations Organization
(UN), United Nations Environment Programme (Unep). Global Antibiotic Research
and Development Partnership (GARDP), List of antibiotics by level of resistance
(AWare Classification).
Thumbnail
Figure 2
Diagram of the institutional dimension of global health in the case of AMR
*The United Nations System comprises specialised agencies and institutional
programmes.
United Nations Environment Programme (Unep), United Nations Food and Agriculture
Organization (FAO), United Nations Organization (UN), World Health Organization
(WHO), World Trade Organization (WTO), World Animal Health Organization (OIE).
Thumbnail
Chart 1
List of documents examined
Thumbnail
Chart 2
The institutional dimension as proposed by Sell and the global health functions
as proposed by Frenk & Moon
Thumbnail
Chart 3
Examples of 'global public goods'5555 Drugs for Neglected Diseases Initiative.
Global Antibiotic Research & Development Partnership (GARDP) [internet].
[Genebra]. [acesso em 2019 set 10]. Disponível em:
https://www.dndi.org/achievements/gardp/.
https://www.dndi.org/achievements/gardp/... in the AMR field
×Close
FIGURE 1 TIMELINE OF AMR RESPONSE FORMULATION
*BIENNIAL BUDGET.
**INTERNATIONAL-LEVEL RESPONSE.
WORLD HEALTH ORGANIZATION (WHO), WORLD ANIMAL HEALTH ORGANIZATION (OIE), UNITED
NATIONS FOOD AND AGRICULTURE ORGANIZATION (FAO), UNITED NATIONS ORGANIZATION
(UN), UNITED NATIONS ENVIRONMENT PROGRAMME (UNEP). GLOBAL ANTIBIOTIC RESEARCH
AND DEVELOPMENT PARTNERSHIP (GARDP), LIST OF ANTIBIOTICS BY LEVEL OF RESISTANCE
(AWARE CLASSIFICATION).
Source: the authors, from document analysis.
×Close
FIGURE 2 DIAGRAM OF THE INSTITUTIONAL DIMENSION OF GLOBAL HEALTH IN THE CASE
OF AMR
*THE UNITED NATIONS SYSTEM COMPRISES SPECIALISED AGENCIES AND INSTITUTIONAL
PROGRAMMES.
UNITED NATIONS ENVIRONMENT PROGRAMME (UNEP), UNITED NATIONS FOOD AND AGRICULTURE
ORGANIZATION (FAO), UNITED NATIONS ORGANIZATION (UN), WORLD HEALTH ORGANIZATION
(WHO), WORLD TRADE ORGANIZATION (WTO), WORLD ANIMAL HEALTH ORGANIZATION (OIE).
Source: the authors, on the theoretical basis proposed by Sell4747 Sell SK. The
quest for global governance in intellectual property and public health:
Structural, discursive, and institutional dimensions. Temp. L. Rev. 2004;
77:363..
×Close
CHART 1 LIST OF DOCUMENTS EXAMINED
YearDocuments1998Report A51/91515 World Health Organization. Report of regional
interest adopted by the fifty-first World Health Assembly [internet]. [Genebra]:
WHO; [1998]. [acesso em 2017 ago 17]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Resolution WHA51.171616 World Health Organization. Resolution and decision of
fifty-first Assembly [internet]. [Genebra]: WHO; [1998]. [acesso em 2017 ago
10]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Financial Report and Audited Financial Statements for the period 1998-19991717
World Health Organization. Financial Report and Audited Financial Statements for
the period 1 January 1998- 31 December 1999. [internet]. [Genebra]: WHO; [1998].
[acesso em 2020 maio 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2001Global Strategy for Containment of
Antimicrobial Resistance - WHO/CDS/CSR/DRS/2001.21818 World Health Organization.
Global strategy for containment of antimicrobial resistance [internet].
