Landscape Analysis of Tools to Address Antimicrobial Resistance - MAY 2021
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Landscape Analysis of Tools to Address Antimicrobial Resistance 1 Landscape Analysis of Tools to Address Antimicrobial Resistance MAY 2021
Appendixes 2 © 2021 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages dissemi- nation of its knowledge, therefore, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: email@example.com.
Table of Contents ACKNOWLEDGMENTS 6 ABBREVIATIONS 7 EXECUTIVE SUMMARY 9 CHAPTER 1: INTRODUCTION 12 CHAPTER 2: METHODOLOGY 16 CHAPTER 3: FINDINGS AND ANALYSIS 23 CHAPTER 4: CONCLUSIONS 51 REFERENCES 55 APPENDIX A: SUMMARY OF TOOLS 61 APPENDIX B: FURTHER DETAILS ON METHODOLOGY 78 APPENDIX C: EXPERT CONSULTATIONS 84
World Bank Group 6 Acknowledgements This report was written by a World Bank team led by Angela Mazimba (Research Analyst), with contributions from Naomi Rupasinghe (Health Specialist) and Ana Cristina Canales Gomez (Food and Agriculture Specialist), under the guidance of Feng Zhao (Practice Manager for Global Engagement within Health, Nutrition and Population) and Muhammad Pate (Global Director, Health, Nutrition and Population). The team is grateful for the peer review guidance provided by Claire Chase (Senior Water Economist), Franck Berthe (Senior Livestock Specialist), Stephen Dorey (Senior Health Specialist), Fatima Barry (Health Specialist), and Sambe Duale (Senior Public Health Specialist), as well as the support of Sanne Helt (Advisor), Anne Himmel- farb (Editor), Gabriel Francis (Program Assistant) and Marize de Fatima Santos (Program Assistant). The team is also grateful for the guidance and advice of Anand Balachandran, Unit Head, National Action Plans and Monitoring and Evaluation Unit, AMR Division, World Health Organization; Arshnee Moodley, Team Leader, International Livestock Research Institute, AMR Hub, CGIAR; Breeda Hickey, Technical Officer, National Action Plans and Monitoring and Evaluation Unit, AMR Division, World Health Organization; Clara L. Davis, Science and Technology Advisor, USAID; Constanza Vergara, Veterinarian and Agricul- tural Economist, Chilean Ministry of Agriculture; Elizabeth Tayler, Team Leader, National Action Plans and Monitoring and Evaluation Unit, AMR Division, World Health Organiza- tion; Javiera Cornejo Kelly, Assistant Professor, Faculty of Animal and Veterinary Scienc- es, University of Chile; Jing Xu, Animal Production and Health Division, Animal Health Service, Food and Agriculture Organization; Jorge Pinto Ferreira, Deputy Head, AMR and Veterinary Products Department, World Organisation for Animal Health; Nobuko Ichikawa, Principal Environmental Economist/Environmental Advisor, European Bank for Reconstruction and Development; Olga B. Jonas, Research Associate, Department of Health Policy and Management, Harvard University T. H. Chan School of Public Health; Renzo Guinto, Associate Professor of Global Public Health, St. Luke’s Medical Center Col- lege of Medicine; Sarah Paulin, Technical Officer, National Action Plans and Monitoring and Evaluation Unit, AMR Division, World Health Organization. The report was funded by the Danish Ministry of Foreign Affairs as part of the World Bank’s program on Antimicrobial Resistance (AMR).
Landscape Analysis of Tools to Address Antimicrobial Resistance 7 Abbreviations AMR antimicrobial resistance ASEAN Association of Southeast Asian Nations CDC US Centers for Disease Control and Prevention FAO Food and Agriculture Organization of the United Nations GAP-AMR Global Action Plan on Antimicrobial Resistance GARP Global Antibiotic Resistance Partnership GDP gross domestic product GLASS Global Antimicrobial Resistance Surveillance System IPC infection prevention and control IHR International Health Regulations JPIAMR Joint Programming Initiative on Antimicrobial Resistance LIC low-income country LMICs low- and middle-income countries MDR multi-drug resistance NGO nongovernmental organization OECD Organisation for Economic Co-operation and Development OIE World Organisation for Animal Health PVS Performance of Veterinary Services SDG Sustainable Development Goal SORT IT Structured Operational Research and Training IniTiative STAR-IDAZ Strategic Alliance for Research on Infectious Diseases of Animals and Zoonoses TB tuberculosis WASH water, sanitation, and hygiene WHO World Health Organization XDR extensive drug resistance
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Landscape Analysis of Tools to Address Antimicrobial Resistance 9 Executive Summary This report describes the current land- The scoping review identified 90 tools scape of tools supporting the develop- aimed at supporting a range of entities ment and implementation of policies and in establishing policies and implement- interventions to address antimicrobial ing interventions to address AMR. These resistance (AMR). A landscape analysis tools are targeted at national govern- was undertaken to provide World Bank ments (ministries of health, agriculture, staff, teams, and clients with a repository environment), national centers for disease of tools that can be used to address AMR. control, medical professionals, veterinar- The analysis defined tools as frameworks, ians, laboratory technicians, pharmacists, guidelines, documents, and strategy the private sector, producers and traders development guides with the primary pur- in agriculture, nongovernmental organiza- pose of supporting development and im- tions, and the country offices of organiza- plementation of policies and interventions tions such as the World Health Organiza- to address AMR. A secondary purpose of tion (WHO) and the Food and Agriculture the report was to identify gaps in the ex- Organization (FAO) of the United Nations. isting landscape of tools and recommend areas for consideration by policy makers, Tools on implementation and surveil- donors, and implementers. lance predominate, but they are spar- ingly contextualized. Of 90 tools identi- A two-stage scoping review of existing fied, 47 focused on implementation, but tools was performed, drawing on the they were rarely focused specifically on Global Action Plan on AMR as a refer- low-income regions. Though tools were ence for global guidance on AMR pre- developed to be adaptable, only six were vention and control (WHO 2015a). In the developed for low-income countries, first stage, landmark reports on AMR were among them the WHO AMR Stewardship reviewed to develop the approach to de- Programmes in Healthcare Facilities in fining and identifying relevant tools, and Low- and Middle-Income Countries Toolkit to help define six programming domains (WHO 2019c); the Fleming Fund’s AMR for addressing AMR. These domains were Surveillance in Low- and Middle-Income (i) awareness raising, (ii) antimicrobial Settings: A Roadmap for Participation in stewardship, (iii) surveillance, (iv) infec- the Global Antimicrobial Surveillance Sys- tion prevention and control in human and tem (GLASS) tool (Fleming Fund 2016); animal health, (v) the reduction of patho- and the Structured Operational Research gen spread in the environment, and (vi) and Training IniTiative on AMR, coor- development of a national research agen- dinated by the Special Programme for da. In the second stage, a targeted search Research and Training in Tropical Diseases of gray and peer-reviewed literature and (TDR) (UNICEF et al. 2019). Given that related websites was performed to iden- low- and middle-income countries (LMICs) tify tools containing intervention options face disproportionate human, animal, and for AMR action. Consultations were also economic impacts from AMR (World Bank conducted with experts across the One 2017), this finding points to a significant Health spectrum1, to seek guidance, vali- gap and suggests that more can be done date findings, and source further tools. to provide tools to support actors in 1 The One Health approach is explained in the last section of chapter 1.
