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Animal & Veterinary

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Integrated Surveillance Systems: Activities at the World Health Organization by Awa Aidara-Kane, Ph.D.

DR. AIDARA-KANE: Thank you very much. Good morning everybody and thank you to the organizers for giving me the opportunity to present WHO Advisory Group on Integrated Surveillance of antimicrobial resistance and give you a quick update on WHO activities. On containment of antimicrobial resistance.


So, this is just a slide stating how important antimicrobial containment in foodborne patterns in disease is important, because antimicrobials are essential drugs for treatment of infectious diseases in human and animal.

In animals important amount of antimicrobials that are used for treatment purposes as for human but also for prophylactic purposes and also as growth promoters.

And the alarming thing is that the same classes of antimicrobials are used in animals and humans and also that resistance is emerging and spreading faster then new drugs are being developed as stated by previous speakers.


As you can see in the slide, at the beginning of the antibiotic era a lot of new drugs were developed between 1958/1960. And as we go we have very few classes of antimicrobials that have been developed.

So, the last one is tycacyclin is in fact not really a new class of antimicrobial because it is tetracycline.


The resistance is a consequence of selective pressure that is created by use. This means that any kind of antimicrobial use we select for antimicrobial resistance and dissemination of resistant bacteria and resistant genes.

And since antimicrobial resistance does not respect phylogenetic, geographic or ecological borders it is important to contain antimicrobial resistance in all sectors, and this highlights the importance of integrated surveillance of antimicrobial resistance as we are doing in AGISAR. And also as this has been set by previous speakers due to globalization of food trade, the issue of antimicrobial resistance in food pathogens need to be addressed globally at the international level.


In WHO this has been recognized since, if I look back to the records, all this report I’ve seen on antimicrobial resistance and integrated surveillance dates back to 1990. But this was a kind of alert that was given at that time. But the real work, ongoing work on antimicrobial resistance started in 1997 with the Berlin Conference. This was followed by the WHO Resolution in 1998, 13 Member States, WHO Member States to develop programs for monitoring and containment of antimicrobial resistance. And to take measures to reduce the use of antimicrobials in food producing animals.


After this resolution a very important milestone for WHO was the publication of the WHO Global Strategy for Containment of Antimicrobial Resistance, in September 2001.


With the five key areas for containment of antimicrobial resistance, meaning rational drug use and regulation, research and development. Okay. So the five areas, rational drug use and regulation, infection control, research and development, surveillance, which is the area where we focus in AGISAR, and also use of antimicrobials in animal husbandry and agriculture.


Follow this global strategy is addressing different issues as I mentioned before. You tie that with importance of international and interdisciplinary collaboration, prudent use of antimicrobial agents in all sectors, no use of antimicrobial agents for growth promoters. And this was followed and at least the European level there is a ban of use of antimicrobials as growth promoters as of the first of January 2006.

There is a need to have in place a good regulation system for approval and licensing of antimicrobials. And we encourage wherever possible to have a prescription only use of antimicrobials in animals. We encourage practitioners to not have economic for profit from prescription of antimicrobial drugs.

Routine prophylactic use antimicrobials should not be used as a substitute of health management. We encourage accurate diagnosis and antimicrobial susceptibility testing, as well as appropriate antimicrobial product and administration route.

WHO encourage people to put in place successful disease control. But rely on holistic approach encompassing hygiene, animal husbandry and management, nutrition, animal welfare and vaccination.


Another important area for WHO is antimicrobials identified as critically important antimicrobials for human medicine as defined by many WHO reports and the list that was published in 2005, 2007 and 2009. These critically important antimicrobials should not be used in animals or should be used only if we have the justification of such use.

Monitoring of antimicrobial resistance and antimicrobial usage in human and animals has been recommended by many international --- including WHO expert contribution, has provide useful information on prevalence and trends this can provide input for risk assessment and risk management and can be a basis for choosing, implementing and evaluating, and implementing the implemented studies and interventions.


The achievements in WHO since 1997 I think they are quite important. International collaboration has been established. This is a very important achievement at the international level, more collaboration between FAO, OIE, WHO and also Codex. More than 15 expert consultations. Establishment of a Codex Ad Hoc Intergovernmental Task Force on antimicrobial resistance. WHO has a list of critically important antimicrobials that has been developed in 2005 and reviewed every two years as recommended. We are now at the third edition of the list. And last but not least, the establishment of an advisory group on integrated surveillance of antimicrobial resistance.