[Genebra]: WHO; [2001]. [acesso em 2017 ago 17]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Financial Report and Audited Financial Statements for the period 2000-20011919
World Health Organization. Financial Report and Audited Financial Statements for
the period 1 January 2000 - 31 December 2001. [internet]. [Genebra]: WHO;
[2000]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2005Report A58/142020 World Health
Organization. Report of regional interest adopted by the fifty-eight Assembly
[internet]. [Genebra]: WHO; [2005]. [acesso em 2017 ago 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Resolution WHA58.272121 World Health Organization. Resolution and decision of
fifty-eight Assembly [internet]. [Genebra]: WHO; [2005]. [acesso em 2017 ago
17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Financial Report and Audited Financial Statements for the period 2002-20032222
World Health Organization. Financial Report and Audited Financial Statements for
the period 1 January 2002 - 31 December 2003. [internet]. [Genebra]: WHO;
[2002]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Performance assessment report: Programme budget 2004-20052323 World Health
Organization. Performance Assessment Report: Programme Budget 2004-2005.
[internet]. [Genebra]: WHO; [2004]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2014Report A67/392424 World Health
Organization. Report of Sixty-Seventh World Health Assembly. [internet].
[Genebra]: WHO; [2014]. [acesso em 2017 ago 17]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Resolution WHA67.252525 World Health Organization. Resolution and decision of
Sixty-Seventh World Health Assembly [internet]. [Genebra]: WHO; [2014]. [acesso
em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Global Action Plan (draft) A67/39 Add.92626 World Health Organization. Draft
global action plan on antimicrobial resistance. [Internet]. [Genebra]: WHO;
[2014]. [acesso em 2017 ago 20]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Performance assessment report: Programme budget 2006-20072727 World Health
Organization. Performance Assessment Report: Programme Budget 2006-2007.
[internet]. [Genebra]: WHO; [2006]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Performance assessment report: Programme budget 2008-20092828 World Health
Organization. Performance Assessment Report: Programme Budget 2008-2009.
[internet]. [Genebra]: WHO; [2008]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Performance assessment report: Programme budget 2010-20112929 World Health
Organization. Performance Assessment Report: Programme Budget 2010-2011.
[internet]. [Genebra]: WHO; [2010]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Performance assessment report: Programme budget 2012-20133030 World Health
Organization. Performance Assessment Report: Programme Budget 2012-2013.
[internet]. [Genebra]: WHO; [2012]. [acesso em 2020 maio 20] Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Performance assessment report: Programme budget 2014-20153131 World Health
Organization. Performance Assessment Report: Programme Budget 2014-2015.
[internet]. [Genebra]: WHO; [2004]. [acesso em 2020 maio 20] Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2015Report A68/19; A68/203232 World Health
Organization. Report of sixty-eight World Health Assembly [internet]. [Genebra]:
WHO; [2015]. [acesso em 2017 ago 2017]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Resolution WHA68.73333 World Health Organization. Resolution and decision of
sixty-eight Assembly [internet]. [Genebra]: WHO; [2015]. [acesso em 2017 ago
2017]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Global Action Plan (draft) A68/20 and A68/20 Add.11111 World Health
Organization. Draft global action plan on antimicrobial resistance [internet].
[Genebra]: WHO; [2015]. [acesso em 2017 ago 17]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2016Report A69/243434 World Health
Organization. Report of sixty-nine World Health Assembly. Antimicrobial
Resistance [internet]. [Genebra]: WHO; [2016]. [acesso em 2017 ago 2017].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Global Action Plan - Stewardship Framework - Report by the Secretariat A69/24
Add.13535 World Health Organization. Global action plan on antimicrobial
resistance. Options for establishing a global development and stewardship
framework to support the development, control, distribution and appropriate use
of new antimicrobial medicines, diagnostic tools, vaccines and other
interventions [internet]. [Genebra]: WHO; [2016]. [acesso em 2017 ago 20].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
High-Level Meeting of the General Assembly on Antimicrobial Resistance (ONU)3636
United Nations Organization. Political Declaration of the High- Level Meeting of
General Assembly on Antimicrobial Resistance [internet]. [Genebra]: UN; [2016].
[acesso em 2017 set 20]. Disponível em:
https://digitallibrary.un.org/record/842813.
https://digitallibrary.un.org/record/842...