World Bank Group 10 LMICs, where implementation of More tools are needed to support costing activities to address AMR is likely AMR interventions, and on leveraging more complex and challenging than public and private finance to address in higher-income countries. AMR. Of 90 tools reviewed, 3 were iden- tified as potential costing mechanisms Stand-alone tools to reduce pathogen for AMR activities. One tool, the RAND spread, specifically related to environ- Corporation (2014) methodology for mental surveillance and management, estimating the economic costs of AMR, is are also limited. Of the 90 tools identi- focused on measuring the cost of AMR at fied, 13 provided some coverage of the the global level. For the national level, the mechanisms required for reducing or lim- PVS Gap Analysis tool (OIE 2020) pro- iting the spread of pathogens in the envi- vides a costing methodology for national ronment. Of these, four tools that address veterinary services. The WHO is also in domestic and agricultural solid waste the process of developing a modular tool and wastewater management specifical- that will support countries with costing, ly acknowledge the threat of pathogen budgeting, and prioritizing activities con- dissemination into the natural environ- tained within their AMR National Action ment. Tools such as the “Technical Brief Plans (NAPs) (WHO 2021). The tool will on Water, Sanitation, Hygiene (WASH) facilitate budgeting gaps analyses and and Wastewater Management to Prevent allow countries to advocate for additional Infections and Reduce the Spread of funding for prioritized AMR activities. Antimicrobial Resistance (AMR)” (WHO, Given the economic limitations that coun- FAO, and OIE 2020b) address WASH and tries in lower-income regions face, there wastewater management to limit dispersal is room to leverage national costing and via fecal sludge and liquid waste, silent economic burden studies for more transmission of resistant microorgan- effective AMR programming. isms, and release of other pollutants and antimicrobial compounds. The Review on There is a need for more tools on inter- Antimicrobial Resistance (2015) paper and ventions that are focused at the commu- the United Nations Environment Pro- nity or individual level. Only one tool, the gramme’s Frontiers report (UNEP 2017) WHO (2018c) Competency Framework for provide an overview of the pathways of Health Workers’ Education and Training environmental transmission from water on Antimicrobial Resistance, focused on and food systems. It is important to note awareness raising interventions at the that this focus on the spread of patho- individual level. A second tool, “Antibiotic gens into the environment entailed im- Prescribing and Resistance” (WHO and portant search limitations. While not the Antimicrobial Resistance Centre at the focus of this review, a broader framework London School of Hygiene and Tropical for the nexus between AMR, environ- Medicine 2017), highlights the perspec- ment, and related issues such as climate tives of prescribers and health profes- change and zoonoses could be outlined sionals in low-income settings. Recently and would result in a broader array of articulated community engagement more indirect tools. For example, certain frameworks for AMR research and action tools in the environmental sector are (Mitchell et al. 2019) may form a founda- designed specifically to address climate tion for the development of further tools change, but there is a high potential that in this area. However, the lack of tools to these tools could also lead to benefits for support implementing agencies in engag- AMR risk reduction. Making these linkages ing with individuals and communities may clearer and more visible will require more be a knowledge and practice gap that is targeted investments to produce clearer of interest to donors and policy makers. guidance and to reinforce knowledge and other resources in the sector.