The AGISAR is the WHO Advisory Group on Integrated Surveillance of Antimicrobial Resistance, is a group of experts working in veterinary, food and public health disciplines that are advising WHO on ensuring globally containment of foodborne antimicrobial resistance through integrated surveillance system of antimicrobial usage and antimicrobial resistance in animal, food and human sectors.


Here I’m just mentioning here the proposal for integrated surveillance, as it has been stated by previous speakers. This will allow the documentation of the situation, identification of trends, identification of the interventions that we need to put in place, to contain antimicrobial resistance. This can serve as a basis for focused and targeted research, basis for communication of the risk, and also a good source of data for establishment of associations between antimicrobial usage and antimicrobial resistance, risk assessment and also evaluation of effectiveness of interventions.


The first meeting of AGISAR took place in Copenhagen in June 2009. During this meeting we updated the WHO list of critically important antimicrobials for human medicine, because AGISAR is the core component of the group of experts that will be reviewing the WHO list of critically important antimicrobials every two years. And also in Copenhagen we developed a strategic plan for containment of foodborne antimicrobial resistance.


Here are the two reports that we can get out of the expert consultation. The first AGISAR Meeting. The first report is a compilation of the two part of the meeting, the first part dealing with the WHO list of critically important antimicrobials. And the second part with drafting a strategic framework for AGISAR activity for the next five years.

And the second small booklet is just the list of critically important antimicrobials because one of the recommendations of the experts was to have a list in a more friendly version so that we can disseminate it more easily at the country level.


And from the discussions we had in Copenhagen we went back to WHO and we decided to have in place the governance of AGISAR. So we have a secretariat in WHO and we have different subcommittees, four of committees in total dealing with AGISAR management and AGISAR government.

One is the usage subcommittee that is led by --- Crain and will be dealing on providing protocols, guidance and tools to WHO members states on how to monitor antimicrobial usage in food animals.

So the antimicrobial resistance subcommittee is chaired by Pat McDermott and will also provide tools, protocols, for -- to WHO Member States.

You have a capacity building and country pilot projects subcommittee that is chaired by --— myself, and Enrique Perez, and --- from Denmark. And we would be dealing with implementing the protocols for that are developed by the different subcommittees at country level.

And we have a data management and software development subcommittee, that is chaired by John Stalling from --- and he will be working very closely with all the subcommittees to have the software that we will implement at country level also to afford that capture and management of antimicrobial resistance.

And also we will have to collaborate very closely with different stakeholders, networks, institutes, universities, academics, individuals that are helping WHO AGISAR achieve the very challenging problem that we have for the next coming years.

And I will take this opportunity to thank all the experts and members of AGISAR that are here present for their commitment and time and also FDA, CDC and others that are providing financial support to the project.


When we had a second meeting, it was one month ago, hosted, kindly hosted by the New University of Guelph and Public Health Agency of Canada. Where we were the first meeting of the AGISAR subcommittees. They met face to face to discuss their plans and activities for the next coming years.


So, briefly, the Usage Sub-Committee will have to develop, will help countries and support AGISAR on how to promote collection of standardize data on usage of antimicrobial agents for humans and animals, including aquatic species at regional/national levels.

This subcommittee will explore the possible ways for supporting and promoting the collection, analyzing and reporting of antimicrobial agents and will develop an action plan. This has been done and we will have a report of this subcommittee very soon.

And also it is very important to know that this usage subcommittee will build on important initiatives that are going on in Europe on surveillance of antimicrobial usage data, the ESAC Project, in humans and also in animals, ESVAC Project.


The Antimicrobial Resistance Monitoring Sub-Committee, has in during the AGISAR, the first meeting of AGISAR, focused on defining the minimum requirements for establishing a program of integrated surveillance of antimicrobial resistance in countries with limited resources.

And at the second meeting one month ago the emphasis was placed on the challenges associated with harmonization, international surveillance programs. The need for harmonization has been recognized by many international --- including the third session of the Codex Ad Hoc Intergovernmental Task Force on Antimicrobial resistance.

So, this is a recommendation on harmonization and using standardized methods that we want to really implement at the international level with the help of the antimicrobial resistance subcommittee.


These are the terms of reference of the subcommittee. They will develop recommendations for international harmonization of integrated antimicrobial resistance monitoring systems, of foodborne bacteria, including pathogens and commensals. They will provide guidance and surveillance and monitoring priorities and minimum requirements of integrated monitoring systems for AGISAR pilot projects. They will provide guidance on sampling strategies. This is a very important point because we have very few protocols that have been developed on what is appropriate sampling schemes for integrated surveillance system.