WHO Results Report: Programme budget 2016-20173737 World Health Organization.
WHO Results Report: Programme Budget 2016-2017. [internet]. [Genebra]: WHO;
[2016]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2017Report A70/123838 World Health
Organization. Report of seventieth World Health Assembly. Antimicrobian
Resistance [internet]. [Genebra]: WHO; [2017]. [acesso em 2020 maio 20].
Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
Guidelines on use of medically important antimicrobials in food-producing
animals3939 World Health Organization. Who guidelines on use of medically
Important antimicrobials in food-producing animals [internet]. [Genebra]: WHO;
[2017]. [acesso em 2017 set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2018Memorandum of Understanding between
FAO/OIE/WHO/Unep1515 World Health Organization. Report of regional interest
adopted by the fifty-first World Health Assembly [internet]. [Genebra]: WHO;
[1998]. [acesso em 2017 ago 17]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/...
WHO Results Report: Programme budget 2018-20194141 World Health Organization.
WHO Results Report: Programme Budget 2018-2019. [internet]. [Genebra]: WHO;
[2018]. [acesso em 2020 maio 20]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... 2019Follow-up to the high-level meetings of
the United Nations General Assembly on health-related
issues4242 World Health Organization. Follow-up to the high-level meetings of
the United Nations General Assembly on health-related issues. [internet].
[Genebra]: WHO; [2019]. [acesso em 2020 maio 20]. Disponível em:
https://apps.who.int/.
https://apps.who.int/...
Resolution and decisions of the Seventy-second World Health Assembly.
Antimicrobial resistance4343 World Health Organization. Resolution and decisions
of Seventy-Second World Health Assembly. Antimicrobial resistance. [internet].
[Genebra]: WHO; [2019]. [acesso em 2020 maio 20]. Disponível em:
https://apps.who.int/.
https://apps.who.int/...
Report to the Secretary-General of the United Nations: 'No time to wait:
Securing the future from drug-resistant infections'4444 United Nations. No time
to wait: securing the future from drug-resistant infections. Report to the
Secretary - General of the United Nations. [internet]. [Genebra]: UN; [2019].
[acesso em 2020 maio 20]. Disponível em: http://apps.who.int/.
http://apps.who.int/...
Source: The authors. Documents available at: https://www.who.int/.
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CHART 2 THE INSTITUTIONAL DIMENSION AS PROPOSED BY SELL AND THE GLOBAL HEALTH
FUNCTIONS AS PROPOSED BY FRENK & MOON
Institutional Dimension
Scope of multilateral institutions (political arenas) that establish binding and
non-binding laws, declarations and resolutions with regard to global health4747
Sell SK. The quest for global governance in intellectual property and public
health: Structural, discursive, and institutional dimensions. Temp. L. Rev.
2004; 77:363..Global Health System
Comprising a group of actors whose aim is to improve global health by setting
rules at the international level. Works on the assumption that no country alone
is able to tackle the health threats to its population. Accordingly, it is
believed that strategies need to be developed at the international level4646
Frenk J, Moon S. Governance challenges in global health. New England Journal of
Medicine. 2013; 368(10):936-942..Governance
The manner in which the global health system is managed. Comprises formal and
informal mechanisms used by government and non-governmental actors to coordinate
strategies in multilateral forums to respond to risks to the world
population4646 Frenk J, Moon S. Governance challenges in global health. New
England Journal of Medicine. 2013;
368(10):936-942..FunctionDescriptionToolMobilising global solidarity4646 Frenk
J, Moon S. Governance challenges in global health. New England Journal of
Medicine. 2013; 368(10):936-942.Commitment by the global community to protecting
the rights of minority groups. The aim is to reduce inequalities in the
distribution of health problems among nations4646 Frenk J, Moon S. Governance
challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.Financial and technical support, professional capacity-building
and humanitarian assistance4646 Frenk J, Moon S. Governance challenges in global
health. New England Journal of Medicine. 2013; 368(10):936-942.Management of
externalities across countries4646 Frenk J, Moon S. Governance challenges in
global health. New England Journal of Medicine. 2013; 368(10):936-942.Some
situations that occur in one country may produce effects in others. This
function proposes to prevent or mitigate adverse effects on global health4646
Frenk J, Moon S. Governance challenges in global health. New England Journal of
Medicine. 2013; 368(10):936-942.Epidemiological surveillance and information
sharing and coordination for preparation and response4646 Frenk J, Moon S.