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World Bank Group 12 Chapter 1: Introduction Background: Why does Antimicrobials used to treat infectious dis- antimicrobial resistance matter? eases in animals are also used in humans, and resistant microorganisms arising in Antimicrobial resistance (AMR)—the humans, animals, or the environment may resistance of microbes to antimicro- spread across any of those boundaries bials—continues to pose a significant (FAO, OIE, and WHO 2017). threat to global health security (World Bank 2019). AMR occurs when microbes Failure to make progress on controlling (bacteria, fungi, viruses, and parasites) AMR is a significant development chal- mutate in response to their exposure to lenge because of AMR’s disproportion- antimicrobials. This natural development ate impact on low- and middle-income means that drugs that were previously countries (LMICs), and specifically its effective in treating diseases become negative impact on poverty reduction, ineffective, making infections lethal or food security, health and well-being, and persistent. Pathogens may be resistant to inequality reduction. AMR is estimated several antimicrobials: multi-drug resis- to cause 700,000 deaths annually, and tance (MDR) describes resistance to two deaths attributed to AMR are predicted or more antimicrobial agents in three or to rise to 10 million annually by 2050 more antimicrobial classes; extensive drug (Review on Antimicrobial Resistance resistance (XDR) describes resistance to 2016). The rise of drug-resistant tubercu- at least one agent in all but one or two losis (TB) highlights the potential impact antimicrobial categories; and pan-drug re- of AMR for LMICs. The cost of treating sistance describes resistance to all agents MDR-TB or XDR-TB can be significantly in all antimicrobial categories. Microbes more expensive than drug-sensitive TB. developing resistance to multiple drugs For example, in 2011 only 2 percent of are sometimes referred to as “superbugs.” South Africa’s TB cases were drug resis- An infection caused by a superbug is tant. However, those cases consumed 32 harder to treat because fewer effective percent of South Africa’s national budget drugs are available. In some extreme cas- for TB treatment.3 es, treatment may not even exist. Given In 2016, the World Bank analyzed the the range of everyday medical interven- global economic impact of AMR and tions that are enabled by effective antimi- found that by 2050 AMR could negative- crobials, the potential impact of losing the ly affect the global economy by as much ability to use antimicrobials constitutes a as 3.8 percent of annual gross domes- “slow-moving tsunami” (WHO 2016a). tic product (GDP). Two scenarios were Successive international declarations considered. In a high-impact scenario, the have acknowledged the global threat of world would lose 3.8 percent of annual AMR (UN General Assembly 2016). While GDP. Mild impacts would likely reduce the devastating potential for the health GDP by 1.1 percent (World Bank 2017). sector has been widely documented, These effects stand to be profound in stakeholders have also recognized that two ways. First, they would be felt on an the causes of resistance go well beyond ongoing basis. Second, they would have the health sector, making it critical to a disproportionate impact on low-income draw on a One Health approach2. countries (LICs), which would experience 2 The One Health approach is explained in the last section of this chapter. 3 T B Alliance, “Drug Resistance: A Response to Antimicrobial Resistance Includes Tackling TB,” https://www.tballiance.org/why-new-tb-drugs/antimicrobial-resistance.
Landscape Analysis of Tools to Address Antimicrobial Resistance 13 larger drops in economic growth than inhibit progress toward the SDGs (Figure wealthy countries, in turn increasing glob- 1), while a focus on the SDGs is also a way al poverty and economic inequality. AMR to contribute to containing AMR. For ex- thus has a two-way relationship with the ample, improved water management and Sustainable Development Goals (SDGs): sanitation will help limit infectious disease the emergence and spread of AMR will risks. FIGURE 1: THE TWO-WAY RELATIONSHIP BETWEEN THE SDGS AND AMR Source: World Bank 2019. Purpose and structure The purpose of this landscape analysis is require collaboration across sectors, as to provide World Bank teams and clients well as adaptive solutions that incentivize with a repository of tools that can be patients, farmers, medical professionals, used to address AMR through the devel- companies, and industries to use antimi- opment and implementation of policies crobials differently (World Bank 2019). and interventions. A secondary purpose is to identify gaps and areas for further Within this wider context, this landscape consideration and support by policy mak- analysis is intended to highlight the ers, donors, and implementers. development of a range of tools and ap- proaches that support programming and Since the Global Action Plan on AMR policy implementation to contain AMR (WHO 2015a) and the UN General As- at the global and national levels. While sembly’s (2016) Political Declaration on gaps and blind spots remain, global- and Antimicrobial Resistance were issued, national-level policy makers, ministries, meetings and reports have documented and implementing institutions have a the importance of AMR as a global threat. substantial foundation on which to draw. These developments reflect a growing While the focus of this report remains understanding of AMR as a technical issue, technical, it is intended as a step toward and a recognition of the threat posed by the uptake of adaptive approaches. For AMR to global health security and socio- example, while efforts to contextualize economic well-being. Nevertheless, action tools remain important, this landscape to address AMR has been slower to mate- analysis demonstrates that a range of ma- rialize, in part because effective action can terials is available to support actors across
World Bank Group 14 the One Health spectrum in addressing importance of a cross-sectoral approach AMR, prioritizing investments, and imple- to global health security. It showcases menting NAPs. how environmental changes, along with ecological and human dynamics, can am- The report is organized as follows. The plify pressures at the interfaces between remainder of this chapter discusses how humans, animals, and the ecosystems they the analysis draws on a One Health ap- share. A growing number of drivers have proach. Chapter 2 explains the methodol- increased the risk of infectious disease ogy used to define, search for, and select emergence and spread. AMR is one of the tools, and lists key domains for action these drivers. Addressing the emergence on AMR. Chapter 3 presents the findings and spread of resistance requires a sys- from the review. Chapter 4 offers some tems approach that includes the human, conclusions concerning gaps and oppor- animal, and environmental dimensions. tunities. Appendix A provides a list of the AMR has widely been acknowledged as tools identified in the analysis, along with a “quintessential” One Health issue (Rob- short descriptions and links. Appendix B inson et al. 2016). The analysis sought offers further details on the methodology. to reflect the multidisciplinary and mul- tisectoral approach associated with One Drawing on a Health by going beyond the confines One Health approach of health and public health systems to consider tools and approaches being The World Bank (2018) Operational used in agriculture, water, and environ- Framework for Strengthening Human, mental programming. Animal, and Environmental Public Health Systems at their Interface highlights the “According to the World Bank (2018, 3), a One Health approach is: a collaborative approach for strengthening systems to prevent, prepare, detect, respond to, and recover from primarily infectious diseases and related issues such as antimicrobial resistance that threatens human health, animal health, and environmental health collectively, using tools such as surveillance and reporting with an endpoint of improving global health security and achieving gains in development.”
