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28-11-2007 - Critically Important Antimicrobials

Posted by: JimEdwards on Nov 27, 2007 - 02:00 PM
Joint FAO/WHO/OIE Stakeholders Meeting, Rome, Italy. 26 November 2007

Professor Leon H. Russell, DVM, MPH, PhD, President, World Veterinary Association

The World Veterinary Association (WVA) is the only Non Governmental Organisation (NGO) representing the veterinary profession globally. As such, the mission of the WVA is to promote globally both animal and human health and well being through sustainable and humane use and management of animals. This includes animal welfare. The WVA also contributes to the veterinary protection and sustainability of the environment.

The WVA will respond to the following questions posed by the organisers of this stakeholders meeting:

a) The possible impact on animal production and consumer protection of the WHO list of critically important antimicrobials for human use and the OIE list of veterinary critically important antimicrobials.
The WVA is in full support of the initiatives taken by the OIE (Terrestrial Animal Health Code, 16th edition – 2007 - APPENDIX 3.9.3) which provide guidelines for the responsible and prudent use of antimicrobial agents in veterinary medicine. The WVA believes that the prudent and responsible use of antimicrobials in veterinary medicine is an essential management option for the prevention, control and treatment of animal diseases in maintaining animal health. The concept of animal health covers not only the absence of disease in animals, but it includes the critical relationship between the health of animals and their welfare. The WVA believes, therefore, that animal welfare is an important component of animal health. In concert with that fact, the relief of animal suffering from infectious diseases through the veterinary availability of effective antimicrobials is essential for the humane treatment of animals. Therefore, any decision to prohibit or restrict the use of veterinary critically important antimicrobials (VCIA) would have great impact on animal health and animal welfare.

b) The provision of information on current risk management strategies and options for maintaining the efficacy of CIA for humans and animals:
The WVA fully supports the laudable initiatives taken by the OIE (Terrestrial Animal Health Code, 16th edition – 2007 - APPENDIX 3.9.4) which provide guidelines for risk assessment of antimicrobial resistance arising from the use of antimicrobials in animals. Although all parts of risk analysis (risk assessment, risk management and risk communication) need to be fully implemented, it is essential that there be a co-ordinated approach in the risk management of antimicrobial resistance on the international level. This is needed especially for veterinary antimicrobials and medicines because of the animal species differences, and great global variations in animal husbandry and animal usage systems. As for the options for maintaining the efficacy of CIA for humans and animals for human and animals, this is a confusing question. The term “efficacy” is usually applied to experimental epidemiological studies using randomised clinical or intervention trials to determine the value of an experimental treatment. Options for maintaining the “effectiveness”, while avoiding adverse reactions (including antimicrobial resistance), should be given in the guidelines for the monitoring of the quantities of antimicrobials used in animal husbandry as given by the OIE (Terrestrial Animal Health Code, 16th edition – 2007 - APPENDIX 3.9.2). This should also be a stated objective of the quantitative risk assessment of human and non-human use of antimicrobial resistance (Terrestrial Animal Health Code, 16th edition – 2007 - APPENDIX 3.9.4). The listing of an antimicrobial as a “critical antimicrobial” should automatically require risk analysis for both human and non-human use to determine the level of risk. One final comment on this section. Since the FAO and WHO have previously charged the Codex Alimentarius Commission with doing risk assessment of antimicrobial resistance, it seems inappropriate to be considering this topic (risk management) at this stake-holders meeting. The CAC should be allowed a free-hand in their process of developing this important subject area without any outside interference at this time.

c) The views on priority combinations: human-pathogen-antimicrobial use and animal species in terms of benefit/risk assessment.
As stated in a previous question (a), the WVA believes that animal welfare is an important component of animal health. Therefore, the relief of animal suffering from infectious diseases through the veterinary availability of effective antimicrobials is essential for the humane and effective treatment of animals. Also, many of the CIA are important therapeutic agents for the treatment of non-human victims of zoonotic agents. It is critical to stop the transmission cycle of zoonotic agents in non-humans before they are transmitted to humans. Since about 70% of newly emerging infectious diseases are zoonotic agents, it is critical to stop outbreaks of zoonotic diseases before they become epidemics, or even pandemics. Prudent use of antimicrobials must be a required part of the usage of CIAs in humans and non-humans.

The effective and humane treatment of non-humans with infectious diseases, including those caused by pathogens which are zoonotic agents, requires that veterinarians have accessibility to some of the critically important antimicrobial agents. The antimicrobial classes that have been identified by the WHO as being of critical importance (CIA) are as follows: third and fourth generation cephalosporins, macrolides, and quinolones.

The benefit/risk assessment is a balance between the reduction of animal suffering from diseases and the intervention of the transmission of zoonotic pathogens to humans versus the risk of the development of antimicrobial resistance. The benefit of the equation has no alternative to preventing the suffering of animals from diseases or the malnutrition of humans from decreased animal proteins. The human lack of animal companionship or work animals is another negative resulting from not having adequate veterinary antimicrobials. The risk side of the equation can be avoided by prudent use of antimicrobials, monitoring of non-human and human applications and proficient risk management on an international level.

The World Veterinary Association (WVA) is a federation of the primary national veterinary associations of over 80 countries. The WVA represents its members through a very active website, publications, and the participation in meetings such as this Stakeholders meeting. One of the WVA members, the American Veterinary Medical Association has been very active in antimicrobial resistance issues and has issued a statement that has been included here.

AVMA’s Council on Public Health and Regulatory Veterinary Medicine and Food Safety Advisory Committee is submitting the following statement for WVA inclusion at the Joint FAO/WHO/ OIE Expert Consultation on Critically Important Antimicrobials:

“Veterinarians take an oath to promote public health, protect animal health and relieve animal suffering. Veterinarians serve public health in many ways, not the least of which is ensuring a healthy, safe, and abundant supply of animals for human nutrition and clothing. We believe that the human and animal medical communities share a common interest assuring an abundance of safe and nutritious food. Responsible use of antimicrobials is one of the pillars upon which we maintain a safe, wholesome, and abundant food supply.

The veterinary community shares with other medical professions a commitment to preventing the selection for, and transmission of, antimicrobial resistant microorganisms, and we support risk-based approaches to the use of antimicrobials through:

• Coordinated programs to educate human and animal health professionals and care-providers on disease prevention measures that reduce the need for antimicrobial use
• Prevention and control of transmission of antimicrobial resistant microorganisms
• Monitoring and surveillance
• Ongoing discovery of the mechanisms of antimicrobial resistance and methods by which resistant microorganisms are transmitted between populations

Preparing lists of critical antimicrobials does not serve the realities of a constantly changing landscape of health needs for humans or animals. The approach of creating specific lists of critical antimicrobials unnecessarily polarizes human and veterinary medical professionals, promotes controversy which weakens efforts to prevent the emergence of antimicrobial resistance, and jeopardizes the safety and availability of the food supply. Further, that an antimicrobial is listed as a critical human antimicrobial should not be equated to mean that there is a direct risk to human health from its use in animals, requiring risk management.

We believe a more sustainable approach is for the health professions to work cooperatively toward our common desire to use antimicrobials responsibly and prevent the selection for, and transmission of antimicrobial resistant organisms. We welcome positive discussion on methods of solving this problem we share in common”.

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