Governance challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.Production of global public goods4646 Frenk J, Moon S.
Governance challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.Information shared by the global community4646 Frenk J, Moon S.
Governance challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.Tools for international standardisation and guidelines on best
practices, e.g., International Classification of Diseases and List of Essential
Drugs4646 Frenk J, Moon S. Governance challenges in global health. New England
Journal of Medicine. 2013; 368(10):936-942.Stewardship4646 Frenk J, Moon S.
Governance challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.Responsible for guiding the whole global health system
strategically, meaning that the other essential functions mentioned depend on it
in order to function properly4646 Frenk J, Moon S. Governance challenges in
global health. New England Journal of Medicine. 2013;
368(10):936-942.Sub-functionsConvening to negotiation and consensus building;
priority setting; specifying managerial rules; assessing actors and their
actions; and advocating for health causes in other political arenas that can
influence decisions taken in the global health arena4646 Frenk J, Moon S.
Governance challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942.
Source: The authors, based on Frenk& Moon4646 Frenk J, Moon S. Governance
challenges in global health. New England Journal of Medicine. 2013;
368(10):936-942. and Sell4747 Sell SK. The quest for global governance in
intellectual property and public health: Structural, discursive, and
institutional dimensions. Temp. L. Rev. 2004; 77:363..
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CHART 3 EXAMPLES OF 'GLOBAL PUBLIC GOODS'5555 DRUGS FOR NEGLECTED DISEASES
INITIATIVE. GLOBAL ANTIBIOTIC RESEARCH & DEVELOPMENT PARTNERSHIP (GARDP)
[INTERNET]. [GENEBRA]. [ACESSO EM 2019 SET 10]. DISPONÍVEL EM:
HTTPS://WWW.DNDI.ORG/ACHIEVEMENTS/GARDP/.
HTTPS://WWW.DNDI.ORG/ACHIEVEMENTS/GARDP/... IN THE AMR FIELD
Initiatives taken at the global level to tackle the lack of research and
development in new antibioticsInitiativeDescriptionGlobal Antibiotic Research
and Development Partnership (GARDP)Partnership between the WHO and the Drugs for
Neglected Diseases Initiative (DNDi), to develop new therapeutic classes of
antibiotics5555 Drugs for Neglected Diseases Initiative. Global Antibiotic
Research & Development Partnership (GARDP) [internet]. [Genebra]. [acesso em
2019 set 10]. Disponível em: https://www.dndi.org/achievements/gardp/.
https://www.dndi.org/achievements/gardp/... .List of resistant pathogensList of
resistant pathogens with priority for R&D of new antibiotics. Classifies
resistant pathogens by threat risk to global health, so as to guide the process
of R&D into new therapeutic classes of antibiotics5656 World Health
Organization. Global Priority List of Antibiotic - Resistant Bacteria to Guide
Research, Discovery, And Development of New Antibiotics [internet]. [Genebra]:
WHO; [2017]. [acesso em 2019 set de 20]. Disponível em: https://www.who.int/.
https://www.who.int/... .'AWaRE' Classification of antibioticsThe WHO has
developed a data base containing 180 classes of antibiotics classified, by level
of resistance, into 'Access', 'Watch' and 'Reserve' groups5757 World Health
Organization. AWaRe Classification Antibiotics [internet]. [Genebra]: WHO;
[2017]. [acesso em 2017 set 17]. Disponível em: https://www.who.int/medicines/.
https://www.who.int/medicines/... . The data base is a tool to guide countries
in monitoring antibiotic use5757 World Health Organization. AWaRe Classification
Antibiotics [internet]. [Genebra]: WHO; [2017]. [acesso em 2017 set 17].