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World Bank Group 16 Chapter 2: Methodology A two-stage scoping review was con- range of tools was identified; these are ducted to examine the landscape of documented in Table 1. The six domains tools on AMR. Building on the steps by identified are (i) awareness raising; (ii) the global community to strengthen the antimicrobial stewardship; (iii) surveil- response to AMR after 2015, the first lance, monitoring and research for nation- stage included a review of the landmark al surveillance systems with a One Health or seminal reports that are considered to approach; (iv) infection prevention and have guided global AMR action over the control in human and animal health; (v) last five years.4 These reports, listed in reduction of the spread of pathogens into Box 1, were selected based on their role the environment; and (vi) the operational in establishing a platform for action at research agenda. Box 2 provides the the global level. From this initial review, definition of tools used for the purpose a series of recurrent priority actions or of this review. domains through which to organize the BOX 1: LANDMARK REPORTS USED TO INFORM DATA COLLECTION AND ORGANIZATION • HO (World Health Organization). W • IE (World Organisation for Animal O 2015. “Global Action Plan Health). 2016. “The OIE Strategy on on Antimicrobial Resistance.” Antimicrobial Resistance and the Prudent Use of Antimicrobials.” • “ Review on Antimicrobial Resis- tance.” 2016. Tackling Drug-Resistant • ECD (Organisation for Economic O Infections Globally: Final Report and Co-operation and Development). Recommendations. Review on Anti- 2018. “Stemming the Superbug microbial Resistance chaired by Tide: Just a Few Dollars More.” Jim O’Neill. • IACG (Interagency Coordination • AO (Food and Agriculture F Group). 2019. “No Time to Wait: Organization of the United Nations). Securing the Future from 2016. “The FAO Action Plan on Anti- Drug-Resistant Infections.” microbial Resistance 2016–2020.” 4 S eminal or landmark reports are sources that “initially presented an idea of great importance or influence within a particular discipline” and are frequently cited in other sources. Northcentral University Library, “Research Process: Finding Seminal Works,” https://ncu.libguides.com/researchprocess/seminalworks.
Landscape Analysis of Tools to Address Antimicrobial Resistance 17 TABLE 1: SIX DOMAINS TO GUIDE DATA COLLECTION AND ANALYSIS Domain Definition for the purpose of this report Awareness raising Improve awareness, understanding, and knowledge of AMR through communication, education, and training at local, national, and regional levels Antimicrobial Promote the optimal use of antimicrobial agents through stewardship appropriate prescribing in diverse health care settings, especially in primary care Surveillance, monitor- Under a One Health approach, strengthen knowledge and ing and research for evidence through AMR and associated public health surveillance, national surveillance monitoring, and research for national systems systems with a One Health approach Infection prevention Reduce infections (including hospital- and community-acquired and control in human infections) in humans and animals and animal health Reduction of the Monitor and regulate environmentally related activities or spread of pathogens products that result in the spread of AMR pathogens into the environment Operational research Strengthen and sustain operational research capacity for evi- agenda dence-based decision-making to improve program performance Source: World Bank.
World Bank Group 18 BOX 2: DEFINING TOOLS For the purpose of this report, tools are defined as frameworks, guidelines, documents, and implementation strategies and similar mechanisms that aim to support government in developing policies and implementing programs that address AMR. This approach is not intended to be exhaustive. Evaluating the effectiveness of a given treatment, approach, or tool is not within scope of this report. Thus the analysis does not seek to comparatively or qualitatively assess the 90 tools identified. There are also many valuable tools that are outside the scope of this report, such as those that focus on diagnostics within health care settings or on specific treatments, therapies, or vaccines. The second stage of the search targeted Supplementary searches were conduct- peer-reviewed and gray literature as well ed on websites of relevant stakeholders as websites of international organiza- and organizations. These included the tions, nongovernmental organizations CGIAR, the Fleming Fund, the Food and (NGOs), government bodies, think tanks, Agriculture Organization of the United and research institutions focused on Nations (FAO), the International Federa- AMR (Figure 2). The review of published tion of Pharmaceutical Manufacturers and and gray literature sought to identify Associations (IFPMA), the Organisation tools that target antimicrobial resistance for Economic Co-operation and Develop- affecting human health, animal health ment (OECD), ReAct, the United Nations (terrestrial and aquatic), and the environ- Children’s Fund (UNICEF), the US Centers ment. In combination with search terms for Disease Control and Prevention (CDC), related to antimicrobial resistance over the Wellcome Trust, World Health Orga- the One Health spectrum, search terms nization (WHO), and the World Organisa- were developed along the six domains for tion for Animal Health (OIE). AMR programing (table 1). Three inter- national databases—PubMed, Cochrane Studies were selected based on the Library, and the FAO database AGRIS— abstracts and titles identified via elec- were searched using the search terms as tronic searches and were independently detailed in (appendix 3, table C.3). These screened based on the specified inclu- databases were selected to be compre- sion criteria. The search of published hensive and to cover a broad range of dis- literature yielded 122 potentially relevant ciplines reflected in the six domains. The citations after title and abstract screening. search terms for international publications After data characterization, 17 relevant were applied to title, abstract, keyword, publications (containing 22 tools—8 listed and full text. The search of gray literature and 14 contextual) remained and were was conducted using Google’s search en- included in the review. Between Sep- gine. The strategy also incorporated back- tember and November 2020, the search ward and forward reference searching to targeting gray literature was conducted; identify important sources, contextualize this produced 226 potentially relevant sources within current developments in publications and resulted in the addition the AMR landscape, and identify addition- of another 82 tools. In total, 90 tools were al publications of relevance.5 included in the analysis. The process from 5 For more information on the method used, see Tricco et al. (2015, 224).