We will disseminate guidelines and standards on laboratory testing methods and quality assurance. Real proposed components of reporting and information sharing systems that permit regional and international comparisons of findings. So, this is also about harmonization.

And also we will communicate all the materials and recommendations through GFN training courses, AGISAR pilot projects and through other partnerships.


Then we have a subcommittee on data management that is shared by John Stelling that will address surveillance of antimicrobial resistance in microbial isolates of human, food and environmental origin. And also will have a competent surveillance on antimicrobial consumption in human and animal population. And also at some point in environmental settings.

This data management subcommittee will work with the other subcommittees to identify the needs and try to answer the needs of other AGISAR subcommittees.

The specific activities will include development of technical specifications for improving the use of WHONET for the management of resistance, surveillance of data for human and animal food and also develop technical specifications specific for improving the use of ABC Calc, which is a software for management of antimicrobial consumption in human, animal and other applications.

We will provide technical guidance on data management, strategies for pilot projects funded by WHO AGISAR. We will also support the expansion of surveillance activities through dissemination of the modified WHONET and ABC Calc


These are just the three phases that will be followed by the data management subcommittee, now we are at phase one of this program. Trying to look at all the existing integrated surveillance programs around the world and see what kind of data are collected, in what format they are collected and from there we will also take expert advice from AGISAR members and see how we can provide information for the specification of the software.

And then at phase two we will implement these specification. At phase three will be the dissemination of the software.


In addition to this we have training and country pilot projects. I will not go into details into the training. --- my colleague from --- will have to go more in details in this program. But we will have country pilot projects on integrated surveillance of antimicrobial resistance in pathogens and commensals. And also we will include an antimicrobial use component.

The object is of these pilot projects are to supplement the work of AGISAR by providing data from various parts of the world but clearly from developing countries. These pilot projects will contribute in strengthening the capacities of countries to establish their own program on integrated surveillance of antimicrobial resistance. They will foster the communication and collaboration between animal, food and health sectors thereby contributing in better prevention and control of foodborne disease including antimicrobial resistance along the entire food chain. They will increase awareness and commitment among the countries to implement strategies for prevention and control of foodborne disease and containment of antimicrobial resistance.

And also we would like to use the competency built through this pilot project to monitor effectiveness of control strategies and also to have national programs on integrated surveillance implemented in a more sustainable way in developing countries.


In conclusion I would say that integration of surveillance systems is a key step towards risk analysis and containment of foodborne antimicrobial resistance. This has been recognized by many WHO, FAO, OIE expert consultations and other national, regional, international fora including the current Codex Ad Hoc Intergovernmental Task Force on Integrated Surveillance of Antimicrobial Resistance.


AGISAR will facilitate integration of surveillance systems globally, in particular in developing countries through development of tools, guidance documents, protocols, software for data management, integrated antimicrobial resistance surveillance training modules by different AGISAR subcommittees.

We will also facilitate dissemination of these tools, through capacity building using the GFN platform and through country pilot projects and also focused research projects.


I would like to thank you for your attention and for more information you can visit our website at WHO. Thank you.


DR. FEDORKA-CRAY: We have discussion time if anyone has a quick question while we’re switching slides.

DR. LYNFIELD: I do have questions.

DR. FEDORKA-CRAY: Please identify yourself.

DR. LYNFIELD: Ruth Lynfield, Minnesota Department of Health and I’m also representing Infectious Disease Society of America, IDSA.

So I’ve very struck about the efforts of WHO to integrate the issue of antimicrobial resistance. And we just heard that the U.S. interagency public health action plan is undergoing its final clearance at HHS. I am wondering, is there a component of that that talks about integration with the global approach?

DR. AIDARA-KANE: Is it a question for me? I don’t think so.

DR. LYNFIELD: It is a question for the --


DR. LYNFIELD: It’s a question for those agencies who have written the public health action plan for the U.S.

DR. BARZILAY: I think honestly the best person to answer that will be here this afternoon, is Tom Chiller. Who was integral in the last phasing of the writing of the report. So if you don’t mind I would like to pose the question when he -– he is moderating the next session, to ask the question of him because it has gone through several alterations that I am not sure that I can answer confidently anymore, to answer your question. But Tom would be able to.

DR. FEDORKA-CRAY: Okay. Our next speaker is Pia Mäkek ä from the European Food Safety Authority, who will give us an overview of their operations.