Disponível em: https://www.who.int/medicines/.
https://www.who.int/medicines/... .Initiatives taken within the WHO to reduce
consumption of antibiotics in animal production
WHO Guidelines on use, in animal production, of important antibiotics for human
health3939 World Health Organization. Who guidelines on use of medically
Important antimicrobials in food-producing animals [internet]. [Genebra]: WHO;
[2017]. [acesso em 2017 set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... GuidelinesBest practicesReduce use of all
classes of antibiotics important to human health in animal production3939 World
Health Organization. Who guidelines on use of medically Important antimicrobials
in food-producing animals [internet]. [Genebra]: WHO; [2017]. [acesso em 2017
set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... New antibiotics developed for human use
should be considered critically important to human health3939 World Health
Organization. Who guidelines on use of medically Important antimicrobials in
food-producing animals [internet]. [Genebra]: WHO; [2017]. [acesso em 2017 set
15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .Antibiotics important to human health should
not be used to promote animal growth3939 World Health Organization. Who
guidelines on use of medically Important antimicrobials in food-producing
animals [internet]. [Genebra]: WHO; [2017]. [acesso em 2017 set 15]. Disponível
em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... Drugs that are important to human health and
are not used in animal production should not be used for that purpose in the
future3939 World Health Organization. Who guidelines on use of medically
Important antimicrobials in food-producing animals [internet]. [Genebra]: WHO;
[2017]. [acesso em 2017 set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... .Antibiotics important to human health should
not be used in animal production to prevent undiagnosed infectious diseases3939
World Health Organization. Who guidelines on use of medically Important
antimicrobials in food-producing animals [internet]. [Genebra]: WHO; [2017].
[acesso em 2017 set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . Antibiotics classified as critically
important (high priority) to human medicine should not be used to treat
animals3939 World Health Organization. Who guidelines on use of medically
Important antimicrobials in food-producing animals [internet]. [Genebra]: WHO;
[2017]. [acesso em 2017 set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . (Conditional recommendation*) Antibiotics
critically important to human medicine should not be used to control the spread
of diseases in animal production3939 World Health Organization. Who guidelines
on use of medically Important antimicrobials in food-producing animals
[internet]. [Genebra]: WHO; [2017]. [acesso em 2017 set 15]. Disponível em:
http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... . (Conditional recommendation*)
Source: the authors, based on DNDi5555 Drugs for Neglected Diseases
Initiative. Global Antibiotic Research & Development Partnership (GARDP)
[internet]. [Genebra]. [acesso em 2019 set 10]. Disponível em:
https://www.dndi.org/achievements/gardp/.
https://www.dndi.org/achievements/gardp/... and WHO3939 World Health
Organization. Who guidelines on use of medically Important antimicrobials in
food-producing animals [internet]. [Genebra]: WHO; [2017]. [acesso em 2017
set 15]. Disponível em: http://apps.who.int/gb/archive/.
http://apps.who.int/gb/archive/... ,5656 World Health Organization. Global
Priority List of Antibiotic - Resistant Bacteria to Guide Research,
Discovery, And Development of New Antibiotics [internet]. [Genebra]: WHO;
[2017]. [acesso em 2019 set de 20]. Disponível em: https://www.who.int/.
https://www.who.int/... ,5757 World Health Organization. AWaRe Classification
Antibiotics [internet]. [Genebra]: WHO; [2017]. [acesso em 2017 set 17].
Disponível em: https://www.who.int/medicines/.
https://www.who.int/medicines/... .
* *
In this document, the WHO endorsed this recommendation as conditional due to
the poor quality of the available scientific evidence.
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HOW TO CITE
Silva, Rafael Almeida da et al. Resistência a Antimicrobianos: a formulação da
resposta no âmbito da saúde global. Saúde em Debate [online]. v. 44, n. 126
[Accessed 27 November 2024] , pp. 607-623. Available from:
<https://doi.org/10.1590/0103-1104202012602>. ISSN 2358-2898.
https://doi.org/10.1590/0103-1104202012602.
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