Landscape Analysis of Tools to Address Antimicrobial Resistance 19 identification to final inclusion of tools is tional agencies, academic institutions, and represented in Figure 2. NGOs involved in AMR. The purpose of these consultations was to seek guidance This search was supplemented by 12 on the methodological approach and the consultations with experts across the appropriateness of the list of tools iden- One Health spectrum. Consultations were tified and to address potential gaps and conducted with purposively selected omissions. Appendix B lists experts who experts from the Tripartite organizations were consulted. (WHO, FAO, and OIE), relevant interna- FIGURE 2: SEARCH STRATEGY AND PROCESS 42 tools identified 12 tools identified 99 tools identified 3 tools identified IDENTIFICATION by searching by searching through expert by searching internet websites of consultations Tripartite (WHO, (via Google) international (including FAO, and OIE) organizations, WHO AMR expert meetings 26 tools identified NGOs, government resource pack) and other AMR by searching bodies, think tanks, symposiums PubMed, Cochrane and research library, and FAO’s institutions focused AGRIS on AMR SCREENING 182 tools identified through primary searches 21 duplicate tools removed 17 tools screened using titles and abstracts ELIGIBILITY 12 tools identified 49 publications via citations in removed for not fitting primary articles the inclusion criteria 110 tools assessed for eligibility using full text 22 tools removed due to exclusion criteria: - Older guidelines INCLUSION or policies 90 tools included in this landscape analysis - Other tool types dated before 2015 - Focused only on pre-clinical antibacterial pipeline research Source: World Bank.
World Bank Group 20 Guided by the AACODS (authority, ac- control or mitigation strategies for antimi- curacy, coverage, objectivity, date, crobial resistance in human health, animal significance) approach (Tyndall 2010), health (terrestrial and aquatic), and the inclusion and exclusion criteria were environment. Publications that includ- developed for the review of frameworks, ed tools on specific population groups, guidelines, documents, and implemen- clinical research, point of care diagnostics, tation strategies (Box 3). Retrieved treatments, therapies, or vaccines were documents were excluded if they were excluded from the review, as were studies published prior to 2015 and did not relate that could not be electronically retrieved. to AMR or to AMR program implemen- Dissertations, theses, letters to the editor, tation, interventions, or policies. The opinion pieces, feature articles, and arti- search was restricted to peer-reviewed cles intended as marketing or advertising and gray literature in English because material were also excluded. of limited resources for translation. The search sought to identify tools that target BOX 3: INCLUSION AND EXCLUSION CRITERIA Inclusion Exclusion • Incorporate international and • ocus on or assess quality of AMR F national guidance on AMR action program implementation • ssess documents associated with A • ocus on specific point of care F policy frameworks, monitoring and diagnostics, treatments, therapies, surveillance frameworks, and NAPs or vaccines • ssess program implementation A or interventions and policies on AMR action Source: World Bank. Two spreadsheets were developed to mendations, implementation strategy, confirm relevance and to extract data regional action plan, national action plan, from published and gray literature. Data regional surveillance program, national extraction was based on the following: (i) surveillance program, and research pro- characteristics of publications—i.e. author, gram. This selection was derived induc- year of publication, title, and related orga- tively from the range of tools selected. nization; (ii) potential tools categorized by The primary audience was also noted intervention area (drawing on the six pre- and included governments, international viously described domains) and intended organizations, NGOs, scientific bodies, audience; and (iii) publication source. research bodies, health professionals, vet- erinarians, human health facilities, surveil- After inclusion, documents underwent lance personnel, and farmers, traders, and more detailed review and were cate- producers. Further details on the catego- gorized by intervention area, tool type, rization are provided in tables B.1 and B.2 and intended audience. The intervention in appendix B. areas drew on the six domains previously described. The tool types included the following: AMR policy, guidelines/recom-
Landscape Analysis of Tools to Address Antimicrobial Resistance 21 The review has important limitations. To provide a manageable scope of in- First, it does not seek to be exhaustive but quiry, this review focused primarily on rather provides a repository of major tools AMR-specific interventions. AMR can be and works that can support a diverse seen through two types of interventions: range of readers in understanding the AMR-specific and AMR-sensitive solutions landscape of existing materials. Second, (Wellcome Trust 2020a). AMR-specific it does not seek to assess the quality of approaches and solutions have the pri- included publications. In line with a scop- mary goal of mitigating the development ing review, this analysis seeks to identify or transmission of resistant pathogens. and map existing tools for antimicrobial AMR-sensitive solutions leverage other resistance programming across the One agendas for the benefit of addressing Health spectrum. AMR, including the broader global health agenda related to (for example) improved hygiene and sanitation.
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Landscape Analysis of Tools to Address Antimicrobial Resistance 23 Chapter 3: Findings and Analysis The scoping review identified 90 tools The chapter also provides findings on the that seek to support a range of inter- tools, across six domains. Table 3 lists the ventions and are relevant in a range of 90 tools organized by domain. In the dis- contexts. This chapter discusses the char- cussion of findings, each domain contains acteristics of the tools reviewed, including a brief definition and examples of tools the types of tools, their target audience, through which various interventions and and their purpose. Table 2 provides a list policies for AMR action are presented. of the tools by type and audience. FIGURE 3: TOOL TYPE ECONOMIC MECHANISMS RESEARCH PROGRAM NATIONAL SURVEILLANCE PROGRAM REGIONAL SURVEILLANCE PROGRAM NATIONAL ACTION PLAN REGIONAL ACTION PLAN IMPLEMENTATION STRATEGY GUIDELINES/ RECOMMENDATIONS AMR POLICY 0 10 20 30 40 50 NUMBER Source: World Bank. Tool type The 90 tools identified in the review of tools focused on implementation strat- were classified into nine categories. egy (47), the provision of guidelines (26), Fourteen tools highlighted efforts to de- policy (4), and support to national (28) velop and coordinate operational research and regional surveillance mechanisms (13). programs for AMR, with only five tools To highlight the low- to middle-income (three specifically) outlining mechanisms focus of this analysis, two NAPs in mid- for costing AMR interventions or evaluat- dle-income countries (Ghana and South ing their cost-effectiveness. The majority Africa) and two NAPs in low-income
World Bank Group 24 countries (Uganda and Malawi) were Over half of the tools in the review (52) reviewed.6 These countries were identified were focused at the national level and through initial research and internal World developed for adaptation by national Bank consultations as potential case governments (ministries of health, agricul- studies for AMR preparedness 7 relative to ture, environment). Over half (48) outlined other LMICs. intervention options for national health fa- cilities, national veterinary services, medical The Association of Southeast Asian Na- doctors, and pharmacists. Thirty-one tools tions Regional Strategy (ASEAN 2016) were developed for national centers for and the Africa Centers for Disease Con- disease control and other national scientific trol’s Antimicrobial Resistance Surveil- bodies, and 20 tools outlined the roles and lance Networks (African Union and Africa appropriate actions of stakeholders such as CDC 2018) were categorized as regional pharmaceutical companies and producers action plans. and traders in agriculture. Audience Most tools were developed to target more than one audience, including stakeholders within the public sector, academia, scien- tific bodies, and the private sector. FIGURE 4: AUDIENCE GOVERNMENTS INTERNAL ORGANIZATIONS, NGOs SCIENTIFIC BODIES, RESEARCH BODIES HEALTH PROFESSIONALS, VETRINARIANS, HUMAN HEALTH FACILITIES, SURVEILLANCE PERSONNEL FARMERS, TRADERS, PRODUCERS, PRIVATE SECTOR 0 10 20 30 40 50 60 NUMBER Source: World Bank. 6 See Government of Ghana (2017); Government of South Africa (2018); Government of Uganda (n.d.). Outline of Malawi’s National AMR Strategy accessed at: https://cdn.southampton.ac.uk/assets/imported/transforms/ content-block/UsefulDownloads_Download/C6C715AED6784622962EB30060C6B30C/A%20Munthali%20 -%20Malawi%20AMR%20Strategy.pdf 7 WHO, FAO, and OIE, Country Progress in the Implementation of the Global Action Plan on Antimicrobial Resistance: WHO, FAO and OIE Global Tripartite Database, https://www.who.int/antimicrobial-resistance/ global-action-plan/database/en/.
Landscape Analysis of Tools to Address Antimicrobial Resistance 25 TABLE 2: SUMMARY OF 90 TOOLS: TOOL TYPE AND AUDIENCE TOOL Tool Type Audience Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies human health facilities, surveil- Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs lance personnel private sector Governments AMP Policy Global Action Plan on AMR (GAP-AMR) Strategy on AMR and the Prudent Use of Antimicrobials FAO Action Plan on Antimicrobial Resistance FAO Assessment Tool for Laboratories and Surveillance Systems (FAO–ATLASS) Progressive Management Path- way for AMR (FAO-PMP AMR) FAO Surveillance Evaluation Tool (SET) FAO Laboratory Mapping Tool (LMT) WHO AMR Stewardship Programmes in Healthcare Facilities and LMICs Toolkit Global Antimicrobial Resistance Surveillance System (GLASS) AWaRe tool AMR Framework for Action Supported by the IACG WHO Situation Analysis Antimicrobial Resistance: A Manual for Developing National Action Plans Country Progress on the Implementation of the Global Action Plan on Antimicrobial Resistance: WHO, FAO and OIE Global Tripartite Database
World Bank Group 26 TOOL Tool Type Audience Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies human health facilities, surveil- Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs lance personnel private sector Governments AMP Policy WHO Competency Framework for Health Workers’ Education and Training on Antimicrobial Resistance Strategic Research Agenda: Joint Programming Initiative on Antimicrobial Resistance Technical Brief on Water, San- itation, Hygiene (WASH) and Wastewater Management to Prevent Infections and Reduce the Spread of Antimicrobial Resistance (AMR) Guidelines on Core Compo- nents of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level FAO Resource Package on Good Hygiene Practices FAO Good Practices for Biose- curity in the Pig Sector Antimicrobials in Agricul- ture and the Environment: Reducing Unnecessary Use and Waste Monitoring and Evaluation of the Global Action Plan on Antimicrobial Resistance: Framework and Recommended Indicators Tripartite AMR Country Self-Assessment Survey (TrACSS) FAOSTAT FAOLEX WHO Benchmarks for IHR Capacity
Landscape Analysis of Tools to Address Antimicrobial Resistance 27 TOOL Tool Type Audience Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies human health facilities, surveil- Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs lance personnel private sector Governments AMP Policy Methodology to Analyze AMR-Relevant Legislation in the Food and Agriculture Sector Global Analysis and Assess- ment of Sanitation and Drinking-Water (GLAAS) AMR Benchmark WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene WHO Hand Hygiene Self-As- sessment Framework, and the WHO Infection Prevention and Control Assessment Framework OIE PVS Pathway PVS Gap Analysis Tool STAR-IDAZ International Research Consortium WHO Model List of Essential Medicines: 20th list ReAct Online Toolbox for National Action Plans Declaration by the Pharmaceu- tical, Biotechnology and Diag- nostics Industries on Combat- ing Antimicrobial Resistance Tackling Antimicrobial Resistance: Ensuring Sustainable R&D World Antibiotic Awareness Week 2018: Monitoring & Evaluation Report Guidelines for the Prevention and Control of Carbapen- em-Resistant Enterobacteria- ceae, Acinetobacter baumannii and Pseudomonas aeruginosa in Health Care Facilities
World Bank Group 28 TOOL Tool Type Audience Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies human health facilities, surveil- Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs lance personnel private sector Governments AMP Policy Global Framework for Development & Stewardship to Combat Antimicrobial Resistance: Draft Roadmap WASH in Health Care Facilities: Practical Steps to Achieve Uni- versal Access to Quality Care WASH in Health Care Facilities: Global Baseline Report 2019 Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines Ghana National Action Plan South African Antimicrobial Resistance Strategy Frame- work: A One Health Approach Global Priority List of Antibiot- ic-Resistant Bacteria to Guide Research, Discovery, and De- velopment of New Antibiotics Diagnostic Stewardship: A Guide to Implementation in Antimicrobial Resistance Surveillance Sites Africa CDC Antimicrobial Resistance Surveillance Network (AMRSNET) ASEAN Regional Strategy on AMR Communication and Advocacy Estimating the Economic Costs of Antimicrobial Resistance: Model and Results
Landscape Analysis of Tools to Address Antimicrobial Resistance 29 TOOL Tool Type Audience Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies human health facilities, surveil- Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs lance personnel private sector Governments AMP Policy Antibacterial Agents in Clinical Development: An Analysis of the Antibacterial Clinical De- velopment Pipeline, Including Tuberculosis Resistance Map Health Workers’ Education and Training on Antimicrobial Resistance: Curricula Guide The Structured Operational Re- search and Training IniTiative on AMR, coordinated by the Special Programme for Re- search and Training in Tropical Diseases (TDR) Integrated Surveillance of Antimicrobial Resistance The 4th Annual OIE Report on Antimicrobial Agents Intended for Use in Animals Tackling Antimicrobial Resis- tance Together (Working Pa- per 5.0): Enhancing the Focus on Gender and Equity Summary Report of the FAO/ WHO Expert Meeting on Foodborne Antimicrobial Re- sistance: Role of Environment, Crops and Biocides The Environment as a Driver of Antibiotic Resistance Frontiers 2017: Emerging Is- sues of Environmental Concern Preventing the Next Pandemic: Zoonotic Diseases and How to Break the Chain of Transmission Reframing Resistance
World Bank Group 30 TOOL Tool Type Audience Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies human health facilities, surveil- Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs lance personnel private sector Governments AMP Policy Gulf–Middle East–North Africa Antimicrobial Stewardship Network Tackling Antimicrobial Re- sistance Together (Working Paper 1.0): Multisectoral Coordination An Analysis of the Animal/ Human Interface with a Focus on Low- and Middle-Income Countries The AWaRe Campaign: “Adopt AWaRe. Handle Antibiotics with Care” Antibiotic Prescribing and Re- sistance: Views from Low- and Middle-Income Prescribing and Dispensing Professionals Uganda Antimicrobial Resis- tance National Action Plan (2018–2023) Malawi National AMR Strategy (2017–2022) The Joint External Evaluation Tool The Global Research on AntiMicrobial Resistance Project (GRAM) International Instruments on the Use of Antimicrobials across Human, Animal and Plant Sectors US CDC Laboratory Assess- ment of AMR Testing Capacity (LAARC) Guidelines for the Develop- ment of National Action Plan for Health Security
Landscape Analysis of Tools to Address Antimicrobial Resistance 31 TOOL Tool Type Audience human health facilities, surveillance Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs private sector Governments AMP Policy personnel Industry Alliance against AMR Progress Report Industry Roadmap for Progress on Combatting Antimicrobial Resistance Time Is Running Out Technical Note OIE Data Collection Template Core Elements of Human Anti- biotic Stewardship Programs in Resource-Limited Settings ACORN (Clinically-Oriented Antimicrobial Resistance Sur- veillance Network) AMR Surveillance in Low- and Middle-Income Settings: A Roadmap for Participation in the Global Antimicrobial Sur- veillance System (GLASS) Critically Important Antimicro- bials for Human Medicine: 5th Revision WHO Guide for the Stepwise Laboratory Improvement Pro- cess Towards Accreditation in the African Region WHO Global Guidelines on the Prevention of Surgical Site Infection Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupa- tional Infection Prevention and Control Services
World Bank Group 32 TOOL Tool Type Audience human health facilities, surveillance Health professionals, veterinarians, International organizations, NGOs Scientific bodies, research bodies Regional surveillance program National surveillance program Guidelines/recommendations Farmers, traders, producers, Implementation strategy Economic mechanisms Regional action plan National action plan Research programs private sector Governments AMP Policy personnel WHO Guidelines on Use of Medically Important Antimicrobials in Food-Producing Animals Draft WHO Costing and Budgeting Tool for National Action Plans on Antimicrobial Resistance Draft WHO Implementation Handbook for National Action Plans on Antimicrobial Resistance Draft FAO Situation Analysis of AMR Risks in the Food and Agriculture Sectors 8 Totals (90 tools in total) 5 26 47 2 7 13 28 15 5 52 14 31 48 20 Discussion of the findings across domains As indicated in chapter 2, six domains for Three domains were well covered by the actions and interventions were identi- tools identified in the review. These were fied for this review based on a review surveillance interventions (46 out of the of seminal reports: (i) awareness raising; 90 tools), infection prevention and control (ii) antimicrobial stewardship; (iii) sur- (34 out of 90), and stewardship policies veillance; (iv) infection prevention and and intervention options (34 out of 90). control in human and animal health; (v) In contrast, only 13 tools considered the the reduction of pathogen spread in the spread of pathogens in the environment environment; and (vi) development of a in detail, with 5 tools providing detailed national research agenda. These domains attention and 8 looking at broader issues cut across human, animal, and environ- related to this area. mental health and key sectors (health, agriculture, and water, sanitation, and Domain 1: Awareness raising hygiene) and are part of a multisectoral Of the tools reviewed, 30 focused on One Health approach. increasing awareness and understanding of AMR and highlighted the importance 8 The tools are listed in order of review.
Landscape Analysis of Tools to Address Antimicrobial Resistance 33 of improved understanding of the behav- for action on AMR (Box 4). Other tools ioral drivers among consumers, health address improved evidence on the be- professionals, veterinarians, farmers, havioral drivers for antimicrobial use and animal owners, and the general public. resistance in human and animal health, At the global level, the Global Action Plan encouraging the development of re- on Antimicrobial Resistance, or GAP-AMR sources for the promotion of appropriate (WHO 2015a) encourages the identifica- antibiotic prescribing in primary health tion and prioritization of existing initia- care and animal health settings. One such tives to improve understanding about tool that is in development, an “antibiotic AMR and appropriate antimicrobial use in footprint” for countries and individuals settings across the One Health spectrum. (Limmathurotsakul et al. (2019), has been The investigation and promotion of new proposed as a global tool to communicate initiatives to introduce AMR information the scale of antibiotic use across human, and key messages to new audiences was animal, and environmental health. The also apparent. For example, the Refram- tool would attribute antibiotic use across ing Resistance toolkit (Wellcome Trust these sectors to specific activities, with 2019) was developed by the Wellcome the wider aim of contributing to global Trust to tailor strategies for impact com- target setting for reductions in antibiotic munication on AMR that would enable use. A useful companion tool is ReAct’s more effective communication for public (2016) AMR Stakeholder Mapping exer- AMR awareness. Through its Responsive cise conducted in 2016, which provides Dialogue Toolkit, the Wellcome Trust has an overview of key actors across areas of also developed participatory approaches intervention and related sectors for AMR. to communication and program design
World Bank Group 34 BOX 4: BUILDING AWARENESS AND ENGAGEMENT: THE WELLCOME TRUST’S RESPONSIVE DIALOGUE TOOLKIT To support engagement and activism on AMR, the Wellcome Trust developed a guide and toolkit for using the Responsive Dialogue framework, an approach that seeks to involve communities in the design, implementation, and enforce- ment of solutions and policies to address antimicrobial resistance. The approach is designed to enable policy makers, practitioners, the public, and other AMR stakeholders to co-create solutions that inform AMR policies. It centers on five principles: Inclusivity: RDs [Responsive Dialogues] provide inclusive and open spaces where people can freely and comfortably express their views. They are designed to include vulnerable, marginalized, less vocal people and to understand a wide range of views, beliefs and knowledge systems. Accessibility: RDs are informative with a range of people and experts providing evidence in accessible, balanced and unbiased ways. Community-based: RDs work with community groups, networks and local citi- zens, involving people from all walks of life. Respectful: RDs move beyond simply gathering views to building dialogue and reflection to genuinely co-design responses, considering people’s views, practic- es and experiences Responsive: RD processes are designed to be transparent and accountable, providing clear and open communication about the RDs to the public and com- mitment to act on recommendation arising from the dialogues (Wellcome Trust 2020b). The toolkit has been piloted in two countries (Thailand and Malawi), where initial research and application focused on the connection between AMR and women’s groups. The dialogues generated ideas on increased communication surround- ing daily hygiene through food preparation, washing, and integration of hygiene facilities in schools. Source: World Bank 2020b.
Landscape Analysis of Tools to Address Antimicrobial Resistance 35 Tools within this domain also provide gaps in the national- or context-specific guidance on how to maximize the effi- tools that are needed to ensure updated cacy of antimicrobials. For the human curriculum outcomes and competencies health sector, frameworks like the WHO’s for AMR-related training, especially for AWaRe tool aim to improve knowledge low-income settings. on the judicious use of antibiotics among human and animal health professionals.9 Domain 2: Antimicrobial stewardship The AWaRe tool classifies antibiotics AMR stewardship tools aim to promote into three groups—access, watch, and mechanisms to measure appropriate reserve—specifying categorizations to antibiotic use, in part by ensuring that account for quality, shortages, access, and prescribing and dispensing practices are appropriate use. The FAO Action Plan on aligned with national prescribing guide- Antimicrobial Resistance (FAO 2016) and lines for antibiotic use in human and an- the Strategy on AMR and the Prudent imal health. In this review, 34 tools show Use of Antimicrobials (OIE 2016) set out the importance of antimicrobial steward- strategies for amplifying knowledge and ship—the reduction of unnecessary or awareness of AMR in the animal and plant inappropriate use of microbials, predom- health sectors. Through annual World An- inantly in clinical settings—for addressing tibiotic Awareness Weeks and subsequent AMR. While antimicrobial stewardship is a accompanying monitoring and evaluation standard practice in some clinical settings, reports,10 the OIE has sought to translate the tools demonstrate that more needs technical and biological concepts for to be done to integrate stewardship in applicability to a wide range of stake- other settings, such as interventions holders in the agriculture, livestock, and designed to improve adherence to pre- fisheries sectors. scribing guidelines. Tools in the human and animal health A series of international standards, set sectors also set out guidance on educa- out in WHO and FAO documentation, tion for health professionals. The WHO also provide important reference points Competency Framework for Health Work- for stewardship programming. In the ers’ Education and Training on Antimi- report “International Instruments on the crobial Resistance (WHO 2018c), which is Use of Antimicrobials across the Human, supplemented by the WHO Health Work- Animal and Plant Sectors” (WHO, FAO, ers’ Education and Training on Antimicro- and OIE 2020a), the Tripartite organiza- bial Resistance: Curricula Guide (WHO tions provide an overview of international 2019b), provides guidelines for health instruments to assist national govern- professionals to better understand and ments in adapting and adopting relevant increase their awareness of antimicrobial international standards with implications resistance. Tools such as the report “Anti- for antimicrobial use. The most recent biotic Prescribing and Resistance: Views version of the WHO Model List of Essen- from Low- and Middle-Income Prescribing tial Medicines (WHO 2019d) is a reference and Dispensing Professionals” (WHO and point for categorizing antibiotics and Antimicrobial Resistance Centre at the organizing stewardship recommendations London School of Hygiene and Tropical (namely identification, testing, and imple- Medicine 2017) highlight the perspectives mentation of stewardship interventions in of prescribers and health professionals in general practice). The WHO list of Criti- low-income settings, providing a founda- cally Important Antimicrobials for Human tion for the development of context-spe- Medicine (WHO 2019a) can be utilized to cific tools. Even so, this review noted formulate risk management strategies for 9 World Health Organization, “Adopt AWaRe: Handle Antibiotics with Care,” https://adoptaware.org/. 10 See for example WHO (2018d).
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